“Fertility and Rheumatic Disease” at the American College of Rheumatology Annual Meeting

When I was diagnosed with rheumatoid arthritis at the age of 25, I must admit that one of my first fears was how the disease might limit me from one of my major life goals – starting a family. Although I have since had two babies, RA certainly made my path to motherhood significantly more complicated. So when I recently attended the American College of Rheumatology’s Annual Meeting, I was excited to hear what was being presented on the topic of motherhood with chronic illness.

The session entitled Pregnancy in Rheumatic Diseaseswent over the various considerations patients ought to take into account before deciding to start a family. It also covered potential pregnancy risks and treatments for symptoms during pregnancy. Unfortunately, for many women, health concerns relating to starting a family may occur well before they are ever able to become pregnant in the first place. For that reason I was very happy that there was also a session on Fertility and Rheumatic Diseases. This session was presented by Dr. Megan E. B. Clowse, Director of the Duke Autoimmunity in Pregnancy Clinic & Registry and Associate Professor of Medicine at Duke University Medical Center. Dr. Clowse started her presentation by explaining to the health care professionals in the audience that the issue of fertility is an important and complicated topic, especially for younger patients.

In general, there are many factors that can impact family size, including cultural issues, personal choice, education, financial security, job security, strength of marriage/relationship, and more. Living with a chronic illness like RA can, in turn, impact many of these factors. Perhaps for this reason, women with RA generally tend to have fewer children than other women. For example, a 2012 study found that 56% of women who had been diagnosed with RA prior to completing their families had fewer children than they originally wanted to have.

A 2012 study of women with RA found that 53% of respondents were worried that they wouldn’t be able to care for a child due to pain and fatigue and 37% were concerned that medications would harm the baby. Dr. Clowse emphasized the importance of doctors discussing options for medication to control the disease that would be effective and also safe for the baby. The same study also found that 17% of respondents were worried that their baby would develop RA. Dr. Clowse stressed that this particular concern is one that doctors should help dispel, as RA is not hereditary and there are actually many genetic components involved. She said that the estimated risk of the baby developing any autoimmune disease at some point in their lives was only about 10%, which is actually relatively low.

Another study, from 2015, followed 231 women with RA who wanted to become pregnant. The study found that 42% were subfertile, meaning that it took them longer than one year to conceive, and 15% were unable to conceive. Several factors were determined to have no impact on the length of time to conceive, including prior methotrexate use, prior smoking, time since RA diagnosis, RF or CCP positivity, and current use of sulfasalazine. The factors that did influence length of time to conceive included older age, increased RA activity, higher doses of prednisone while trying to conceive (over 7.5mg), and the use of non-steroidal anti-inflammatory medications (NSAIDs).

In particular, Dr. Clowse emphasized the potential negative impact of NSAIDs – even the over-the-counter variety – on a woman’s chances of conception. It turns out that NSAIDs can actually inhibit ovulation, and studies have even been done considering NSAIDs as an emergency form of contraceptive. Dr. Clowse shared an anecdote about pig farmers using NSAIDs to control female pigs ovulation, so that the farmer’s entire stock could be made pregnant at the same time for convenience. The conclusion was that women who are trying to conceive should definitely avoid the use of any kind of NSAIDs.

Dr. Clowse concluded that many women with rheumatic diseases choose to limit the sizes of their families, and she encouraged providers to discuss these reasons to make sure patients have full and accurate knowledge when making this important decision. As for women with RA who would like to become pregnant, she advises them to stop harmful medications, control RA with safe medications, avoid NSAIDs, and try to conceive naturally first. The amount of time each patient should try naturally depends on the patient’s current age and diagnosis. Patients can then be referred to a specialist if they still are having difficulty conceiving.

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