How Rheumatoid Arthritis Impacts a Woman's Fertility

Women who have rheumatoid arthritis (RA) may be wondering how this chronic condition affects their fertility. Maybe you're one of them. Unfortunately, infertility in women with rheumatoid arthritis is common, though researchers are still exploring the underlying causes.

We talked to experts to discover more about fertility and RA and what you need to know in order to proceed with your pregnancy planning.

What should you know about rheumatoid arthritis?

"Rheumatoid arthritis is an autoimmune disorder that can cause joint pain, swelling, stiffness and fatigue," said Himali Maniar, M.B.B.S., an OB-GYN at Nisha Women's Hospital and IVF Centre and associated with ClinicSpots in South Bopal, Ahmedabad, India.

With rheumatoid arthritis, your immune system attacks your healthy cells, which causes inflamed joints, including in your hands, wrists, shoulders and knees. More than joint damage, people with rheumatoid arthritis experience painful joints and a reduced quality of life.

One percent to 2 percent of people worldwide have RA, and women are two to three times more likely to develop the disorder, according to Johns Hopkins Arthritis Center.

How can rheumatoid arthritis affect fertility?

"Infertility in women with RA is an under-recognized but remarkably common phenomenon," the authors of a 2014 review wrote in the medical journal Current Opinion in Rheumatology. Though the underlying causes of infertility in RA patients are still being studied, scientists know fertility is impacted in several ways.

"The disease has been found to be associated with infertility, adverse pregnancy outcomes and complications during labor and delivery," Maniar said.

Some of the potential ways RA can affect women's fertility include delayed conception, pregnancy complications and sexual function.

Delayed conception

"Women with rheumatoid arthritis may take longer to conceive," said Brittany Bettendorf, M.D., a rheumatologist and clinical assistant professor with the University of Iowa Hospitals and Clinics in Iowa City, Iowa.

A 2015 study of 245 women with rheumatoid arthritis published in the Annals of Rheumatic Diseases found that 42 percent of women were subfertile, meaning it took them longer than one year to conceive.

"[That is] compared to the reported rate of subfertility in the general population of 9 percent to 20 percent," Bettendorf said.

This is possibly due to the disease's inflammatory nature, according to Wang Lushun, M.B.B.S., M.Med., a double fellowship-trained orthopedic surgeon and medical director at Arete Orthopaedic Clinic in Singapore.

The 2015 study found that certain risk factors were associated with taking longer to conceive, including:

• Older age
• Not having previous children
• Having more active rheumatoid arthritis
• Preconception use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, and prednisone use of greater than 7.5 milligrams per day

"Thus, it is very important that women with rheumatoid arthritis work with their care team to achieve good control of their arthritis before attempting to conceive," Bettendorf said.

Pregnancy complications

"Rheumatoid arthritis may also increase a woman's risk of pregnancy complications," Bettendorf said.

These complications may include:

• Having a child who is low birth weight or small for gestational age
• Higher risk of preeclampsia
• Increased risk of having a C-section

"It's important to note that well-controlled RA may have a lesser impact on fertility and pregnancy outcomes," Wang said.

In a seeming contradiction, many women with rheumatoid arthritis feel better during pregnancy, Bettendorf said. This may be due to the hormonal changes associated with pregnancy.

Sexual function

The 2014 review mentioned previously also found that the pain and fatigue caused by RA inhibit women's sexual function, which decreases their opportunities to become pregnant.

"Declined fertility rate in RA women seems to stem from modified inflammatory settings, advanced maternal age, limited sexual activity and adverse effects of drugs on ovarian function," the authors of a 2020 review concluded. "A complex interaction between RA disease and fertility-related issues is present."

Because of these factors, more than half of women with RA or systemic lupus erythematosus (SLE) have fewer biological children than desired, a 2012 study stated.

Unfortunately, no known cures for RA exist, Maniar said. Proper treatment, however, can help manage the condition and potentially reduce its effects on fertility.

How RA medication affects fertility

Several medications can be used to treat RA, and fortunately, according to Bettendorf, most rheumatologic medications do not impact fertility.

"In fact, using appropriate medication to achieve disease remission is important since active disease is a risk factor for taking a longer time to conceive," Bettendorf said. "Pregnancy-compatible rheumatologic medication typically poses less risk to the mother and infant than uncontrolled disease."

However, some medications are known to negatively affect fertility or pregnancy. It's important to be aware of these drug interactions.

NSAIDs

"The use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen may interfere with ovulation, which could impact fertility," Bettendorf said.

What does it mean for women who have used NSAIDs in the past?

"This effect is related to current use of NSAIDs while attempting to conceive. Past use of NSAIDs does not have any lasting impact on fertility," Bettendorf said. "If a woman is having difficulty conceiving, she may want to discuss the discontinuation of NSAIDs with her care team."

Methotrexate

"Methotrexate, a medication commonly used to treat rheumatoid arthritis, does not have negative long-term effects on fertility," Bettendorf said, adding a caveat. "Methotrexate is teratogenic and may increase the risk of spontaneous abortion."

But someone wanting to become pregnant should stop taking methotrexate one to three months before trying to conceive, said Bettendorf, per the American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases.

"I recommend reviewing your specific medications with your care team prior to attempting to conceive to make sure your regimen is optimal," Bettendorf said.

Can I continue to take my RA medication while pregnant?

Once you become pregnant, a change in your treatment plan may be necessary, depending on your medication regimen and its side effects.

"Some medications, such as methotrexate, leflunomide and mycophenolate mofetil, should never be used during pregnancy," Bettendorf said. "Many other medications lack safety data to determine their risk for use in pregnancy. Some medications have been well studied in pregnancy and are compatible."

Pregnant women should consult the American College of Rheumatology, which provides reproductive health guidelines that women and their care teams can consult to ensure a safe and effective treatment plan during pregnancy, Bettendorf added.

"The ideal medication plan should balance the mother's disease management with the safety of the developing fetus," Wang said.

The bottom line

Becoming pregnant while dealing with rheumatoid arthritis isn't impossible. Some women who become pregnant experience preterm labor and babies smaller than their gestational age, according to the Arthritis Foundation.

Discuss your plans with your doctor so you can figure out the right path to conception and how to handle your condition.