Page 39 - Fertility in Women with Rheumatoid Arthritis Vruchtbaarheid van vrouwen met reumatoïde artritis

given month. This was not assessed in our study, but after adjustment for DAS28,
which reflects a patient’s pain, other variables are still signi cant.
Body mass index (BMI) is also known to affect fertility. Overweight and underweight
women both have a higher chance of ovulation disorders.35 Overweight women with 2 regular menses also have an increased risk of subfertility.36 The association of RA with
BMI is less clear.37,38 BMI was not recorded for the women included in the PARA study, but the median BMI for women 18-42 years in a representative Dutch RA cohort was 24.2 (21.9-28.3).34
Based upon our results, it should be recommended that RA patients trying to conceive should strive for low disease activity, thereby avoiding NSAIDs and daily dosages of prednisone exceeding 7.5 mg. The treatment of some women in our cohort, reflecting common care for women with RA during the preconception period, does not seem to have been optimal as two-thirds of patients had a DAS28>3.2. While nearly a third of these women used no medication, over a third received monotherapy with sulfasalazine or prednisone. Combination therapy of sulfasalazine, prednisone and hydroxychloroquine in these patients may have resulted in lower disease activity. Suppression of disease activity in RA women who wish to conceive is also important for the outcome of pregnancy. Higher DAS28 is associated with lower birth weight and rapid postnatal catch-up growth, which are both related to worse cardiovascular and metabolic pro les in adults.4,39 Use of prednisone during pregnancy is associated with lower birth weight due to delivery at lower gestational age and with higher cortisol levels in the offspring.4,40 Furthermore, women with high DAS28 more often undergo caesarean section.4
As the proportion subfertile women is much larger in the RA population than in the general population,15 patients likely to have a longer TTP might be helped by early consultation with a gynaecologist on options for reproductive treatment. If the TTP can be limited in these patients, this may prevent extended suboptimal treatment and consequently functional disability and progression of joint damage.
The results of our study also have implications for patients with conditions other than RA. When patients wish to conceive and are using high daily dosages of prednisone, or NSAIDs on a regular basis, their treatment should be critically evaluated. Similarly in patients with other inflammatory auto-immune diseases, disease activity may impair fertility and should be suppressed whenever possible.
Fertility in RA – clinical factors
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