Page 124 - Fertility in Women with Rheumatoid Arthritis Vruchtbaarheid van vrouwen met reumatoïde artritis

Chapter 8
Fertility care in a woman with rheumatoid arthritis is preferably started as soon as she is diagnosed. In all women of fertile age, rheumatologists should discuss family planning in an early stage. Patients should be made aware that their ovarian function may decline more rapidly compared to healthy women, especially when they are ACPA positive. In the light of the general tendency to postpone pregnancy beyond age 30 in Western countries, patients with ACPA positive disease especially should not delay trying to conceive. Whether the presence of ACPAs in serum by itself is responsible for the reduced ovarian function, or the more active disease associated with ACPA positivity4 causes damage to the ovary in the long run, remains unclear. Follow-up of current early arthritis cohorts with implemented strict treat-to-target antirheumatic therapy, could clarify whether tight disease control has a protective effect on the ovarian function.
Besides general lifestyle recommendations regarding fertility, such as cessation of smoking, body weight reduction in obese patients, and the use of folic acid, sexual functioning should be a recurrent topic. The help of a sexologist should be offered when patients experience problems in this area.
Early consultation of a gynaecologist or endocrinologist to exclude other issues regarding fertility in the patient or her partner may prevent unnecessary delay of conception.
Implications for gynaecologists
Gynaecologists and fertility specialists attending patients with RA should be aware of the possible effects of the disease, its manifestations, and antirheumatic treatment on both fertility, as well as on different treatments. When active disease is present, it may be worthwhile to postpone fertility treatment until antirheumatic treatment has been optimized and resulted in less active disease or preferably remission, and the patient does not require regular NSAIDs use or high dosages of prednisone. The increased chance of spontaneous conception when the disease is more strictly controlled, should be considered and discussed with patients, thus avoiding possibly unnecessary fertility treatments.
The distinction between different rheumatic diseases should be made. Many rheumatic conditions are known, but in only a few the effect on fertility has been documented. This thesis demonstrates a reduced fertility and a decline in ovarian function in women with RA. However, in patients with systemic lupus erythematosus (SLE), fertility is not compromised, although miscarriages and pregnancy complications are more frequent, resulting in smaller family sizes in women with SLE.5
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