What medications can help a woman with Systemic Lupus Erythematosus (SLE) conceive?

Medications to Help Women with SLE Conceive

For women with SLE planning pregnancy, hydroxychloroquine is the cornerstone medication that should be continued throughout the preconception period and pregnancy, combined with disease-modifying agents safe in pregnancy (azathioprine, tacrolimus, or cyclosporine) to achieve stable disease remission for 6-12 months before conception. 1, 2

Essential Preconception Medications

Hydroxychloroquine (Primary Agent)

• Continue hydroxychloroquine preconceptionally and throughout pregnancy for all SLE patients unless contraindicated 1, 3
• This medication reduces disease activity, prevents flares, and directly improves obstetrical outcomes 1, 2
• The FDA confirms hydroxychloroquine readily crosses the placenta but has not been associated with major birth defects, miscarriage, or adverse maternal/fetal outcomes based on decades of clinical experience 3
• No retinal toxicity, ototoxicity, cardiotoxicity, or developmental abnormalities have been observed in children exposed in utero 3

Safe Immunosuppressive Agents for Disease Control

When additional immunosuppression is needed to achieve disease remission before conception:

• Azathioprine: Safe for maintenance therapy throughout the preconception period and pregnancy 1, 4
• Tacrolimus or cyclosporine: Compatible with pregnancy and can be used for disease control 4
• Oral glucocorticoids: Use at the lowest effective dose (ideally ≤7.5 mg/day prednisone equivalent) 1, 2

Critical Medication Adjustments BEFORE Conception

Stop these teratogenic medications and switch to pregnancy-compatible alternatives:

• Mycophenolate mofetil/mycophenolic acid: Teratogenic, must be discontinued 4
• Methotrexate: Teratogenic, must be discontinued 4
• Leflunomide: Teratogenic, must be discontinued 4
• Cyclophosphamide: Teratogenic, must be discontinued 4
• ACE inhibitors/ARBs: Teratogenic in first trimester, switch to nifedipine or labetalol 1

Fertility Preservation Considerations

For Women Requiring Alkylating Agents

• GnRH analogues should be considered for all menstruating women with SLE who require alkylating agents to preserve fertility 5
• Treatment with alkylating agents must be balanced against the risk of ovarian dysfunction 5
• Women should be counseled about fertility issues, especially adverse outcomes associated with increasing age and alkylating agent use 5

Assisted Reproduction Techniques

• Ovulation induction treatments and in vitro fertilization protocols can be safely used in patients with stable/inactive SLE 5
• Disease must be stable/inactive before proceeding with assisted reproduction 5

Special Considerations for Antiphospholipid Antibodies

• Patients with positive antiphospholipid antibodies/APS undergoing assisted reproduction should receive anticoagulation (at pregnancy dosage) and/or low-dose aspirin 5

Optimal Timing for Conception

Disease Activity Requirements

• Lupus should be in stable remission for 6-12 months before conception 1
• Active disease at conception significantly increases flare risk and adverse pregnancy outcomes 1
• Blood pressure monitoring and use of safe medications to control disease activity are essential measures 5

Major Risk Factors to Address Before Conception

The following increase risk of adverse maternal and fetal outcomes and must be optimized:

• Active/flaring SLE, especially active nephritis 5
• History of lupus nephritis 5
• Presence of antiphospholipid antibodies/APS 5
• Uncontrolled hypertension 5

Additional Preconception Interventions

Low-Dose Aspirin

• Start low-dose aspirin (81 mg daily) preconceptionally or no later than gestational week 16 to reduce pre-eclampsia risk 1
• Particularly important for patients with lupus nephritis or antiphospholipid antibodies 1

Anticoagulation for APS

• For patients with definite APS, combination therapy with low-dose aspirin plus low-molecular-weight heparin (or unfractionated heparin) should be planned for throughout pregnancy 1

Common Pitfalls to Avoid

• Never allow conception while on teratogenic medications (mycophenolate, methotrexate, leflunomide, cyclophosphamide, ACE inhibitors/ARBs) 4
• Do not discontinue hydroxychloroquine when planning pregnancy—this is a critical error that increases flare risk 1, 2, 3
• Do not attempt conception with active disease—wait for 6-12 months of stable remission 1
• Do not use combined hormonal contraceptives in patients with positive antiphospholipid antibodies due to thrombosis risk; use progesterone-only methods or IUD instead 5