To develop an evidence-based guideline for rheumatic and musculoskeletal disease (RMD) patients regarding contraception; assisted reproductive technology (ART); fertility preservation; pregnancy assessment, counseling, and management; medication use before, during and after pregnancy; and hormone replacement therapy (HRT).
We conducted a systematic review of evidence relating to contraception, ART, fertility preservation, pregnancy and lactation, and HRT in RMD populations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence, and a group consensus process to determine final recommendations and grade their strength (conditional or strong). Good practice statements (GPS) were agreed upon when indirect evidence was sufficiently compelling that a formal vote was unnecessary.
This ACR guideline provides 12 ungraded GPS and 131 graded recommendations for reproductive health care in RMD patients. These recommendations are intended to guide care for all patients with RMD, except where indicated as being specific for patients with systemic lupus erythematosus (SLE), those positive for antiphospholipid antibody (aPL) and/or those positive for anti-Ro/SSA and/or anti-La/SSB antibodies. Recommendations and GPS support several guiding principles: use of safe and effective contraception to prevent unplanned pregnancy, pre-pregnancy counseling to encourage conception during periods of disease quiescence and while on pregnancy compatible medications, and ongoing physician-patient discussion with obstetrics/gynecology collaboration for all reproductive health issues given the overall low level of evidence available for RMD patients in this area.
This guideline provides evidence-based recommendations developed and reviewed by panels of experts and RMD patients. Many recommendations are conditional, reflecting a lack of data or low-level data. We intend that this guideline be used to inform a shared decision-making process between patients and their physicians on issues related to reproductive health that incorporates patients’ values, preferences and comorbidities.

© 2019, American College of Rheumatology.