Family Planning With Epilepsy

Epilepsy impacts 1.3 million women of childbearing age across the United States. Couples with epilepsy often have concerns about passing the condition to their children, fertility, and pregnancy safety. 

Though epilepsy can present challenges, positive pregnancy outcomes are possible. This is especially true with planning and guidance from your healthcare team. 

This article reviews how antiepileptic drugs (AEDs) may affect fertility, risk factors affecting a couple’s ability to get pregnant, pregnancy safety, and family planning with your healthcare provider.

Medication for Epilepsy and Fertility

When it comes to family planning, managing epilepsy and keeping seizures under control is key. But antiepileptic drugs (AEDs) can have unwelcome side effects regarding fertility (the ability to get pregnant) for both sexes. 

Not all antiepileptic drugs carry the same potential side effects. Some AEDs affect sex hormones, while others affect the areas of the brain responsible for sexual desire and function.

AED fertility effects are often dose-dependent. For example, gabapentin-induced sexual dysfunction occurs more often with daily doses larger than 900 milligrams (mg). 

Women

Seizures can harm female fertility. For example, hormone fluctuations trigger certain seizures, especially for those with catamenial epilepsy. This often occurs during ovulation (egg production), when a woman is most likely to conceive. 

Some hormonal medications that treat catamenial epilepsy will alter or stop a woman’s menstrual cycle. Antiepileptic drugs (AEDs) can make it more challenging for women to become pregnant by causing:

• Disruption of hormone levels
• Menstrual cycle irregularities 
• Decreased libido (sex drive) 
• Weight gain (which can lead to metabolic problems) 

In addition, higher AED doses tend to increase the risk of ovulation problems.

Men

For some, epilepsy may cause male infertility related to sperm quality, count, and mobility. Certain AEDs can also contribute by causing:

• Decreased sex hormones (especially enzyme-inducing AEDS)
• Decreased libido
• Problems with sperm count and quality
• Sexual or erectile dysfunction

Not all AEDs cause the same types and levels of male fertility problems. For example:

• Trileptal (oxcarbazepine), Keppra (levetiracetam), and Lamictal (lamotrigine) don’t significantly affect sexual function or hormones.
• Trileptal (oxcarbazepine) may improve sperm quality but occasionally causes orgasm and ejaculation problems. 
• Lamictal (lamotrigine) is less likely to cause erectile dysfunction than Depakote (valproic acid) and Tegretol (carbamazepine).

Other Factors Affecting the Ability to Get Pregnant

Those with epilepsy have lower pregnancy rates than those without it. However, fertility rates (ability to get pregnant) are similar. Experts agree that multiple factors contribute to these statistics, not just the disease alone.

Hormones

The endocrine system is a web of organs and glands working with hormones to assist the body in many functions, including reproduction. 

Epilepsy and AEDs can interfere with this balancing act by disrupting the hypothalamic-pituitary axis and gonadotropin-releasing hormones (GnRH). This causes problems with reproductive hormone development and regulation. 

Disruptions in female hormones such as estrogen and progesterone can lead to menstrual cycle disruption and a decrease in sexual interest or enjoyment.

An imbalance of male sex hormones, such as testosterone, can cause decreased sex drive and sexual dysfunction (problems with erection, orgasm, or ejaculation).

Menstrual Cycles

Epilepsy and AEDs can cause an imbalance of the following hormones:

• Estrogen
• Progesterone
• Luteinizing hormone (LH)
• Follicle-stimulating hormone (FSH)
• Gonadotropin-releasing hormone (GnRH)  

These imbalances can cause fertility problems by slowing or stopping ovulation and menstrual cycles (periods).

Catamenial epilepsy affects about 40% of women with epilepsy. Their seizures frequently worsen with hormone fluctuations. Treatment often involves hormones that stop menstrual cycles, impacting fertility.

Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is a condition that affects many women with epilepsy, especially those who take valproic acid. Symptoms include excessive hair growth, weight gain, and difficulty sleeping.

PCOS stems from an imbalance of hormones and can impact fertility by causing irregular periods and stopping ovulation. It also increases the risk of miscarriage. 

Mental Health

Various mental health disorders, including depression, anxiety, and obsessive-compulsive disorder (OCD), are more common in individuals with epilepsy.

Mental health disorders and treatment can cause fertility issues or sexual problems due to the following:

• Decreased self-esteem
• Social isolation
• Sexual dysfunction 
• Decreased sexual desire
• Inadequate vaginal lubrication
• Problems with interpersonal interactions

For some, a fear that sexual activity can induce seizures can negatively impact fertility. 

Risks During Pregnancy Related to Epilepsy

Over 90% of pregnancies involving women with epilepsy proceed without any significant issues. However, seizure control and epilepsy care can change during pregnancy, making it high-risk. 

Medication

The body's physiological and hormonal changes during pregnancy can affect how AEDs work. Your healthcare provider might adjust your dosage or monitor AED blood levels throughout pregnancy. They may also change your AED to minimize the risk to your unborn baby.

Seizures

Tight seizure control is essential during pregnancy because prolonged seizure activity can decrease the oxygen supply to your unborn infant. It’s important to avoid triggers, get plenty of rest, and take AEDs as prescribed.  

If your seizure activity changes with pregnancy, notify your healthcare provider immediately. They can monitor you and your medication to help minimize seizure risk. 

Miscarriage

Miscarriage rates for women with epilepsy double when the pregnancy is unplanned. This is compared to those with epilepsy who plan their pregnancy and the general population.

When planning a family, it’s important to note that some AEDs reduce how well hormonal birth control works. This is especially true with enzyme-inducing AEDs. 

Birth Defects

In the general population, the rate of birth defects is 2.3%. This increases to 7% for mothers with epilepsy. Though the exact cause of this is unknown, it’s most likely due to poor seizure control (depriving the baby of oxygen) and taking certain AEDs during pregnancy.

AEDs can increase the risks of congenital (present at birth) disabilities such as:

• Cleft lip and palate
• Spina bifida (cleft spine)
• Developmental problems
• Cognitive impairment (lower IQ)

The risk appears greater with older-generation AEDs, higher doses, and polypharmacy (taking multiple AEDs together). Healthcare providers typically avoid Depakote (valproic acid) during pregnancy. They may also avoid Topamax (topiramate), especially during the first trimester and in higher doses.

Though newer-generation medications carry a lower risk of birth defects, they are not risk-free, especially in higher doses.

Preparing for Pregnancy

You can begin pregnancy planning by making healthy lifestyle choices. This includes:

• Getting enough sleep
• Maintaining a healthy weight
• Eating a healthy diet
• Avoiding cigarettes, alcohol, caffeine, and illegal drugs

Though it’s not always possible, discussing your pregnancy plans with your healthcare provider before getting pregnant is important. It’s safer for you and your unborn baby. It is also essential to:

• Notify your healthcare provider(s) if you have changes in seizure activity
• Go to all prenatal appointments (when pregnant)
• Take prenatal vitamins and folic acid (if prescribed)

Talk to Your Healthcare Provider About Family Planning

If you're considering starting a family, have an open conversation with your healthcare team. It's best to reach out sooner rather than later. You can discuss the best way to prevent breakthrough seizures, possible congenital disabilities, and potential fertility problems.

Your team may suggest expert consultations, changes in medication or lifestyle, frequent monitoring, and genetic testing (to evaluate the risk of your baby having epilepsy).

Summary

Prospective parents with epilepsy often have concerns about fertility and safety during pregnancy. Positive pregnancy outcomes are possible with proper planning and guidance from your healthcare team.

When it comes to family planning, managing epilepsy and keeping seizures under control is critical. Ask your healthcare provider if your antiepileptic drugs (AEDs) can cause issues with your hormones, fertility, menstruation (period), and sexual function and cause potential birth defects.