How does NMOSD impact fertility and pregnancy in women?

Question

Hi doctor,

I am a 28-year-old woman diagnosed with NMOSD last year after severe optic neuritis and spinal cord inflammation. I am currently on Rituximab, and while my condition has stabilized, I am facing several reproductive health challenges.

My periods have become very irregular, sometimes skipping for two to three months, which is causing anxiety about my fertility. I am engaged and planning to marry next year, but I am worried about how pregnancy could affect NMOSD and whether my medications could harm a baby.

I am also dealing with significant fatigue and mood swings that worsen around my menstrual cycle. Additionally, I have neurogenic bladder issues that affect my sexual confidence, along with recurring UTIs. I have noticed breast tenderness and small lumps, which concerns me, given my treatment.

Could NMOSD or Rituximab affect my menstrual cycle and fertility?
Is it safe to become pregnant with NMOSD, and how should I plan conception while on immunosuppressive therapy?
Are my mood changes around my period related to NMOSD or hormonal imbalance?
How can I manage neurogenic bladder symptoms to reduce UTI risk and improve sexual health?
Should I be concerned about breast changes while on Rituximab, and what monitoring is needed?
What contraceptive methods are safest for women with NMOSD on immunosuppressants?

Please guide.

Answer 1

Hi,

Welcome to icliniq.com.

I read your query and understand your concerns.

Neuromyelitis optica spectrum disorder (NMOSD) itself, as well as its treatment, can indirectly impact menstrual regularity and fertility. Although Rituximab is not directly gonadotoxic (toxic to the ovaries), immune-mediated diseases and chronic illness can disrupt the hypothalamic-pituitary-ovarian (HPO) axis, leading to irregular menstrual cycles.

Hormonal fluctuations and the neuroinflammatory nature of NMOSD may amplify fatigue and mood swings around your periods. However, these symptoms could also indicate underlying hormonal imbalances that warrant evaluation, such as testing prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroid function.

Pregnancy in women with NMOSD is possible and can be successful, but it requires careful planning in collaboration with both your neurologist and an obstetrician experienced in high-risk pregnancies.

While Rituximab is typically avoided during pregnancy, some women continue it prior to conception to help maintain disease stability. The timing and risks of treatment should be discussed in advance, as NMOSD can flare in the postpartum period.

Neurogenic bladder and recurrent urinary tract infections (UTIs) are common in NMOSD and can significantly affect quality of life and sexual health. Management strategies may include scheduled voiding, pelvic floor physical therapy, and, in some cases, prophylactic antibiotics or bladder-specific medications to reduce infections and improve confidence.

Regarding breast tenderness and palpable lumps, Rituximab is not commonly associated with the development of breast masses. However, any new breast changes should be evaluated promptly with appropriate imaging, such as ultrasound or mammography, to rule out benign or rare complications.

In terms of contraception, barrier methods (e.g., condoms) are safe, but for more reliable options, non-estrogenic methods are generally preferred due to the potential vascular risks and immune system activation associated with estrogen. These include the copper intrauterine device (IUD) and progestin-only contraceptives such as the progestin IUD, injection, or implant.

I hope this answers your query. Feel free to reach out anytime.

Thank you.