LONDON — The approach to reproductive health and management of pregnancy in rheumatic and musculoskeletal disease (RMD) has changed radically over the past three decades. In the past, a diagnosis often meant a discouraging conversation regarding family building. However, data presented at the European Alliance of Associations for Rheumatology (EULAR) 2026 Annual Meeting showed that a strict treat-to-target approach can help the vast majority of patients to safely plan a pregnancy.

“Living with RMD per se, not only severe disease, was considered not compatible with motherhood and fatherhood,” Laura Andreoli, MD, PhD, associate professor of rheumatology at the University of Brescia in Brescia, Italy, and co-chair of the EULAR Study Group on Reproductive Healthcare and Family Planning, told Medscape Medical News. But the EULAR 2024 recommendations on the use of medications during reproduction state that all patients, women and men, should be offered “early and regular counseling about reproductive health and the need for adjustment of therapy in relation to pregnancy.”

“Clinicians who take care of patients with RMD [should] start the conversation around reproduction and make sure that the wish of the patient is taken into account while making plans for the management of RMD,” Andreoli said. “A very quick question such as ‘would you like to get pregnant in the next year?’ can be useful to understand whether the conversation should focus on pregnancy planning or on contraception.”

Real-world registry data show that continuous biologic use throughout pregnancy has risen sharply. Clinicians have been able to successfully break the vicious cycle of active maternal inflammation and subsequent obstetric complications while significantly decreasing patient reliance on harmful corticosteroids.

Yet while modern therapies have drastically improved patients’ quality of life, mental and emotional health domains during the reproductive journey have seen zero improvement. In addition, the historical neglect of male fertility in RMD means that male patients frequently experience psychological anxiety over fatherhood, suffer from undocumented subfertility driven by uncontrolled systemic inflammation, and are even subject to extreme clinical mishaps, such as elective pregnancy termination, due to completely unfounded fears surrounding paternal drug exposure.

“It is important that patients don’t feel alone in managing reproductive issues and are reassured from the very beginning that they can speak about it with the physician who manages RMD,” Andreoli said. “The physician has the possibility to refer the patient to all the relevant specialists [with the] overarching principle [being that] the choice of treatment before, during, and after pregnancy should be a shared decision-making process between the treating healthcare providers and the patient.”

Breaking the Cycle 

Women who continue disease-modifying antirheumatic drugs (DMARDs) after conception have significantly lower disease activity than those who stop them at the beginning of pregnancy, Andreoli explained during her lecture at EULAR 2026. That allows the placenta to function properly and the baby to develop normally to term. “If the mother is unwell, most probably the baby will also be unwell. If the mother is okay during pregnancy — no disease activity, no symptoms...this will also help the baby to be in good condition,” she said.

A recent 10-year cohort study from Japan evaluating 118 pregnant women with rheumatoid arthritis (RA) revealed that, thanks to a treat-to-target strategy, 85% of patients maintained remission or low disease activity throughout their pregnancy.

The study showed that women who continued biologic DMARDs after conception experienced significantly lower disease activity than those who halted therapy. Conversely, preconception disease activity, longer disease duration, and baseline glucocorticoid use significantly predicted gestational flares.

To achieve stable gestations safely, guidelines advise tapering prednisone down to 5 mg/d or equivalent or discontinuing it entirely where possible, Andreoli explained. “We know that the prolonged use of corticosteroids is associated with preterm birth,” she said.

Real-world practice has gradually evolved to align with this benefit-risk profile. Administrative data from the US encompassing nearly 4000 pregnancies exposed to TNF inhibitors showed that the continuous use of TNF inhibitors throughout pregnancy surged from 55% in 2011 to 73% by 2021. Andreoli pointed out that robust evidence of the safety of using TNF inhibitors in pregnancy has been built over time, taking more than 15 years of postmarketing use to build such confidence, she said. “Having an earlier generation of [safety] data [on new therapies] will have a positive impact on the communication that we have every day with our patients, and this will prevent anxiety,” she said.

Male Fertility: The Forgotten Half of the Equation 

The reproductive conversation has historically focused almost exclusively on the maternal perspective, a bias that has actively harmed male patients, argued Luis Fernando Perez, MD, PhD, a rheumatologist and clinical researcher at Erasmus University Medical Center in Rotterdam, Netherlands. At EULAR 2026, Perez recalled a clinical case of a 37-year-old man with psoriatic arthritis whose partner’s first pregnancy was electively terminated solely due to unfounded fears regarding paternal methotrexate exposure. Later, the patient halted therapy, sacrificing disease control and developing severe joint and skin flares alongside subsequent fertility issues. “Fear and uncertainty were bigger than the evidence that we have,” Perez said.

Current European and American guidelines now explicitly incorporate the male perspective, affirming that the majority of standard rheumatic medications are entirely compatible with paternal use, he explained. A recent systematic review confirmed there are no clear signals linking paternal methotrexate exposure to increased risks for congenital malformations, stillbirth, preterm birth, or miscarriage. Perez urged clinicians to “use the evidence we have to gain their [patients’] trust, so we can facilitate their family planning journey.”

EULAR data suggest that the primary threat to male fertility is often uncontrolled disease activity rather than its treatment. “For many years, we wrongly believed that it was [merely] an immune system [issue],” Perez said. But the reproductive system can be vulnerable to systemic inflammation associated with an RMD, so disease activity can influence fertility.

Perez presented data from a 2021 study on Swedish medical registries showing that men diagnosed with RA, psoriatic arthritis, or spondyloarthritis before the age of 50 carry a significantly higher baseline risk for infertility. This underlying reproductive dysfunction was confirmed by a randomized controlled safety trial for the JAK inhibitor filgotinib. While filgotinib demonstrated no negative impact on semen parameters, researchers had to exclude half of the male candidates before treatment began because 3 in 5 had abnormally low semen count before treatment, and 1 in 5 had abnormal reproductive hormones. “These were young men from all over Europe,” Perez said.

Counseling and Communication

While the physical management of disease during pregnancy has gradually improved, the psychological burden of family planning when dealing with an RMD often remains unaddressed.

Evidence suggests that mental health issues, such as depression and anxiety, are common among patients with RMD, yet they remain unrecognized and untreated. In addition, data from a dedicated reproductive rheumatology clinic in Rotterdam highlighted that even when patients report high satisfaction with specialized, nurse-led multidisciplinary care, their mental health might still be neglected. “The patients said that they were very satisfied with the care that was offered. Still, some of them reported that they wanted to receive more help on how to manage disease flares and how to manage difficulties around conceptions, and also in the postpartum period, with the emotional sphere being specifically mentioned,” Andreoli said.

“This is still an under investigated area as there are few articles exploring the psychological journey of women with RMD going through a pregnancy and motherhood,” she told Medscape Medical News. “Our patients are women who live in society like any other woman, so they face the same problems. But they have a chronic condition on top of it. This is likely to bring an additional burden to mental health.”

She said physicians responsible for RMD management do not have sufficient time or competence to address these aspects, so problems are often overlooked. But simple questions can help open the conversation and refer the patient to the appropriate healthcare pathway.

Andreoli also added that the partner should always be invited to consultations to listen directly to what physicians say and ask for clarification. “The female patient who is planning a pregnancy shouldn’t deal with the additional burden of transmitting information to the partner and the surrounding family.”

Material such as brochures in lay language can be very useful during this process. It is important that all players make an informed decision based on what physicians have offered.

Early and regular counseling is important for optimizing pregnancy outcomes, agreed Karen Schreiber, MD, PhD, associate professor at the Institute for Regional Health Research at the University of Southern Denmark, Odense, Denmark, and co-chair of the EULAR Study Group on Reproductive Healthcare and Family Planning. Data indicate that 1 in 10 people now live with an autoimmune long-term condition, and the population of women at child-bearing ages within this cohort is steadily increasing, she said. “There has been an attitude change in the community from being cautious about pregnancy to thinking that pregnancies are possible. We will see more pregnancies in the future,” Schreiber said.

“Pregnancy counseling is the essence,” she said and added that reproductive care is highly challenging because there is no one-size-fits-all. “You have different diseases with different risk patterns, you have a lot of medications, and you have the individual patient where you have to think about the risk and benefit of treatment.”

For example, systemic lupus erythematosus (SLE) carries a 9%-16% risk for flare during pregnancy and postpartum, heavily predicted by disease activity at the time of conception. Adequate management improves fetal and maternal outcomes, she explained. But counseling reduces trauma for the mother and the family when adverse pregnancy outcomes, whether it’s a late fetal death or recurrent miscarriages, happen.

One study tracked over 300 pregnant women with SLE. The researchers identified four protective preconception factors: stable disease for at least 6 months, absence of vital organ involvement, corticosteroid use below 7.5 mg/d, and concomitant hydroxychloroquine therapy. When these conditions were fulfilled, patients experienced a linear increase in live birth rates and a halved risk for adverse pregnancy outcomes. “This is really nice because it quantifies the success of pregnancy counseling: Information improves compliance; alignment between patient and healthcare professionals is absolutely essential,” Schreiber said.

However, another study reviewing data from about 360 patients found that while 70% obtain family planning information from hospital rheumatologists, patients also rely heavily on patient advocacy groups and social media. “Rheumatologists apparently are really good at providing information. Equally important, though, [are] patient advocacy groups, and not surprisingly, the internet, social media, ChatGPT, Google,” Schreiber said.

This fragmented search for answers is compounded by a structural disconnect between clinical evidence and regulatory documentation. Schreiber explained that “clinical guidelines are one thing” — they are developed to help healthcare professionals in daily practice on the basis of a systematic review — but “the package insert is developed as safety information from a toxicology point of view,” and sometimes these pieces of information contradict each other.

This frequently results in cases where a rheumatologist prescribes a medication based on consensus data, only for the patient to read an absolute contraindication on the box insert at home, Schreiber explained.

Some of the decisions made are based on limited scientific evidence; therefore, it is important that both the patient and partner understand the key concepts and that the partner supports the mother-to-be as best as possible, Andreoli said.

She offered an example: Taking medications during pregnancy is not a selfish act, such as the patient not wanting to feel pain or have problems during pregnancy, but it is vital for minimizing the risk for adverse pregnancy outcomes related to active RMD. “The motto should be: If the mother is doing well, then the baby is going to be fine. If the mother is unwell, then the baby will also be unwell. If medications, which are compatible with use during pregnancy, are needed to keep maternal disease under control, then they are welcome,” she said.

Perez added that the drive for reproductive counseling must be identical for both men and women. Also, clinicians must recognize that male anxieties often shift beyond basic biological semen parameters. “When we think about counseling, we tend to think immediately of objective things, biological things: sperm, testosterone,” he said. But men might be afraid of not being able to play football with their child, to provide for their family, or whether their baby inherits their disease. “Half of the conversation [on fertility] has been missing,” Perez said. “But it should not remain the missing half of care.”

Andreoli reported receiving consulting and speaking fees from Abbott, Pfizer, and UCB. Schreiber reported having no relevant financial relationships. Perez reported received consulting fees from Alfasigma and Johnson & Johnson; receiving a research grant from AstraZeneca; and owning stocks in Novo Nordisk, Johnson & Johnson, and CRISPR Therapeutics. 

Manuela Callari is a freelance science journalist specializing in human and planetary health. Her work has been published in The Medical Republic, Rare Disease Advisor, New Scientist, The Guardian, MIT Technology Review, and others.