We conducted a cross-sectional, web-based survey of male patients with rheumatic diseases attending outpatient rheumatology clinics at government hospitals in Kuwait. A survey-based design was selected to capture patient-reported experiences, knowledge, and perceptions regarding reproductive health counseling.

Eligible participants were adult men (≥18 years) with a rheumatologist-confirmed diagnosis of a rheumatic disease. Eligibility for participation was determined through screening questions at the beginning of the survey. Only participants who met the eligibility criteria were allowed to proceed. To minimize duplicate responses, the survey platform restricted multiple submissions from the same device/IP address. Patients with known primary or secondary infertility were excluded to minimize confounding from established reproductive pathology, as pre-existing infertility may independently influence reproductive health perceptions and counseling experiences.

Data were collected using an anonymized electronic survey comprising 22 items. The survey was structured into three domains: 1) demographic and baseline clinical characteristics, 2) current and future reproductive planning, and 3) experiences with healthcare services related to male reproductive health counseling.

The survey included Likert-scale items to quantify patient perceptions and experiences, as well as open-ended questions to capture qualitative insights. The survey items were developed based on a review of relevant literature and refined through expert input from rheumatologists to ensure content validity and clinical relevance. The survey was reviewed by rheumatology experts for internal consistency and clinical applicability prior to dissemination. Although the instrument was not formally pilot-tested or externally validated, efforts were made to ensure clarity, applicability, and relevance to the target population. This approach was considered appropriate given the exploratory nature of the study and the absence of previously validated instruments specific to male reproductive health in rheumatic diseases within this context. The survey was administered electronically using a secure platform, ensuring anonymity and confidentiality of responses.

The primary outcome of the study was the frequency of reproductive health counseling, defined as physician-initiated discussions regarding the impact of disease or medications on fertility and reproductive health. Family planning discussions were defined as any conversation related to future paternity intentions. “Adequate consideration of reproductive concerns”, referred to the patient’s perception that their rheumatologist sufficiently addressed reproductive health issues during the clinical interview.

Participants were recruited through the distribution of a QR code linked to the electronic survey in rheumatology clinics at government hospitals in Kuwait and via social media platforms affiliated with rheumatology groups and patient support communities. This dual recruitment strategy was employed to enhance accessibility and capture a broader representation of patients across different healthcare settings. Participation was voluntary, and informed consent was obtained electronically prior to survey completion.

The study was conducted between 29 October 2024 and 16 December 2025. Of approximately 700 individuals who accessed the survey link (as recorded in the survey platform export), 170 completed the survey and were included in the final analysis (response rate ≈ 24%). The survey did not capture the recruitment source (clinic vs. social media) at the individual respondent level.

Descriptive statistics were used to summarize demographic characteristics and survey responses. Categorical variables were presented as frequencies and percentages, while continuous variables were summarized using means with standard deviations or medians with interquartile ranges, as appropriate. Given the exploratory nature of the study, analyses were primarily descriptive, and no formal subgroup comparisons or inferential statistical tests were performed. No adjustments for multiple comparisons were performed, given the exploratory nature of the study. All analyses were performed using IBM SPSS Statistics for Windows, version 28. No formal sample size calculation was performed; however, the sample size was considered adequate for descriptive analysis of patient-reported outcomes. Missing data were handled using a complete-case approach, whereby analyses for each variable were based on available responses. The extent of missing data is reported for each variable where applicable, and percentages are calculated using variable-specific denominators rather than the total sample size when responses were incomplete.

Open-ended responses were reviewed descriptively by the study investigators to identify general patterns and provide contextual insights. Given the limited number and variability of responses, no consistent additional themes were identified; therefore, no formal qualitative analytical framework was applied.

This study was conducted in accordance with the principles of the Declaration of Helsinki. The Ministry of Health in Kuwait’s Ethical Approval Committee approved the study protocol (Approval Number: 2024/2670). Participation was voluntary, and informed consent was obtained electronically prior to survey initiation. All responses were collected anonymously, and data confidentiality was maintained throughout the study.

A total of 170 male patients with rheumatic diseases were included in the analysis. The mean age was 43.9 (±11.5) years. Most participants were married (79.4%), employed (71.2%), and had attained at least a college-level education (54.7%). A substantial proportion were current smokers (41.8%).

The majority of participants (93.7%) reported having children, with a median of 4 (IQR 3). A history of pregnancy loss in partners was reported by 26.8%. Baseline demographic characteristics are summarized in Table 1.

Table 1. Baseline demographic and clinical characteristics of study participants.

Values are presented as n (%) unless otherwise indicated. Continuous variables are expressed as mean (SD) or median (IQR), as appropriate.

Inflammatory arthritis, comprising rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (axSpA), was the predominant disease category, affecting 76.5% of participants. This was followed by connective tissue diseases, including systemic lupus erythematosus (SLE), Sjögren’s disease (SjD), idiopathic inflammatory myopathies (IIM), and systemic sclerosis (SSc) (11.2%), and other rheumatic diseases, such as Behçet’s disease, vasculitis, and gout (12.3%). The mean disease duration was 9.6 (±8.2) years (Table 2).

Regarding treatment exposure, 44.1% of participants had used conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), 48.8% had been treated with biologic therapies, 6.5% had been exposed to Janus kinase inhibitors (JAKi), and 15.9% had received combination therapy (Table 2). Methotrexate was the most commonly used csDMARD (25.9%), followed by hydroxychloroquine (11.8%) and mycophenolate (7.1%). Among biologic agents, adalimumab (10.6%) and secukinumab (7.1%) were the most frequently reported. Disease characteristics and treatment exposure are summarized in Table 2.

Table 2.Disease characteristics and treatment exposure among study participants.

Inflammatory arthritis comprises rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis; connective tissue diseases comprise systemic lupus erythematosus, Sjögren’s disease, idiopathic inflammatory myopathies, and systemic sclerosis; other rheumatic diseases include Behçet’s disease, vasculitis, and gout. Values are presented as numbers (percentages) unless otherwise indicated; continuous variables are expressed as mean ± standard deviation. Participants may have received more than one therapy; therefore, percentages may exceed 100%. csDMARDs: conventional synthetic disease-modifying antirheumatic drugs; JAKi: Janus kinase inhibitors.

Despite a high prevalence of prior fatherhood (93.7%), more than half of participants (52.4%) reported a desire for future paternity (Table 3).

Reproductive concerns were common and diverse. Among the 81 respondents who completed these questions, the most frequently reported concern was financial burden related to disease (65.4%), followed by concerns regarding medication effects on parenting ability (56.8%) and disease transmission to offspring (51.9 %). Concerns related to disease impact on parenting ability (51.8%) and potential birth defects (46.9.%) were also prevalent. Less frequently reported concerns included medication-related teratogenicity (35.8%) and fertility impairment (30.9%). Reproductive history, concerns, and future intentions are summarized in Table 3.

Table 3. Reproductive history, intentions, and concerns among study participants.

Values are presented as numbers (percentages) unless otherwise indicated. Percentages are calculated based on available responses within each subgroup. Analyses of parental status and history of pregnancy loss exclude missing responses*. The number of children was assessed among participants reporting having children**. Family planning concerns were assessed among participants reporting future reproductive intention***.

3.4.1. Physician-Initiated Reproductive Health Discussions

Engagement in physician-initiated reproductive health discussions was limited. Only 26.5% (n = 45) of the 170 participants reported that their rheumatologist had discussed the potential impact of disease on fertility or reproductive health, and 25.3% (n = 43) reported discussions regarding medication-related reproductive risks.

Notably, despite 52.4% (n = 89) of participants expressing a desire for future paternity, family planning discussions were initiated by physicians in only 17.1% (n = 29) of cases. Furthermore, only 32.4% (n = 55) of participants perceived that their rheumatologist adequately considered reproductive health concerns, while 56.5% (n = 96) remained uncertain (Figure 1).

Proportion of participants reporting physician-initiated discussions regarding the impact of disease and medications on reproductive health. Percentages are calculated based on available responses.

Figure 1.Frequency of physician-initiated discussions on disease- and medication-related reproductive health.

3.4.2. Patient-Initiated Discussions and Reported Barriers

Among the 170 respondents, only 30.0% (n = 51) reported initiating discussions regarding reproductive health with their rheumatologist.

Barriers to communication were frequently reported. The most common barrier was general discomfort in discussing reproductive health (34.1%, n = 58), followed by perceived lack of physician engagement (24.7%, n = 42). Physician gender-related discomfort was reported by 14.7% (n = 25) of participants, while cultural (8.8%, n = 15) and religious (2.9%, n = 5) barriers were less frequently cited (Figure 2).

Patient-reported barriers to initiating reproductive health discussions, including personal, physician-related, and sociocultural factors. Percentages are calculated based on available responses.

Figure 2. Patient-initiated reproductive health discussions and reported barriers to communication.