Rheumatoid arthritis does not stop people from having babies, but active disease, NSAID use, and higher-dose prednisone have each been linked to taking longer to conceive. The American College of Rheumatology’s reproductive health guideline supports keeping RA well controlled with pregnancy-compatible medicines — several common ones, including hydroxychloroquine, sulfasalazine, and TNF inhibitors, can be continued — while methotrexate and leflunomide need a planned stop. Your rheumatologist should set that plan.
Control first, then conception
RA and the time it takes to conceive
The most-cited study on this question followed 245 women with RA in the Netherlands who were trying to conceive (Brouwer and colleagues, Annals of the Rheumatic Diseases). About 42% took longer than 12 months to become pregnant. The study found several things linked to a longer time to pregnancy:
- Higher disease activity — each one-point increase in the DAS28 score was associated with a lower chance of conceiving in a given period.
- NSAID use before conception.
- Prednisone use, with a dose-dependent effect; time to pregnancy was significantly longer at daily doses above 7.5 mg.
- Older age and never having given birth before, as in the general population.
The authors concluded that care before conception should aim for the best possible control of disease activity while weighing the possible downsides of NSAIDs and higher prednisone doses. That is the core idea of this whole article: well-controlled RA on the right medicines is the goal, not “no medicines.”
The medication review, using the ACR guideline
In 2020 the American College of Rheumatology published its first guideline on reproductive health in rheumatic and musculoskeletal diseases. Its medication recommendations for people planning pregnancy look roughly like this:
| Category | Examples (ACR 2020) |
|---|---|
| Recommended to continue | Hydroxychloroquine, sulfasalazine, azathioprine/6-mercaptopurine, colchicine (strong); cyclosporine and tacrolimus (conditional) |
| TNF inhibitors | Certolizumab: continue before and during pregnancy (strong). Other TNF inhibitors: continue before and during pregnancy (conditional). |
| Other biologics | Several non-TNF biologics (for example abatacept, tocilizumab, anakinra) are conditionally recommended to continue through conception, then stop once pregnant. Rituximab: continue through conception (conditional). |
| Stop before trying | Methotrexate, mycophenolate (at least 6 weeks before), cyclophosphamide, thalidomide |
| Needs a washout | Leflunomide — see below |
| Not enough data to recommend | JAK inhibitors such as tofacitinib and baricitinib, and apremilast |
Two practical notes. First, this is a decision framework for your rheumatologist, not a self-serve chart; guidelines are periodically updated, and your rheumatologist may be working from newer data. Second, the guideline also says that if a teratogenic drug is taken unintentionally in pregnancy, it should be stopped immediately and you should be referred to maternal-fetal medicine or genetic counseling — so if you find yourself pregnant on one of the “stop” drugs, call right away rather than waiting for your next appointment.
Methotrexate and leflunomide: the two that shape your timeline
Methotrexate
Methotrexate is the anchor drug for many people with RA, and it is one that needs to stop before conception. The ACR guideline recommends discontinuing it before attempting conception. On timing, MotherToBaby notes that some providers suggest waiting 1 to 3 months after stopping, while the drug label is more conservative at 3 to 6 months. MotherToBaby also notes that methotrexate interferes with how the body uses folic acid, so ask your provider what folic acid dose to take after stopping.
Your rheumatologist will usually plan a replacement before or as methotrexate stops, so you are not left untreated during the waiting period.
Leflunomide
Leflunomide stays in the body for a long time. The ACR guideline says that anyone treated with leflunomide in the previous 24 months should either show undetectable drug levels or complete a cholestyramine washout before trying to conceive. If pregnancy happens while taking it, the guideline recommends stopping it and starting a washout until levels are undetectable.
NSAIDs and steroids while trying
NSAIDs such as ibuprofen and naproxen are a common part of RA symptom control. The ACR guideline conditionally recommends stopping NSAIDs in people who are having difficulty conceiving, if that can be done without losing disease control. It strongly recommends avoiding NSAIDs in the third trimester, and the FDA advises avoiding NSAIDs at 20 weeks of pregnancy or later unless a clinician specifically advises them (low-dose aspirin prescribed for pregnancy conditions is an exception).
For prednisone, the practical goal is the lowest dose that keeps you comfortable and controlled. In the Dutch study, daily doses above 7.5 mg were linked to a noticeably longer time to pregnancy. If you rely on prednisone, ask whether a steroid-sparing medicine that is compatible with pregnancy could lower your dose before you start trying.
Over-the-counter pain relief counts here too. If you have been self-managing flares with NSAIDs, mention it — it may be one of the easier levers to adjust.
If the partner with RA is not the one getting pregnant
The ACR guideline also addresses people with rheumatic disease who plan to father a child. For men planning conception, it recommends continuing hydroxychloroquine, azathioprine, TNF inhibitors, and colchicine (strong), and conditionally recommends continuing several others, including sulfasalazine, leflunomide, mycophenolate, NSAIDs, and some biologics. It recommends stopping cyclophosphamide and thalidomide before trying.
For methotrexate in men, MotherToBaby notes the label advises contraception during treatment and for 3 months after the last dose, while studies have not found a higher chance of birth defects in children of men taking methotrexate around conception. This is a nuanced area; ask the rheumatologist which approach they recommend. For general sperm-health basics, see how to improve sperm health.
Pregnancy and the postpartum months
RA often — but not always — quiets down during pregnancy. A 2019 systematic review in The Journal of Rheumatology pooled 10 prospective studies and found disease activity improved in about 60% of pregnancies, and increased after birth in about 47%. Notably, older studies reported improvement more often than recent ones; the authors suggest that people now start pregnancy with better-controlled disease, leaving less room for change.
The postpartum months deserve a plan before the baby arrives:
- Which medicines will you restart, and when?
- Which are compatible with breastfeeding if you plan to breastfeed?
- Who can help with lifting, bathing, and night feeds during a flare?
- What baby gear reduces strain on hands and wrists (lighter car seat, easy-open bottles, changing station at waist height)?
- Who do you call if a flare starts in the first weeks?
If you are already thinking about spacing a second pregnancy, our guide to getting pregnant while breastfeeding covers the fertility side.
The human side of trying with RA
RA can make the ordinary parts of trying harder: sex when joints hurt, energy on high-fatigue days, the mental load of medication timing, and the worry about caring for a baby during a flare. A few things people find useful:
- Say the worry out loud. Many people with RA wonder whether they will be able to manage physically. Your rheumatologist, a physical or occupational therapist, and your partner can all help plan for that.
- Adjust intimacy without guilt. Timing sex to the fertile window means you do not need to push through every day. Positions and timing that spare painful joints are fine.
- Track your disease, not just your cycle. A simple log of flares and medicine changes helps your rheumatologist judge whether you are ready to start trying.
- Ask for help early if it is slow. With a chronic condition, it is reasonable to seek an evaluation sooner. See when to see a fertility specialist.
Frequently asked questions
Does rheumatoid arthritis affect fertility?
It can lengthen the time to conceive. In a Dutch study of 245 women with RA trying to conceive, about 42% took longer than 12 months, and higher disease activity, NSAID use, and prednisone above 7.5 mg per day were linked to longer time to pregnancy.
How long before trying to conceive should I stop methotrexate?
The ACR guideline recommends stopping methotrexate before attempting conception. MotherToBaby notes some providers suggest waiting 1 to 3 months and the drug label suggests 3 to 6 months. Your rheumatologist should set your timing and replacement.
Which RA medications can I keep taking while trying to conceive?
The 2020 ACR guideline recommends continuing hydroxychloroquine, sulfasalazine, azathioprine, and colchicine, and supports continuing TNF inhibitors before and during pregnancy. Confirm your own regimen with your rheumatologist.
Should I stop ibuprofen or naproxen while trying?
The ACR guideline conditionally recommends stopping NSAIDs if you are having difficulty conceiving and it can be done without losing disease control. The FDA advises avoiding NSAIDs from 20 weeks of pregnancy unless a clinician advises otherwise.
Will my RA get better during pregnancy?
Often, but not always. A 2019 systematic review found disease activity improved in about 60% of pregnancies and increased after birth in about 47%, so a postpartum plan is important.
Sources & guidance
- Sammaritano LR, et al. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis & Rheumatology
- RheumNow: ACR 2020 Reproductive Guidelines — Medication Use in Pregnancy
- Brouwer J, et al. Fertility in women with rheumatoid arthritis: influence of disease activity and medication. Annals of the Rheumatic Diseases
- Jethwa H, et al. Does Rheumatoid Arthritis Really Improve During Pregnancy? A Systematic Review and Metaanalysis. J Rheumatol 2019;46(3):245-250
- MotherToBaby: Methotrexate fact sheet
- FDA: Avoid use of NSAIDs in pregnancy at 20 weeks or later