Which epilepsy medicines are safe in pregnancy?

Question

Hello doctor,

My epilepsy management has become very complicated since trying to conceive, and I need urgent guidance. I am 26 years old and have had seizures since my teenage years. They were well controlled on Lamotrigine 200 mg twice daily. However, my neurologist switched me to Levetiracetam because it is considered safer in pregnancy, and since then, I have started having breakthrough seizures again. I have had three tonic–clonic seizures in the past month.

We have been trying to get pregnant for 18 months, and my reproductive endocrinologist mentioned that seizure medications might be affecting ovulation. My periods became irregular after switching medications, and my LH surge is now harder to detect. I am taking folic acid 5 mg daily as recommended, but I am worried about possible drug interactions.

I had a seizure during my last fertility appointment, which was terrifying and embarrassing. My EEG now shows more epileptiform activity than before the medication change. My partner is worried about pregnancy risks and the possibility of seizure inheritance, but we strongly want to have children.

I would like to know:

Which epilepsy medications are safest during pregnancy and breastfeeding?
Should we consider IVF to reduce the time to conception?

The stress from fertility struggles seems to be triggering more seizures, creating a vicious cycle. Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com

Thank you for sharing this. You are navigating an incredibly difficult intersection of epilepsy management and fertility, and your concern is completely valid. What you are experiencing is challenging, but there is reassurance in knowing that many women with epilepsy go on to have safe, healthy pregnancies with the right planning and support. Let us walk through this together, step by step.

1. Why do the seizures return?

Your seizures were well controlled on Lamotrigine. When the medication was changed to Levetiracetam, even though it is generally considered safer in pregnancy, it likely did not provide the same level of seizure control for you. Not all anti-seizure medications work equally well for every individual.

In addition, Levetiracetam can sometimes contribute to menstrual cycle irregularities, mood changes, and increased epileptiform activity, which aligns with the changes seen on your EEG (electroencephalogram).

The fact that you have had three tonic-clonic seizures within a single month is concerning. At this level of seizure activity, it is important to pause attempts at conception until your seizures are better controlled, as uncontrolled seizures pose risks both before and during pregnancy.

2. Reconsidering your medication

When it comes to pregnancy, the two most preferred and relatively safer anti-seizure medications are:

Lamotrigine: This medication is well studied in pregnancy and is associated with a low risk of major congenital malformations. For many women, especially those who were previously well controlled on it, Lamotrigine is often the best option when trying to conceive.
Levetiracetam: This is also considered low risk during pregnancy. However, it may be less effective for certain seizure types and does not work optimally for everyone.

Given your history of excellent seizure control on Lamotrigine, it would be reasonable to have a detailed discussion with your neurologist about returning to Lamotrigine or considering a carefully monitored treatment plan that prioritizes seizure control while maintaining pregnancy safety.

Kindly revert if there are any queries.

Thank you.