Page 126 - Fertility in Women with Rheumatoid Arthritis Vruchtbaarheid van vrouwen met reumatoïde artritis

Chapter 8
frequency and timing of intercourse during the menstrual cycle. Prospective studies in women with RA, documenting menstrual cycles and intercourse frequencies, along with pain scores and the use of antirheumatic drugs, may provide insight in the effect of pain and antirheumatic medication on sexual intercourse.
The mechanism behind subfertility in active disease may be subject of future research. Although the implantation rate after IVF or ICSI treatments in RA patients was high (chapter 3), the number of patients was low, and possible selection bias was present. Therefore, the possibility of failure of embryo implantation as underlying cause for subfertility should be considered. Many growth factors and cytokines are involved in the embryo-endometrium interaction.13 Serum cytokine levels have been shown to be altered in RA patients. Exploratory studies on the association of serum cytokine levels in RA with subfertility or time to pregnancy may point towards cytokines of interest. Whether the intrauterine environment also suffers from this imbalance, might be studied subsequently by proteome studies in aspirated endometrial fluid. Identi cation of fertility impairing cytokines in the future may even indicate treatment targets in this speci c patient group.
Regarding ovarian function, long term studies of serum AMH levels at different time points in existing cohorts of women with established RA, and studies in early arthritis cohorts, may provide information on the actual age at menopause. Studies on serum AMH levels in women receiving the current more intensive treatment strategies, can reveal whether early diagnosis and start of treatment, current treat-to-target guidelines, and treatment with biological DMARDs have a protective effect on ovarian function. AMH recovery has been described in childhood cancer survivors, in whom decreased AMH levels are found as well at diagnosis as shortly after chemotherapy. Future studies of serum AMH levels in RA, should reveal whether intensive treat-to- target antirheumatic treatment may lead to recovery of ovarian function in young women with RA.
Conclusion
The results in this thesis emphasize the need for personalized medicine in fertility care. Current national and international guidelines, both in rheumatology, as well as in reproductive medicine, should take into account the interaction between comorbidity and fertility. For patients with RA, but also for patients with other comorbidities, when planning a family, a multidisciplinary approach may limit the time to pregnancy and favour maternal health.
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