Evaluation of ovarian reserve using anti-müllerian hormone and antral follicle count in Sjögren's syndrome: Preliminary study

Ovarian reserve in patients with Sjögren's syndrome: a cross-sectional study

OBJECTIVE

This study aimed to assess the potential impact of primary Sjögren's syndrome (pSS) on fertility and ovarian reserve by evaluating the number of antral ovarian follicles (AFC) through ultrasound and analysing serum levels of anti-müllerian hormone (AMH) and follicle-stimulating hormone (FSH), which are currently the most reliable indicators of fertility potential.

METHOD

A total of 52 premenopausal women were recruited from the Maternal, Infantile, and Urological Sciences Department at Umberto I Hospital, Sapienza University of Rome. Among them, 26 had pSS, and 26 served as healthy controls. All participants underwent a gynaecological examination, a transvaginal ultrasound, and serum testing for AMH and FSH levels.

RESULTS

The study found that serum AMH levels were significantly lower (p = 0.002) in pSS patients compared to the controls, indicating a potential reduction in ovarian reserve in these patients. However, no statistically significant differences were observed in FSH levels between the two groups.

CONCLUSIONS

The findings suggest that pSS may have a negative impact on ovarian reserve, as evidenced by lower AMH levels in comparison to age-matched controls. AFC and FSH levels, however, were similar to those of healthy women. These results provide new insights that could be beneficial for this patient population, though further, larger-scale studies are necessary to more comprehensively understand the relationship between pSS and female fertility. Key Points • The study assesses the possible impact of pSS on fertility and ovarian reserve by evaluation of AMH, FSH, and AFC. • Family planning and fertility are important issues for patients with rheumatic disorders and must be considered and discussed with the patient already at the time of diagnosis, and appropriate counselling must be performed.

NSAID exposure delays time-to-pregnancy in patients with spondyloarthritis: an analysis of the GR2 prospective cohort

BACKGROUND

The impact of disease activity and treatment on fertility outcomes in patients with spondyloarthritis (SpA) has been little explored. This study aimed to describe median time to pregnancy (TTP) in women with SpA and the factors influencing TTP in this population.

METHODS

This prospective observational multicentre (63 centres) French cohort (GR2 study-NCT02450396) included consecutive women with a diagnosis of SpA (according to their rheumatologist) who wanted to become pregnant between 2015 and 2021. TTP (in months) was the main outcome criterion, prospectively calculated from the date of study inclusion to the date of conception. Data on demographics, disease characteristics, disease activity, severity and treatment were prospectively collected at inclusion and each year thereafter until pregnancy occurred. TTP and its associated factors were estimated by survival analysis (Shared Frailty Cox models), with a random centre effect and multiple imputation to address missing data.

RESULTS

We analysed 88 women included before conception. Among them, 56 (63.6%) became pregnant during follow-up. Median TTP was 16.1 (95% CI (12.2 to 25.3)) months. Mean preconceptional Bath Ankylosing Spondylitis Disease Activity Index at inclusion was 2.9 (±SD 2.1). Patients were treated with TNF inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs), conventional synthetic disease-modifying antirheumatic drugs and glucocorticoids in 61 (69.3%), 23 (26.1%), 12 (13.6%) and 8 (9.1%) cases, respectively. The multivariate model found a significant association between TTP and age (HR) (per year) 1.22 95% CI (1.08 to 1.40); p<0.001) and the use of NSAIDs during preconception (HR 3.01 95% CI (2.15 to 3.85); p=0.01).

CONCLUSION

Age and NSAID use during preconception were significantly associated with a longer TTP, after adjustment for other confounding factors. These findings warrant caution in the use of NSAIDs in SpA patients trying to conceive.

A new insight on evaluation of the fertility and pregnancy outcome in patients with primary Sjögren syndrome: a propensity score matched study in multi-IVF centers

BACKGROUND

Primary Sjögren syndrome (pSS) is often related to adverse neonatal outcomes. But it's currently controversial whether pSS has an adverse effect on female fertility and clinical pregnancy condition. More importantly, it's unclear regarding the role of pSS in oocyte and embryonic development. There is a lack of comprehensive understanding and evaluation of fertility in pSS patients.

OBJECTIVE

This study aimed to investigate oocyte and embryonic development, ovarian reserve, and clinical pregnancy outcomes in Primary Sjögren syndrome (pSS) patients during in vitro fertilization (IVF) treatment from multi-IVF centers.

METHODS

We performed a muti-central retrospective cohort study overall evaluating the baseline characteristics, ovarian reserve, IVF laboratory outcomes, and clinical pregnancy outcomes between the pSS patients and control patients who were matched by Propensity Score Matching.

RESULTS

Following PSM matching, baseline characteristics generally coincided between the two groups. Ovarian reserve including anti-müllerian hormone (AMH) and antral follicle counting (AFC) were significantly lower in the pSS group vs comparison (0.8 vs. 2.9 ng/mL, P < 0.001; 6.0 vs. 10.0, P < 0.001, respectively). The pSS group performed significant reductions in numbers of large follicles, oocytes retrieved and MII oocytes. Additionally, pSS patients exhibited obviously deteriorate rates of oocyte maturation, 2PN cleavage, D3 good-quality embryo, and blastocyst formation compared to comparison. As for clinical pregnancy, notable decrease was found in implantation rate (37.9% vs. 54.9%, P = 0.022). The cumulative live birth rate (CLBR) following every embryo-transfer procedure was distinctly lower in the pSS group, and the conservative and optimal CLBRs following every complete cycle procedure were also significantly reduced in the pSS group. Lastly, the gestational weeks of the newborns in pSS group were distinctly early vs comparison.

CONCLUSION

Patients with pSS exhibit worse conditions in terms of female fertility and clinical pregnancy, notably accompanied with deteriorate oocyte and embryo development. Individualized fertility evaluation and early fertility guidance are essential for these special patients.

Sexual health in women with Sjogren's syndrome: A review

BACKGROUND

Rheumatic diseases, mainly affecting women, including rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus, etc., are chronic, inflammatory, autoimmune disorders that may involve multiple organs or systems and are closely related to sexual health, which is an important aspect of human physical and mental health. Sjogren's syndrome (SS) is the second most common rheumatic illnesses after rheumatoid arthritis with a female predominance. At present, the research on sexual health of female SS patients is still scarce and difficult to summarize.

OBJECTIVES

The objective of our study was to systematically review the literature for the influence of maternal SS on sexual health, such as sexual function, sex hormones, fertility, and pregnancy outcomes.

METHODS

We performed a comprehensive literature search based on PubMed and Web of science databases from inception to 1 November 2022. Outcomes were divided into 4 categories: sex hormones, sexual function, fertility, and pregnancy and offspring outcomes.

RESULTS

A total of 756 potentially eligible papers were retrieved. After eliminating duplicate articles and reviewing the titles and abstracts to exclude records, we read the remaining 92 articles in full for further evaluation, and selected 42 studies. Results on sex hormones, sexual function, fertility and pregnancy and offspring outcomes were reported in 13, 12, 3 and 14 SS-related articles, respectively. The levels of some sex hormones in SS patients may have undergone changes. Female patients with SS have a high prevalence of sexual dysfunction compared with controls. Most studies suggested SS had an adverse impact on maternal and fetal outcomes following pregnancy. However, there is insufficient evidence that directly indicating the fertility of SS women is diminished.

CONCLUSIONS

In summary, certain aspects of sexual health (sexual function, sex hormones and pregnancy outcomes) are impaired in SS women. Screening for sexual health problems in SS female should become an integral part of medical clinical practice. Rheumatologists should be aware of this association and collaborate with gynecologists, obstetricians, psychologists, and other experts on this issue to determine appropriate therapeutic approaches.

A review of autoimmunity and immune profiles in patients with primary ovarian insufficiency

Primary ovarian insufficiency (POI) is a complicated clinical syndrome characterized by progressive deterioration of ovarian function. Autoimmunity is one of the main pathogenic factors affecting approximately 10% to 55% of POI cases. This review mainly focuses on the role of autoimmunity in the pathophysiology of POI and the potential therapies for autoimmunity-related POI. This review concluded that various markers of ovarian reserve, principally anti-Müllerian hormone, could be negatively affected by autoimmune diseases. The presence of lymphocytic oophoritis, anti-ovarian autoantibodies, and concurrent autoimmune diseases, are the main characteristics of autoimmune POI. T lymphocytes play the most important role in the immune pathogenesis of POI, followed by disorders of other immune cells and the imbalance between pro-inflammatory and anti-inflammatory cytokines. A comprehensive understanding of immune characteristics of patients with autoimmune POI and the underlying mechanisms is essential for novel approaches of treatment and intervention for autoimmune POI.

Assessment of Ovarian Reserve in Patients with Migraine

Objective The aim of our study is to investigate the relationship between migraine and ovarian reserve. Methods The study group consists of women between the ages of 25-51, including 44 patients diagnosed with migraine and 43 controls. Ovarian reserves were performed by antral follicle count and measured anti-Müllerian hormone level. The cohort was divided into four subgroups according to age as follows: 30 years and below, 31-35 years, 36-40 years, and 41 years of age and above. Results Of the 87 individuals included in this study, 44 were migraine patients, and 43 were healthy controls. The mean ages of the study and control groups were 34.3 (minimum: 25, maximum: 51) and 36.5 (minimum: 27, maximum: 51) years, respectively. There was no statistically significant difference between the two groups regarding age (p=0.48). In the study and control groups, respectively; mean AMH levels were 2.67 ± 2.46 ng/mL and 2.55 ± 2.38 ng/mL (p=0.819), mean basal FSH levels were 7.92 ± 2.52 U/L and 9.11 ± 3.19 U/L (p=0.066), mean basal LH levels were 6.35 ± 3.59 U/L and 6.06 ± 2.86U/L (p=0.681), mean basal estradiol levels were 65.02 ± 69.54 ng/L and 49.47 ± 27.08 ng/L (p=0.244), and mean AFC were 10.9 ± 3.9 and 10.2 ± 3.7 (p=0.435). Between subgroups aged ≤30 years, serum anti-Müllerian hormone levels were found to be significantly different (p=0.036). There was no statistically significant difference between any age subgroups in terms of antral follicle count. Conclusion In conclusion, detecting possible reduction of ovarian reserves in reproductive-age (especially younger than 30 years) migraine patients by utilizing anti-Müllerian hormone and ultrasonographic markers would allow these women to make cognizant decisions regarding marriage and family planning, as well as inform them whether they are in early menopause risk

The Impact of Pediatric Rheumatic Diseases on Sexual Health, Family Planning, and Pregnancy

A comprehensive review of reproductive health subtopics, including sexual intercourse, romantic relationships, contraception, sexually transmitted infections, pregnancy, and infertility, as they pertain to patients with pediatric rheumatic diseases and those who care for them.

2021 recommendations of the Brazilian Society of Rheumatology for the gynecological and obstetric care of patients with Sjogren's syndrome

Sjogren's syndrome (SS) is an autoimmune disease characterized by lymphocytic infiltration of the exocrine glands and other organs. Women with SS often experience gynecological symptoms due to the disease and need extra care regarding their sexual activity, reproductive health and during pregnancy, conditions that are not properly conducted in the clinical practice. To cover this gap, a panel of experts from the Brazilian Society of Rheumatology conducted a systematic review and meta-analysis on the identification of symptoms, diagnosis, monitoring, prognosis, and treatment of these manifestations. A Focus Group meeting was held and included experts in the field and methodologists, based on a previously developed script, with themes related to the objective of the study. The most important topics were summarized and 11 recommendations were provided.

Anti-Müllerian hormone concentration as an indicator of female general health status: a cross-sectional study

RESEARCH QUESTION

To evaluate the correlation between clinical and hormonal parameters and comorbidity burden in Caucasian women presenting for fertility treatment.

DESIGN

Monocentric cross-sectional study including a cohort of 3163 Caucasian women seeking medical care for fertility treatment. All patients underwent centralized laboratory testing for hormonal assessment. Complete clinical and laboratory data from the entire cohort were retrospectively analysed. Comorbidity burden score was assessed by the Charlson Comorbidity Index (CCI; categorized as 0 versus 1 versus ≥2).

RESULTS

Descriptive statistics and regression models tested the associations between clinical and laboratory parameters and CCI. Among the entire cohort of patients, a CCI = 0 was found in 2977 women (94.1%), and CCI = 1 and CCI ≥2 were found in 113 (3.6%) and 73 (2.3%) patients, respectively. Age (P = 0.009), gravidity (P = 0.001), anti-Müllerian hormone (AMH, P < 0.001) and TSH (P = 0.003) values were significantly different among CCI groups. In regression models, age at presentation and AMH emerged as independent indicators of CCI ≥ 1. Age at presentation <36 years (odds ratio [OR] 1.742, 95% confidence interval [CI] 1.284-2.364) and an AMH concentration ≤2.3 ng/ml (OR 1.864, 95% CI 1.29-2.69) were the most informative cut-off values for CCI ≥ 1 in the study population.

CONCLUSIONS

A younger age at presentation and lower AMH concentrations are significant independent indicators of decreased general health in women requiring clinical evaluation for fertility treatment. As observed for sperm parameters in men, AMH might serve as a proxy of women's general health status.

Ovarian reserve in patients with ankylosing spondylitis

PURPOSE

The aim of this study was to determine the autoimmune effects of ankylosing spondylitis (AS) on the fertility potential of women by evaluating ovarian reserves of AS patients.

METHODS

A total of 104 patients, 52 in the AS group (study group) and 52 in the control group were included in the study. Ovarian reserve was evaluated by serum anti-Müllerian hormone (AMH) levels, antral follicle count (AFC) and baseline serum follicle-stimulating hormone (FSH) levels.

RESULTS

The mean serum AMH levels were significantly lower in the study group when compared to the controls (2.203 ± 1.110 vs. 1.188 ± 0.891, p < 0.001). In addition, the mean AFC was also significantly lower in the study group. (10.67 ± 1.81 vs. 9.54 ± 2.50, p = 0.009). Mean FSH levels were calculated to be 6.72 ± 1.14 in the study group and 7.21 ± 1.22 in the control group. The difference was not statistically significant (p = 0.781).

CONCLUSION

This study shows that AS like several other autoimmune conditions has an adverse effect on the female fertility potential. Therefore, an early start and long-term management of AS patients who have fertility desire is recommended. Serum AMH levels can be used in monitoring ovarian reserve and in early detection of reproductive decline of AS patients.

CLINICALTRIAL NUMBER

NCT04209881.

Evaluation of ovarian reserve in women with psoriasis

The aim of this study is to evaluate ovarian reserve in women with psoriasis. Thirty-six women with psoriasis and 36 healthy women were enrolled in this prospective study. On day 3 of the menstrual cycle, blood samples for AMH and other hormones were collected. On the same day, antral follicle count (AFC), and ovarian volumes were measured. A multiple regression analysis was carried out to examine the contribution of factors to the serum AMH levels in patients with psoriasis. The serum AMH levels and ovarian volumes were lower in the psoriasis group than in the control group (1.85 ± 1.13 ng/ml vs 2.46 ± 1.21 ng/ml, p = .029 and 10.43 ± 3.08 cm³ vs 11.93 ± 3.01 cm³, p = .038). However, the mean AFC between the two groups was not significantly different. The psoriasis area severity index (PASI) score did not correlate with AMH. On the other hand, the duration of the disease negatively correlated with AMH, total AFC and ovarian volume. In the multiple regression analysis, duration of disease and total AFC were the most significant contributors to the serum AMH levels in patients with psoriasis. Autoimmune diseases may affect ovarian reserve regardless of immunosuppresive treatment. Longitudinal follow-ups regarding reproductive function might be required in women with psoriasis.

Ovarian reserve in young juvenile idiopathic arthritis patients

OBJECTIVES

Juvenile idiopathic arthritis (JIA) occurs during reproductive age, however, there are no systematic data regarding ovarian function in this disease.

METHODS

Twenty-eight post-pubertal JIA patients and age-matched 28 healthy controls were studied. Complete ovarian function was assessed during the early follicular phase of the menstrual cycle including anti-Müllerian hormone (AMH), estradiol, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and antral follicle count (AFC) by ovarian ultrasound, and anti-corpus lutheum antibodies (anti-CoL). Demographic data, menstrual abnormalities, disease parameters and treatment were also evaluated.

RESULTS

The mean current age (22.6 ± 6.59 vs. 22.5 ± 6.59 years, p = .952) was similar in JIA patients and healthy controls with a higher median menarche age [13(8-16) vs. 12(8-14) years, p = .029]. A lower median AMH levels [2.65(0.47-9.08) vs. 4.83(0.74-17.24) ng/mL, p = .029] with a higher LH [8.44 ± 4.14 vs. 6.03 ± 2.80 IU/L, p = .014] and estradiol levels [52.3(25.8-227.4) vs. 38.9(26.2-133.6) pg/mL, p = .008] were observed in JIA compared to control group. Anti-CoL and AFC were similar in both groups (p > .05). Further analysis of JIA patients revealed that current age, disease duration, number of active/limited joints, ESR, CRP, patient/physician VAS, JADAS 71, DAS 28, CHAQ, HAQ, patient/parents PedsQL, PF-SF 36, cumulative glucocorticoid and cumulative methotrexate doses were not correlated with AMH, FSH, estradiol levels or AFC (p > .05).

CONCLUSION

The present study was the first to suggest diminished ovarian reserve, not associated to hypothalamic pituitary gonadal axis, in JIA patients during reproductive age. The impact of this dysfunction in future fertility of these patients needs to be evaluated in prospective studies.