Systemic lupus erythematosus in women: impact on family size

Infertility in systemic lupus erythematosus: what rheumatologists need to know in a new age of assisted reproductive technology

Fertility is often a concern for women with SLE. In addition to known indirect factors that influence the ability of a woman with SLE to become pregnant, such as cytotoxic agents, other medications, advanced age and psychosocial effects of the disease, direct disease-related factors are believed to influence fertility. These include diminished ovarian reserve, menstrual irregularities (a function of disease activity) and the presence of antiphospholipid antibodies. The question of whether SLE intrinsically affects fertility, however, remains unanswered. In this review, we address known factors affecting fertility, assess current data regarding a direct impact of SLE on fertility and evaluate potential disease-related risk factors. We focus primarily on studies measuring anti-Müllerian hormone and antral follicle count, the most widely measured markers of ovarian reserve. Our goal is to provide information to rheumatologists faced with counselling patients with SLE regarding their fertility, family planning and options for assisted reproductive technologies, which now include fertility preservation through oocyte cryopreservation.

Pregnancy in patients with systemic lupus erythematosus: a systematic review

Systemic lupus erythematosus (SLE)-a most common disorder in women of reproductive age-has been described to be associated with adverse pregnancy outcomes. Despite the increased health risks for the mother (preeclampsia, lupus flare, arterial hypertension, gestational diabetes mellitus and thrombotic risk when antiphospholipid antibodies are present) and fetus (miscarriage, stillbirth, premature birth, intrauterine growth restriction and neonatal lupus), the majority of patients can deliver healthy neonates. With appropriate management by a multidisciplinary team, composing rheumatologists, obstetricians and neonatologists, women with SLE can achieve better pregnancy outcomes by monitoring associated predictive indicators, raising major concern for severe complications and somewhat early delivery if necessary. In this review, we summarize the latest advances in secondary infertility and pregnancy-related risk perception for lupus patients, with an emphasis on the safety of biological agents (mainly belimumab and rituximab) and traditional therapeutic regimens.

Systematic Review of the Impact of Inflammatory Arthritis on Intimate Relationships and Sexual Function

OBJECTIVE

To systematically review evidence of the impact of inflammatory arthritis on, or association of inflammatory arthritis with, intimate relationships and sexual function.

METHODS

Ovid Medline, Ovid PsycINFO, Ovid Embase, and EBSCO CINAHL databases were searched. Two independent reviewers selected articles, extracted data, and conducted manual searches of reference lists from included studies and previous reviews. The quality of evidence was assessed using standard risk-of-bias tools.

RESULTS

Fifty-five eligible studies were reviewed. Of these, 49 (89%) were quantitative, 5 (9.1%) were qualitative, and 1 (1.8%) used a mixed-method design. Few quantitative studies were rated as low risk of bias (n = 7 [14%]), many were rated as moderate (n = 37 [74%]) or high risk (n = 6 [12%]). Quantitative study sample sizes ranged from 10 to 1,272 participants, with a reported age range 32-63 years. Qualitative study sample sizes ranged from 8 to 57 participants, with a reported age range 20-69 years. In studies reporting the Female Sexual Function Index, all inflammatory arthritis groups demonstrated mean scores ≤26.55 (range of mean ± SD scores: 14.2 ± 7.8 to 25.7 ± 4.7), indicating sexual dysfunction. In studies reporting the International Index of Erectile Function, all inflammatory arthritis groups reported mean scores ≤25 (range of mean ± SD scores: 16.0 ± 5.3 to 23.8 ± 7.0), indicating erectile dysfunction. Key qualitative themes were impaired sexual function and compromised intimate relationships; prominent subthemes included inflammatory arthritis-related pain and fatigue, erectile dysfunction, diminished sexual desire, and sexual function fluctuations according to disease activity.

CONCLUSION

Sexual dysfunction appears highly prevalent among men and women with inflammatory arthritis, and increased clinician awareness of this impairment may guide provision of tailored education and support.

Use of combined hormonal contraceptives among women with systemic lupus erythematosus with and without medical contraindications to oestrogen

OBJECTIVES

To assess the prevalence of combined hormonal contraceptives (CHCs) in reproductive-age women with SLE with and without possible contraindications and to determine factors associated with their use in the presence of possible contraindications.

METHODS

This observational cohort study included premenopausal women ages 18-45 years enrolled in the SLICC Registry ⩽15 months after SLE onset, with annual assessments spanning 2000-2017. World Health Organization Category 3 or 4 contraindications to CHCs (e.g. hypertension, aPL) were assessed at each study visit. High disease activity (SLEDAI score >12 or use of >0.5 mg/kg/day of prednisone) was considered a relative contraindication.

RESULTS

A total of 927 SLE women contributed 6315 visits, of which 3811 (60%) occurred in the presence of one or more possible contraindication to CHCs. Women used CHCs during 512 (8%) visits, of which 281 (55%) took place in the setting of one or more possible contraindication. The most frequently observed contraindications were aPL (52%), hypertension (34%) and migraine with aura (22%). Women with one or more contraindication were slightly less likely to be taking CHCs [7% of visits (95% CI 7, 8)] than women with no contraindications [9% (95% CI 8, 10)].

CONCLUSION

CHC use was low compared with general population estimates (>35%) and more than half of CHC users had at least one possible contraindication. Many yet unmeasured factors, including patient preferences, may have contributed to these observations. Further work should also aim to clarify outcomes associated with this exposure.

Infertility - Prevention and Management

Infertility and subfertility, menstrual irregularities, and decreased parity may occur in women with autoimmune diseases due to multiple factors, including underlying inflammatory disease, gonadotoxic medications, and psychosocial issues related to living with chronic disease. Awareness of these factors, as well as validation and support of patients confronting reproductive challenges, is important for providing comprehensive care to these women. An understanding of the expanding options for fertility preservation strategies during gonadotoxic medications is essential. Referral to a reproductive endocrinology clinic is indicated in this patient population.

Characteristics related to early secondary amenorrhoea and pregnancy among women diagnosed with systemic lupus erythematosus: an analysis using the GOAL study

Objective

Systemic lupus erythematosus (SLE) disproportionately affects women and often develops during their reproductive years. Research suggests that some women who receive cyclophosphamide as treatment for SLE experience earlier decline in menstrual function, but reproductive health among women with SLE who have not taken this drug is less well understood. This study aims to better understand the relation between SLE and reproduction by assessing early secondary amenorrhoea and pregnancy in women treated with and without cyclophosphamide from a population-based cohort with large numbers of African-Americans.

Methods

Female patients with SLE, ages 20–40 at time of diagnosis, who were 40 years or older at the time of the survey were included in this analysis (N=147). Participants in the Georgians Organized Against Lupus (GOAL) study were asked about their reproductive histories including early secondary amenorrhoea, defined as loss of menstruation before age 40.

Results

Women who were cyclophosphamide naïve had an increased prevalence of early secondary amenorrhoea compared with population estimates, 13–17% compared with 1–5%. Factors associated with early secondary amenorrhoea in women not treated with cyclophosphamide were marital status and receipt of a kidney transplant. Treatment with cyclophosphamide doubled the prevalence after adjustment for patient characteristics. Over 88% of women reported being pregnant at least once, and about 83% of these had a child, but the majority of pregnancies occurred before diagnosis.

Conclusions

SLE diagnosed in early adulthood may affect women's reproductive health even if they are not treated with cyclophosphamide. Better understanding of other factors related to reproductive health in this population will improve clinicians' and patients' abilities to make treatment and family planning decisions.

Impact of Childbearing Decisions on Family Size of Korean Women with Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) predominantly affects women in their reproductive years and has a significant impact on childbearing. We investigated the influence of personal decision on family size among Korean women with SLE and factors that affect the decisions. A case-control study comparing childbearing history and decisions of 112 SLE patients and 135 controls was performed. Women with SLE participating in the Network for Lupus Clinical Research in South Korea and matching controls between ages of 18-45, who are/were married or living with a partner were included. Data regarding socio-demographics, reproductive history, and childbearing decisions were collected through a survey using a standardized questionnaire and medical record review. More women with SLE reported at least one pregnancy (85.7% vs. 71.9%, P = 0.009) or at least one live birth (85.7% vs. 71.9%, P = 0.003) compared with controls. Mean number of pregnancies was significantly higher (2.4 ± 1.6 vs. 1.4 ± 1.3, P < 0.001), and mean number of live births was significantly lower in women with SLE (1.2 ± 0.8 vs. 1.6 ± 0.8, P < 0.001). Significantly more women with SLE made the decision not to have children compared with controls (54.5% vs. 40.7%, P = 0.031), and health-related concerns were the major cause of the decision. Other socio-demographic factors did not influence the decision to limit childbearing in SLE women. The disease-related concerns had significant impact on family size and childbearing decisions among Korean women with SLE.

Fertility and pregnancy in rheumatoid arthritis and systemic lupus erythematosus

Background

Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are disorders that commonly impact reproductive aged women.

Findings

Both women with RA and SLE have smaller sized families than do controls. In the case of RA factors other than fertility contribute, while in women with SLE there may be diminished ovarian reserve due to cyclophosphamide therapy and advanced maternal age. RA pregnancies can be complicated by preterm birth and small-for-gestational aged infants. SLE pregnancies have higher rates of fetal loss, in particular in those patients with co-existing antiphospholipid syndrome. SLE pregnancies are also more likely to be complicated by pre-eclampsia and hypertension and to result in preterm birth and small-for-gestational aged infants.

Conclusion

Appropriate fertility evaluation and careful pregnancy planning with coordinated obstetrical care help ensure better outcomes in these patient populations.

Decreased live births in women with systemic lupus erythematosus

OBJECTIVE

Multiple disease-related factors may limit the number of children born to women with systemic lupus erythematosus (SLE). We calculated live births in women with SLE and compared this with general population rates.

METHODS

We studied women with SLE from a subset of centers participating in the Systemic Lupus International Collaborating Clinics Prospective Inception Cohort Study of SLE. Women diagnosed as having SLE before age 50 years were included. Using age, calendar-period, and country-specific general population birth rates, we calculated the standardized incidence ratio (SIR) of observed to expected live births. We also performed a multivariate analysis with the SIR as the dependent variable to explore potential predictors of live births.

RESULTS

A total of 339 women with SLE were studied. The number of live births over the interval (n = 313) was substantially below that which would be expected (n = 479; SIR 0.65, 95% confidence interval [95% CI] 0.58-0.73). In the multivariate analyses, black race/ethnicity (SIR 1.47, 95% CI 1.08-2.00) and being married or living common-law (SIR 2.04, 95% CI 1.52-2.74) were associated with increased live births (relative to what would be expected). There were trends for fewer live births in women exposed to cyclophosphamide (SIR 0.88, 95% CI 0.56-1.38) and in those with high disease activity (mean SLE Disease Activity Index 2000 update score ≥5; SIR 0.82, 95% CI 0.54-1.25).

CONCLUSION

Overall, we found that women with SLE have fewer live births compared with the general population. Marital status, race/ethnicity, and possibly clinical factors may mediate this effect.

Managing pregnancy in inflammatory rheumatological diseases

Historically, pregnancy in women with many inflammatory rheumatic diseases was not considered safe and was discouraged. Combined care allows these pregnancies to be managed optimally, with the majority of outcomes being favorable. Disease activity at the time of conception and anti-phospholipid antibodies are responsible for most complications. Disease flares, pre-eclampsia, and thrombosis are the main maternal complications, whereas fetal loss and intrauterine growth restriction are the main fetal complications. Antirheumatic drugs used during pregnancy and lactation to control disease activity are corticosteroids, hydroxychloroquine, sulphasalzine, and azathioprine. Vaginal delivery is possible in most circumstances, with cesarean section being reserved for complications.

Systemic Lupus and Risk of Restless Legs Syndrome

Objective.

To determine the prevalence of restless legs syndrome (RLS) in women with systemic lupus erthythematosus (SLE), and to compare this to a rheumatic disease sample without SLE.

Methods.

Unselected consecutive female patients were SLE were recruited from a lupus clinic. A RLS questionnaire based on 4 criteria, validated by the International Restless Legs Syndrome Study Group, was administered during a face-to-face interview. Smoking history and height and weight data were collected. Similar methods were used to determine RLS prevalence in a comparator group of women with rheumatic diseases other than SLE. Controls were frequency-matched by age group (in 5-year age bands) to SLE subjects. Controls were otherwise unselected.

Results.

We recruited 33 women with SLE and 32 controls. Twelve of 33 female SLE subjects scored positively for RLS (37.5%; 95% CI 22.9, 54.7) compared to 4 of 32 controls (12.5%; 95% CI 5.0, 28.1). Multivariate logistic regression showed that adjusted for age, obesity, and smoking, women with SLE were more likely to have RLS than the female controls (adjusted odds ratio 6.61, 95% CI 1.52, 28.77). In our multivariate analyses of all rheumatic patients, including SLE, the adjusted OR for obesity and RLS was 5.14 (95% CI 1.07, 24.6).

Conclusion.

These novel data indicate that RLS is more prevalent in women with SLE than in controls. Although obesity was a significant risk factor for RLS in our sample, the predictive covariates examined were limited.

Management of rheumatic diseases during pregnancy

Systemic rheumatic diseases commonly affect women during the childbearing years. Many women with these diseases may be contemplating pregnancy or discover an inadvertent pregnancy, leading to concerns regarding medication use, changes in disease activity during pregnancy, safety of lactation, and future ability to care for a child given the presence of chronic illnesses. There are outstanding reviews that summarize the safety and use of immunosuppressive medications during pregnancy. However, in addition to medication use, providers need to be aware of the available data regarding fertility, pregnancy outcomes, delivery, and lactation issues that may be specific to individual diseases. Optimally, women should plan pregnancies to occur around times of disease quiescence, several months after potentially teratogenic medications have been discontinued. The course of the underlying rheumatic disease during pregnancy is variable, and there are no specific clinical or laboratory variables that consistently predict disease improvement or worsening during pregnancy. Recent data suggest that increased disease activity in women with most autoimmune diseases during pregnancy may lead to increased risk of premature delivery, low-birth-weight infants, and other adverse pregnancy outcomes. Arthritis involving the cervical spine and hips may impact delivery and must be considered by both obstetricians and obstetric anesthesiologists. Data are mixed regarding the impact of breastfeeding on underlying autoimmune diseases; the choice to continue breastfeeding is a personal decision.