The relationship between pregnancy and autoimmune disease goes both ways. Having an autoimmune disease significantly influences pregnancy — from before conception to the postpartum period. Likewise, pregnancy can trigger certain autoimmune diseases, exacerbate existing ones, and even put some into temporary remission. Typically, with the proper care and disease management, most women with autoimmune diseases are able to get pregnant. However, there are proven connections between autoimmune diseases and fertility, and certain autoimmune diseases and medications may make it challenging to conceive.

What Is Infertility?

Infertility is the inability to get pregnant. Specifically, your health care provider will diagnose you with infertility if you’ve been trying to conceive (by having unprotected sex) for 1 year without success. Infertility can affect both men and women; of course, both you and your partner will need to be fertile to conceive.

If you’re struggling to get pregnant, you’re not alone. Infertility is a relatively common condition, affecting around 9% of men and 11% of women of reproductive age in the United States. In couples who can’t get pregnant, a third of cases are clearly attributable to the man and a third to the woman, while in the remaining cases either the issue is with both partners or the cause can’t be determined. (Source)

Aside from being infertile, a person may also be subfertile or have impaired fertility, meaning they can get pregnant, but it’s more difficult than it should be. Unlike infertility, subfertility lacks a distinct clinical definition. In their review of research on subfertility, one team of researchers suggested that, to avoid confusion, subfertility could simply be described as any level of reduced fertility. (Source)

What Autoimmune Diseases Can Cause Infertility?

Infertility affects both men and women, and autoimmune diseases can trigger fertility issues in both. In women, infertility (your health care provider may call it reproductive failure) is most commonly associated with abnormalities in ovulation or menstruation. In men, it’s often connected to poor sperm quality or low sperm activity.

Rheumatoid Arthritis

Women with rheumatoid arthritis (RA) are less likely to have children than those without the condition. On average, they spend more time trying to conceive and are more likely to undergo fertility treatments. Further, women with RA may have to put their pregnancy plans on hold due to disease status or medications that shouldn’t be taken during pregnancy.

In a study of 178 women with RA who were pregnant or trying to conceive, nearly half of all cases of diagnosed subfertility were unexplained. Another 28% of subfertility issues were linked to anovulation (where the egg fails to release). In participants for whom the cause was unknown, the researchers suggested that subfertility might be related to both disease-related factors and use of nonsteroidal anti-inflammatory drugs (NSAIDs).

Fortunately, according to the same study, fertility treatments are as effective (or more effective) in women with RA compared to other subfertile groups. (Source)

Graves’ Disease

The CDC estimates that the prevalence of infertility among the general population of heterosexual women is around 20%. Research indicates this number is much higher — about 52% — in women with Graves’ disease.

Infertility associated with Graves’ disease may be directly linked to the disease’s characteristic thyroid dysfunction. However, Graves’ disease also causes menstrual irregularities, which can make it challenging to conceive. (Source, Source)

Hashimoto’s Disease

Like Graves’ disease, Hashimoto’s is an autoimmune thyroid disease. In the study mentioned above, researchers found that participants with Hashimoto’s were slightly less likely (47%) to experience infertility than those with Graves’, but still much more likely than the general population.

Women with Hashimoto’s typically have fewer children and struggle with subfertility at a younger age. It’s unclear why, but fertility in women with Hashimoto’s seems to be most affected in the 6 years following diagnosis. More research is needed to draw solid conclusions, but the increased likelihood of subfertility may be connected to a spike in autoimmune processes that lead to thyroid issues in the initial years. Regardless of the “why,” autoimmune thyroid diseases, such as Hashimoto’s, interfere with ovulation, causing fertility issues.

While both Graves’ and Hashimoto’s are more common in women than men, the fertility problems linked to thyroid autoimmunity are not exclusive to women. Men with thyroid diseases are more likely to experience issues with sperm quality and activity than those without it. (Source, Source)

Inflammatory Bowel Disease

There’s no evidence that women with ulcerative colitis are more likely to struggle with infertility than the general population. However, fertility is impaired in women with Crohn’s disease. Infertility linked to Crohn’s disease is related to disease activity; in most cases, it’s not permanent. When they achieve remission, women with Crohn’s disease typically see restored fertility. (Source)

Type I Diabetes

Type I diabetes impairs fertility in women because of its effects on ovulation and menstruation, but it’s much less concerning now than it was in the past. With adequate control of their condition, women with diabetes are able to get pregnant and have children. However, diabetes complications can drastically affect fertility, so if you have type I diabetes and plan to get pregnant in the near (or not so near) future, the impact of complications on fertility is just one more motivator to get your disease under control.

In men, type I diabetes is associated with low semen volume and decreased sperm activity. Type I diabetes can also trigger erectile dysfunction, further complicating the journey to conception. (Source, Source)

Addison’s Disease

Addison’s is a disease of the adrenal glands, which produce cortisol and other hormones that affect blood pressure and fertility. In particular, people with Addison’s have lower levels of androgens — hormones that contribute to growth and reproduction. The condition significantly reduces a woman’s likelihood of conceiving. One group of researchers found that infertility among women with Addison’s was caused by ovarian insufficiency (or ovarian failure) in 7% of participants, but more research is needed to establish further connections. (Source)

Scleroderma/Systemic Sclerosis

Most women with scleroderma will not experience impaired fertility. However, there’s some evidence that, before disease onset, people with scleroderma who have tried to become pregnant were more likely to struggle with infertility and experience delays in conceiving. Interestingly, women who had never given birth were more likely to have scleroderma than women with children, indicating the presence of unidentified or poorly-understood relationships between scleroderma and fertility. (Source)

How Do Autoimmune Drugs Influence Fertility?

If you have an autoimmune disorder and you’re trying to conceive, it’s essential to consider that even if your particular disease doesn’t cause fertility issues, the medications used to treat it might.

Fortunately, with advances in autoimmune treatment, including the development of new medications and increased awareness of the side effects associated with the drugs, many women who could have been affected by autoimmune drug-induced infertility in the past can now conceive and carry to term. However, many commonly-prescribed autoimmune drugs can affect fertility.

NSAIDs

NSAIDs are prescribed to alleviate pain and fight inflammation in people with and without autoimmune diseases.

In their review of relevant research, a panel of 29 medical specialists found connections between NSAID use and temporary infertility. NSAIDs may hinder or prevent egg release, making pregnancy impossible. While research is limited on the effects of NSAIDs on male fertility, one study (notably focusing on men who use non-prescription NSAIDs) found that long-term use may lead to a decline in sperm count and quality. (Source, Source)

Sulphasalazine

Sulphasalazine (SSZ) is a disease-modifying anti-rheumatic drug (DMARD) commonly prescribed to improve some symptoms and reduce the risk of certain complications in people with rheumatoid arthritis, inflammatory bowel disease, and several other inflammatory diseases.

There’s no known link between SSZ and infertility in women. Men who take the drug may have lower sperm counts while taking it, but usually resume normal sperm production if they stop. (Source, Source)

Cyclophosphamide

Doctors use cyclophosphamide (CYC) to treat major complications in a range of autoimmune diseases. An immunosuppressant, CYC is often used short-term to push a disease into remission. Once remission is achieved, it’s replaced with a less potent drug with fewer side effects.

CYC is gonadotoxic in both women and men — that is, it’s known to destroy eggs and sperm. In some cases, men who take CYC will become permanently sterile. Unfortunately, it’s impossible to know what dose will limit permanent infertility risk for a particular person, and there’s no way to predict whether or not a person will face sterility as a result of taking the drug. For that reason, men who need to take CYC should consider preserving and banking their sperm if there’s a chance they may want to have children in the future. (Source, Source)

It’s worth noting that some drugs that have no known effect on fertility, such as methotrexate, may negatively impact pregnancy in other ways. For example, some drugs drastically increase the risk of miscarriages. In some cases, pregnancy-friendly replacements are available. If you’re taking autoimmune medications and trying to get pregnant, speak with your health care provider about possible drug substitutions. (Source)

Do Fertility Treatments Affect Autoimmune Symptoms?

There are reported cases where fertility treatments caused severe flares in women with autoimmune diseases (systemic lupus erythematosus, in particular). Fortunately, most women with autoimmune conditions handle fertility treatments very well. If you’re planning a pregnancy, speak to your autoimmune care team well in advance. (Source)

How Is Infertility Treated in People With Autoimmune Diseases?

Doctors use several different techniques to treat infertile patients. Your care team can help you decide which is best suited for you. Fertility treatment types include:

Ovulation Induction (OI)

Ovulation induction is a process in which medication is used to induce ovulation. Ovulation is an essential part of the reproductive cycle that is marked by the release of an egg from one of the ovaries. Until an egg is released, it can’t meet the male sperm cells. Ovulation induction encourages egg release, and it’s particularly helpful in infertile women with irregular menstrual cycles or those who don’t release eggs naturally (ovarian insufficiency). Ovulation induction is typically recommended in conjunction with another form of fertility treatment called intrauterine insemination (more on that below). (Source)

Intrauterine Insemination (IUI)

In IUI, a concentrated sample of sperm is placed directly into the uterus. The procedure is strategically timed to align with ovulation. The health care provider may first prescribe a medication to trigger ovulation in the female patient (OI). A small tube containing the sperm sample is then inserted into the uterus, a process that only takes a few minutes. (Source)

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In Vitro Fertilization (IVF)

In IVF, the egg and sperm are combined in a lab, then transferred to the woman’s uterus for implantation. It’s more costly than other techniques, so it’s usually recommended in cases where other treatment options result in implantation failure and a woman fails to get pregnant. IVF is a multi-step process:

• the woman takes medication to boost egg production
• her eggs are retrieved through a minor surgery
• eggs are combined with sperm in a controlled environment that emulates ideal natural conditions
• a fertilized egg (or eggs) divides and becomes an embryo
• the embryo (or embryos) is transferred to the woman’s uterus
• if at least one embryo implants in the uterus, pregnancy results

(Source)

Intracytoplasmic Sperm Injection (ICSI)

Intracytoplasmic sperm injection is a more complex IVF procedure. As with IVF, OI is used to stimulate egg release, and the resulting eggs are retrieved. Rather than just combining eggs and sperm and hoping for fertilization, though, in ICSI a healthy sperm is injected by needle directly into an egg. This process may be helpful for couples who just want to increase their chances of successful fertilization, but it is especially indicated when the man is not producing normal amounts of healthy sperm. (Source)

Tips for Conceiving With an Autoimmune Condition

If you’re planning on getting pregnant, you’ll need to get your disease under control. If you haven’t already, you should seek guidance from a team of professionals specializing in autoimmune care. Your care team should consist of, at minimum, a primary care provider, a health coach, and a Nutritional Therapy Practitioner. Beyond that, there are steps you can take to improve your condition:

• Eat well.
• Exercise for at least 150 minutes per week.
• Practice stress management techniques.
• Prioritize sleep.

(Source, Source, Source)

The Bottom Line on Autoimmune Disease and Infertility

There are clear and proven connections between autoimmune disease and infertility. Autoimmune diseases influence fertility in both women and men. In women, autoimmune conditions are associated with abnormalities in ovulation and menstruation. In men, they’re linked to issues with sperm count and quality. In addition to the direct connections between autoimmune diseases and fertility, some medications used to treat autoimmune conditions cause fertility problems.

Fortunately, with guidance from qualified professionals, most women with autoimmune diseases are able to get pregnant and have healthy, safe pregnancies. Fertility treatments, such as IVF and IUI, are safe and effective in most women, including those with autoimmune conditions. To ensure your path to conception is as smooth as possible, you’ll need to keep your condition in check. If you’re struggling with autoimmune symptoms and desiring to get your condition under control to improve your odds of success, WellTheory can help.