As soon as the immune rheumatic disease is in remission and stable, insemination and pregnancy can be considered. Under what condition and with what drugs is fertility suitable? Wen Chengping, Department of Traditional Chinese Medicine and Immuno-Rheumatology, The Third Hospital of Zhejiang University of Traditional Chinese Medicine
More than 100 kinds of immune rheumatic diseases have been found so far, and the relatively common ones in clinical practice are dry syndrome, rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, osteoarthritis, osteoporosis, leukoarthrosis, dermatomyositis, scleroderma and vasculitis, etc. They are often difficult to be cured and have a long treatment course. Nevertheless, there are not many western drugs suitable for treatment at present, and the more commonly used ones are: hormones, methotrexate, leflunomide, hydroxychloroquine, salazosulfapyridine, biologics, total glucosides of peony and leucovorin, etc.
A. Drugs prohibited before preparing for childbirth.
1.Legomide polysaccharide.
Long-term application will cause irreversible damage to the gonads and reproductive function, such as causing amenorrhea, uterine atrophy, tubal atrophy in women, and atrophy of the testes and vas deferens in men, and a decrease in the viability of eggs and sperm, so it is prohibited.
2. Salicyclovir.
It can cause male infertility, and most of these drugs can restore fertility after stopping. Generally within 2 months of taking the drug, there will be a decrease in the number of sperm, sperm operation and morphological abnormalities. Its incidence is high but mostly reversible, and fertility is restored after a few weeks of discontinuation. However, it can be used during a woman’s pregnancy and needs to be supplemented with folic acid at the same time.
3.Methotrexate.
A few after taking it will cause a decrease in sexual function and a decrease in sperm activity and number, but most of them can return to normal after stopping the drug. Generally, when considering childbirth, men should stop taking the drug 90 days in advance, and women should stop taking the drug at least one menstrual cycle in advance, while supplementing folic acid before and during pregnancy.
4. Leflunomide.
Has teratogenic side effects and is prohibited for use in women who are pregnant or about to become pregnant. It is usually discontinued before 6 months of planned pregnancy. Discontinue for men three months before considering childbirth. In case of unplanned pregnancy during treatment, use abciximide (8g per dose, 3 times daily) for rapid cleansing of the active metabolites of leflunomide.
II. Drugs to be discontinued in case of pregnancy.
1. Reactive discontinuation.
Also known as thalidomide, its use during pregnancy can cause fetal teratogenicity and peripheral nerve (sensory neuritis). The 34th to 50th day after the last menstrual period of pregnancy is the sensitive period for the action of reactive stop, and its use is absolutely prohibited during this period.
2. Anti-TNF biologics.
Although the short-term efficacy of such biological agents is encouraging, the disturbance of the immune internal environment that it may trigger is equally worrying. Although the results of the long-term effects of TNF antagonists on the fetus are not yet clear, it is recommended to discontinue their use during pregnancy.
III. Drugs that can be used both before childbirth and during pregnancy
1. Hydroxychloroquine.
From the current clinical follow-up shows that it is safe for the fetus, and pregnant women should have regular eye examinations.
2.Total glucoside of peony.
From the current clinical use is safe for childbirth and fetus, loose stools can be taken during the ginger tea.
3. Azathioprine.
Can be used during pregnancy, but the dose should be less than 2mg/kg, d. If the dose is high, there is a risk of suppressed fetal erythropoiesis.
4. Hormones.
Oral prednisone or intra-articular injections of hormones may be used. However, the smallest dose, usually less than 15 mg per day, should be given during the first 3 months of pregnancy to reduce the risk of orofacial fracture. Long-term hormone users need to increase the dose appropriately in the perinatal period. For those whose condition worsens during pregnancy, the hormone dosage can also be increased appropriately until the condition is in remission.
5. Non-steroidal anti-inflammatory drugs.
Drugs with a short half-life are preferred during the first 32 weeks of pregnancy and should be discontinued after the seventh month of pregnancy. If joint pain worsens during pregnancy, drugs such as diclofenac sodium extended-release tablets and celecoxib capsules can be used appropriately and withdrawn and reduced after pain relief. It is best to intermittently take the lowest effective dose of NSAIDs to reduce the risk of adverse fetal reactions.
Fourth, the role of Chinese medicine on fertility
1. Relieve the condition and create good conditions for conception.
The combination of Chinese and Western medicine treatment helps the rapid remission of the disease. And because of the need to prepare for childbirth, the use of rehmannia multi-glucoside, methotrexate, leflunomide, reaction stop and biological agents may be limited. Therefore, at this stage, TCM will be duty-bound to take up its due burden to improve the patient’s weak constitution, relieve symptoms such as swollen and painful joints, rashes and dry mouth and eyes by transporting the spleen and kidneys, tonifying Qi and invigorating Blood, dispelling wind and removing dampness, and also alleviating the side effects of Western medicine. Drugs often used at this stage include Qiang Zhi, Dou Shu, Gentiana, Sang Sang, Gui Zhi, Ma Huang, Chuan Xiong, Ge Ge Ge, Wu Zhi Snake, Herb Snake, Snow Lotus, and so on.
2. Conditioning the whole body and creating a harmonious fetal environment.
Through the holistic therapeutic effect of TCM, it helps regulate the neuro-endocrine-immune environment of pregnant women and provides nourishing growth for the fetus. After pregnancy, under the premise of maintaining the stability of the disease, the principle of western medicine application is to use as little as possible if there is no need for more, and to stop using if there is no need. The long-term application of hormones and immunosuppressants will more or less disrupt the internal environment of pregnant women. The herbs often used in this stage are: Astragalus, Atractylodes, Radix Angelicae Sinensis, Radix et Rhizoma, Radix Paeoniae Alba, Rhizoma Polygonati, Radix Scutellariae Sinensis, Radix Scutellariae Sinensis and Radix et Rhizoma Sibiricum. There are many pregnant women with rheumatism who have been taking herbs clinically to preserve their fetus until delivery, and no problems with the fetus have been found.