Page 53 - Fertility in Women with Rheumatoid Arthritis Vruchtbaarheid van vrouwen met reumatoïde artritis

DISCUSSION
This study aimed to explore the outcome of fertility assessments in those RA patients with subfertility. We found that subfertility in women with RA was most often unexplained or caused by anovulation. Moreover, the majority of subfertile RA patients received fertility treatments, and a considerable number of all pregnancies were conceived after women had been treated for subfertility.
In comparison to the general population, female RA patients appear to be more often 3 diagnosed with unexplained subfertility,5,7,15,16 whereas the percentage of subfertile
women with anovulation was equal or slightly increased compared to percentages
found in the general population.5,7,15,16 The incidence of primary ovarian insuf ciency
(POI) appears to be higher than in the general population.17
The high percentage of RA patients diagnosed by the gynaecologist with unexplained subfertility may imply that fertility in female RA patients is influenced by disease related factors. There was a signi cant association of periconceptional NSAIDs use with unexplained subfertility. This is in concordance with a previous study within the PARA cohort where we have shown that a longer TTP was associated with the periconceptional use of NSAIDs, also when corrected for disease activity scores.3 In this previous study, a longer TTP was also associated with an increase in periconceptional disease activity and the periconceptional use of prednisone.3 The current results did neither show signi cant differences in disease activity nor in periconceptional prednisone use between unexplained subfertile women and other subfertile RA women. However, since the current study was not designed to look into these associations, the numbers of patients in these comparisons were relatively small, and the timing of the study visit was not concurrent with the timing of the fertility work-up, these results do not exclude disease activity or prednisone use as a cause for subfertility in RA.
Looking further into the association of NSAIDs with subfertility, NSAIDs have not been reported to compromise embryo-implantation in IVF treatments,18 but there have been reports on NSAIDs interrupting the ovulatory process, possibly leading to the so-called luteinized unruptured follicle (LUF) syndrome.19-22 In LUF syndrome, ovulation is inhibited without changes in menstrual cycle length and cycle regularity and therefore patients with LUF would probably be classi ed as ovulatory during their fertility work-up. However, among gynaecologists the existence of LUF syndrome is controversial, and criteria for the existence of LUF syndrome include a laparoscopic
Fertility in RA – fertility assessments
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