Infertility 101: What Every Rheumatologist Should Know

Infertility is a frequently encountered issue in medicine, seen in about 9% of men and about 11% of women of reproductive age in the U.S.¹ Many rheumatologists may not be aware of the prevalence of infertility and the implications this issue may have on the care of their patients. Here, Anat Chemerinski, MD, instructor in the Division of Reproductive Endocrinology and Infertility, in the Department of Obstetrics, Gynecology and Reproductive Health, Rutgers New Jersey Medical School, Newark, N.J., sheds light on the topic.

Dr. Chemerinski completed her residency at the University of Pennsylvania, Philadelphia, and her fellowship at Rutgers New Jersey Medical School. She is a Rutgers Presidential Clinical Scientist Scholar and a Clinical Research/Reproductive Scientist Training (CREST) Program Scholar.

The Rheumatologist (TR): How common is infertility in the general population, and which rheumatic conditions or medications are associated with infertility?

AC: Infertility affects about one in eight couples trying to conceive. Several studies have reported a reduction in fertility in women diagnosed with rheumatic diseases. Whether this is related to the disease, treatment or impact on sexual function and quality of life is unclear.

Certain medications used in the treatment of rheumatic disease can be associated with infertility. High doses of cyclophosphamide, for example, can be gonadotoxic and may lead to primary ovarian insufficiency. Women should be counseled about the risk of gonadotoxicity with this medication and referral to a reproductive endocrinologist should be considered.

In patients with active vasculitis, the ACR recommends against ovarian stimulation to decrease the risk of venous thromboembolism. If disease is inactive, EULAR recommends in favor of using low-dose aspirin or low molecular weight heparin during ovarian stimulation.

Certain medications used in the treatment of rheumatic disease are teratogenic, including mycophenolate, cyclophosphamide and methotrexate, and this should be discussed with patients planning an assisted reproductive technology cycle.

Finally, it’s important to remember that NSAIDs [non-steroidal anti-inflammatory drugs] can delay or inhibit ovulation. Patients who are trying to conceive should be made aware of this information.

TR: What is your approach to family planning with patients?

AC: Family planning discussions usually include the patient’s timeline for starting a family, the number of children the patient feels would complete their family and spacing between pregnancies. It also includes a discussion about age and age-related decline in fertility for patients presenting for this type of discussion in their later reproductive years.