Lupus (Systemic lupus erythematosus or SLE) is a chronic autoimmune disease where the immune system mistakenly attacks healthy tissues, causing widespread inflammation that can affect various parts of the body, including joints, skin, kidneys, and blood cells. This can also impact reproductive health, potentially influencing fertility in both men and women.
How Lupus Can Affect Female Fertility
Lupus can significantly impact female fertility through several mechanisms. Systemic inflammation and high disease activity can disrupt the hormonal balance necessary for regular menstrual cycles and ovulation. Autoimmune activity may directly cause ovarian damage, leading to a reduced ovarian reserve or even premature ovarian insufficiency, where ovaries stop releasing eggs before age 40. Studies show women with lupus can have significantly lower anti-Müllerian hormone (AMH) levels, an indicator of ovarian reserve, even in cases of mild disease activity.
Certain autoantibodies, particularly antiphospholipid antibodies (aPL), are also linked to reproductive challenges. While evidence suggests aPL may not directly cause infertility, they are strongly associated with complications like recurrent pregnancy loss and implantation issues. These antibodies can interfere with the development of the corpus luteum, a structure vital for early pregnancy, and may affect the uterine lining’s ability to support an implanted embryo.
Medications used to manage lupus can influence female fertility. Cyclophosphamide, a potent immunosuppressant, is gonadotoxic and can impair ovarian function, potentially leading to premature ovarian failure. The risk of ovarian damage from cyclophosphamide depends on the dose, duration of treatment, and patient’s age. Other medications, like high-dose corticosteroids, can also suppress the hypothalamic-pituitary-ovarian axis, affecting hormone levels and menstrual regularity.
How Lupus Can Affect Male Fertility
Lupus can also affect male fertility. Inflammation and disease activity associated with lupus can directly impact sperm production, quality, and motility. Some research indicates that men with lupus may have lower sperm counts, reduced sperm volume, and a higher percentage of abnormally formed sperm. Damage to the seminiferous tubules within the testes, which are responsible for sperm production, may contribute to these issues.
Certain lupus medications can similarly affect male reproductive health. Cyclophosphamide, for instance, can impair spermatogenesis (sperm production) and may lead to permanent sperm damage. The extent of this impact is often related to the dosage and duration of the treatment. Other immunosuppressants like methotrexate and sulfasalazine have also been associated with reduced sperm count.
Planning for Conception with Lupus
Pre-conception Counseling
For individuals with lupus considering pregnancy, careful planning is important for optimizing outcomes. Pre-conception counseling with a multidisciplinary team, including a rheumatologist and an obstetrician specializing in high-risk pregnancies, is highly recommended. This allows for a thorough assessment of disease activity, medication review, and risk stratification.
Disease Stability and Medication Management
Achieving and maintaining low disease activity or remission for at least six months prior to conception is important. Active lupus at the time of conception significantly increases the risk of flares during pregnancy and adverse maternal and fetal complications. Medications should be reviewed and adjusted to those considered safe for pregnancy, such as hydroxychloroquine, azathioprine, and certain corticosteroids. Conversely, medications like cyclophosphamide, methotrexate, and mycophenolate mofetil are generally contraindicated and require discontinuation or switching well before conception due to potential birth defects.
Assisted Reproductive Technologies (ART)
The healthcare team can advise on the optimal timing for conception based on disease stability and medication adjustments. If natural conception proves challenging, assisted reproductive technologies (ART) may be considered. Ovarian stimulation for ART is generally deemed safe for lupus patients if the disease is clinically inactive and appropriate prophylactic measures, such as anticoagulants, are administered when indicated.
Fertility Preservation for Lupus Patients
Fertility preservation offers important options for lupus patients, particularly those facing treatments that could compromise their reproductive potential. It is often recommended before initiating high-risk medications like cyclophosphamide, which can cause premature ovarian failure or permanent sperm damage. Younger patients who are not yet ready to conceive but wish to protect future options should also discuss these possibilities with their healthcare team.
For women, common fertility preservation methods include oocyte (egg) freezing and embryo freezing. Egg freezing is most effective when performed earlier in life, ideally before age 35, as lupus can accelerate ovarian aging. Embryo freezing, involving in vitro fertilization followed by cryopreservation of embryos, is another viable option.
For men, sperm banking is the primary method of fertility preservation. Discussions about sperm banking should occur early in the treatment of men diagnosed with lupus, especially before starting cyclophosphamide. Consulting with a reproductive endocrinologist early in lupus management is essential to explore these options and develop a personalized fertility preservation plan.