Background/Purpose:  Rheumatoid arthritis (RA) is a rheumatic disease that can affect women of reproductive age, and data suggest infertility is increased in RA. The objective of this analysis was to determine the frequency of infertility among RA patients, as well as reasons for infertility.

Methods:  Women with RA aged 20-40 seen in a university clinic without a history of ovarian surgery or prior exposure to possible ovary-toxic medications were invited to participate in a cross-sectional survey. The survey included questions on infertility, reasons for infertility, physician-assisted reproductive methods, and how RA affected the desired number of children. Infertility was defined as a patient reporting being unable to get pregnant after 12 months of trying or a patient reporting physician-diagnosed infertility. Ovarian reserve was assessed by measuring anti-Müllerian hormone (AMH). Decreased ovarian reserve was defined as AMH <1 ng/ml. Multivariate linear models estimated the effect of age, hormonal contraceptives, and cumulative methotrexate (MTX) dose on AMH levels.

Results:  There were 52 RA patients; 79% white with a mean age of 31. Infertility was reported in 23% of 26 patients who had previously tried to conceive. Reasons for infertility included problems with ovulation (17%), unexplained infertility (50%), or unknown (17%). Physician-assisted reproductive methods had been used by 19% of patients who had previously tried to conceive, including taking oral medications (100%), injections (60%), insemination with partner’s sperm (20%), and in vitro fertilization with patient’s eggs (20%). Half of the 50 patients who had not completed childbearing prior to RA diagnosis responded that being diagnosed with RA led to wanting fewer children. The main reasons for wanting fewer children included concerns of being able to care for children, RA medications harming the baby, and a postpartum flare. Health was the most frequently reported factor patients took into consideration when making the decision to have children (73%), followed by financial concerns (56%), fatigue (50%), and pain (39%). Mean AMH was 3.2 ng/ml (SD: 2.6), with 21% of patients having decreased ovarian reserve. Decreased ovarian reserve was found in 23% of patients with prior MTX use and 11% of patients without prior MTX use (p=0.7). In a multivariate linear model, AMH decreased with age (-0.23 ng/ml per 1-year increase in age) and current hormonal contraceptive use (-1.43 ng/ml compared to patients not taking hormonal contraceptives), but cumulative MTX dose had no observed effect on AMH levels. There were no observed differences in AMH levels in women who reported infertility compared to fertile patients.

Conclusion:  The prevalence of infertility among RA patients who had tried to conceive was greater than the prevalence in the general population (23% compared to ~10%). There was not obvious cause for infertility among these women with RA. Age and hormonal contraceptives appeared to be associated with decreased AMH levels. However, there was no evidence of decreased AMH levels with increasing cumulative MTX, and AMH levels did not differ in patients reporting infertility.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/infertility-in-women-with-rheumatoid-arthritis/