Fertility, Family Planning, Pregnancy & Autoimmune Disease

Women's Health

I see many females of childbearing age with autoimmune diseases like Lupus, Sjorgren’s Syndrome, Scleroderma, MS, Autoimmune Thyroid Disease (Hashimoto Thyroiditis) and RA that express worry and fear that their disease will prohibit them from having a family.  They worry about infertility like so many women in this world.

 I empathize.  

Becoming a mother is the gift that many women want to have in their lives.  It does not come easily for so many of us and we may experience extreme heartache from the miscarriages and obstacles that are encountered during this journey.

CONCERNS WITH FERTILITY

  • There is evidence that suggests that several factors associated with autoimmune disease may influence the fertility of women AND men. Infertility or pregnancy loss may be a consequence.  
  • Chronic inflammation may affect ovarian function and fertility.
  • The processes that are involved in the immune response of females with Lupus may affect the fertility stages including ovarian failure, implantation failure, and pregnancy loss.
  • Women who are diagnosed with antiphospholipid syndrome (APS) have antibodies or proteins that may directly cause early pregnancy loss and blood clots. 
  • Many of my female patients also simultaneously have premature ovarian failure, endometriosis, and polycystic ovarian syndrome which can also contribute to decreased fertility.
  • Lupus patients may have infertility from amenorrhea (absence of periods) from the disease itself or from chemotherapy (Cytoxan) which causes ovarian failure.
  • Sulfasalazine or steroids used for rheumatoid arthritis can also cause MALE fertility problems such as reduced sperm count.

WHAT ABOUT WOMEN WITH LUPUS?

Pregnancy complications are more common in women with Lupus. They are more at risk for:

  • Stillbirths
  • Preeclampsia
  • Preterm births
  • C sections

Women with Lupus have higher risk of pregnancy complications, pre-term birth/delivery/loss  if they have:

  • Highly active lupus disease activity especially with kidney disease
  • High Blood pressure
  • Hematologic abnormalities like low platelets
  • Untreated Antiphospholipid syndrome/APS (can cause pregnancy complications like high blood pressure as well as stillbirths, recurrent miscarriages and thrombosis in the mother)

With other disease like MS and RA, there may be an improvement in symptoms and disease activity during the pregnancy possibly due to hormonal factors and then a relapse of disease or worsening of symptoms after the delivery of the baby.

AVAILABLE RESOURCES

1) The American College of Rheumatology (ACR) offers Reproductive Health guidelines

2) There is also now the HOP-STEP website/program for Lupus patients (founded at Duke University Medical Center) which assists patients with family planning and provides an option for individuals to share their feelings openly and allows the physician to offer guidance based on the provided information.

 The patient’s medication list, risk factors and details about disease activity are reviewed as well as other medications that may place a pregnancy at risk.  Birth control options are also discussed.

PREGNANCY COMPATIBLE MEDICATIONS

  • Hydroxychloroquine  (Plaquenil)
  • Azathioprine (Imuran)
  • Cyclosporine
  • Colchicine (for Bechet’s, Erythema nodosum or other other diseases)
  • Prednisone (but not used chronically)
  • Steroids, especially at miderate to high doses may lead to high blood pressure, bone loss or osteoporosis, Gestational Diabetes, Decreased intrauterine growth, premature rupture of membranes, and premature labor.
  • Blood thinner medications like low molecular weight Heparin or low dose aspirin may be necessary for Antiphospholipid Syndrome.

MEDICATIONS NOT COMPATIBLE WITH PREGNANCY (cause birth defects)

  • Methotrexate
  • Mycophenolate Mofetil (Cellcept)
  • Leflunomide (Arava)- used mostly in RA
  • Mycophenolic acid (Myfortic)
  • Cyclophosphamide (Cytoxan), Rituximab, and Belimumab (Benlysta) must be used with caution because more information is needed to determine the category these medications will belong to.

KEY POINTS

  • It is important for women to know that maintaining good disease activity before pregnancy (6 months or more) is needed to having a safe pregnancy and delivery.  Women with a controlled disease or who are in remission have fewer pregnancy complications.
  • Having a discussion with your rheumatologist about how to successfully control disease activity, review, and adjust medications is the first step in family planning. 
  • It is IMPERATIVE TO STOP SMOKING, ELIMINATE ALCOHOL, LIMIT CAFFEINE.
  • KEEP MOVING AND STAY ACTIVE
  • TAKE FOLIC ACID
  • Keeping the mother healthy will also keep the baby healthy!!

Please know that there is your rheumatologist as well as fertility specialists /maternal-fetal medicine physicians that are in your corner and will do everything possible to discuss your options, make adjustments to your medication and hold your hand along the way.  Depending on the severity of the disease other specialists like a cardiologist, pulmonologist, hematologist, a nephrologist may also be required for follow up care during the pre and post-pregnancy period. 

References:

HOP-STEP           lupuspregnancy.org, American College of Rheumatology Reproductive Health Guidelines, Current Diagnosis and Treatment in Rheumatology