Paternal safety of anti-rheumatic medications

There is lack of research on the safety of medications used to treat rheumatic diseases in men wishing to conceive. When evaluating medication safety for potential fathers, two major reproductive issues are to be considered: first, whether a drug induces infertility, and second, whether a drug can cause adverse pregnancy outcomes. Cyclophosphamide is the only medication used in rheumatic disease management that causes irreversible infertility. All men prescribed cyclophosphamide should be counseled on fertility preservation including sperm banking. Sulfasalazine can cause reversible azoospermia; when conception is delayed, this medication should be held for three months and semen analysis should be performed. There are limited data on the teratogenic risk of paternal exposure to medications. Men wanting to conceive should avoid cyclophosphamide and thalidomide. Methotrexate; NSAIDs; glucocorticoids; sulfasalazine; the immunosuppressive agents azathioprine, 6-mercaptopurine, cyclosporine, tacrolimus, and mycophenolate mofetil; colchicine; TNF-alpha blockers; hydroxychloroquine; IVIG; rituximab; abatacept; and anakinra are compatible with paternal exposure. There are insufficient data to conclude the safety of other biologics and small molecules in men seeking to father a child.