Anti-müllerian hormone and ovarian reserve in systemic lupus erythematosus

Potential factors result in diminished ovarian reserve: a comprehensive review

The ovarian reserve is defined as the quantity of oocytes stored in the ovary or the number of oocytes that can be recruited. Ovarian reserve can be affected by many factors, including hormones, metabolites, initial ovarian reserve, environmental problems, diseases, and medications, among others. With the trend of postponing of pregnancy in modern society, diminished ovarian reserve (DOR) has become one of the most common challenges in current clinical reproductive medicine. Attributed to its unclear mechanism and complex clinical features, it is difficult for physicians to administer targeted treatment. This review focuses on the factors associated with ovarian reserve and discusses the potential influences and pathogenic factors that may explain the possible mechanisms of DOR, which can be improved or built upon by subsequent researchers to verify, replicate, and establish further study findings, as well as for scientists to find new treatments.

Ovarian reserve in patients with multiple sclerosis: A systematic review and meta-analysis

OBJECTIVE

To summarize recent evidence about ovarian reserve markers in women affected by multiple sclerosis (MS) compared with healthy controls, as women with MS seem to be characterized by lower anti-Müllerian hormone (AMH) levels.

METHODS

The research was conducted using PubMed (MEDLINE), Scopus, ClinicalTrial.gov, OVID and Cochrane Library from inception of each database to June 30, 2022. Studies comparing ovarian reserve markers between women with MS and healthy controls were considered eligible for inclusion. The primary outcome was serum AMH (ng/mL) levels. Results were reported as pooled odds ratio (OR) for categorical outcomes and as mean difference (MD) for continuous variables, with their 95% confidence intervals (CIs). The random effect model of DerSimonian and Laird was adopted for all analyses. A P-value less than 0.05 was considered significant.

RESULTS

Serum AMH circulating levels were not significantly different (MD -0.25, 95% CI -0.83 to 0.32; P = 0.390), as well as blood levels of follicle-stimulating hormone or ovarian volume. However, antral follicle count (AFC) and estradiol blood levels were significantly lower, and luteinizing hormone (LH) levels were significantly higher in women with MS than in controls.

CONCLUSION

A significant difference in AFC, estradiol and LH levels was observed, but not for AMH levels.

A new insight into the impact of systemic lupus erythematosus on oocyte and embryo development as well as female fertility

Background

Systemic lupus erythematosus (SLE) is often associated with adverse reproductive outcomes. But it's currently unclear regarding the role of SLE in oocyte and embryonic development. Also, it's controversial whether SLE has an adverse effect on fertility. There is a lack of comprehensive understanding and assessment of fertility in patients with SLE.

Objective

This study was aim to investigate oocyte and embryonic development as well as ovarian reserve, and clinical outcomes in SLE patients during in vitro fertilization (IVF) treatment. By combining data on embryonic and gamete development in SLE patients, we hope to provide new insights into a comprehensive assessment of fertility in SLE patients.

Methods

In this study, we collected data from 34 SLE patients who were previously diagnosed and in remission for a total of 44 IVF cycles and matched 102 infertile women with a total of 148 IVF cycles by Propensity Score Matching (PSM) of 1:3 ratio. We then evaluated baseline characteristics, ovarian reserve, IVF laboratory outcomes, and clinical outcomes between the two groups.

Results

After PSM matching, baseline characteristics including age, infertility types, and duration, as well as infertility causes overall coincided between the two groups. Anti-müllerian hormone (AMH) was significantly lower in the SLE group vs comparison (1.9 vs. 3.3 ng/mL, P=0.001). The SLE group performed a significant reduction in available embryo rate (76.6% vs. 86.0%, P=0.001), good-quality blastocyst formation rate (35.1% vs. 47.0%, P=0.003), and blastocyst formation rate (51.0% vs. 67.7%, P=0.001) compared to the comparison. As for clinical outcomes, the implantation rate in the SLE group was notably lower (37.9% vs. 54.9%, P=0.022). The CLBR following every embryo-transfer procedure was distinctly lower (41.2% vs 64.7%, P=0.016) in the SLE group vs comparison. Also, the conservative and optimal CLBRs following every complete cycle procedure were significantly reduced in the SLE group vs the comparison (P=0.001, both).

Conclusion

Patients with SLE present worse outcomes in oocyte and embryonic development, thus yielding compromised female fertility and clinical pregnancy. Individualized fertility assessment and early fertility guidance are necessary for these special groups.

Efficacy and safety of total glucosides of paeony in the treatment of systemic lupus erythematosus: A systematic review and meta-analysis

Background: Total glucosides of paeony (TGP), extracted from the Chinese medicine Paeonia lactiflora Pall., have been proven to be effective in various autoimmune diseases. We aim to systematically evaluate the efficacy and safety of TGP combined with different conventional therapeutic agents in the treatment of systemic lupus erythematosus (SLE). Methods: Eight databases were searched for randomized controlled studies of TGP for SLE. The search time was set from the establishment of the databases to March 2022. The risk of bias was assessed by the Cochrane Evaluation Manual (5.1.0), RevMan 5.3 software was used for meta-analysis, and the certainty of the evidence was assessed by the GRADE methodology. Results: A total of 23 articles were included, including 792 patients overall in the treatment group and 781 patients overall in the control group. The meta-analysis results showed that TGP combined with conventional treatments was superior to the conventional treatments in reducing the SLE disease activity and the incidence of adverse reactions (SMD_TGP+GC+CTX = -1.98, 95% Cl = [-2.50, -1.46], p < 0.001; SMD_TGP+GC+HCQ = -0.65, 95% Cl = [-1.04, -0.26], p <0.001; SMD_TGP+GC+TAC = -0.94, 95% Cl = [-1.53, -0.34], p < 0.05; SMD_TGP+GC = -1.00, 95% Cl = [-1.64, -0.36], p < 0.05; and RR_TGP+GC+CTX = 0.37, 95% Cl = [0.21, 0.64], p < 0.001). The results also showed that TGP helped improve other outcomes related to SLE disease activity, such as complement proteins (C3 and C4), immunoglobulins (IgA, IgM and, IgG), ESR, CRP, 24 h urine protein, and recurrence rate. In addition, TGP may also be effective in reducing the average daily dosage of glucocorticoids (GCs) and the cumulative dosage of cyclophosphamide (CTX). The certainty of the evidence was assessed as moderate to low. Conclusion: TGP is more effective and safer when used in combination with different conventional therapeutic agents. It helped reduce the disease activity of SLE and the incidence of adverse reactions. However, we should be cautious about these conclusions as the quality of the evidence is poor. Future studies should focus on improving the methodology. High-quality randomized controlled trials (RCTs) will be necessary to provide strong evidence for the efficacy of TGP for SLE. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO, identifier CRD42021272481.

Lupus nephritis: new progress in diagnosis and treatment

Systemic lupus erythematosus (SLE) is a chronic multifactorial autoimmune disease that affects many organs, including the kidney. Lupus nephritis (LN) is a common manifestation characterized by heterogeneous clinical and histopathological findings, and often associates with poor prognosis. The diagnosis and treatment of LN is challenging, depending largely on renal biopsy, and there is no reliable non-invasive LN biomarker. Up to now, the complete remission rate of LN is only 20%∼30% after receiving six months of standard treatment, which is far from satisfactory. Moreover, adverse reactions to immunosuppressants, especially glucocorticoids, further compromise the prognosis of LN. Biological reagents targetting autoimmune responses and inflammatory pathways, bring hope to the treatment of intractable lupus. The European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) and KDIGO (Kidney Disease: Improving Global Outcomes) have been working on and launched the recommendations for the management of LN. In this review, we update our knowledge in the pathogenesis, diagnosis, and management of LN and prospect for the future potential targets in the management of LN.

Reproductive concerns and contributing factors in women of childbearing age with systemic lupus erythematosus

OBJECTIVES

Reproductive concerns are common in women of childbearing age with systemic lupus erythematosus (SLE) with inadequate disclosure. This study aimed to investigate the contributing factors of reproductive concerns and to evaluate their impact on health-related quality of life.

METHODS

One hundred eighty women of childbearing age with SLE were enrolled in this cross-sectional study in Affiliated Hospital of Nantong University from March 2021 to December 2021. A series of questionnaires were conducted: Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), the Hospital Anxiety and Depression Scale (HADS), the Multidimensional Fatigue Inventory (MFI-20), Female Sexual Distress Scale-Revised (FSDS-R), Family Assessment Device (APGAR), the Medical Coping Modes Questionnaire (MCMQ), the Short-Form 36 (SF-36), and the Chinese version of Reproductive Concerns After Cancer (RCAC). Independent t test, one-way ANOVA, Mann-Whitney U test, Pearson/Spearman, and multiple linear stepwise regression were used to analyze the data.

RESULTS

The results indicated that female SLE patients were more concerned about the child's health and personal health than becoming pregnant, fertility potential, partner disclose and acceptance; SLE patients with the characteristics of living in rural residence, having no reproductive history, fearing unexpected pregnancy, sexual distress, and depression showed more serious fertility concerns. Meanwhile, most female SLE patients adopted active confrontation when facing reproductive concerns, and these patients were significantly lower in the dimension score of mental related quality of life.

CONCLUSIONS

Our study demonstrated that female SLE patients should be paid more attention to their fertility concerns and effective intervention measures should be carried out to relieve their reproductive concerns, so as to improve their long-term quality of life if their disease condition permits.

Osteoarthritis Affects Mammalian Oogenesis: Effects of Collagenase-Induced Osteoarthritis on Oocyte Cytoskeleton in a Mouse Model

Known as a degenerative joint disorder of advanced age affecting predominantly females, osteoarthritis can develop in younger and actively working people because of activities involving loading and injuries of joints. Collagenase-induced osteoarthritis (CIOA) in a mouse model allowed us to investigate for the first time its effects on key cytoskeletal structures (meiotic spindles and actin distribution) of ovulated mouse oocytes. Their meiotic spindles, actin caps, and chromatin were analyzed by immunofluorescence. A total of 193 oocytes from mice with CIOA and 209 from control animals were obtained, almost all in metaphase I (M I) or metaphase II (MII). The maturation rate was lower in CIOA (26.42% M II) than in controls (55.50% M II). CIOA oocytes had significantly larger spindles (average 37 μm versus 25 μm in controls, p < 0.001), with a proportion of large spindles more than 64% in CIOA versus up to 15% in controls (p < 0.001). Meiotic spindles were wider in 68.35% M I and 54.90% M II of CIOA oocytes (mean 18.04 μm M I and 17.34 μm M II versus controls: 11.64 μm M I and 12.64 μm M II), and their poles were approximately two times broader (mean 6.9 μm) in CIOA than in controls (3.6 μm). CIOA oocytes often contained disoriented microtubules. Actin cap was visible in over 91% of controls and less than 20% of CIOA oocytes. Many CIOA oocytes without an actin cap had a nonpolarized thick peripheral actin ring (61.87% of M I and 52.94% of M II). Chromosome alignment was normal in more than 82% in both groups. In conclusion, CIOA affects the cytoskeleton of ovulated mouse oocytes—meiotic spindles are longer and wider, their poles are broader and with disorganized fibers, and the actin cap is replaced by a broad nonpolarized ring. Nevertheless, meiotic spindles were successfully formed in CIOA oocytes and, even when abnormal, allowed correct alignment of chromosomes.

Anti-Müllerian hormone concentration as an indicator of female general health status: a cross-sectional study

RESEARCH QUESTION

To evaluate the correlation between clinical and hormonal parameters and comorbidity burden in Caucasian women presenting for fertility treatment.

DESIGN

Monocentric cross-sectional study including a cohort of 3163 Caucasian women seeking medical care for fertility treatment. All patients underwent centralized laboratory testing for hormonal assessment. Complete clinical and laboratory data from the entire cohort were retrospectively analysed. Comorbidity burden score was assessed by the Charlson Comorbidity Index (CCI; categorized as 0 versus 1 versus ≥2).

RESULTS

Descriptive statistics and regression models tested the associations between clinical and laboratory parameters and CCI. Among the entire cohort of patients, a CCI = 0 was found in 2977 women (94.1%), and CCI = 1 and CCI ≥2 were found in 113 (3.6%) and 73 (2.3%) patients, respectively. Age (P = 0.009), gravidity (P = 0.001), anti-Müllerian hormone (AMH, P < 0.001) and TSH (P = 0.003) values were significantly different among CCI groups. In regression models, age at presentation and AMH emerged as independent indicators of CCI ≥ 1. Age at presentation <36 years (odds ratio [OR] 1.742, 95% confidence interval [CI] 1.284-2.364) and an AMH concentration ≤2.3 ng/ml (OR 1.864, 95% CI 1.29-2.69) were the most informative cut-off values for CCI ≥ 1 in the study population.

CONCLUSIONS

A younger age at presentation and lower AMH concentrations are significant independent indicators of decreased general health in women requiring clinical evaluation for fertility treatment. As observed for sperm parameters in men, AMH might serve as a proxy of women's general health status.

Pregnancy in patients with systemic lupus erythematosus after cyclophosphamide therapy

Systemic lupus erythematosus (SLE) often affects females of reproductive age and Cyclophosphamide, an alkylating agent leading to premature ovarian insufficiency (POF) and labelled category D for pregnancy is used as induction therapy for severe manifestations of lupus. There have been multiple case series reflecting variable outcomes of pregnancies after cyclophosphamide use for cancers and autoimmune diseases. With increasing maternal age, we have an increasing population of lupus patients who may wish to conceive after having received cyclophosphamide therapy. The objective of our study was to improve our understanding of the impact of cyclophosphamide exposure on fertility and pregnancy outcomes in patients with SLE.We retrospectively reviewed the charts of all patients who had received intravenous cyclophosphamide at our academic institute in the time period from 2000-2018 and identified 440 patients which included 157 female patients of reproductive age. There were 37 documented pregnancies after the cyclophosphamide infusion, of which 23 patients had successful outcomes; 4 elective abortion and 10 miscarriages. There were 17 patients who developed POF, of which 7 also had end stage renal disease. The average cumulative dose of cyclophosphamide in the patients who had successful pregnancy was 4080.37 mg compared to 2806.25 mg in those who had a miscarriage (p 0.164) and 5526.47 mg in those who developed POF (p 0.046). Using multiple regressions to evaluate risk factors impacting pregnancy outcomes, when taken as a set, the predictors including race, serological profile, exposure to steroids and Mycophenolate mofetil, age at cyclophosphamide infusion, age at pregnancy, and cumulative cyclophosphamide dose accounted for 46.29% of the variance in outcome of pregnancy (p 0.23) and 39.58% of the variance in development of premature ovarian failure (p 0.008). We noted statistical significance in the impact of maternal age at time of pregnancy (p 0.04) and duration of time between the last infusions to subsequent pregnancy (p 0.02) to pregnancy outcome.Our findings suggest that a longer time interval between the last cyclophosphamide infusion and subsequent pregnancy was favorable for a successful outcome and higher cumulative cyclophosphamide dose is more likely to be associated with premature ovarian failure.

Anti-Müllerian hormone in African-American women with systemic lupus erythematosus

OBJECTIVE

Women with SLE may experience ovarian insufficiency or dysfunction due to treatment or disease effects. Anti-Müllerian hormone (AMH), a marker of ovarian reserve, has been examined in small populations of women with SLE with conflicting results. To date, these studies have included very few African-American women, the racial/ethnic group at greatest risk of SLE.

METHODS

We enrolled African-American women aged 22-40 years diagnosed with SLE after age 17 from the Atlanta Metropolitan area. Women without SLE from the same area were recruited from a marketing list for comparison. AMH was measured in serum using the Ansh Labs assay (Webster, Texas, USA). We considered AMH levels <1.0 ng/mL and AMH <25th percentile of comparison women as separate dichotomous outcomes. Log-binomial regression models estimating prevalence ratios were adjusted for age, body mass index and hormonal contraception use in the previous year.

RESULTS

Our sample included 83 comparison women without SLE, 68 women with SLE and no history of cyclophosphamide (SLE/CYC-) and 11 women with SLE and a history of cyclophosphamide treatment (SLE/CYC+). SLE/CYC+ women had a greater prevalence of AMH <1.0 ng/mL compared with women without SLE (prevalence ratio (PR): 2.90, 95% CI: 1.29 to 6.51). SLE/CYC- women were also slightly more likely to have AMH <1.0 ng/mL (PR: 1.62, 95% CI: 0.93 to 2.82) than comparison women. Results were similar when considering AMH <25th percentile by age of comparison women.

CONCLUSIONS

Treatment with CYC is associated with low AMH in African-American women with SLE. SLE itself may also be associated with reduced AMH, but to a lesser extent.

Ovarian Reserve Assessment in Celiac Patients of Reproductive Age

Background

This study aimed to investigate ovarian reserve in patients of reproductive age with Celiac disease (CD) using anti-Müllerian hormone (AMH) levels, antral follicle counts (AFCs), and ovarian volume.

Material/Methods

We included into this study 46 CD female patients and 40 healthy female subjects of reproductive age, ages 18–45 years. Venous blood samples were taken from both groups on days 2–4 of the menstrual cycle, and follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E₂), prolactin (PRL), and AMH levels were measured. On the same day, AFCs and ovarian volumes were determined. Data on body mass index (BMI), gravidity/parity/abortions/alive counts, disease duration, and Marsh histological classification were recorded.

Results

There were no statistically significant differences between CD and control groups in terms of mean age, BMI, or median gravidity/parity/abortions/alive counts (p>0.05). Also, there were no statistically significant differences between the 2 groups in terms of mean FSH, LH, E₂, PRL levels, right and left ovarian volumes, and median right and left ovarian AFCs (p>0.05). However, AMH level was significantly lower in the CD group (p=0.032). No statistically significant correlation was found between AMH levels and age, BMI, FSH, LH, E₂, PRL levels, right and left ovarian volumes, right and left ovarian AFCs, or Marsh histological classification using the Spearman correlation test (p>0.05). However, an inverse correlation was detected showing that AMH levels decrease with increasing CD duration (r=−0.054, p=0.001).

Conclusions

We found that AMH level and ovarian reserve was decreased in CD patients of reproductive age compared to healthy controls, and that AMH level and ovarian reserve decreased with increasing disease duration in CD patients.