Rheumatic diseases

Detailed information and a list of references can be found in Chapter 2.7 of the FertiPROTEKT book, "Indications and fertility preservation methods for oncological and non-oncological disorders", which can be downloaded free of charge.

PROGNOSis

Autoimmune diseases often affect young women of childbearing age. Despite great advances in treatment, general rheumatic diseases such as connective tissue disease and vasculitis are still often the reason for chemotherapy. Cyclophosphamide (CYC) is almost exclusively used here and also in stem cell transplants.

With early diagnosis and initiation of appropriate therapy, most patients can now be given effective and permanent treatment.   Since the life expectancy of a treated patient is drawing closer to that of a healthy woman, the subject of fertility and preservation of fertility plays an increasingly important role.

 

damage to the ovaries caused by chemotherapy

The ovarian reserve, determined by the concentration of Anti-Müllerian hormone (AMH), is already often limited by the illness itself in autoimmune disease. A consultation on fertility preservation should therefore be carried our before CYC treatment in patients with autoimmune disease.

CYC significantly increases the risk of premature failure of ovarian function (= premature ovarian insufficiency, POI) in autoimmune disease. The stated probabilities are between 12% and 54% and are mainly influenced by the age of the patients at the time of treatment and the total dose of CYC.

 

Risks of fertility preservation

GNRH-AGONISTs (GNRHA)

The risk of GnRHa therapy is be considered to be low in patients with rheumatic disease. The effectiveness is considered to be controversial; however several studies have shown a detectable protection of ovarian function through the use of GnRHa for CYC treatment.

 

Hormonal Stimulation of the ovaries

Stimulation therapy for freezing fertilized or unfertilized eggs should be decided on an individual basis.

Basically, there are two possible risks:

  1. The risk of stimulation worsening the disease
    • Stimulation can lead to an increase in disease activity, particularly in connective tissue disease and especially in SLE. However, few studies are available. 
  2. Risik of thrombosis
    • The risk of thrombosis is generally increased in autoimmune disease. There are limited studies on thrombosis risk under hormonal stimulation.

 

freezing of ovarian tissue

In young women up to the age of 35 years (to a maximum of. ca.38 years), freezing of ovarian tissue is a sensible method. Since autoimmune disease is a chronic condition, this method also offers fertility preservation if CYC therapy needs to be repeated. Due to the often diminished ovarian reserve, however, the AMH value should be measured and the number of small follicles (AFC) should be evaluated using ultrasound to assess whether cryopreservation is reasonable.

 

practical approach

The choice of fertility preservation method is an individual decision which should be made after consultation with the patient, the responsible gynaecologists and rheumatologists.

Patients should be referred to a reproductive medical centre as soon as possible to allow a sufficient time frame for the implementation of fertility preservation measures. The figure opposite illustrates the possible practical approach.