Expert Answers to Your Concerns
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If you have psoriatic arthritis (PsA) and are thinking about starting a family, you may have a number of questions and concerns.
How might the disease and treatment affect your pregnancy? And what is the likelihood of passing on PsA to your child?
Here are six questions that might be going through your mind, along with expert answers to calm some of your fears. Read on, and then talk with your doctor about your concerns and your overall health.
1. Is It Harder to Get Pregnant With PsA?
Having an inflammatory, autoimmune disease like psoriatic arthritis doesn’t necessarily make it harder to conceive, says Mohammad Kamran, MD, a rheumatologist at Wellstar Rheumatology Associates in Marietta, Georgia.
When inflammation is high, however, some research suggests it may be more difficult to become pregnant; and there are reports of a higher incidence of polycystic ovary syndrome — a metabolic and hormonal disorder that can affect fertility — in patients with psoriatic arthritis.
While further study is needed, Dr. Kamran notes that “as a rule of thumb, our patients usually do not have that much of an issue with conception.” The larger issue, he adds, is that if psoriatic arthritis is not well controlled, it can lead to complications and poor outcomes during pregnancy.
RELATED: Fertility and Getting Pregnant — What You Need to Know
2. How Might Psoriatic Arthritis Affect My Pregnancy?
According to Norbert Gleicher, MD, a fertility expert and the founder of the Center for Human Reproduction in New York City, autoimmunity and pregnancy have a very complex relationship. Research suggests that the relationship is bidirectional, meaning that autoimmune diseases may selectively affect women of reproductive age and that pregnancy may affect the improvement or worsening of autoimmune diseases.
Dr. Kamran’s general recommendation to patients who have autoimmune inflammatory diseases is that the best time to conceive is when the disease is in remission or relatively well controlled.
“When your disease is well controlled, the outcomes tend to be better for the mother and for the baby,” he says. “The mother has a healthier pregnancy, the baby is healthier, the disease does not cause as much damage.” The likelihood of carrying the pregnancy to full term is greater. If PsA inflammation is not wellcontrolled, there’s an increased risk of preeclampsia and elevated blood pressure, among other complications. And Kamran adds that in the majority of patients whose disease is well controlled to begin with, the risk of postpartum complications is also likely to be lower.
The Arthritis Foundation cautions that if your PsA affects your back or hips, you may experience more pain in these areas during pregnancy as the fetus grows, and vaginal delivery may be more challenging. Inflammation in the spine could also make it difficult to administer an epidural for pain relief during labor.
After delivery, people with PsA may experience more fatigue than others, though new parenthood can be exhausting for anyone. If you plan on breastfeeding, there’s no evidence that PsA lowers milk production, according to the Arthritis Foundation, and while some PsA medications could be passed along through breastmilk, many of them are safe to use.
RELATED: 9 Dos and Don’ts to Ease Psoriatic Arthritis Inflammation
3. Can My PsA Medications Harm the Fetus?
Certain medications commonly taken for PsA are known to cause a higher risk of miscarriage and fetal abnormalities. These medications include methotrexate and retinoids. Leflunomide — which may be used to treat PsA, though Kamran notes this isn’t common — can also cause fetal abnormalities.
“When we start [treating] a female patient, of child-bearing age, especially with methotrexate or leflunomide, we educate the patient and request that the patient … use contraception and try not to conceive.” When you’re ready to start a family, tell your rheumatologist. These medications should be stopped three to six months before you try to conceive.
Nonsteroidal anti-inflammatory drugs (NSAIDs) should not be taken at 20 weeks or after during pregnancy, per the U.S. Food and Drug Administration (FDA), as they can cause low levels of amniotic fluid. Use of NSAIDS later in pregnancy may also lead to high blood pressure in the lungs of the fetus, according to Mother to Baby.
As for biologic medications, the majority of the data available on taking biologics during pregnancy comes from pregnancy exposure registries rather than studies, per the FDA. “Some biologics are safer than others,” says Kamran. TNF blockers which have been around for a long time, and where registry data has not shown any fetal harm, can be safely used in pregnancy, he adds. Of course, you should discuss your treatment with both your rheumatologist and your ob-gyn.
4. Should I Undergo Genetic Testing?
Can genetic testing predict if your child will develop PsA? The short answer: Not at this time. “There is a genetic predisposition, certain genes have been identified that probably predispose you to a higher risk of psoriasis or psoriatic arthritis,” says Kamran, however not everybody with those genes goes on to develop the disease process. “We do not recommend genetic testing to predict the occurrence of the disease process down the line. It does not predict it well. The problem is that these genes can stay dormant all your life.”
The current thinking is that a combination of environmental factors along with a genetic predisposition causes the immune to system to overreact, triggering the disease process. “Doing genetic testing does not, at least at this time, give a positive predictive value that’s good enough to be clearly recommended to the general population,” says Kamran.
5. Will PsA Medications Affect a Male Partner’s Fertility?
Research has shown that sulfasalazine therapy in men may decrease sperm quality and sperm count. But Kamran notes that it’s “a reversible process and once they stop the medication, the majority of the men will regain their sperm quality and quantity.” The use of sulfasalazine to treat PsA has also “dropped dramatically,” says Kamran, though it is commonly used to treat diseases that sometimes overlap with PsA, such as ankylosing spondylitis and ulcerative colitis.
6. How Will Pregnancy Affect My PsA?
Disease activity tends to be reduced during pregnancy, but may flare in the postpartum period. A study of women with PsA found that disease activity was “altogether low and stable” from planning pregnancy to one year after delivery, but even so, was highest at six months postpartum. Women taking a TNF blocker during pregnancy had significantly lower disease activity. A review of research found improvement in PsA disease activity during pregnancy, but a flare up of symptoms during the postpartum period.
Delivery by itself is a stress on the body, says Kamran, and any time there’s stress on the body, there is a risk of flare in autoimmune diseases, including psoriatic arthritis.
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