Effect of Active Spondyloarthropathy on Fertility in Females
Active spondyloarthropathy does not directly impair fertility in women, but disease-related factors including pain, fatigue, functional limitations, depression, anxiety, negative body image, and preconceptional NSAID use are associated with subfertility and may prolong time to conception 1, 2.
Direct Impact on Fertility
The existing evidence does not support a causal relationship between spondyloarthritis and infertility 3. Women with axSpA demonstrate:
- Normal conception rates: Most pregnancies (90.2%) are achieved through natural conception 2
- Reasonable time to pregnancy: 68.3% of women conceive within 1 year 2
- Low use of assisted reproductive technology: Assisted conception is reported infrequently 2
- Normal reproductive performance: Average of 2.4 pregnancies per woman, comparable to general population 4
However, some studies suggest a higher risk of subfertility compared to the general population 1, with 15% of women experiencing conception difficulties requiring more than one year 5.
Disease-Related Factors Affecting Fertility
The impact on fertility is indirect and mediated through disease activity and symptoms:
Factors Associated with Impaired Fertility:
- Pain and stiffness limiting sexual activity
- Fatigue reducing frequency of intercourse
- Functional disorders affecting physical intimacy
- Depression and anxiety
- Negative body image
- Preconceptional NSAID use (may interfere with ovulation and implantation) 1
Potential Protective Factor:
- TNF-alpha inhibitors may improve fertility in certain cases, likely by controlling inflammation 1
Clinical Implications for Disease Management
The key to optimizing fertility is achieving low disease activity or remission before conception 6. The 2020 ACR guideline emphasizes that:
- Unplanned pregnancies in women with active disease carry greater risk than planned pregnancies during periods of low disease activity 7
- With adequate planning, treatment, and monitoring, most women with rheumatic diseases can have successful pregnancies 7
- Pregnancy-compatible disease-modifying drugs and biologics should be continued rather than discontinued 7
Practical Approach to Preconception Counseling
Initiate fertility discussions early and periodically with all women of reproductive age 7:
- Assess current disease activity and optimize control before conception attempts
- Review medications: Switch from teratogenic agents (methotrexate, leflunomide) to pregnancy-compatible options (sulfasalazine, TNF inhibitors)
- Address modifiable factors: Optimize pain control, treat depression/anxiety, consider switching from NSAIDs to biologics if trying to conceive
- Discuss contraception until disease is well-controlled and medications are pregnancy-compatible
- Coordinate with reproductive endocrinology if conception difficulties persist beyond 1 year 7
Important Caveats
- Disease activity matters more than diagnosis: Active inflammation is the primary concern, not the SpA diagnosis itself
- Pre-pregnancy concerns are common: 74.8% of women worry about pain levels increasing, 62.6% about birth complications, and 63.3% about passing SpA to their child 2
- Postpartum flares are frequent: 60% experience flares within 6 months after delivery, especially those with active disease at conception 4
- Quality of life impact: 61.3% report that axSpA affects their perceived ability to care for the baby in the first 6 months 2
The evidence consistently shows that SpA itself does not cause infertility, but active disease and its consequences can prolong time to conception. The priority is achieving disease control with pregnancy-compatible medications before attempting conception 7, 1, 2.