Family planning in multiple sclerosis: An Australian perspective

To develop evidence-based, Australia-specific recommendations for managing multiple sclerosis (MS) before conception, during pregnancy and after birth, balancing maternal health, disease control, and fetal safety.

A panel of seven Australian MS specialists, from academic and clinical backgrounds, convened (April-October 2025) via virtual meetings and email correspondence. A targeted literature review covered MS, pregnancy, postpartum relapse, breastfeeding, vaccination and disease-modifying therapy safety. Guidance from the Therapeutic Goods Administration, international clinical guidelines, and safety data were examined to inform interpretation.

Evidence indicates that MS does not increase adverse pregnancy outcomes, although a higher risk of small-for-gestational-age birth may occur. Treatment selection should account for teratogenicity and rebound risk. Teriflunomide, fingolimod, siponimod and cladribine require cessation well before conception and are contraindicated during breastfeeding. Natalizumab can be continued until conception and through the first and second trimesters using extended-interval dosing; postpartum resumption is advised to minimise rebound relapses. Ofatumumab and ocrelizumab should be stopped if pregnancy is confirmed. Treatment decisions should be individualised through shared decision-making. European Union guidance supports use of ocrelizumab during breastfeeding, consistent with evidence of minimal monoclonal antibody transfer into breastmilk. As breastfeeding does not prevent relapse, early postpartum DMT resumption is recommended to reduce relapse risk. Contraceptive use remains low despite requirements for many therapies.

With proactive planning, women with MS can achieve optimal pregnancy outcomes. This consensus integrates evidence, regulatory considerations and Australian guidance to support a practical framework for family planning in MS.