Pregnancy and Rheumatic Diseases

M. Gayed; C. Gordon

Disclosures

Rheumatology. 2007;46(11):1634-1640. 

In This Article

Fertility

SLE, RA, the vasculitides and the spondyloarthropathies are not known to directly affect fertility. Although SLE patients are as fertile as the general population, with a reported pregnancy rate of 2.0 to 2.4 pregnancies per patient during remission and active disease, studies comparing fertility before and after a diagnosis of SLE have found that fertility dropped significantly when compared with the control group, from 3.4% to 2.1%.[2] There is a reported reduced fertility rate in patients with active disease who are treated with high dose corticosteroid therapy, as menstrual irregularities and anovulatory cycles may occur. End-stage renal failure secondary to lupus nephritis can result in amenorrhoea.[3] Amenorrhoea in renal patients may also be due to ovarian failure secondary to cyclophosphamide or it may be of autoimmune origin.

The risk of ovarian failure in SLE and vasculitis patients due to cyclophosphamide therapy is dependant on the route of administration, age of the woman at the start of therapy and the cumulative dose of cyclophosphamide.[3,4] Females under the age of 26 yrs including prepubertal girls are less likely to develop premature ovarian failure than women who start cyclophosphamide treatment at a later age.[4] The reported frequency of premature ovarian failure in patients receiving cyclophosphamide treatment for severe lupus nephritis over the last two decades has ranged from 11 to 59%.[3] Although not often used, a recent study showed that treatment with synthetic Gonadotropin Releasing Hormone (GnRH) whilst receiving cyclophosphamide significantly reduced the risk of premature ovarian failure, as only 5% of the GnRH-treated group developed ovarian failure, in contrast to 30% of the control group.[5] Further efforts at preserving fertility in women receiving cyclophosphamide therapy have been tried using the combined oral contraceptive, but there has been no supportive data and it may increase the risk of flares in lupus patients.[5]

Although APS is not generally thought to cause infertility, antiphospholipid antibodies may be associated with infertility but the precise underlying mechanism has yet to be determined.[6,7] APS is also associated with a risk of ovarian vein thrombosis, which can affect fertility.[8]

There is no direct evidence that primary Sjögren's syndrome is associated with a reduced fertility rate, but an association between endometriosis and Sjögren's syndrome has been demonstrated, which may affect fertility depending on severity.[9] In one study, 5.9% of women affected with primary Sjögren's syndrome chose not to have children due to their connective tissue disease, but those who made the decision to have children were not found to have a reduced fertility rate, which concords with previous studies.[9,10] There is no evidence that there is a significant difference in fertility between healthy controls and systemic sclerosis,[11] but as with primary Sjögren's syndrome, there are few data as women often present after the reproductive period.

Ovulation Induction

Ovulation induction and in vitro fertilization (IVF) have provided further insight into how hormonal manipulation can affect rheumatic diseases such as SLE and APS. There is a reported increased risk fetal and maternal complications when undergoing ovulation induction and IVF, such as lupus flares and ovarian hyper stimulation that has led some women to opt for surrogacy.[6] There is also a risk of thrombosis in women with APS undergoing ovarian induction,[12] associated with the oestrogen surge but this is less than that associated with the levels of oestrogen in later pregnancy.[13] Thus women should be counselled appropriately of these risks before embarking on ovulation induction.

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