How do rheumatoid arthritis drugs affect pregnancy at 33?

Question

Hello doctor,

My wife has had rheumatoid arthritis (RA) for about 10 years now. She is 33 years old and currently in remission thanks to Methotrexate (an immunosuppressant) and biologics. We are eager to have a child, but we have read that Methotrexate is not safe in pregnancy. Please tell me;

How long should she be off Methotrexate before trying to conceive?
Are there safer alternatives she can take during pregnancy without risking a flare?
Can IVF (in-vitro fertilization) trigger a flare-up due to hormonal shifts?

What if she has a flare during pregnancy?
Are corticosteroids safe to use then?
Could her medications affect ovulation or egg quality?
What delivery method is safer for RA patients? Does joint involvement make a natural birth risky?
Can biologics like TNF (tumor necrosis factor) inhibitors be continued through pregnancy and breastfeeding?
What is the safest birth control post-pregnancy to avoid unplanned conception while managing disease stability?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I read your query and can understand your concern.

I am glad you are planning for a safe pregnancy. You are right that Methotrexate (an immunosuppressant) must be stopped well before conception. It is recommended to discontinue it at least three months before trying for pregnancy due to its teratogenic effects. During that washout period and beyond, her rheumatologist can consider switching her to pregnancy-safe medications such as Hydroxychloroquine (an antirheumatic drug) or certain biologics (like TNF (tumor necrosis factor) inhibitors like Etanercept or Certolizumab pegol ), which have safer profiles and can help maintain disease control. Some biologics can be continued through pregnancy and even into breastfeeding, especially those with minimal placental transfer.

IVF (in-vitro fertilization) is possible, but the hormonal stimulation can occasionally trigger flares, so her disease must be well-controlled beforehand and monitored closely by her rheumatologist in collaboration with the fertility team. If she experiences a flare during pregnancy, corticosteroids like Prednisone can be used short-term under supervision. They are generally safe in moderation but should be used judiciously. Some rheumatoid arthritis (RA) medications may impact ovulation or egg quality, especially Methotrexate and chronic steroid use, but this varies by individual and should be evaluated with her fertility specialist.

When it comes to delivery, vaginal birth is possible and safe for many women with RA, but if the disease has affected the hips, spine, or hands severely, a planned C-section may be safer and less stressful.

Post-pregnancy, non-hormonal options like the copper IUD (intra-uterine device) or progestin-only pills may be preferred to avoid triggering flares, but the final choice should be made based on her disease status and personal preference, ideally with input from both rheumatology and gynecology.

I hope this information helps you.

Feel free to ask further queries.

Thank you.