Did you know that rheumatoid arthritis (RA) has been associated with a higher rate of infertility? Over the past 10 years, many of my RA patients have struggled with infertility, but I have attributed it to age, stress and societal trends. After listening to Megan Clowse present this afternoon, I may have to re-evaluate.
Researchers in the 1960s observed higher rates of infertility in patients with RA compared to age-matched controls. This was blamed, in part, on high NSAID use and sore joints, leading to less intercourse and fewer children. Interestingly, in 1965, researchers observed that women who were diagnosed with rheumatoid after menopause also had fewer children than their age-matched counterparts. Does this mean that multiple pregnancies are protective against the development of RA? Or, is there some biological reason why those with RA or who are susceptible to RA have fertility issues? This is yet another area that we need to better understand.
Clowse recently surveyed patients in her RA Cohort at Duke University and found that 56% of women had fewer children than they wanted and 42% reported infertility (taking more than 1 year to conceive). Similarly, in the PARA study from Norway, 42% of 231 women with RA were reported to be subfertile and 15% were unable to conceive at all. Older age, increased RA disease activity, NSAID use and prednisone were associated with subfertility, whereas prior MTX, smoking, disease duration and serology were not associated with subfertility.
These data suggest that stopping MTX altogether and using prednisone and NSAIDs to control disease in those planning pregnancy may not be the optimal strategy. We know that NSAIDs can inhibit ovulation by preventing rupture of the dominant follicle. A better strategy to facilitate pregnancy in our RA patients might be to switch to DMARDs that are safe in pregnancy, including sulfasalazine, hydroxychloroquine and TNFi to control RA disease activity.
Dr. Jamal is a Clinical Associate Professor at the University of British Columbia and an active staff physician at Vancouver Coastal Health. Her interests include diagnosis and prognosis of early inflammatory arthritis, and timely assessment and access to care for patients with rheumatoid arthritis.View Full Bio