were prevented by the administration of anticoagulants (aspirin, heparin) during and after ovarian stimulation, while lupus activity was controlled with the use of corticosteroids.
The use of oral contraceptives for cycle programming should be discouraged because of the increased risk of thrombosis, particularly in women with positive aPL[14]. A milder hormonal stimulation, a GnRH antagonist protocol, a GnRH agonist for ovulation triggering, administration of lower doses of hCG, freeze‐all approach and a single embryo transfer are some of the strategies available to prevent OHSS syndrome[11].
Progestins can be administered in patients with SLE and/or APS for luteal phase support (LPS) and during pregnancy. Depending on the individual thromboembolic risk, anticoagulant therapy may be required during progestins administration (aPL positivity) [9]. Nonoral route administration of natural progesterone (P) should be preferred to synthetic oral drugs in terms of thrombotic risk prevention [11].
Pregnancy and SLE
A strict clinical, serological and laboratory follow‐up is mandatory during pregnancy to recognize early the signs of disease flare or pregnancy complications. The evaluation should include physical examination, with particular attention to blood pressure monitoring, and regular blood tests including blood count, renal and hepatic function, urine analysis and anti‐dsDNA and complement. Furthermore, pregnant women with SLE and/or APS, in addition to routine controls, should undergo supplementary ultrasound surveillance in the second and third trimester in order to early diagnose fetal growth restriction and abnormal Doppler patterns. Special monitoring with fetal echocardiography is required in women with anti‐Ro/SSA and/or anti‐La/SSB antibodies. The most serious complication associated with the presence of these antibodies is complete fetal heart block (CHB), which occurs in about 2% of women with no previous CHB. The recurrence rate of CHB in women with a previously affected child is 16%. These patients should have a weekly fetal monitoring between 16 and 26 weeks of gestation [15].
Obstetric outcomes in SLE patients are characterized by increased risk of complications related to placental insufficiency, including miscarriage, intrauterine fetal death, hypertension, preeclampsia, intrauterine growth restriction, low birth weight and preterm delivery [16].
In the Case History, a complete clinical and laboratory monitoring was performed before starting ovarian stimulation. Because of her serological profile, with aPL positivity, and her previous obstetric history, the patient was considered to be at increased risk for complications and was closely monitored during pregnancy and the postpartum period, which is critical for SLE flares.
In conclusion, ovarian stimulation in SLE and/or APS women seems to be effective and generally safe if the disease is in clinical remission and adequate prophylactic anticoagulant or anti‐inflammatory therapy is administered. Only in specific conditions such as active SLE, renal failure, heart disease and major previous thrombotic events infertility treatments have to be discouraged, due to the high risk of complications for both mother and fetus during pregnancy and puerperium.
Key points
Challenge: Infertility treatments in women with SLE with or without APS.
Background:
SLE mainly affects young women during their childbearing years.
aPL antibodies are present in around 40% of SLE women.
Neither SLE nor APS are a cause of primary infertility.
aPL antibodies are a risk factor for adverse events, vascular or obstetric.
Increased risk of maternal complications (lupus flares, thrombosis) in women with SLE and/or APS undergoing ovarian stimulation.
Management options:
Mild ovarian stimulation.
Coadjuvant therapy (anticoagulation, corticosteroids, immunosuppressants) according to the individual risk profile
Nonoral route administration of natural progesterone for luteal phase support and during pregnancy.
Prevention:
Postpone pregnancy at least 6 months after a lupus flare.
Avoid OHSS and multiple pregnancy.
Strict pregnancy monitoring for the early identification of pregnancy complications related to placental insufficiency.
Answers to questions patients ask
1 Q1. Does SLE cause infertility? A1. SLE is not a cause of infertility if the disease is mild. However, fertility can be reduced in women with severe active disease, especially lupus nephritis, and with the use of immunosuppressive drugs.
2 Q2. Are there forms of SLE considered to be high risk for complications during pregnancy? A2. Patients with aPL antibodies/APS, renal or cardiac disease, pulmonary hypertension, prior history of poor obstetric outcomes, active lupus, antibodies to Ro/La and multiple gestation are at increased risk of complications during pregnancy and postpartum.
3 Q2. Does the risk of complications for SLE decrease after childbirth? A3. No, the postpartum period is a high‐risk time for lupus flares and thrombotic events. Close monitoring is required not only during pregnancy, but also in this period.
References
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