Short abstract
Background
We evaluated serum anti-Müllerian hormone in women with rheumatoid arthritis newly introduced to tumor necrosis factor-α inhibitor treatment for 54 weeks to investigate the treatment’s effect on ovarian reserve.
Methods
A total of 12 premenopausal women with rheumatoid arthritis aged 20–50 years were recruited at our division, who had been newly treated with tumor necrosis factor-α inhibitor (infliximab or etanercept) from 1 April 2008 to 31 March 2014. Serial serum anti-Müllerian hormone levels and disease activity scores (DAS28-CRP) were examined at defined periods: start of treatment and 14, 30, and 54 weeks after start of treatment.
Results
DAS28-CRP scores in 12 women were significantly decreased from a mean of 4.6 (±SD: 0.4) to 2.3 (±0.4) after 54 weeks of treatment (p < 0.001). Serum anti-Müllerian hormone levels and its z scores did not change significantly.
Conclusion
Treatment with a tumor necrosis factor-α inhibitor did not affect serum anti-Müllerian hormone levels in 12 women with rheumatoid arthritis during 54-week treatment.
Keywords: Anti-Müllerian hormone, rheumatoid arthritis, tumor necrosis factor-α inhibitor
Introduction
Rheumatoid arthritis (RA) affects women approximately three times more frequently than men1 and often occurs in women during their childbearing years. It has been recognized for decades that the fertility of women with RA is decreased,2 and several studies have suggested that infertility in women with RA is a common phenomenon.3 However, the reason for the infertility remains largely unknown and seems to be multifactorial. There are several postulated causes including age-related fertility decline, decreased ovarian reserve, systemic inflammation, decreased sexual desire, simple personal choice, and medication side-effects.2–4
Anti-Müllerian hormone (AMH) is secreted in the ovary by granulosa cells, and serum AMH levels reflect the ovarian follicular pool.5,6 Therefore, it is often used as an endocrine parameter for ovarian reserve, which shows a potential ability to estimate the future reproductive lifespan. In addition to the estimation of ovarian reserve, AMH could be used as a diagnostic for ovarian dysfunction, including polycystic ovary syndrome, granulosa cell tumors, and early ovarian aging.6,7 At present, there are two conflicting reports regarding the putative diminished ovarian reserve in women with RA.8,9 Brouwer et al. reported that serum AMH levels in women with early RA were comparable to those in healthy controls by comparing 72 women with recent-onset RA aged 18–42 years and 509 healthy women.8 By contrast, Henes et al. reported reduced serum AMH levels in women with RA by comparing 33 women with RA with age-matched controls.9 Therefore, evidence-based data regarding serum AMH levels in women with RA seem to be insufficient for physicians to provide appropriate counseling for women with RA desiring pregnancy.
Management of RA has progressed greatly in recent years, and tumor necrosis factor-alpha (TNF-α) inhibitor treatment has been widely used, including women with RA who become pregnant.10–13 However, the effects of this treatment on fertility remains largely unknown. It is important for women with RA who want to get pregnant to have access to evidence-based data regarding the effects of this treatment on fertility. Considering that it is reported that 15% of women with RA limit their family size fearing the side-effects of RA medications,14 it is vital to accumulate the data for TNF-α inhibitor treatment with regard to fertility. Therefore, it would be very useful to know if and how serum AMH levels change during treatment.
Our study aimed to assess serum AMH levels in women with RA who had been newly started on TNF-α inhibitor treatment. We evaluated them over a period of 54 weeks of treatment in order to investigate the effect of the treatment on their ovarian reserve.
Patients and methods
Population
Premenopausal women with RA aged 20–50 years were recruited at the Division of Rheumatology, Department of Medicine, Showa University School of Medicine. These patients were newly treated with a TNF-α inhibitor (infliximab or etanercept) between 1 April 2008 and 31 March 2014. All recruited women fulfilled the 2010 American College of Rheumatology (ACR/EULAR) classification criteria15 and were enrolled continuously. We excluded women who had previously received other biological drug treatments, had a gynecological disease, or were obese (defined as body mass index of 25 kg/m2 or more according to the criteria by the Japan Society for the Study of Obesity). We obtained written informed consent from all women who enrolled in the study. This study was approved by the Bio-Ethics Committee of the Department of Medicine, Showa University School of Medicine (No. 1434), and conducted in accordance with the Declaration of Helsinki.
Data collection
Serial serum AMH levels and disease activity scores were examined at defined periods during TNF-α inhibitor treatment. The defined periods were as follows: the start of the treatment and 14, 30, and 54 weeks after the start of treatment. Disease activity was evaluated by using the DAS28 in 28 joints (DAS28-CRP).16
AMH measurement
Blood samples for the determination of AMH were centrifuged at room temperature for 10 min at 3000 r/min. The sera obtained were stored on ice and placed into freezers at –80°C immediately. Serum AMH levels were measured at a standardized laboratory (SRL, Hachioji, Japan). Other measurements were determined by standardized and certified procedures. It is widely known that serum AMH levels decline over the reproductive years, reflecting a decrease in the follicular reserve. Therefore, in this study, we not only used serum AMH concentrations but also age-specific z scores, which were calculated from the published reference chart.6
First, a correlation between serum AMH levels at the start of treatment and disease duration was examined. Second, we studied the effect of TNF-α inhibitor treatment on the ovarian reserve by comparing serum AMH levels at different time points of the treatment.
Statistical analyses
The results are expressed as the mean (standard deviation). Univariate comparisons were made using the Student’s t-test for continuous variables. Correlations between serum AMH levels (laboratory data and z score) at the start of treatment and disease duration were evaluated using Pearson’s test (correlation coefficient, r). All analyses were performed using JMP 12 (SAS Institute Inc., Cary, NC, USA), and two-sided p values <0.05 were considered statistically significant.
Results
During the study period, 12 women with RA started TNF-α inhibitor treatment and agreed to participate in the study. Table 1 shows the characteristics of these women.
Table 1.
Clinical characteristics of the women with RA analyzed in this study.
| Patient | Age (years) | Disease duration (years) | Concomitant medication | TNF-α inhibitor |
|---|---|---|---|---|
| 1 | 44 | 1 | MTX 8 mg, PSL 7.5 mg | IFX |
| 2 | 44 | 14 | MTX 8 mg | IFX |
| 3 | 27 | 11.5 | MTX 8 mg, PSL 7.5 mg | IFX |
| 4 | 42 | 0.6 | MTX 10 mg | IFX |
| 5 | 24 | 2.5 | MTX 10 mg, PSL 5 mg | IFX |
| 6 | 36 | 2.7 | MTX 8 mg, PSL 4 mg | IFX |
| 7 | 32 | 1.9 | MTX 12 mg | IFX |
| 8 | 43 | 1.2 | MTX 10 mg | IFX |
| 9 | 48 | 4.2 | MTX 6 mg, PSL 4 mg | IFX |
| 10 | 36 | 4.6 | MTX 8 mg, PSL 10 mg | ETN |
| 11 | 36 | 1.2 | No treatment | ETN |
| 12 | 32 | 1 | PSL 4 mg | ETN |
MTX: methotrexate, PSL: prednisolone, IFX: infliximab; ETN: etanercept.
Serum levels of AMH and the associated z scores at the start of the treatment were 3.0 (±2.3) and –0.038 (±0.90), respectively. Figure 1 shows the correlations between AMH levels (A: serum AMH levels, B: AMH z scores) and disease duration at the start of the treatment. There were no significant correlations between disease duration and serum AMH levels or AMH z scores (r=−0.36, p = 0.25: Figure 1(a), r=−0.42, p = 0.17: Figure 1(b)).
Figure 1.
Correlations between disease duration and serum anti-Müllerian hormone (AMH) levels (a: serum AMH, b: AMH z scores) at the start of tumor necrosis factor-α inhibitor treatment.
There were no statistically significant correlations between them ((a): r=−0.36, p = 0.25, (b): r=−0.42, p = 0.17).
Figure 2 shows the time courses of the DAS28-CRP scores (a), serum AMH levels (b), and its z scores (c) after TNF-α inhibitor treatment. After 54 weeks of treatment, mean DAS28-CRP scores were significantly decreased from 4.6 (±0.4) before the treatment to 2.3 (±0.4) after 54 weeks of treatment (p < 0.001), which indicates that this treatment was effective for controlling disease activity in these women. By contrast, neither serum AMH levels nor z scores showed statistically significant changes throughout the treatment (Figure 2(b) and (c)).
Figure 2.
Time courses of DAS28-CRP scores, serum anti-Müllerian hormone (AMH) levels, and z scores after tumor necrosis factor-α inhibitor treatment. DAS28-CRP scores were significantly decreased from mean 4.6 (±SD 0.4) before treatment to 2.3 (±0.4) (p<0.001). By contrast, both serum AMH levels and z scores did not change significantly throughout the treatment.
Discussion
In this study, we found that serum AMH levels in women with RA did not change significantly throughout 54 weeks of successful TNF-α inhibitor treatment (Figure 2). To our knowledge, this is the first study to report serum AMH levels in women with RA undergoing this treatment. Although our finding suggests that this treatment may not affect the ovarian reserve of women with RA over 54 weeks of treatment, which suggested that an ovarian reserve is not a main factor for successful pregnancy of women with this treatment, our data are limited by the small sample size. Nevertheless, our finding provides additional information regarding this widely used treatment for women with RA.
This is the third study that investigated serum AMH concentrations in women with RA. The previous two studies provided conflicting conclusions.8,9 In this study, serum AMH levels and the z scores at the start of the treatment were 3.0 (±2.3) and -0.038 (±0.90), respectively (Figure 2). Our study did not include healthy control subjects therefore, we cannot provide a definite conclusion. However, considering that the mean AMH z scores were nearly zero, our results suggest that serum AMH levels in women with RA do not diminish. Further investigation is needed to elucidate whether serum AMH levels are conserved in women with RA.
There were no significant correlations between disease duration and serum AMH levels (Figure 1). Henes et al. reported that there was no significant difference when comparing patients with a short disease duration (less than two years) and those with a long disease duration, although there was a reduced ovarian reserve in women with RA.9 Taking into consideration both our study and the previous report, disease duration is not the main factor that affects serum AMH levels in women with RA.
There are three limitations to this study. First, the sample size was very small. We could enroll only 12 women in the six years of the study period. Second, our cohort included older women, in which a total of 42% were more than 40 years of age. Serum AMH levels decline with age, which may have affected the results. Third, our data included only measurements for 54 weeks of treatment. To establish the safety of treatment in women with RA with regard to ovarian function, we should continue to follow-up these women.
In conclusion, these preliminary data for TNF-α treatment are reassuring with regard to fertility in women with RA and show that AMH is not affected by this treatment. One can therefore infer that ovarian reserve is not altered by this treatment. Further studies with a larger sample size and longer study duration are required to validate our findings.
Acknowledgments
We wish to thank all the patients and physicians for their time spent and commitment to this study. Cooperation for data collection: All members of the Rheumatoid Arthritis Group of Showa University (ASHURA groups): Takeo Isozaki, Kuninobu Wakabayashi, Ryo Takahashi, Hidekazu Furuya, Ryo Yanai, Nao Oguro, Yuzo Ikari, Takahiro Tokunaga, Sho Ishii, Shinichiro Nishimi, Airi Nishimi, Mika Hatano, Tomoki Hayashi, Kosuke Sakurai, Yoichi Toyoshima, and Katsunori Inagaki.
Declaration of conflicting interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Yusuke Miwa received research grants from Astellas Pharma Inc., Mitsubishi Tanabe Pharma Corporation, AbbVie CK, Pfizer Japan Inc., Chugai Pharmaceutical Co., Ltd., Eizai Co., Ltd, Asahi Kasei Pharm Co., Ltd, YL Biologics Ltd, Japan Blood Products Organization, Ono Pharmaceutical Co., Ltd, Nippon Kayaku Co., Ltd, and Teijin Pharma Ltd. The other authors have no potential conflicts of interest to disclose.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical approval
This study was approved by the Bio-Ethics Committee of the Department of Medicine, Showa University School of Medicine (No. 1434), and conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all patients who enrolled in the study.
Guarantor
Sakiko Isojima.
Contributorship
All authors contributed significantly to the article and approved the final version. Sakiko Isojima contributed to the concept and design, analyzed the data, and drafted the article. Yoko Miura and Mayu Saito acquired the data. Nobuyuki Yajima, Yusuke Miwa and Tsuyoshi Kasama interpreted the data and reviewed the article.
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