Page 125 - Fertility in Women with Rheumatoid Arthritis Vruchtbaarheid van vrouwen met reumatoïde artritis

Studies on ovarian function in SLE show conflicting results.6,7 In Sjögren’s disease, no reduced fertility has been reported,8,9 but lower AMH levels have been found.10 Since the spectrum of rheumatic diseases is broad, collaboration between gynaecologists and rheumatologists is an essential part of preconception care in women with rheumatic diseases. Not only should the effect and safety of medical treatment in the preconception period be considered, but also the timing of fertility treatments. This will optimize the chance of a successful outcome.
Not only in patients with rheumatic diseases, but in all patients visiting a reproductive medicine unit, comorbidities and medication use should be considered as possible fertility compromising factors. Current guidelines on fertility assessments, such as the national guideline on fertility assessments of the Dutch Society of Obstetrics and Gynaecology (NVOG), and the guideline on ‘Fertility Problems: Assessment and Treatment’ by the National Institute for Health and Care Excellence (NICE) do mention possible effects of prescription and over-the-counter drugs on conception and pregnancy. However, comorbidity is only mentioned in the context of possible tubal occlusion and anovulation. Guidelines should also mention the possibility of direct interaction of comorbidity and fertility. For a patient with comorbidity, consultation of attending physicians on the effects of the condition on fertility and vice versa, and on possible treatment adjustments, as well as discussing timing of the start of fertility treatments, may both increase the chance of a positive outcome of fertility treatment as well as favour maternal health.
Suggestions for future research
The studies in this thesis have revealed several associations of rheumatoid arthritis
and antirheumatic drugs with subfertility or a prolonged time to pregnancy.
Prospective studies in women with RA who will start planning a family, may elucidate 8 whether a strict control of the disease, and avoidance of preconception use of NSAIDs
and high dosages of prednisone will result in less subfertility in this patient group.
However, the effect of earlier diagnosis since the introduction of the ACR/EULAR 2010
classi cation criteria for rheumatoid arthritis,11 and of the current treat-to-target
guidelines, including use of biologic DMARDs12 should be taken into consideration.
Active disease as well as the use of NSAIDs in women with RA, are associated with
a longer time to pregnancy and subfertility. Hence, pain as a manifestation of active
disease may be an underlying cause for a longer time to pregnancy, causing problems
in sexual intercourse, or a reduced intercourse frequency. Since the studies in this thesis
were post-hoc analyses of the PARA study, no information was available on intercourse
General discussion
123