The impact of rheumatic disease on fertility and reproduction can be remarkable. Many disease-related factors can influence patients’ sexual functioning, perturb fertility and limit family planning.
Irregular ovulation, decreased libido, or infrequent sex due to pain and fatigue are possible explanations of reduced fertility in women with rheumatoid arthritis. Women with rheumatic diseases have a lower number of births, a reduced period of reproduction and a longer inter-pregnancy interval with difficulties in achieving subsequent pregnancy, in comparison with healthy controls. Delivery by cesarean section has been demonstrated to be more common among women with RA across multiple cohorts with wide-ranging geographic locations.
In men, acute flares of rheumatoid arthritis can temporally reduce sperm count and function thus causing erection problems and decreased libido. The reproduction potential of male patients is impaired by the disease directly in the testicular tissue or by immunosuppressive therapy. The evaluation of male subjects should rely on careful medical history, complete physical examination, semen analysis and sexual hormone profile.
In optimally treated patients, fertility is probably normal. For both genders, treatment improves symptoms affecting sexual function symptoms, but also may have side effects.
Drug treatment is probably the main factor for gonadal dysfunction. Some drugs can cause reversible infertility, such as nonsteroidal anti-inflammatory drugs in women and sulfasalazine/methotrexate in men whereas irreversible (permanent) infertility is occasionally observed after treatment with alkylating agents (cyclophosphamide-CYC and chlorambucil) in both genders. When fertility is an issue, alkylating agents should be used at lowest possible dose and alternative therapies (such as azathioprine or mycophenolate mofetil) must be considered.
Anti-rheumatic pharmacological treatment can also have a crucial role in this field. Proper counseling, preferably provided by a multidisciplinary team of rheumatologists, obstetricians, gynecologists and neonatologists, is recommended for patients taking anti-rheumatic drugs, not only at the beginning, but also during the course of treatment.