Page 123 - Fertility in Women with Rheumatoid Arthritis Vruchtbaarheid van vrouwen met reumatoïde artritis

This thesis illustrates the need for individualized decision making and a multidisciplinary approach in fertility care for patients with rheumatoid arthritis. Moreover, it provides some useful new insights into fertility, having distinct implications for both rheumatologists as well as for gynaecologists.
Implications for rheumatologists
In young women with rheumatoid arthritis who desire to build a family, for years the policy among rheumatologists has been to limit the prescription of antirheumatic drugs. Fear of possible teratogenic effects withheld intensive treatment in women during the preconception period.
Nowadays, attention for preconception care in patients with RA is gradually increasing among rheumatologists. In 2016, a EULAR task force has reported considerations on antirheumatic treatment in women before, during and after pregnancy.1 However, concerns on preconception treatment are mainly limited to drug safety for the foetus during pregnancy and breastfeeding, whereas the effects on fertility are only briefly addressed.
This thesis has shown, that during the preconception period, antirheumatic treatment should be maintained, or adjusted in case teratogenic drugs are part of a patient’s current treatment. Active disease should be treated intensively during the preconception period, both to reduce the negative effect of disease activity on the time to pregnancy, as well as to avoid the use of NSAIDs and high dosages of prednisone and their negative effect on fertility.
Developing adjusted treat-to-target guidelines for the preconception period can
guide rheumatologists in effectively treating patients and minimalizing risks for
pregnancy and offspring. Regarding fertility, treatment targets should preferably
aim for disease remission to reduce time to pregnancy, with avoidance of the use 8 of NSAIDs and high dosages of prednisone. The largest bene cial effect on time to
pregnancy is to be expected in women with high disease activity, but patients with intermediate and low disease activity will also bene t. Previous studies on pregnancy and offspring in women with RA have already shown the importance of treating patients with active disease when they are planning a family. An increased maternal disease activity during pregnancy has been associated with lower birth weight2 and rapid postnatal catch-up growth in the offspring, which in turn is associated with a higher risk for cardiovascular and metabolic disease in later life.3 Furthermore, high and intermediate disease activity have both been associated with a higher occurrence of caesarian sections.2 This thesis emphasizes the need for treatment adjustment early in the process of family planning.
General discussion
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