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Cuoghi Edens, MD: Fertility and Assisted Reproductive Technologies in Rheumatic Disease

Cuoghi Camille Edens, MD, discusses her upcoming American College of Rheumatology Convergence presentation, “Fertility and the Use of Assisted Reproductive Technologies: Perceptions, Thoughts and Experiences of Men and Women with Rheumatic Disease.” Edens is Assistant Professor of Pediatrics, Assistant Professor of Medicine at the University of Chicago and a medical advisor to CreakyJoints.

Rheumatology Network: Your abstract mentioned that patients with rheumatic diseases tend to have fewer biological children. Why do you think that is?

Cuoghi Camille Edens, MD: There are a few reasons we know why this occurs. Since some treatments in rheumatology are not safe for pregnancy, specifically methotrexate, leflunomide, mycophenolate, and cyclophosphamide, women with rheumatic diseases are counseled on this and recommended to use on birth control. Markers of egg stores, called anti-mullerian hormone and antral follicle count are found to be lower in women with rheumatic diseases, possibly due to chronic inflammation and this may contribute. Women with rheumatic diseases may also go through menopause earlier than the general population. Studies have shown endometriosis and polycystic ovarian syndrome are increased in autoimmune diseases and both play a role in infertility. Dating, age of marriage, sexual relationships, and partner intimacy have been shown to be negatively affected by one's rheumatic disease which plays a role in having less children. Lastly, some patients with rheumatic diseases choose not to have children at all due to their disease or its treatment, not wanting to pass on their diagnosis to their children or worry about being unable to care for their future children.

RN: Can you tell me a bit more about assisted reproductive technologies (ART)?

CE: ART is a broad medical term for any intervention that helps someone become pregnant. This may include things like taking medications like clomiphene (Clomid) or letrozole (Femara) and procedures like intrauterine insemination (IUI) or invitro fertilization (IVF). ART also includes trying to have a baby using things like donor eggs, donor sperm, donor embryo, and a surrogate, also called gestational carrier. Egg and sperm freezing are also considered ART.

RN: A quarter of patients believed that medications used to treat their rheumatic disease may have affected their fertility. Is that a possibility?

CE: This statistic is very unlikely. Our goal was specifically to ask patients (sourced from ArthritisPower Research Registry and other social media platforms) what they thought may impact their fertility and gave them the choices of almost every medication used in rheumatology, not to limit what medications are known to contribute to infertility. There are actually few medications used in rheumatology that are known to cause infertility. In women and men cyclophosphamide can permanently lower sperm and eggs counts. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can also affect sperm growth and ovulation, however this is reversible if these are stopped. In men, sulfasalazine can also cause low sperm numbers but is also reversible. Many patients worry that methotrexate can hurt their fertility, however, studies don't show this is true. The hard part about studying medications and their effect on fertility in rheumatology is that you can't remove the disease itself as part of the cause. While the patients in our survey may have thought their medications were the cause, it's very unlikely to be the case. 

RN: How can rheumatologists better serve their patients regarding fertility?

CE: Asking important questions about their patient's sexual activity, relationship status, and pregnancy plans are key. If a rheumatology doesn't ask, they won't ever know! But rheumatologists may not have the time to address these or the experience to answer questions that arise from these conversations. While topics like sex and contraception and infertility can be awkward to bring up with any medical provider, if patients have concerns or questions, they should bring them up with a medical provider they feel comfortable with. The American College of Rheumatology (ACR) Reproductive Health Guidelines encourages rheumatologists to inquire about family planning at every visit and also supports ART in patients with rheumatic diseases.

RN: Were there any strengths or limitations that you’d like to highlight?

CE: While the response number was low, our study is the first to examine this topic in men with rheumatic diseases, a group often overlooked in reproductive health studies. This study did not review patient's charts, so we aren't able to correlate their medications with their reported infertility, nor confirm their self-reported diagnoses, only what the patient thought contributed. We also looked at ART knowledge and barriers which is data not reported before.

RN: Does your team plan on doing any further research on this topic?

CE: Studying rheumatologists' knowledge about ART will be the next step to be able to help patients. Interviewing patients about infertility with a rheumatic disease as well as fertility specialists will give additional information to how to better address these topics with patients and how to raise awareness.

RN: Is there anything else you’d like our audience to know?

CE: One in 8 couples in the US have a hard time becoming or staying pregnant (are infertile). If you have a rheumatic disease and have been trying for more than 6 months or have had multiple miscarriages, it's time to see a fertility specialist. If you want to have a child, there is likely a way to medically make that happen, however there are a number of barriers such as ART knowledge, access, and cost that may stand in the way. Thankfully the treatment of rheumatic diseases has improved considerably in the past 20 years, and with that fertility treatment acceptance and awareness. Patients with rheumatic diseases are now closer to achieving their family planning goals, although may need assistance in doing so.