Page 87 - Fertility in Women with Rheumatoid Arthritis Vruchtbaarheid van vrouwen met reumatoïde artritis

INTRODUCTION
Rheumatoid arthritis (RA) is a chronic inflammatory auto-immune disease that not only affects the joints, but also has extra-articular manifestations. RA can already be manifest at reproductive age and might therefore reduce the ability to have children. Approximately 40% of female RA patients suffer from subfertility – a time to pregnancy (TTP) longer than 12 months despite regular unprotected intercourse – compared to 10-15% of women from the general population.1-3 Overall, RA patients have less children and are more often nulliparous than non- RA controls.4
A longer TTP in RA patients has been associated with older age, no previous
pregnancies, higher disease activity, and the periconceptional use of NSAIDs and
prednisone.2 However, little is known about the ovarian function in RA patients and
its effect on fertility. Since women with RA appear to reach menopause at a slightly
younger age,4,5 and since several autoimmune disorders have been related to primary
ovarian insuf ciency,6,7 the ovarian follicle pool in female RA patients may be reduced
at a relative early age. A recent small study has indeed reported results suggesting a
reduced ovarian reserve in women with established RA.8 Since in general a woman 6 becomes less fertile approximately 10 years before she experiences menopause, a
younger menopausal age is related to an earlier decrease in fertility,9 reflected by a longer TTP or not achieving pregnancy at all.
The reduced fertility with increasing age is strongly correlated with the decline in number of follicles present in the ovary.9 The size of the primordial follicle pool can be estimated by measuring serum levels of Anti-Müllerian hormone (AMH), which is speci cally produced by the granulosa cells of the small growing ovarian follicles.10,11 AMH levels are highest in early adulthood and decline with age, until they are undetectable around menopause.12 Unlike other hormonal markers for ovarian function, such as follicle stimulating hormone (FSH), fluctuations in serum AMH levels throughout the menstrual cycle are small.13 It should be noted that AMH expression in follicles may be downregulated, causing a discrepancy between AMH levels and the actual primordial follicle pool. For example, declined serum AMH levels during pregnancy have been reported.14-17 Still, at present, a woman’s serum AMH level is the most reliable predictor for the age at which she will enter menopause.18 Regarding fertility, AMH levels have been reported to add to the prediction of live birth
AMH in RA – time to pregnancy
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