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Mao R, Wang X, Long R, Wang M, Jin L, Zhu L. A new insight into the impact of systemic lupus erythematosus on oocyte and embryo development as well as female fertility. Front Immunol 2023; 14:1132045. [PMID: 37033965 PMCID: PMC10076658 DOI: 10.3389/fimmu.2023.1132045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/14/2023] [Indexed: 04/11/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Lei Jin
- *Correspondence: Lixia Zhu, ; Lei Jin,
| | - Lixia Zhu
- *Correspondence: Lixia Zhu, ; Lei Jin,
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Giambalvo S, Garaffoni C, Silvagni E, Furini F, Rizzo R, Govoni M, Bortoluzzi A. Factors associated with fertility abnormalities in women with systemic lupus erythematosus: a systematic review and meta-analysis. Autoimmun Rev 2022; 21:103038. [PMID: 34995765 DOI: 10.1016/j.autrev.2022.103038] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/01/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fertility is thought to be not affected in women with systemic lupus erythematosus (SLE), however disease-related factors, psychosocial effects of chronic disease, as well as medications exposure might impair gonadal function. OBJECTIVE This systematic literature review (SLR) aimed to explore clinical, hormonal, serological and treatment factors associated with fertility outcomes in women of childbearing age with SLE. METHODS This SLR was conducted following the Preferred Reporting Items for systematic reviews and Meta-analysis (PRISMA) statement. All articles available in English (1972 - 30th April 2021) in Pubmed, EMBASE, Scopus and Cochrane Library were screened. Study selection and data collection were performed by two independent reviewers. All data were extracted using a standardized template. The risk of bias of the included studies was assessed using the NIH risk-of-bias tool. RESULTS Of 789 abstracts evaluated, we included in this review 46 studies, of which 1 SLR, 16 cross-sectional studies, 18 cohort studies, 10 observational studies and 1 case-series, with data pertaining to 4704 patients (mean age 31.5 ± 3.7 years, disease duration 83.27 ± 38.3 months). Definitions of premature ovarian failure (POF) adopted in the studies varied in terms of the number of months of amenorrhea considered and the age of onset of amenorrhea. Clinical factors associated with the development of POF were older age at the time of initiation of therapy, and older age at the onset of SLE disease. Cyclophosphamide exposure (CYC) and its cumulative dose influenced gonadal function in SLE women, leading to amenorrhoea and POF, as reported in 19 studies. Mycophenolate, azathioprine, calcineurin inhibitors and steroids associated with a lower risk of POF compared to CYC. POF was less frequent in patients co-treated with CYC and gonadotropin-releasing hormone analogues (GnRH-a) compared with patients not receiving GnRH-a (risk ratio 0.798, 95%-CI [0.1417; 0.5525]). 11 studies evaluated the impact of damage accrual and disease activity on ovarian reserve with conflicting evidence. Finally, 18 studies investigated exposure to hormonal and serological factors and, among others, neither Anti-Müllerian Hormone nor anti-corpus luteum antibodies were associated with POF. CONCLUSION The strongest evidence regarding management factors associated with fertility in SLE women of childbearing age remains the treatment with CYC, as well as its cumulative dosage. Hormonal and serological factors appeared not to impact fertility outcomes, but they might be used as a surrogate of fertility, especially during the treatment with disease-specific drugs.
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Affiliation(s)
- S Giambalvo
- Unit of Rheumatology, Department of Medical Sciences, University of Ferrara, Azienda Ospedaliera-Universitaria Sant'Anna of Ferrara, Italy
| | - C Garaffoni
- Unit of Rheumatology, Department of Medical Sciences, University of Ferrara, Azienda Ospedaliera-Universitaria Sant'Anna of Ferrara, Italy
| | - E Silvagni
- Unit of Rheumatology, Department of Medical Sciences, University of Ferrara, Azienda Ospedaliera-Universitaria Sant'Anna of Ferrara, Italy
| | - F Furini
- Unit of Rheumatology, Ospedale Maggiore, Bologna, Italy
| | - R Rizzo
- Department of Chemical, Pharmaceutical and Agricultural Science, University of Ferrara, Italy
| | - M Govoni
- Unit of Rheumatology, Department of Medical Sciences, University of Ferrara, Azienda Ospedaliera-Universitaria Sant'Anna of Ferrara, Italy
| | - A Bortoluzzi
- Unit of Rheumatology, Department of Medical Sciences, University of Ferrara, Azienda Ospedaliera-Universitaria Sant'Anna of Ferrara, Italy.
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3
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Karvonen-Gutierrez CA, Leis A. Impact of menopause on women with systemic lupus erythematosus. Maturitas 2021; 154:25-30. [PMID: 34736577 DOI: 10.1016/j.maturitas.2021.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 09/05/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by chronic and systemic inflammation affecting multiple organ systems, including an increased risk of cardiovascular disease due to the SLE-associated hyperinflammatory state. SLE shows a strong female predominance, suggesting a potential role of sex hormones in the pathogenesis of the disease. Evidence suggests an earlier age of menopause among women with SLE, despite mixed findings regarding other markers of ovarian aging. In healthy populations, the menopausal transition is associated with important physiologic changes resulting in increased cardiometabolic risk and risk of osteoporosis. Thus, women with SLE who experience the inflammatory effects of the autoimmune condition combined with the (potentially earlier) menopausal transition may represent a particularly vulnerable group of individuals during a particular window of time. Little is known, however, about strategies for cardiovascular risk or bone loss mitigation in women with SLE during the menopausal transition. Further, despite lack of knowledge regarding the burden of menopausal symptoms in women with SLE, existing recommendations provide only cautionary guidance for the use of hormone replacement therapy to address menopausal symptoms in this population. Importantly, the data regarding both SLE and menopause-associated cardiovascular and osteoporotic risk demonstrate the critical need for additional research to identify the type and timing of treatments or interventions needed to best mitigate this increased risk.
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Affiliation(s)
- Carrie A Karvonen-Gutierrez
- Department of Epidemiology, University of Michigan School of Public Health-I, 1415 Washington Heights, Room 6618, Ann Arbor, MI, United States.
| | - Aleda Leis
- Department of Epidemiology, University of Michigan School of Public Health-I, 1415 Washington Heights, Room 6618, Ann Arbor, MI, United States
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Morales-Martínez FA, Salas-Castro C, García-Garza MR, Valdés-Martínez O, García-Luna SM, Garza-Elizondo M, Vidal-Gutiérrez O, Saldívar-Rodríguez D, Sordia-Hernández LH. Evaluation of the Ovarian Reserve in Women With Systemic Lupus Erythematosus. J Family Reprod Health 2021; 15:38-44. [PMID: 34429735 PMCID: PMC8346742 DOI: 10.18502/jfrh.v15i1.6076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective: Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disorder where the disease activity itself and the medications used for its treatment, may have adverse effects on ovarian function. This study aimed to assess the ovarian reserve (OR) in SLE patients. Materials and methods: The anti-müllerian hormone (AMH) and the antral follicle count (AFC), two markers to evaluate the OR was assessed in 64 SLE patients and compared to normal individuals. Additionally, we assessed whether the disease per se or the pharmacological treatments affect the OR. Results: Patients with SLE displayed alterations in the OR regardless of the presence of alterations of the menstrual cycle. The AFC and AMH were significantly lower in SLE patients with and without menstrual alterations when compared to control individuals (p<0.0001). However, the AFC and AMH levels were significantly correlated (p=0.006) in the SLE patients with menstrual alterations. Except for hydroxychloroquine that was statistically higher in SLE patients with menstrual alterations (p=0.04), the cumulative dose for cyclophosphamide, corticosteroid, and methotrexate was similar in SLE patients regardless of the occurrence of menstrual alterations. Conclusion: The monitoring of AMH and AFC in SLE patients should be used to detect the rapid and irreversible decline of the OR to provide a possibility of pregnancy to the SLE patients.
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Affiliation(s)
- Felipe Arturo Morales-Martínez
- University Center of Reproductive Medicine, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Celina Salas-Castro
- University Center of Reproductive Medicine, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Manuel Rolando García-Garza
- University Center of Reproductive Medicine, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Otto Valdés-Martínez
- University Center of Reproductive Medicine, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Selene Marysol García-Luna
- University Center of Reproductive Medicine, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Mario Garza-Elizondo
- Reumatology ward, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Oscar Vidal-Gutiérrez
- Departament of Gynecology and Obstetrics, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Donato Saldívar-Rodríguez
- Departament of Gynecology and Obstetrics, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
| | - Luis Humberto Sordia-Hernández
- University Center of Reproductive Medicine, Dr. José Eleuterio González Hospital, Free University of New León, Monterrey, Mexic
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5
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Blomjous BS, Johanna I P DV, Zijlstra E, Cramer K, Voskuyl AE, Bultink AIEM. Desire to have children and preferences regarding to pre-pregnancy counselling in women with SLE. Rheumatology (Oxford) 2021; 60:2706-2713. [PMID: 33241288 PMCID: PMC8489423 DOI: 10.1093/rheumatology/keaa684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 09/17/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Pre-pregnancy counselling in women with systemic lupus erythematosus (SLE) is important in order to improve knowledge on the risks of pregnancy and to optimize pregnancy outcomes. Knowledge on the preferences of women with SLE regarding pre-pregnancy counselling have not yet been studied. In a closely monitored cohort of women with SLE we enquired about the present status of their wish to have children, and wish for and experiences with pre-pregnancy counselling. METHODS A questionnaire developed by physicians in collaboration with two women with SLE was sent to all (n = 177) women participating in the Amsterdam SLE cohort. The questionnaire comprised 32 items, of which 15 focused on the above-mentioned three themes. RESULTS A total of 124 women (70%) returned the questionnaire. The median disease duration was 13 years (interquartile range 9-19). Childlessness occurred in 51 women and 31% declared this was due to SLE [conscious decision (21%), stringent medical advice (6%), infertility due to medication (4%)]. Half of the women preferred the first pre-pregnancy counselling immediately after the SLE diagnosis (53%), together with their partner (69%). Information given by healthcare providers (81%) was preferred over information provided via brochures (35%) or the internet (26%). Pre-pregnancy face-to-face counselling from a rheumatologist and/or gynaecologist separately was preferred in 54%. CONCLUSION One-third of women attributed their childlessness to SLE-related reasons. Pre-pregnancy counselling was preferred shortly after the onset of the disease in a non-multidisciplinary setting. The results of this study underline the importance of timely pre-conceptional counselling by healthcare providers on fertility, risks and pregnancy outcomes in women with SLE.
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Affiliation(s)
- Birgit S Blomjous
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and immunology Center, Amsterdam Infection & Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - de Vries Johanna I P
- Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Kyra Cramer
- Patient Research Partner, Amsterdam, The Netherlands
| | - Alexandre E Voskuyl
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and immunology Center, Amsterdam Infection & Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - And Irene E M Bultink
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and immunology Center, Amsterdam Infection & Immunity, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Anderson RA, Amant F, Braat D, D'Angelo A, Chuva de Sousa Lopes SM, Demeestere I, Dwek S, Frith L, Lambertini M, Maslin C, Moura-Ramos M, Nogueira D, Rodriguez-Wallberg K, Vermeulen N. ESHRE guideline: female fertility preservation. Hum Reprod Open 2020; 2020:hoaa052. [PMID: 33225079 PMCID: PMC7666361 DOI: 10.1093/hropen/hoaa052] [Citation(s) in RCA: 254] [Impact Index Per Article: 63.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/02/2020] [Indexed: 12/15/2022] Open
Abstract
STUDY QUESTION What is the recommended management for women and transgender men with regards to fertility preservation (FP), based on the best available evidence in the literature? SUMMARY ANSWER The ESHRE Guideline on Female Fertility Preservation makes 78 recommendations on organization of care, information provision and support, pre-FP assessment, FP interventions and after treatment care. Ongoing developments in FP are also discussed. WHAT IS KNOWN ALREADY The field of FP has grown hugely in the last two decades, driven by the increasing recognition of the importance of potential loss of fertility as a significant effect of the treatment of cancer and other serious diseases, and the development of the enabling technologies of oocyte vitrification and ovarian tissue cryopreservation (OTC) for subsequent autografting. This has led to the widespread, though uneven, provision of FP for young women. STUDY DESIGN SIZE DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 November 2019 and written in English were included in the review. PARTICIPANTS/MATERIALS SETTING METHODS Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE This guideline aims to help providers meet a growing demand for FP options by diverse groups of patients, including those diagnosed with cancer undergoing gonadotoxic treatments, with benign diseases undergoing gonadotoxic treatments or those with a genetic condition predisposing to premature ovarian insufficiency, transgender men (assigned female at birth), and women requesting oocyte cryopreservation for age-related fertility loss.The guideline makes 78 recommendations on information provision and support, pre-FP assessment, FP interventions and after treatment care, including 50 evidence-based recommendations-of which 31 were formulated as strong recommendations and 19 as weak-25 good practice points and 3 research only recommendations. Of the evidence-based recommendations, 1 was supported by high-quality evidence, 3 by moderate-quality evidence, 17 by low-quality evidence and 29 by very low-quality evidence. To support future research in the field of female FP, a list of research recommendations is provided. LIMITATIONS REASONS FOR CAUTION Most interventions included are not well studied in FP patients. As some interventions, e.g. oocyte and embryo cryopreservation, are well established for treatment of infertility, technical aspects, feasibility and outcomes can be extrapolated. For other interventions, such as OTC and IVM, more evidence is required, specifically pregnancy outcomes after applying these techniques for FP patients. Such future studies may require the current recommendations to be revised. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in female FP, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in FP. STUDY FUNDING/COMPETING INTERESTS The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. R.A.A. reports personal fees and non-financial support from Roche Diagnostics, personal fees from Ferring Pharmaceuticals, IBSA and Merck Serono, outside the submitted work; D.B. reports grants from Merck Serono and Goodlife, outside the submitted work; I.D. reports consulting fees from Roche and speaker's fees from Novartis; M.L. reports personal fees from Roche, Novartis, Pfizer, Lilly, Takeda, and Theramex, outside the submitted work. The other authors have no conflicts of interest to declare. DISCLAIMER This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at www.eshre.eu/guidelines.) †ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.
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Affiliation(s)
| | - Richard A Anderson
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Frédéric Amant
- Department of Gynaecological Oncology, Academic Medical Centres Amsterdam, Amsterdam, The Netherlands.,Department of Gynaecology, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Oncology, Catholic University Leuven, Leuven, Belgium
| | - Didi Braat
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Arianna D'Angelo
- Wales Fertility Institute, Swansea Bay Health Board, University Hospital of Wales, Cardiff University, Cardiff, UK
| | | | - Isabelle Demeestere
- Fertility Clinic, CUB-Hôpital Erasme and Research Laboratory on Human Reproduction, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Lucy Frith
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Matteo Lambertini
- Department of Medical Oncology, U.O.C Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
| | | | - Mariana Moura-Ramos
- Reprodutive Medicine Unit, Unit of Clinical Psychology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,University of Coimbra, Center for Research in Neuropsychology and Cognitive and Behavioral Intervention, Coimbra, Portugal
| | - Daniela Nogueira
- Laboratory of Reproductive Biology, INOVIE Fertilité Clinique Croix du Sud, Toulouse, France
| | - Kenny Rodriguez-Wallberg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Division of Gynaecology and Reproduction, Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Nathalie Vermeulen
- European Society of Human Reproduction and Embryology, Central Office, Grimbergen, Belgium
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Angley M, Spencer JB, Lim SS, Howards PP. Anti-Müllerian hormone in African-American women with systemic lupus erythematosus. Lupus Sci Med 2020; 7:e000439. [PMID: 33132225 PMCID: PMC7607611 DOI: 10.1136/lupus-2020-000439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/18/2020] [Accepted: 10/01/2020] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Meghan Angley
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jessica B Spencer
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - S Sam Lim
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Division of Rheumatology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Penelope P Howards
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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8
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Angley M, Lim SS, Spencer JB, Howards PP. Infertility Among African American Women With Systemic Lupus Erythematosus Compared to Healthy Women: A Pilot Study. Arthritis Care Res (Hoboken) 2020; 72:1275-1281. [PMID: 31282105 PMCID: PMC6946885 DOI: 10.1002/acr.24022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/02/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Some treatments for systemic lupus erythematosus (SLE) can cause infertility, but the effect of SLE itself on fertility, particularly in African American women, is less clear. We undertook this study to examine infertility experiences in African American women with SLE compared to healthy women. METHODS We enrolled women ages 22-40 years living in the Atlanta metropolitan area who were diagnosed with SLE after age 17 years. Women who had ever been treated with cyclophosphamide or who had a hysterectomy were excluded. African American women ages 22-40 years who were from the same area and recruited from a marketing list were used for comparison. Women were interviewed about their reproductive histories and goals. Periods of infertility were identified as times when women had regular, unprotected sex for ≥12 months without conceiving after 20 years of age. We separately considered any period of infertility and periods of infertility when attempting pregnancy. We used Cox proportional hazards regression to examine the association between SLE and time to infertility. Models were adjusted for age, nulliparity, and smoking. An age-matched analysis was also conducted to examine periods of infertility occurring after SLE diagnosis. RESULTS Our sample included 75 women with SLE and 154 women without SLE. SLE was associated with any infertility (adjusted hazard ratio [HRadj ] 2.08 [95% confidence interval (95% CI) 1.38-3.15]), but less so with infertility when attempting pregnancy (HRadj 1.30 [95% CI 0.62-2.71]). The matched analysis generated similar point estimates. CONCLUSION Women with SLE may be more likely to experience episodes of infertility, but this may not translate to an inability to meet reproductive goals.
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Affiliation(s)
- Meghan Angley
- Department of Epidemiology, Rollins School of Public Health, Emory University
| | - S. Sam Lim
- Department of Epidemiology, Rollins School of Public Health, Emory University
- Department of Medicine, Division of Rheumatology, Emory University School of Medicine
| | - Jessica B. Spencer
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine
| | - Penelope P. Howards
- Department of Epidemiology, Rollins School of Public Health, Emory University
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9
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Sharma SK, Jain S, Bahl P, Potturi P, Rathi M, Naidu S, Sachdeva N, Dhir V, Jain S. Ovarian dysfunction with moderate-dose intravenous cyclophosphamide (modified NIH regimen) and mycophenolate mofetil in young adults with severe lupus: a prospective cohort study. Arthritis Res Ther 2020; 22:189. [PMID: 32799907 PMCID: PMC7429750 DOI: 10.1186/s13075-020-02292-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/07/2020] [Indexed: 01/22/2023] Open
Abstract
Background Ovarian toxicity is a dreaded complication of cyclophosphamide (CYC). With the use of lower cumulative doses of intravenous CYC (modified NIH regimens) and availability of better markers of ovarian toxicity, the incidence of ovarian dysfunction needs reassessment. Lupus disease activity, by itself, is also believed to affect ovarian function negatively. Methods This single-centre prospective cohort study recruited 50 female patients of severe lupus aged 18–40 years. Twenty-five patients each received induction with either monthly intravenous CYC (0.5–0.75 g/m2) for 6–9 months or daily oral mycophenolate mofetil (MMF). Details of menstrual irregularities; serum levels of FSH, LH, estradiol, AMH, and inhibin B; and sonographic assessment of ovarian volume and antral follicular count were done at baseline and 6 months after treatment. Amenorrhoeic patients were re-evaluated at 1 year. Results Mean (SD) age of subjects in the CYC and MMF groups was 31.4 (6.3) and 28.4 (4.4) years, respectively. Mean (SD) SLEDAI at the initiation of therapy was 7.2 (2.5) in the CYC group and 5.8 (3.4) in the MMF group. The mean cumulative dose of CYC used was 4.6 (1.8) g. Three patients in the CYC group (versus none in MMF) had amenorrhoea at 6 months—two of these regained menses within 6 months, while only one (4%) developed sustained amenorrhoea (lasting more than 12 months) at 41 years of age, likely menopause. Serum FSH levels increased (p = 0.03), while AMH (p = 0.002) and inhibin B (p < 0.001) levels decreased significantly with 6 months of CYC therapy. Ovarian volume also reduced significantly (p = 0.005) with 6 months of CYC therapy, while antral follicular count reduced numerically (p = 0.32). Levels of AMH, inhibin-B, estradiol, ovarian volume, and antral follicular count after 6 months therapy were significantly lesser in the CYC group compared to the MMF group, despite being similar before the start of therapy. Conclusions Ovarian dysfunction with monthly intravenous CYC (modified NIH regimen) was predominantly subclinical, with a negative effect on ovarian reserve. No premature ovarian failure was noted at 1 year. No ovarian dysfunction occurred in the MMF group, despite having patients with severe background lupus. Use of intravenous CYC for induction may thus not be restricted in young lupus females with incomplete families for fear of gonadotoxicity, especially in life- or organ-threatening situations, where the benefits outweigh this subclinical risk.
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Affiliation(s)
- Shefali Khanna Sharma
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Siddharth Jain
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pooja Bahl
- Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pragna Potturi
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shankar Naidu
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naresh Sachdeva
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Clinical Immunology and Rheumatology Division, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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10
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Kadiroğulları P, Demir E, Bahat PY, Kıyak H, Seckin KD. Evaluation of relationship between HbA1c levels and ovarian reserve in patients with type 1 diabetes mellitus. Gynecol Endocrinol 2020; 36:426-430. [PMID: 31909635 DOI: 10.1080/09513590.2019.1708893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
In organ or non-organ-specific autoimmune disorders, human ovary is usually the target of the autoimmune attack. We aimed to demonstrate the correlation between ovarian reserve and DM1, based on the view that women with type-1 diabetes mellitus (DM1) will have lower AMH levels secondary to poor glycemic control and autoimmune attacks. Ovarian functions of 42 patients diagnosed with DM1 who use insulin and 65 healthy volunteers were analyzed. Basal hormone and AMH levels were measured during the follicular phase. Fasting and postprandial blood glucose concentrations, HbA1c and C-peptide levels were evaluated. The mean antral follicle count (AFC) was significantly lower in DM1 patients than in healthy controls (p = .001). The AMH levels were lower in women with DM1 than in the controls (p = .001). The HbA1c values of DM1 patients, who formed the study group, was significantly higher than the control group. Ovarian reserve that is evaluated with serum AMH level is affected by poor glycemic control in type 1 diabetes. Due to the time of the autoimmune damage in the ovaries and the observable effects of this damage, more comprehensive and longer-term studies are needed to be conducted for the follow-up of reproductive abnormalities.
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Affiliation(s)
- Pınar Kadiroğulları
- Department of Obstetrics and Gynecology, Istanbul Health Sciences University, Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
| | - Esra Demir
- Department of Internal Medicine, Istanbul Health Sciences University, Kanuni Sultan Süleyman Research and Training Hospital, Istanbul, Turkey
| | - Pinar Yalcin Bahat
- Department of Obstetrics and Gynecology, Istanbul Health Sciences University, Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
| | - Huseyin Kıyak
- Department of Obstetrics and Gynecology, Istanbul Health Sciences University, Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
| | - Kerem Doga Seckin
- Department of Obstetrics and Gynecology, Istanbul Health Sciences University, Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
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11
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Luong SN, Isaacs A, Liu Z, Sin FE, Giles I. A systematic review and meta-analysis of the gonadotoxic effects of cyclophosphamide and benefits of gonadotropin releasing hormone agonists (GnRHa) in women of child-bearing age with autoimmune rheumatic disease. Expert Rev Clin Immunol 2020; 16:321-333. [PMID: 32005081 DOI: 10.1080/1744666x.2020.1724091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objectives: To systematically review risk of sustained amenorrhea with intravenous (IV) cyclophosphamide in autoimmune rheumatic disease (ARD), and evaluate efficacy of gonadotropin-releasing hormone agonists (GnRHa) to reduce this risk.Methods: Systematic search for papers reporting incidence of sustained amenorrhea ≥12 months in ARD following: IV cyclophosphamide; or GnRHa and IV cyclophosphamide compared to IV cyclophosphamide alone.Results: From 31 articles and 1388 patients (mean age 27.7 years) sustained amenorrhea occurred in 273 patients (19.7%). Of 56 patients (mean age range 23.9-25.6 years) receiving GnRHa and IV cyclophosphamide, and 37 controls (mean age range 25-30.1 years) given IV cyclophosphamide only, sustained amenorrhea occurred in 2/56 (3.6%) patients treated with GnRHa, compared to 15/37 (40.5%) controls. Pooled odds ratio of sustained amenorrhea with GnRHa and cyclophosphamide versus cyclophosphamide alone was 0.054 (95% CI 0.0115-0.2576 p < 0.001), corresponding to a number needed to treat of 2.7 (95% CI 1.955-4.388) and absolute risk reduction of 36.95% (95% CI 35.6-38.4%).Conclusion: Sustained amenorrhea with IV cyclophosphamide was observed in patients with ARD, especially with increasing age and cumulative doses >5 g. GnRHa reduced this risk and should be considered with IV cyclophosphamide in women of childbearing age with ARD.
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Affiliation(s)
- Shi-Nan Luong
- Department of Rheumatology, University College London Hospital, London, UK.,Centre for Rheumatology, Division of Medicine, Rayne Institute, University College London, London, UK.,South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Anthony Isaacs
- Department of Rheumatology, University College London Hospital, London, UK
| | - Zhixin Liu
- Stats Central, Mark Wainwright Analytical Centre, University of New South Wales, Sydney, Australia
| | - Fang E Sin
- Department of Rheumatology, University College London Hospital, London, UK
| | - Ian Giles
- Department of Rheumatology, University College London Hospital, London, UK.,Centre for Rheumatology, Division of Medicine, Rayne Institute, University College London, London, UK
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12
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Wiles K, Anckaert E, Holden F, Grace J, Nelson-Piercy C, Lightstone L, Chappell LC, Bramham K. Anti-Müllerian hormone concentrations in women with chronic kidney disease. Clin Kidney J 2019; 14:537-542. [PMID: 33623676 PMCID: PMC7886554 DOI: 10.1093/ckj/sfz164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/23/2019] [Indexed: 01/01/2023] Open
Abstract
Background Serum anti-Müllerian hormone (AMH) is a biomarker of ovarian reserve. There are limited data to guide the clinical interpretation of AMH in women with chronic kidney disease (CKD). The purpose of this study was to examine AMH concentrations in women with CKD compared with women without CKD. Methods We conducted a prospective cohort study of serum AMH concentrations in 163 non-pregnant women with CKD. Serum AMH concentrations were compared with age-specific AMH centiles from 887 healthy female controls. Results Participants included 30 women with Stage 1 CKD, 37 women with Stage 2 CKD, 26 women with Stage 3a CKD, 31 women with Stage 3b CKD and 39 women with Stages 4 and 5 CKD. The median estimated glomerular filtration rate (eGFR) was 51 (interquartile range 31–80) mL/min/1.73 m2. Serum AMH concentrations were lower in all CKD stages compared with women without CKD. Women ages 20–24 years with CKD had comparable serum AMH concentrations (median 1.959 ng/mL) to women ages 35–39 years without CKD (median 1.995 ng/mL). There was no evidence that eGFR was an independent modifier of serum AMH concentrations. More than half of women with CKD (58%) were predicted to have a low response to gonadotrophin stimulation. Conclusions Women with CKD have a lower ovarian reserve and are predicted to have a lower ovarian response to gonadotrophin stimulation compared with women without CKD of a similar age. Women with CKD who fail to conceive within 6 months of regular unprotected intercourse should be considered for fertility assessment and intervention.
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Affiliation(s)
- Kate Wiles
- Department of Women and Children's Health, King's College London, London, UK.,Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Ellen Anckaert
- Laboratory of Hormonology and Tumour Markers, Universitair Ziekenhuis Brussel, Free University of Brussels, Brussels, Belgium
| | - Francesca Holden
- Department of Renal Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Jan Grace
- Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Catherine Nelson-Piercy
- Guy's and St Thomas NHS Foundation Trust, London, UK.,Imperial Healthcare NHS Trust, London, UK
| | - Liz Lightstone
- Imperial Healthcare NHS Trust, London, UK.,Faculty of Medicine, Centre for Inflammatory Disease, Imperial College London, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, London, UK.,Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Kate Bramham
- Department of Women and Children's Health, King's College London, London, UK.,Department of Renal Medicine, King's College Hospital NHS Foundation Trust, London, UK
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13
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Wakimoto Y, Fukui A, Wakimoto G, Ikezawa Y, Matsuoka M, Omote M, Sugiyama Y, Ukita Y, Kato T, Shibahara H. Association between spontaneous ovulation and serum anti-Müllerian hormone levels in a premature ovarian insufficiency patient after a multimodal treatment for breast cancer. J Obstet Gynaecol Res 2019; 45:2297-2301. [PMID: 31456293 DOI: 10.1111/jog.14101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 08/14/2019] [Indexed: 12/29/2022]
Abstract
The high toxicity of chemotherapy can damage a patient's gonadal function, leading to premature ovarian insufficiency (POI). Here, we report the case of a patient suffering from POI after chemotherapy for breast cancer, who 3 years later ovulated spontaneously and became pregnant. The patient, a 31-year-old infertile women, nulligravida, was diagnosed with breast cancer. The Anti-Müllerian Hormone (AMH) level in her serum was 1.85 ng/mL before multimodal treatment for cancer. She later visited our hospital for amenorrhea and 2 years after cancer treatment, she was diagnosed with POI. Her AMH level at that point was less than 0.1 ng/mL. One year after the diagnosis of POI, the patient's AMH level increased slightly to 0.14 ng/mL and she ovulated spontaneously. The patient later became pregnant using Assisted Reproductive Technology on the fourth attempt.During the course of treatment for infertility at our hospital, the AMH levels in her serum changed along with the recovery of ovarian function. These findings suggest the possibility that ovulation and pregnancy could be predicted by the chronological changes of the AMH levels in the patient's serum.
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Affiliation(s)
- Yu Wakimoto
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Atushi Fukui
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Goh Wakimoto
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yuji Ikezawa
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Michie Matsuoka
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Maya Omote
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yukiko Sugiyama
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yuji Ukita
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Toru Kato
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hiroaki Shibahara
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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14
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Vanni VS, De Lorenzo R, Privitera L, Canti V, Viganò P, Rovere-Querini P. Safety of fertility treatments in women with systemic autoimmune diseases (SADs). Expert Opin Drug Saf 2019; 18:841-852. [PMID: 31238745 DOI: 10.1080/14740338.2019.1636964] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Systemic Autoimmune Diseases (SADs) include systemic lupus erythematosus, antiphospholipid antibody syndrome, rheumatoid arthritis, systemic sclerosis, Sjogren's syndrome, mixed connective tissue disease, idiopathic inflammatory myopathies and vasculitis. SADs often occur in women of childbearing age and can affect fertility. Both infertility treatments and fertility preservation techniques are thus often indicated. Areas covered: The literature regarding the safety of fertility-related drugs for both fertility preservation and infertility treatment in patients affected by SADs was reviewed. Based on current knowledge, all the options for fertility preservation should be contemplated in patients with SADs who are at risk for fertility loss, including GnRH analogue administration, oocyte/embryo vitrification and ovarian tissue cryopreservation. Similarly, if pregnancy is not contraindicated in a patient with a SAD, neither should be any fertility treatment. Expert opinion: Women with SADs should postpone conception until a stable disease has been achieved for at least 6 months. When infertility treatments are needed, women with antiphospholipid antibodies should receive concomitant anticoagulation. If in vitro fertilization/intra-cytoplasmic sperm injection and embryo transfer is required, ovarian hyperstimulation and the inherent risk of thrombosis should be eliminated by GnRH-agonist trigger and cycle segmentation. Counselling about adherence to anti-rheumatic therapy to prevent disease exacerbations is also critical.
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Affiliation(s)
- V S Vanni
- a Reproductive Sciences Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute , Milan , Italy.,b Vita-Salute San Raffaele University , Milan , Italy
| | - R De Lorenzo
- b Vita-Salute San Raffaele University , Milan , Italy
| | - L Privitera
- c Division of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - V Canti
- b Vita-Salute San Raffaele University , Milan , Italy
| | - P Viganò
- a Reproductive Sciences Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - P Rovere-Querini
- b Vita-Salute San Raffaele University , Milan , Italy.,d Division of Immunology, Transplantation & Infectious Diseases, IRCCS San Raffaele Scientific Institute , Milan , Italy
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15
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Stratifying management of rheumatic disease for pregnancy and breastfeeding. Nat Rev Rheumatol 2019; 15:391-402. [DOI: 10.1038/s41584-019-0240-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2019] [Indexed: 12/16/2022]
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16
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Di Mario C, Petricca L, Gigante MR, Barini A, Barini A, Varriano V, Paglionico A, Cattani P, Ferraccioli G, Tolusso B, Gremese E. Anti-Müllerian hormone serum levels in systemic lupus erythematosus patients: Influence of the disease severity and therapy on the ovarian reserve. Endocrine 2019; 63:369-375. [PMID: 30324323 DOI: 10.1007/s12020-018-1783-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 10/03/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE Systemic lupus erythematosus (SLE) mainly affects childbearing age women and pharmacological treatments may negatively influence the ovarian reserve. Anti-Müllerian hormone (AMH) could be a good biomarker for ovarian reserve. METHODS AMH serum levels were assessed in 86 consecutive SLE female patients with regular menstrual cycle compared with 44 aged matched healthy controls. Clinical and demographic characteristics, disease duration, pattern of organ involvement, and previous and current therapies were recorded. RESULTS AMH levels were comparable between patients and controls (4.2 ± 3.1 ng/ml vs. 5.0 ± 3.1 ng/ml, p = 0.21). According to disease severity, AMH levels were lower in SLE patients with major organ involvement than in controls (3.8 ± 2.7 ng/ml vs. 5.0 ± 3.1 ng/ml, p = 0.08); no difference was found between SLE patients with mild organ involvement (4.5 ± 3.4 ng/ml) and controls (p = 0.43). Grouping patients based on the pharmacological treatments, AMH serum levels did not differ among SLE patients treated with antimalarials only (4.7 ± 3.3 ng/ml), conventional disease-modifying antirheumatic drugs (cDMARDs) only (4.8 ± 3.2 ng/ml), cDMARDs and antimalarials (3.9 ± 2.9 ng/ml) or cyclophosphamide (CYC) only (4.9 ± 3.9 ng/ml), compared to controls, but patients sequentially treated with cDMARDs and CYC, had significantly lower AMH serum levels than controls (p = 0.01). CONCLUSIONS SLE patients showed comparable AMH levels than controls, however, a reduction of the ovarian reserve was associated with sequentially therapy with CYC and cDMARDs and with the disease severity. AMH could be a sensitive and specific biomarker of ovarian reserve in SLE and it could be useful for therapeutic strategy and family planning.
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Affiliation(s)
- Clara Di Mario
- Institute of Rheumatology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Petricca
- Division of Rheumatology, Fondazione Policlinico Universitario "A. Gemelli"-I.R.C.C.S., Rome, Italy
| | - Maria Rita Gigante
- Division of Rheumatology, Fondazione Policlinico Universitario "A. Gemelli"-I.R.C.C.S., Rome, Italy
| | - Angelina Barini
- Institute of Biochemistry and Clinical Biochemistry, Università Cattolica del Sacro Cuore, Rome, Italy
- Institute of Biochemistry and Clinical Biochemistry, Fondazione Policlinico Universitario "A. Gemelli"-I.R.C.C.S., Rome, Italy
| | - Antonella Barini
- Institute of Biochemistry and Clinical Biochemistry, Fondazione Policlinico Universitario "A. Gemelli"-I.R.C.C.S., Rome, Italy
| | - Valentina Varriano
- Institute of Rheumatology, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Paola Cattani
- Institute of Microbiology, Università Cattolica del Sacro Cuore, Rome, Italy
- Institute of Microbiology, Fondazione Policlinico Universitario "A. Gemelli"-I.R.C.C.S., Rome, Italy
| | - Gianfranco Ferraccioli
- Institute of Rheumatology, Università Cattolica del Sacro Cuore, Rome, Italy
- Division of Rheumatology, Fondazione Policlinico Universitario "A. Gemelli"-I.R.C.C.S., Rome, Italy
| | - Barbara Tolusso
- Division of Rheumatology, Fondazione Policlinico Universitario "A. Gemelli"-I.R.C.C.S., Rome, Italy
| | - Elisa Gremese
- Institute of Rheumatology, Università Cattolica del Sacro Cuore, Rome, Italy.
- Division of Rheumatology, Fondazione Policlinico Universitario "A. Gemelli"-I.R.C.C.S., Rome, Italy.
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17
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Yildirim GY, Celik HG, Koroglu N, Karakus E. Do ovarian reserve markers predict the subsequent pregnancy outcomes in women with recurrent pregnancy loss? ACTA ACUST UNITED AC 2018. [DOI: 10.1515/tjb-2017-0238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objective(s):
Chromosomal abnormalities are more commonly seen in embryos with decreased oocyte quality. Therefore aneuploidy due to diminished ovarian reserve may be one of the causative reasons of RPL. We investigated the relationship between ovarian reserve markers especially serum antimullerian hormone (AMH) level and antral follicle count (AFC) and recurrent pregnancy loss (RPL).
Materials and methods:
This prospective cross-sectional clinical trial including 88 women with RPL and 84 age-matched women without RPL.
Results:
There were statistically significant differences in body mass index, live birth number, menstrual cycle length, AFC and serum AMH level between groups. There was no statistically significant difference between groups regarding age, menstrual cycle regularity and serum follicle stimulating hormone (FSH) and estradiol (E2) levels. The percentage of women with levels of AMH<1 was 21.4% in the RPL group and 11.4% in the control group. AFC <7 in both ovaries was lower in the RPL group when compared with the control group (73.8% vs 44.3%, respectively).
Conclusion(s):
Serum AMH levels and AFC can be assessed in patients with RPL as a part of the work up parameters. Lower Serum AMH levels and AFC especially may predict the quantity of oocytes that may be consequently be related with RPL.
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18
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Ahmed SB, Vitek WS, Holley JL. Fertility, Contraception, and Novel Reproductive Technologies in Chronic Kidney Disease. Semin Nephrol 2018; 37:327-336. [PMID: 28711071 DOI: 10.1016/j.semnephrol.2017.05.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Chronic kidney disease (CKD) affects hypothalamic-pituitary-gonadal axis function, leading to menstrual abnormalities, sexual dysfunction, functional menopause, and loss of fertility. Pregnancy in a patient with CKD is associated with a higher risk of complications to both the mother and the fetus, highlighting the importance of contraceptive counseling at all stages of CKD. There has been limited research on the safety and efficacy of different contraceptive methods in the CKD population, and it is important to tailor the choice of contraception to the patient's lifestyle and comorbidity status. Cyclophosphamide is a commonly used immunosuppressive agent that impairs fertility in a dose-dependent fashion, with greater impact in older women of child-bearing age. Strategies to reduce the impact of cyclophosphamide on ovarian reserve as well as fertility preservation technologies are options to consider when treating immune-mediated CKD. A multidisciplinary approach in counseling the woman with CKD who wishes to contemplate or avoid pregnancy is necessary to optimize outcomes. Further research in this important area is required.
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Affiliation(s)
- Sofia B Ahmed
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Alberta Kidney Disease Network, Alberta, Canada; Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada.
| | - Wendy S Vitek
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY
| | - Jean L Holley
- Department of Medicine, University of Illinois, Urbana-Champaign, IL
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19
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Stoumpos S, Lees J, Welsh P, Hund M, Geddes CC, Nelson SM, Mark PB. The utility of anti-Müllerian hormone in women with chronic kidney disease, on haemodialysis and after kidney transplantation. Reprod Biomed Online 2017; 36:219-226. [PMID: 29233504 DOI: 10.1016/j.rbmo.2017.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 11/15/2017] [Accepted: 11/15/2017] [Indexed: 11/19/2022]
Abstract
Women with renal disease have menstrual and gonadal dysfunction manifesting as hormonal imbalance. Anti-Müllerian hormone (AMH) is a potential measure of ovarian reserve. We examined circulating AMH concentrations in young women with renal failure, determined associations with clinical characteristics, and compared AMH with age-matched healthy individuals. AMH was measured in 77 women: 26 had chronic kidney disease (CKD), 26 were on haemodialysis (HD), and 25 had a kidney transplant. Random AMH levels were highest in women on HD [HD 2.9 (1.1-5.2), CKD 1.6 (0.7-2.2), transplant 1.5 (1.0-4.2) ng/ml]. On multiple linear regression, AMH was 53% higher [95% CI 0.20-0.98, P = 0.002] in women on HD and decreased by 20% per 5-year increase in age (P < 0.001). AMH was 43% lower in women with renal failure compared with 600 age-matched controls [1.7 (0.9-3.8) versus 3.0 (1.9-5.0) ng/ml, P < 0.001]; however, we found no difference in AMH between those on HD and healthy individuals [2.9 (1.1-5.2) versus 3.0 (1.9-5.0) ng/ml]. AMH may be a useful biomarker in female renal patients with non-dialysis dependent renal disease pursuing pregnancy. In contrast, AMH levels are higher in HD but unlikely to reflect ovarian reserve.
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Affiliation(s)
- Sokratis Stoumpos
- The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK; Institute of Cardiovascular and Medical Sciences, Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
| | - Jennifer Lees
- The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK; Institute of Cardiovascular and Medical Sciences, Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Paul Welsh
- Institute of Cardiovascular and Medical Sciences, Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Martin Hund
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | - Colin C Geddes
- The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Patrick B Mark
- The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK; Institute of Cardiovascular and Medical Sciences, Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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20
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Abstract
Menopause occurs naturally in women at about 50 years of age. There is a wealth of data concerning the relationship of menopause to systemic lupus erythematosus, rheumatoid arthritis, and osteoarthritis; there are limited data concerning other rheumatic diseases. Age at menopause may affect the risk and course of rheumatic diseases. Osteoporosis, an integral part of inflammatory rheumatic diseases, is made worse by menopause. Hormone replacement therapy has been studied; its effects vary depending on the disease and even different manifestations within the same disease. Cyclophosphamide can induce early menopause, but there is underlying decreased ovarian reserve in rheumatic diseases.
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Affiliation(s)
- Mitali Talsania
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, 1000 Lincoln Blvd, Oklahoma City, OK 73104, USA
| | - Robert Hal Scofield
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, 1000 Lincoln Blvd, Oklahoma City, OK 73104, USA; Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, 825 Northeast 13th Street, MS 24, Oklahoma City, OK 73104, USA; Medical Service, Department of Veterans Affairs Medical Center, 920 NE 13th Street, Oklahoma City, OK 73104, USA.
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Gao H, Ma J, Wang X, Lv T, Liu J, Ren Y, Li Y, Zhang Y. Preliminary study on the changes of ovarian reserve, menstruation, and lymphocyte subpopulation in systemic lupus erythematosus (SLE) patients of childbearing age. Lupus 2017; 27:445-453. [PMID: 28820360 DOI: 10.1177/0961203317726378] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective The main aim of this study was to investigate the ovarian reserve, menstruation, and lymphocyte subpopulation in systemic lupus erythematosus (SLE) patients of childbearing age. Methods We enrolled 40 SLE patients of childbearing age and 40 age-matched healthy controls. Anti-Müllerian hormone (AMH) was tested by electrochemiluminescence, and lymphocyte subsets were tested by flow cytometry. Menstruation situation was obtained by interview. Results The AMH level of the SLE group was significantly lower than that of the control group ( p < 0.001), which was negatively correlated with erythrocyte sedimentation rate (ESR ( r = −0.316, p = 0.047)) and disease activity (SLEDAI ( r = −0.338, p = 0.033)). The AMH concentration of SLE patients with normal menstruation was higher than those with abnormal menstruation ( p < 0.001). The percentages of CD4+ T lymphocytes and NK (natural killer) cells in the SLE group were significantly lower than those in the control group ( p < 0.001). However, the percentages of B cells and CD8+ T lymphocytes in the SLE group were higher than those in the control group ( p < 0.05). Conclusion Decreased AMH and high incidence of abnormal menstruation indicated that autoimmunity activities of SLE can impair the ovarian reserve of female patients. Lymphocytes in SLE patients were in a state of disorder.
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Affiliation(s)
- H Gao
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - J Ma
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - X Wang
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - T Lv
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - J Liu
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - Y Ren
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - Y Li
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
| | - Y Zhang
- Department of Rheumatology and Immunology, Tangdu Hospital of The Fourth Military Medical University, Xi'an, China
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23
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Fischer-Betz R, Specker C. Pregnancy in systemic lupus erythematosus and antiphospholipid syndrome. Best Pract Res Clin Rheumatol 2017; 31:397-414. [DOI: 10.1016/j.berh.2017.09.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 08/09/2017] [Accepted: 09/02/2017] [Indexed: 01/02/2023]
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25
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Tamirou F, Husson SN, Gruson D, Debiève F, Lauwerys BR, Houssiau FA. Brief Report: The Euro-Lupus Low-Dose Intravenous Cyclophosphamide Regimen Does Not Impact the Ovarian Reserve, as Measured by Serum Levels of Anti-Müllerian Hormone. Arthritis Rheumatol 2017; 69:1267-1271. [PMID: 28235250 DOI: 10.1002/art.40079] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 02/16/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The Euro-Lupus regimen of low-dose intravenous cyclophosphamide (IV CYC) (cumulative dose of 3 gm) was developed to reduce gonadal toxicity. To address the possibility of a marginal effect on the ovarian reserve, we measured serum titers of anti-Müllerian hormone (AMH) in patients with systemic lupus erythematosus (SLE) treated with the Euro-Lupus regimen and compared them with those measured in patients who were treated with higher doses of IV CYC or were never treated with IV CYC. METHODS Serum AMH levels were measured by enzyme-linked immunosorbent assay in a cohort of 155 premenopausal SLE patients; 30 of these patients had been treated with the Euro-Lupus regimen, and 24 had received higher doses of IV CYC. None had received oral CYC. AMH levels were age-adjusted using a slope computed from levels measured across the group of SLE patients who had not been treated with IV CYC. Demographic and clinical data were collected. RESULTS Serum titers of AMH measured in SLE patients treated with the Euro-Lupus IV CYC regimen (median dose 1.46 ng/ml) did not differ from those measured in patients never treated with the cytotoxic drug (median 1.85 ng/ml). As expected, patients given >6 gm of IV CYC had significantly lower serum titers of AMH (median 0.83 ng/ml) compared with those never treated with IV CYC (P = 0.047). Median serum AMH titers did not change before (1.24 ng/ml) and after (2.50 ng/ml) treatment with the Euro-Lupus IV CYC regimen in the subset of patients for whom paired samples could be tested (P = 0.43). CONCLUSION The Euro-Lupus regimen of low-dose IV CYC does not impact the ovarian reserve of SLE patients and can therefore be proposed as treatment in patients seeking to become pregnant.
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Affiliation(s)
- Farah Tamirou
- Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | | | - Damien Gruson
- Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Frédéric Debiève
- Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Bernard R Lauwerys
- Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Frédéric A Houssiau
- Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
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26
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Nahata L, Sivaraman V, Quinn GP. Fertility counseling and preservation practices in youth with lupus and vasculitis undergoing gonadotoxic therapy. Fertil Steril 2016; 106:1470-1474. [DOI: 10.1016/j.fertnstert.2016.07.1102] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 07/18/2016] [Accepted: 07/18/2016] [Indexed: 01/19/2023]
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27
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Oktem O, Yagmur H, Bengisu H, Urman B. Reproductive aspects of systemic lupus erythematosus. J Reprod Immunol 2016; 117:57-65. [DOI: 10.1016/j.jri.2016.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 05/27/2016] [Accepted: 07/04/2016] [Indexed: 12/23/2022]
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28
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Andreoli L, Bertsias GK, Agmon-Levin N, Brown S, Cervera R, Costedoat-Chalumeau N, Doria A, Fischer-Betz R, Forger F, Moraes-Fontes MF, Khamashta M, King J, Lojacono A, Marchiori F, Meroni PL, Mosca M, Motta M, Ostensen M, Pamfil C, Raio L, Schneider M, Svenungsson E, Tektonidou M, Yavuz S, Boumpas D, Tincani A. EULAR recommendations for women's health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome. Ann Rheum Dis 2016; 76:476-485. [PMID: 27457513 PMCID: PMC5446003 DOI: 10.1136/annrheumdis-2016-209770] [Citation(s) in RCA: 448] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/13/2016] [Accepted: 06/25/2016] [Indexed: 12/26/2022]
Abstract
Objectives Develop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS). Methods Systematic review of evidence followed by modified Delphi method to compile questions, elicit expert opinions and reach consensus. Results Family planning should be discussed as early as possible after diagnosis. Most women can have successful pregnancies and measures can be taken to reduce the risks of adverse maternal or fetal outcomes. Risk stratification includes disease activity, autoantibody profile, previous vascular and pregnancy morbidity, hypertension and the use of drugs (emphasis on benefits from hydroxychloroquine and antiplatelets/anticoagulants). Hormonal contraception and menopause replacement therapy can be used in patients with stable/inactive disease and low risk of thrombosis. Fertility preservation with gonadotropin-releasing hormone analogues should be considered prior to the use of alkylating agents. Assisted reproduction techniques can be safely used in patients with stable/inactive disease; patients with positive antiphospholipid antibodies/APS should receive anticoagulation and/or low-dose aspirin. Assessment of disease activity, renal function and serological markers is important for diagnosing disease flares and monitoring for obstetrical adverse outcomes. Fetal monitoring includes Doppler ultrasonography and fetal biometry, particularly in the third trimester, to screen for placental insufficiency and small for gestational age fetuses. Screening for gynaecological malignancies is similar to the general population, with increased vigilance for cervical premalignant lesions if exposed to immunosuppressive drugs. Human papillomavirus immunisation can be used in women with stable/inactive disease. Conclusions Recommendations for women's health issues in SLE and/or APS were developed using an evidence-based approach followed by expert consensus.
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Affiliation(s)
- L Andreoli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
| | - G K Bertsias
- Department of Rheumatology, Clinical Immunology and Allergy, University of Crete Medical School, Heraklion, Greece
| | - N Agmon-Levin
- The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel.,The Faculty of Medicine, Tel Aviv University, Israel
| | - S Brown
- Royal National Hospital For Rheumatic Diseases, Bath, UK
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Catalonia, Spain
| | - N Costedoat-Chalumeau
- AP-HP, Hôpital Cochin, Centre de référence maladies auto-immunes et systémiques rares, Paris, France.,Université Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - A Doria
- Rheumatology Unit, Department of Medicine, University of Padua, Italy
| | - R Fischer-Betz
- Policlinic of Rheumatology, Hiller Research Unit, University Clinic Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - F Forger
- Department of Rheumatology, Immunology and Allergology, University Hospital of Bern, Bern, Switzerland
| | - M F Moraes-Fontes
- Unidade de Doenças Auto-imunes-Serviço Medicina Interna 7.2, Hospital Curry Cabral/Centro Hospitalar Lisboa Central, NEDAI/SPMI, Lisboa, Portugal
| | - M Khamashta
- Lupus Research Unit, The Rayne Institute, St. Thomas Hospital, London, UK.,Department of Rheumatology, Dubai Hospital, Dubai, United Arab Emirates
| | - J King
- EULAR PARE Patient Research Partner, London, UK
| | - A Lojacono
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Obstetrics and Gynaecology, Spedali Civili, Brescia, Italy
| | - F Marchiori
- EULAR PARE Patient Research Partner, Rome, Italy
| | - P L Meroni
- Department of Clinical Sciences and Community Health, University of Milan, Istituto Auxologico Italiano, Milan, Italy
| | - M Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M Motta
- Neonatology and Neonatal Intensive Care Unit, Spedali Civili, Brescia, Italy
| | - M Ostensen
- Norwegian National Advisory Unit on Pregnancy and Rheumatic Diseases, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - C Pamfil
- Department of Rheumatology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - L Raio
- Department of Obstetrics and Gynaecology, University Hospital of Bern, Inselspital, Switzerland
| | - M Schneider
- Policlinic of Rheumatology, Hiller Research Unit, University Clinic Duesseldorf, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - E Svenungsson
- Rheumatology Unit, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Tektonidou
- Rheumatology Unit, Joint Academic Rheumatology Programme, 1st Department of Propaedeutic Internal Medicine Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - S Yavuz
- Department of Rheumatology, Istanbul Bilim University, Istanbul Florence Nightingale Hospital, Esentepe-Istanbul, Turkey
| | - D Boumpas
- 4th Department of Internal Medicine, 'Attikon' University Hospital, Medical School, University of Athens, Athens, Greece.,Joint Academic Rheumatology Program, National and Kapodestrian University of Athens, Athens, Greece
| | - A Tincani
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Unit of Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
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Bénard J, Calvo J, Comtet M, Benoit A, Sifer C, Grynberg M. [Fertility preservation in women of the childbearing age: Indications and strategies]. ACTA ACUST UNITED AC 2016; 45:424-44. [PMID: 27021926 DOI: 10.1016/j.jgyn.2016.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 02/15/2016] [Accepted: 02/24/2016] [Indexed: 12/21/2022]
Abstract
Advances on cryopreservation techniques now allow considering oocyte, embryo or ovarian tissue freezing for female fertility preservation. Originally developed for patients suffering from cancer, fertility preservation has rapidly invaded others medical fields, and represents now the standard of care for all young patient diagnosed with a disease that could impair fertility or having to receive possibly gonadotoxic treatment. As a result, autoimmune diseases, some genetic pathologies or iterative pelvic surgeries, at risk of premature ovarian failure, have become common indications of fertility preservation. In addition, the social egg freezing aiming at preventing the age-related fertility decline is still debated in France, although authorized in numerous countries. This review will discuss the different strategies of fertility preservation in young girls and women of reproductive age, regarding different medical or non-medical indications.
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Affiliation(s)
- J Bénard
- Service de médecine de la reproduction, hôpital Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France; Université Paris XIII, 93000 Bobigny, France
| | - J Calvo
- Service de médecine de la reproduction, hôpital Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France
| | - M Comtet
- Service de médecine de la reproduction, hôpital Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France
| | - A Benoit
- Service de médecine de la reproduction, hôpital Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France
| | - C Sifer
- Service de cytogénétique et biologie de la reproduction, hôpital Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France
| | - M Grynberg
- Service de médecine de la reproduction, hôpital Jean-Verdier, avenue du 14-Juillet, 93140 Bondy, France; Université Paris XIII, 93000 Bobigny, France; Unité Inserm U1133, université Paris-Diderot, 75013 Paris, France.
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Roman H, Bubenheim M, Auber M, Marpeau L, Puscasiu L. Antimullerian hormone level and endometrioma ablation using plasma energy. JSLS 2016; 18:JSLS-D-14-00002. [PMID: 25392649 PMCID: PMC4208885 DOI: 10.4293/jsls.2014.00002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: To investigate the impact of ovarian endometrioma vaporization using plasma energy on antimullerian hormone (AMH) level. Method: We report a prospective, noncomparative series (NCT01596985). Twenty-two patients with unilateral ovarian endometriomas ≥30 mm, with no surgical antecedent and no ongoing pregnancy, underwent vaporization of ovarian endometriomas using plasma energy during the period of November 29, 2010 to November 28, 2012. We assessed AMH levels before surgery, 3 months postoperatively, and at the end of follow-up. Results: The mean length of postoperative follow-up was 18.2 ± 8 months. AMH level significantly varied through the 3 assessments performed in the study, as the mean values ± SD were 3.9 ± 2.6 ng/mL before the surgery, 2.3 ± 1.1 ng/mL at 3 months, and 3.1 ± 2.2 ng/mL at the end of the follow-up (P = .001). There was a significant increase from 3 months postoperatively to the end of follow-up (median change 0.7 ng/mL, P = .01). Seventy-one percent of patients had an AMH level >2 ng/mL at the end of the follow-up versus 76% before the surgery (P = 1). During the postoperative follow-up, 11 patients tried to conceive, of whom 8 (73%) became pregnant. Conclusions: The ablation of unilateral endometriomas is followed in a majority of cases by a significant decrease in AMH level 3 months after surgery. In subsequent months, this level progressively increases, raising questions about the real factors that impact postoperative ovarian AMH production.
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Affiliation(s)
- Horace Roman
- Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France, Research Group 4308 ≪ Spermatogenesis and Gamete Quality≫, IHU Rouen Normandy, IFRMP23, Reproductive Biology Laboratory, Rouen University Hospital, Rouen, France
| | | | - Mathieu Auber
- Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France, Research Group 4308 ≪ Spermatogenesis and Gamete Quality≫, IHU Rouen Normandy, IFRMP23, Reproductive Biology Laboratory, Rouen University Hospital, Rouen, France
| | - Loïc Marpeau
- Department of Gynecology and Obstetrics, Rouen University Hospital, Rouen, France, Research Group 4308 ≪ Spermatogenesis and Gamete Quality≫, IHU Rouen Normandy, IFRMP23, Reproductive Biology Laboratory, Rouen University Hospital, Rouen, France
| | - Lucian Puscasiu
- Department of Gynecology and Obstetrics, University Hospital, Targu Mures, Romania
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Ovarian function and reproductive outcomes of female patients with systemic lupus erythematosus and the strategies to preserve their fertility. Obstet Gynecol Surv 2015; 70:196-210. [PMID: 25769434 DOI: 10.1097/ogx.0000000000000160] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune systemic disease that mainly affects women of reproductive age. Emerging data from recent molecular studies show us that estrogen hormone plays a central role in the development of this disease. By acting via its cognate receptors ERα and ERβ expressed on immune cells, estrogen can modulate immune function in both the innate and adaptive immune responses. Interestingly, estrogen may also evoke autoimmune responses after binding to B lymphocytes leading to the generation of high-affinity autoantibodies and proinflammatory cytokines (so-called estrogen-induced autoimmunity). Unfortunately, reproductive function of young female patients with this disease is commonly compromised by different pathophysiologic processes. First, ovarian reserve is diminished even in the presence of mild disease suggesting a direct impact of the disease itself on ovarian function possibly due to ovarian involvement in the form of autoimmune oophoritis. Second, SLE patients with severe manifestations of the disease are treated with alkylating chemotherapy agent cyclophosphamide. Cyclophosphamide and other drugs of alkylating category have the highest gonadotoxicity. Therefore, SLE patients exposed to cyclophosphamide have a much higher risk of developing infertility and premature ovarian failure than do the counterparts who are treated with other less toxic treatments. Third, the functions of the hypothalamic pituitary ovarian axis are perturbed by chronic inflammatory state. And finally adverse pregnancy outcomes are more commonly observed in SLE patients such as fetal loss, preterm birth, intrauterine fetal growth restriction, preeclampsia-eclampsia, and fetal congenital heart block. We aimed in this review article to provide the readers an update on how estrogen hormone closely interacts with and induces lupus-prone changes in the immune system. We also discuss ovarian function and other reproductive outcomes in SLE patients and the current strategies to preserve their fertility in the light of the most recent evidence-based findings of the clinical trials and molecular studies.
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Mayorga J, Alpízar-Rodríguez D, Prieto-Padilla J, Romero-Díaz J, Cravioto MC. Prevalence of premature ovarian failure in patients with systemic lupus erythematosus. Lupus 2015; 25:675-83. [PMID: 26678443 DOI: 10.1177/0961203315622824] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/24/2015] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To estimate the prevalence of premature ovarian failure (POF) and its associated factors in patients with systemic lupus erythematosus (SLE). METHODS Cross-sectional study including consecutive SLE women <60 years of age attending a rheumatology clinic. A face-to-face interview was undertaken to obtain demographic, gynaecological and lupus characteristics. Additional rheumatologic and endocrine data were retrieved from patients' medical records. POF prevalence was estimated in the study sample and in a subgroup of patients aged <40 years at interview. Associations between POF and selected variables were assessed by logistic regression analyses. RESULTS A total of 961 patients were analysed. Prevalence of POF, secondary amenorrhea of known cause, menopause and hysterectomy were 5.4%, 0.8%, 7.8% and 4.4%, respectively. In 674 (70%) patients who had not been exposed to cyclophosphamide (CYC) the prevalence of POF was 0.6%. Disease activity over time (OR 1.4 (CI 95% 1.0-1.8, p < 0.05)) and CYC treatment (OR 5.9 (CI 95% 1.8-18.8, p < 0.01)) were associated with higher prevalence. Association between POF and endocrine autoimmune diseases was not found. CONCLUSIONS In the absence of CYC treatment, the prevalence of POF in lupus patients is consistent with that reported in the general population. The existence of autoimmune processes at the ovary seems unlikely in most lupus patients.
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Affiliation(s)
- J Mayorga
- Department of Reproductive Biology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - D Alpízar-Rodríguez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
| | - J Prieto-Padilla
- Department of Reproductive Biology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - J Romero-Díaz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - M C Cravioto
- Department of Reproductive Biology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
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Roosa KA, Zysling DA, Place NJ. An assessment of anti-Müllerian hormone in predicting mating outcomes in female hamsters that have undergone natural and chemically-accelerated reproductive aging. Gen Comp Endocrinol 2015; 214:56-61. [PMID: 25801548 DOI: 10.1016/j.ygcen.2015.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 03/09/2015] [Accepted: 03/15/2015] [Indexed: 10/23/2022]
Abstract
In mammals, female fertility declines with age due in part to a progressive loss of ovarian follicles. The rate of follicle decline varies among individuals making it difficult to predict the age of onset of reproductive senescence. Serum anti-Müllerian hormone (AMH) concentrations correlate with the numbers of ovarian follicles, and therefore, AMH could be a useful predictor of female fertility. In women and some production animals, AMH is used to identify which individuals will respond best to ovarian stimulation for assisted reproductive technologies. However, few studies have evaluated AMH's predictive value in unassisted reproduction, and they have yielded conflicting results. To assess the predictive value of AMH in the context of reproductive aging, we prospectively measured serum AMH in 9-month-old Siberian hamsters shortly before breeding them. Female Siberian hamsters experience substantial declines in fertility and fecundity by 9months of age. We also measured serum AMH in 5-month-old females treated with 4-vinylcyclohexene diepoxide (VCD), which selectively destroys ovarian follicles and functionally accelerates ovarian aging. Vehicle-treated 5-month-old females served as controls. AMH concentrations were significantly reduced in VCD-treated females yet many females with low AMH reproduced successfully. On average, both young and old hamsters that littered had higher AMH concentrations than females that did not. However, some females with relatively high AMH concentrations failed to litter, whereas several with low AMH succeeded. Our results suggest that mean AMH concentration can predict mating outcomes on a population or group level, but on an individual basis, a single AMH determination is less informative.
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Affiliation(s)
- Kristen A Roosa
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA.
| | - Devin A Zysling
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
| | - Ned J Place
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA
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Abstract
Purpose of review To provide an update on the latest clinical applications of serum antimüllerian hormone (AMH) testing with practical approaches to mitigate the impact of significant variability in AMH results. Recent findings Recent studies continue to demonstrate that AMH is the best single serum test for ovarian response management with, at most, a weak-to-moderate age-independent association with live-birth rate and time to conception. Data confirm serum AMH levels improve menopause prediction, monitoring of ovarian damage, and identification of women at risk for several ovary-related disorders such as polycystic ovary syndrome and premature or primary ovarian insufficiency. However, it is now recognized that serum AMH results can have dramatic variability due to common, biologic fluctuations within some individuals, use of hormonal contraceptives or other medications, certain surgical procedures, specimen treatment, assay changes, and laboratory calibration differences. Practical guidelines are provided to minimize the impact of variability in AMH results and maximize the accuracy of clinical decision-making. Summary AMH is an ovarian biomarker of central importance which improves the clinical management of women's health. However, with the simultaneous rapid expansion of AMH clinical applications and recognition of variability in AMH results, consensus regarding the clinical cutpoints is increasingly difficult. Therefore, a careful approach to AMH measurement and interpretation in clinical care is essential.
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Kavanaugh A, Cush JJ, Ahmed MS, Bermas BL, Chakravarty E, Chambers C, Clowse M, Curtis JR, Dao K, Hankins GDV, Koren G, Kim SC, Lapteva L, Mahadevan U, Moore T, Nolan M, Ren Z, Sammaritano LR, Seymour S, Weisman MH. Proceedings From the American College of Rheumatology Reproductive Health Summit: The Management of Fertility, Pregnancy, and Lactation in Women With Autoimmune and Systemic Inflammatory Diseases. Arthritis Care Res (Hoboken) 2015; 67:313-25. [DOI: 10.1002/acr.22516] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 11/04/2014] [Indexed: 01/31/2023]
Affiliation(s)
| | | | | | | | | | | | - Megan Clowse
- Duke University Medical Center; Durham North Carolina
| | | | | | | | - Gideon Koren
- The Hospital for Sick Children, Toronto; Ontario Canada
| | | | | | | | - Thomas Moore
- School of Medicine, University of California at San Diego
| | - Martha Nolan
- Society for Women's Health Research; Washington DC
| | - Zhaoxia Ren
- National Institute of Child Health and Human Development, National Institutes of Health; Bethesda Maryland
| | - Lisa R. Sammaritano
- Hospital for Special Surgery, Weill Medical College of Cornell University; New York New York
| | - Sally Seymour
- US Food and Drug Administration; Silver Spring Maryland
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Tuten A, Hatipoglu E, Oncul M, Imamoglu M, Acikgoz AS, Yilmaz N, Ozcil MD, Kaya B, Misirlioglu AM, Sahmay S. Evaluation of ovarian reserve in Hashimoto's thyroiditis. Gynecol Endocrinol 2014; 30:708-11. [PMID: 24905723 DOI: 10.3109/09513590.2014.926324] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Human ovary is commonly the target of an autoimmune attack in cases of organ- or non-organ-specific autoimmune disorders. Hashimoto's thyroiditis (HT) is likely to be associated with ovarian dysfunction and diminished ovarian reserve. In this study, we aimed to evaluate the possible negative association between this significantly prevalent autoimmune disease and the ovarian reserve. Thirty-two premenopausal women with primary hypothyroidism, who under replacement therapy with thyroxine were recruited. Forty-nine healthy female subjects who had normal anti-thyroid antibody levels and were comparable with the HT group in terms of age and BMI values, comprised the control group. There was no statistically significant difference between the study and the control patients in terms of antral follicle count. Serum anti-Müllerian hormone (AMH) levels were significantly higher in woman with HT compared to the control group. The results of this study found no impairment in ovarian reserve parameters of patients with HT. Interestingly, the results revealed a significant increase in serum AMH levels of the patients with HT compared to controls. Hashimoto's thyroiditis may share a common etiologic linkage with polycystic ovary syndrome; therefore, leading to elevated serum AMH levels, which we are currently unable to define elaborately.
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Iwase A, Nakamura T, Nakahara T, Goto M, Kikkawa F. Anti-Müllerian hormone and assessment of ovarian reserve after ovarian toxic treatment: a systematic narrative review. Reprod Sci 2014; 22:519-26. [PMID: 25228631 DOI: 10.1177/1933719114549856] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Since serum anti-Müllerian hormone (AMH) levels enable quantitative evaluation of ovarian damage, we conducted a computer-based search, using key words, of all articles published in English through the PubMed database from inception until September 2013 to summarize available studies evaluating ovarian reserve after ovarian toxic interventions to discuss the usefulness of serum AMH levels. We found that most of the studies demonstrated a decline in serum AMH levels when compared to control or pretreatment levels, with levels dependent on the type of treatment modality. Measurement of serum AMH levels enables quantitative evaluation of ovarian damage caused by ovarian toxic interventions, such as chemotherapy and radiotherapy, instead of qualitative evaluation using menstrual condition or basal follicle-stimulating hormone levels. Serum AMH levels are becoming indispensable to assess the ovarian reserve of patients who desire preservation of ovarian function for fertility and endogenous sex steroid hormones.
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Affiliation(s)
- Akira Iwase
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan Department of Maternal and Perinatal Medicine, Nagoya University Hospital, Showa-ku, Nagoya, Japan
| | - Tomoko Nakamura
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | - Tatsuo Nakahara
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | - Maki Goto
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
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38
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Velarde-Ochoa MDC, Esquivel-Valerio JA, Vega-Morales D, Skinner-Taylor CM, Galarza-Delgado DÁ, Garza-Elizondo MA. Anti-Müllerian hormone in reproductive age women with systemic lupus erythematosus. ACTA ACUST UNITED AC 2014; 11:78-82. [PMID: 24815955 DOI: 10.1016/j.reuma.2014.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 03/02/2014] [Accepted: 03/14/2014] [Indexed: 01/11/2023]
Abstract
UNLABELLED Systemic lupus erythematosus (SLE) is an inflammatory autoimmune systemic and chronic disease. Fertility in SLE patients is considered normal; factors that have been associated in these patients with ovarian failure are: disease activity, autoantibodies, and the use of cytotoxic agents. The anti-Müllerian hormone (AMH) is a marker that helps to determine the follicular reserve. OBJECTIVE Determinate the objective was to determine AMH levels in women of reproductive age with SLE. MATERIAL AND METHODS We included 65 women with SLE classified according to the 1997 ACR criteria, 18- to 40-years old. We obtained demographic, clinical, obstetric, and gynecological characteristics as well as serum levels of AMH. We performed a bivariate analysis among patients with low ovarian reserve and those with normal ovarian reserve. We also performed a correlation analysis between activity and damage index and between the cumulative cyclophosphamide dose and AMH levels. RESULTS We found a median of serum AMH in SLE patients of .61 ng/mL. The prevalence of low ovarian reserve in our study was 3.07%. We found a median MEX-SLEDAI score of 1 point and the median SLICC score was 2 points. Twenty-five patients (38.4%) had used cyclophosphamide and their cumulative average dose was 7.5 grams. CONCLUSIONS We found a median of AMH of .61 ng/mL in our population. The prevalence of low ovarian reserve in SLE patients was 3.07%. We did not find a correlation between AMH levels, the use of cyclophosphamide, and disease activity.
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Affiliation(s)
- María Del Carmen Velarde-Ochoa
- Servicio de Reumatología, Departamento de Medicina Interna, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, México
| | - Jorge Antonio Esquivel-Valerio
- Servicio de Reumatología, Departamento de Medicina Interna, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, México
| | - David Vega-Morales
- Servicio de Reumatología, Departamento de Medicina Interna, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, México.
| | - Cassandra Michele Skinner-Taylor
- Servicio de Reumatología, Departamento de Medicina Interna, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, México
| | - Dionicio Ángel Galarza-Delgado
- Servicio de Reumatología, Departamento de Medicina Interna, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, México
| | - Mario Alberto Garza-Elizondo
- Servicio de Reumatología, Departamento de Medicina Interna, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, México
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