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Fertility preservation options should be presented to patients as early as possible after the diagnosis of a rheumatic disorder, such as rheumatoid arthritis, systemic lupus erythematosus, and scleroderma. These rheumatologic diseases often strike both men and women during childbearing years, and the diseases themselves as well as the long-term therapies used to treat them can have a negative impact on reproductive health.
A number of antiinflammatory and immunosuppressive drugs have advanced the treatment of rheumatoid arthritis (RA), spondyloarthritis, systemic lupus erythematosus, and other rheumatic disorders; however, information regarding the effects of these agents on reproductive function has been limited. Many of the available data have focused on the effects of antiinflammatory and immunosuppressive drugs on pregnancy. However, male and female gonadal function may be affected by these drugs as well.
According to Marybeth Gerrity, Ph.D., who presented at the 2008 American College of Rheumatology symposium, the list of rheumatic drugs that are known to affect reproductive health includes, but may not be limited to:
- nonsteroidal anti-inflammatory drugs (NSAIDs)
With respect to cyclophosphamide treatment for lupus nephritis, for example, while the cytotoxic-induced damage is reversible in some tissues of rapidly dividing cells, the damage to the ovary, with its limited germ cells, tends to be progressive and irreversible. In studies, up to 70% of adult female patients taking daily oral cyclophosphamide and nearly half of those receiving a monthly intravenous pulse developed amenorrhea and experienced permanent ovarian failure within a year of first dose.
The alkylating agent chlorambucil has been shown to affect both male and female fertility. Studies have shown that adult and adolescent women taking chlorambucil exhibit an increased rate of ovarian failure. Chlorambucil may cause an arrest in follicular maturation, stromal fibrosis, and a decreased number of ova in the ovary, leading to delayed onset of menstruation and amenorrhea. In adolescent and adult male patients, chlorambucil, either alone or in combination with prednisone or azathioprine, has been linked to temporary azoospermia, possibly due to inhibition of DNA synthesis in developing sperm and damage to the cells of the seminiferous epithelium.
Males taking sulfasalazine, methotrexate, cyclophosphamide, and leflunomide may also face the risk of oligospermia and impaired sperm motility, while females taking NSAIDs may have trouble conceiving because the drugs can inhibit blastocyst implantation.
Rheumatologists can help patients by initiating conversations regarding the adverse effect of certain rheumatic treatments on fertility. To determine the best fertility preservation option, patients should have a fertility preservation consultation with a reproductive endocrinologist. The Oncofertiltiy Consortium can assist rheumatologists with the referral process.
According to Dr. Gerrity, it is critical that the rheumatologist keeps an open line of communication with the reproductive endocrinologist and is clear about what can be done in terms of treatment- for example whether a female patient can go 3 weeks without treatment for her rheumatologic condition in order to undergo a fertiltiy preservation procedure.
The Oncofertility Consortium® provides a variety of oncofertility resources for rheumatologists to aid in the initiation of fertilty preservation conversations.
Join the National Physicians Cooperative, a nationwide network of health care providers and fertility preservation centers who share the common goal to protect and preserve reproductive health through the continuum of care of care and across the lifespan of patients.
National Physicians Cooperative Membership Benefits
- Access to a national referral network for patients seeking fertility preservation
- Information on how to establish a multidisciplinary Fertility Preservation program
- Training in the best practices, including technology updates and practice management
- Templates and assistance for obtaining IRB approval for participation in multicenter NPC studies
- Access to materials and tools as needed to support clinical studies
- Compensation for the time and materials required to freeze tissues for the research pool
- Invitations to Virtual Grand Rounds, annual meetings, special events
- Information about the financial aspects of fertility preservation
- Use of a Fertility Preservation Brochure tailored to your program
Implement a Fertility Preservation Program
The Oncofertility Consortium and National Physicians Cooperative provide resources to assist providers intereted in implementing a fertility preservation program.
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Education and Communication Strategies
The Decision Tool Web Portal is a library of existing fertility preservation resources designed to help rheumatologists navigate fertility preservation conversations. Available Resources include:
- Communication strategies for discussing fertility preservation options with patients of all ages and their family members
- Decision tools and aids designed to guide patient fertility preservation discussions
- ASRM clinical guidelines and recommendations
- Information on existing and experimental fertility preservation techniques and technology
- Print and online patient educational resources
Each patient needs an individualized consultation to determine the best and most mature technology available in their unique circumstances and according to their informed choice. To refer a patient for a fertility preservation consultation, call the FERTline at 312-503-FERT or 866-708-FERT and print out this flyer to give to your patients.
Patients are often concerned about the cost of fertility preservation procedures. To learn more about insurance coverage for fertility preservation, read Incorporating Insurance Education into the Fertility Preservation Process from Oncofertility Communication (2014) or check out the Oncofertility Consortium® blog post on Insurance Coverage for Fertility Preservation.