Fertility and Birth Outcomes in Rheumatoid Arthritis: A Narrative Review.

Women and men with RA experience higher rates of subfertility compared to the general population.

• Multiple factors contribute to subfertility in RA, including disease activity, treatment effects, psychosocial concerns, and sexual dysfunction.
• Subfertility contributes to delayed childbearing and reduced family size in the RA population.
• Both sexes are affected, indicating RA-related subfertility is not limited to women.

Disease activity is a contributing factor to subfertility and adverse reproductive outcomes in RA.

• Active disease is identified as one of several mechanisms contributing to subfertility in RA patients.
• Achieving well-controlled disease prior to conception is recommended to optimize maternal and neonatal outcomes.
• Disease activity is also associated with delayed childbearing and reduced family size.

Assisted reproductive technology (ART) procedures are safe and effective options for RA patients experiencing subfertility or seeking fertility preservation.

• ART is described as safe and effective for patients who experience subfertility.
• ART is also an option for patients interested in preserving future fertility while continuing pregnancy-incompatible medications.
• The review identifies ART as a viable reproductive strategy within the RA population.

Women with RA have an increased risk of adverse pregnancy outcomes compared to the general population.

• Specific adverse outcomes identified include preterm delivery and having small-for-gestational-age (SGA) infants.
• These risks are elevated relative to women without RA.
• Pregnancy-compatible, well-controlled disease management is emphasized as key to reducing these risks.

There are no RA-specific contraindications to the use of hormonal birth control.

• Contraception is identified as important for patients with childbearing potential who are taking teratogenic medications.
• Hormonal contraception is considered safe in the RA population without disease-specific restrictions.
• This finding supports the use of standard contraceptive options in RA care.

Sexual dysfunction contributes to subfertility and reproductive challenges in the RA population.

• Sexual dysfunction is listed alongside disease activity, treatment, and psychosocial concerns as a contributing factor to subfertility.
• Sexual dysfunction affects both women and men with RA.
• The review calls for a multidisciplinary, patient-centered approach to address sexual and reproductive health in RA.

Significant gaps in evidence remain regarding the safety of non-TNFi biologic DMARDs during pregnancy and lactation.

• Non-tumor necrosis factor inhibitor biologic disease-modifying antirheumatic drugs (non-TNFi bDMARDs) have insufficient safety data for use during pregnancy and lactation.
• Future studies are specifically called for to investigate this area.
• This represents a gap compared to the existing evidence base for TNF inhibitors in pregnancy.

The mechanisms underlying impaired fertility and adverse pregnancy outcomes in RA are not yet fully understood.

• The review identifies elucidating these mechanisms as a priority for future research.
• Contributing factors discussed include disease activity, medication effects, psychosocial factors, and sexual dysfunction, but mechanistic pathways remain incompletely characterized.
• Patient perspectives and priorities regarding reproductive health across the lifespan are also highlighted as an understudied area.