Reproductive health guidance for women with vasculitis: consensus on guidelines for family planning, contraception, and fertility protection

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On October 3, 2022, foreign scholars published a review in the authoritative journal Nat Rev Rheumatol (impact factor 32.
286), aiming to synthesize the recommendations of the American College of Rheumatology (ACR), the American College of Obstetricians and Gynecologists (ACOG), the European Council of Obstetricians and Gynecologists (EBCOG) and the European Union Against Rheumatism (EULAR) expert group and other literature, to provide reproductive health and pregnancy for vasculitis patients and clinicians Comprehensive guidance
on disease management and medication safety.
Continuing from today's previous article, this article mainly presents the guidelines on reproductive health recommendations
for female vasculitis patients.

family planning

The ACR, EULAR, EBCOG, and ACOG guidelines strongly recommend that medical professionals have regular discussions
with patients about family planning.
EULAR, EBCOG, and ACR guidelines strongly recommend that patients with rheumatology consider pregnancy
during quiescent or low disease activity.
In addition, according to ACR guidelines, serious disease-related impairments such as pulmonary hypertension, renal insufficiency, and heart failure may be contraindicated to pregnancy, in which case EBCOG recommends pregnancy counseling
.

contraception

Patients should choose a tool based on the safety and efficacy of the contraceptive method, and the Vasculitis Foundation provides comprehensive contraceptive guidance (Figure 1).

EULAR guidelines propose that patients should consider the influence of
disease-related risk factors (such as disease activity and risk of thrombosis) and non-disease-related risk factors (such as hypertension, obesity, smoking, and family history of hormone-related cancers) when counseling for contraception.
ACR guidelines strongly recommend that women of reproductive age with no history of rheumatism use effective methods of contraception (hormonal contraceptives or IUDs) rather than less effective methods or non-contraception, particularly in patients with SLE or those with
a high risk of thrombosis that are positive for antiphospholipid (aPL) antibodies.

**Should not be used in patients at risk of thrombosis or with a history of thrombosis

Figure 1 Vasculitis Foundation contraceptive guidance

Maintain fertility

High-dose cyclophosphamide can cause ovarian insufficiency in women, leading to infertility and/or early
menopause.
To avoid this adverse effect, EULAR and ACR guidelines recommend that women treated with cyclophosphamide should be treated
with a gonadotropin-releasing hormone agonist (e.
g.
, leuprolide) every month.
The dose of leuprolide is usually 3.
75 mg per month, and the first dose
is done at least 10 days before cyclophosphamide is used.
However, women receiving low-dose cyclophosphamide (e.
g.
, Euro-Lupus regimen, 500 mg intravenous cyclophosphamide every 2 weeks for a total of 6 doses) have minimal ovarian damage
.

Infertility and assisted reproductive technologies

For patients who have infertility or wish to freeze their eggs prior to cyclophosphamide treatment, ACR guidelines recommend avoiding assisted reproductive technology (ART) treatment
when vasculitic is active.
EULAR guidelines recommend low-dose aspirin or low-molecular weight heparin (LMWH) therapy
during ART, depending on the patient's risk profile.
ACR guidelines recommend LMWH therapy for patients who are positive for aPL antibodies
.

References: Sims C, Clowse MEB.
A comprehensive guide for managing the reproductive health of patients with vasculitis.
Nat Rev Rheumatol.
2022 Oct 3:1–13.
doi: 10.
1038/s41584-022-00842-z.
Epub ahead of print.
PMID: 36192559; PMCID: PMC9529165.