Special situations
If you have Crohn's disease and you're thinking about starting a family, the first thing worth knowing is that most people with Crohn's can and do have healthy pregnancies. The second thing worth knowing is that the decisions you make before conception matter as much as anything you do during pregnancy itself. From medication management to delivery planning to the postpartum months, Crohn's adds layers of complexity that general pregnancy guidance doesn't cover. This article walks through the full journey, stage by stage, grounded in the latest evidence including the first-ever global consensus guidelines for pregnancy and inflammatory bowel disease (IBD) published in 2025.
Before You Conceive: Why Remission Is the Starting Point
The strongest predictor of a healthy pregnancy with Crohn's disease is your disease activity at the time of conception. Women who conceive while in remission have rates of miscarriage, stillbirth, and congenital abnormalities comparable to the general population. Women who conceive during active disease face meaningfully higher risks of preterm birth and low birth weight.
The 2025 global consensus recommends achieving stable remission for three to six months before attempting conception. That means preconception planning isn't optional. It's the single most impactful thing you can do. Talk to your gastroenterologist well before you start trying, ideally six months to a year ahead, so there's time to optimize your treatment, check labs, and confirm that your disease is genuinely quiet rather than just feeling okay.
This planning window also matters because some medications need to be stopped well in advance, and switching treatments takes time to reach full effect.
Medications: What Stays, What Goes, and What Needs a Washout
Medication decisions during pregnancy planning are where Crohn's patients face the most anxiety, and where outdated advice causes the most harm. The instinct to stop all medications "just to be safe" is understandable but, in most cases, wrong. Uncontrolled inflammation during pregnancy poses a greater threat than the medications used to control it.
Biologics should generally be continued. The 2025 global guidelines are clear: all monoclonal antibody biologics, including anti-TNF agents like infliximab and adalimumab, as well as vedolizumab and ustekinumab, should be continued throughout pregnancy and breastfeeding. A meta-analysis of nearly 7,000 patients found that biologic therapy in IBD pregnancies was associated with low rates of adverse outcomes, and stopping biologics prematurely carries its own risk by triggering flares.
Methotrexate is the critical exception. It is the only IBD medication that is absolutely contraindicated in pregnancy due to teratogenicity, meaning it can cause birth defects affecting the head, face, limbs, and bones. Women must stop methotrexate at least three months before trying to conceive, and many providers recommend a six-month washout to be conservative. This applies to men as well. Male patients on methotrexate should stop the drug three to six months before attempting conception with their partner.
Aminosalicylates and thiopurines are generally considered low-risk during pregnancy. Mesalamine and its variants can be continued. Azathioprine and 6-mercaptopurine have extensive safety data in pregnancy and are typically maintained if needed for disease control.
JAK inhibitors and S1P modulators are the other category to flag. The global guidelines advise against these newer small-molecule therapies during pregnancy due to insufficient safety data.
Male Fertility: A Frequently Overlooked Factor
Conversations about Crohn's and pregnancy tend to focus on the person carrying the pregnancy. But male fertility deserves equal attention.
Sulfasalazine, sometimes used for mild Crohn's, is well-documented to cause reversible male infertility. It reduces sperm count, motility, and morphology through direct toxicity to developing sperm. The effects typically reverse within two to three months of stopping the medication, and switching to mesalamine eliminates the issue while maintaining disease control.
Methotrexate also affects male fertility and, as noted above, should be stopped three to six months before conception attempts. Men on methotrexate should coordinate with their gastroenterologist to transition to a pregnancy-compatible treatment well in advance.
Active Crohn's disease itself can also impair male fertility through inflammation, nutritional deficiencies, and the systemic stress of uncontrolled disease. Achieving remission benefits both partners' reproductive health.
During Pregnancy: Monitoring, Flares, and Staying the Course
Once pregnant, the priority is maintaining the remission you worked to achieve. Most women who enter pregnancy in remission stay in remission. But pregnancy is not a guaranteed grace period, and flares can and do happen.
If a flare occurs during pregnancy, treatment should be prompt. Delaying treatment out of fear of medication exposure typically leads to worse outcomes than the medications themselves would cause. Your gastroenterologist and obstetrician should be communicating directly, and many IBD centers now have dedicated pregnancy pathways for exactly this reason. The American Gastroenterological Association's IBD Parenthood Project outlines a clinical care pathway designed for this coordination.
Monitoring during pregnancy may include more frequent lab work and, when needed, non-radiation imaging like ultrasound or MRI. Endoscopy is generally avoided unless truly necessary, but can be performed safely in the second trimester if the clinical situation demands it.
Nutritional monitoring also matters more during a Crohn's pregnancy. Iron, folate, vitamin B12, and vitamin D levels should be checked regularly, as deficiencies are common in Crohn's patients and can compound the nutritional demands of pregnancy.
Delivery Decisions: Vaginal Birth, C-Section, and Perianal Disease
For most women with Crohn's disease, vaginal delivery is safe and appropriate. The decision about delivery method should be guided by obstetric factors, not by a Crohn's diagnosis alone.
The major exception is active perianal disease. Current guidelines recommend cesarean delivery for women with active perianal fistulas or abscesses, because healing of perineal tissue is unreliable in the presence of active perianal inflammation, and third- or fourth-degree tears could create serious complications. However, women with a history of perianal disease that is currently inactive do not automatically need a C-section. Recent research has found no significant difference in fecal continence or perianal disease progression between vaginal and cesarean delivery in women with inactive perianal Crohn's.
Women who have had previous bowel resections or carry an ileostomy should discuss delivery planning with both their gastroenterologist and obstetrician, as surgical history can affect abdominal anatomy in ways that influence delivery decisions.
The key takeaway: delivery mode should be an individualized conversation, not a blanket policy. Active perianal disease warrants a C-section. Inactive disease or no perianal involvement leaves vaginal delivery as a reasonable and well-supported option.
The Postpartum Period: Higher Flare Risk Than Many Expect
The months after delivery represent an underrecognized risk window. Research shows that roughly one-third of women with Crohn's disease experience a postpartum flare, typically within the first nine weeks after delivery. Most of these flares can be managed on an outpatient basis with medication adjustments, but they require attention.
The biggest modifiable risk factor is medication continuity. Women who discontinued, delayed restarting, or de-escalated their biologic therapy after delivery were 7.4 times more likely to flare compared to those who maintained their treatment. Postpartum is not the time to experiment with reducing therapy. The combination of sleep deprivation, hormonal shifts, and the physical demands of newborn care already strains the body, and removing pharmaceutical support compounds that stress.
Smoking during pregnancy also dramatically increased postpartum flare risk in one study, with an odds ratio of 16.2. If you smoke, this is another reason to quit before or during pregnancy.
Breastfeeding and Medications
Breastfeeding is both safe and encouraged for most women with Crohn's disease. The 2025 global guidelines recommend continuing all monoclonal antibody biologics during lactation. While small amounts of these drugs may be present in breast milk, they are large protein molecules that are broken down in the infant's digestive tract and are not absorbed in clinically meaningful amounts.
One common concern is whether infants exposed to biologics in utero or through breast milk can receive routine vaccinations. The answer for most vaccines is yes. The 2025 guidelines specifically note that the rotavirus vaccine, a live vaccine, can be given on schedule to infants exposed to monoclonal antibody biologics. This represents a shift from earlier, more cautious recommendations.
Methotrexate remains contraindicated during breastfeeding, as do JAK inhibitors. If your disease requires one of these medications postpartum, you'll need to discuss the tradeoffs between breastfeeding and disease control with your care team.
Will Your Child Develop Crohn's Disease?
This question weighs on every prospective parent with Crohn's. The honest answer: the risk is elevated but far from certain. If one parent has Crohn's disease, their child has roughly a 7 to 9 percent lifetime risk of developing the condition. When both parents have IBD, that risk rises to about 35 percent.
Genetics account for approximately 50 percent of Crohn's disease risk, with the remainder driven by environmental factors, gut microbiome composition, and triggers that researchers are still working to understand. Having a parent with Crohn's disease is a risk factor, but it is not a diagnosis. The vast majority of children born to a parent with Crohn's will not develop the disease.
Planning Makes the Difference
Pregnancy with Crohn's disease is manageable, and the outcomes for both parent and child are overwhelmingly positive when the groundwork is laid early. The core principles are straightforward: achieve remission before conceiving, continue your medications unless specifically advised otherwise, coordinate between your gastroenterologist and obstetrician, and maintain treatment continuity through delivery and the postpartum months.
The 2025 global consensus guidelines represent the clearest, most evidence-based roadmap available. If your current provider isn't familiar with these recommendations, consider seeking out a gastroenterologist with IBD pregnancy experience. The questions are too important to leave to guesswork.