Improving fertility in women with RA Save

For many women, the journey to motherhood brings a sense of anticipation and joy. However, for those with rheumatoid arthritis (RA), this journey presents unique challenges. Women with RA often face longer times to conception, known as time to pregnancy (TTP), and have infertility rates twice as high as those without RA. Various factors, including high disease activity, the regular use of nonsteroidal anti-inflammatory drugs (NSAIDs), and more than moderate doses of steroids (prednisone >7.5mg), negatively influence fertility.

At ACR Convergence 2024, Dr. Radbound Dolhain discussed how advancements in reproductive medicine and RA management are paving the way for improved outcomes (abstract 1647). Utilizing data from the Dutch Pregnancy-induced Amelioration of RA (PARA) cohort and the Preconception Counseling in Active RA (PreCARA) study, Dr. Dolhain demonstrated the feasibility of a treat-to-target (T2T) approach during pregnancy.

Both cohorts studied women with RA who either wished to conceive or were in their first trimester. While women in the PARA cohort received treatment from their rheumatologists, the PreCARA cohort followed a clinical pathway including preconception counseling and a T2T strategy aimed at achieving remission. This approach prioritized minimizing the use of NSAIDs and high-dose prednisone, utilizing treatments like sulfasalazine and hydroxychloroquine, with TNF inhibitors (TNFi) or low-dose prednisone added as needed.

A key question was whether a dedicated T2T healthcare pathway could improve fertility, specifically by shortening the time to conception. Updated results from Dr. Dolhain's studies are promising: the PreCARA study revealed a significantly shorter median TTP for women who became pregnant (84 days) compared to the historical PARA cohort (196 days). Additionally, fewer women in the PreCARA study experienced TTP exceeding 12 months (23%) compared to the PARA study (42%).

Fertility challenges can be a significant concern for women with RA. However, a holistic approach focusing on achieving remission through T2T and optimizing medication use enhances overall disease management and improves reproductive health outcomes. The 2020 ACR guidelines for managing reproductive health in rheumatic and musculoskeletal diseases provide recommendations for treatment choices before and during pregnancy and even for men planning to father children, which can help tailor T2T approaches. 

As research progresses, the path to motherhood for women with RA will hopefully become less complex and filled with more moments of joy.