Lupus erythematosus mainly affects women in their reproductive age. Menstrual alterations ranging from increased cycle flow, generally due to thrombocytopenia (low blood platelet count), to temporary amenorrhea (cessation of menstrual cycle) and premature menopause are fairly common in these patients. Ovarian failure, especially premature menopause, should be a constant concern in the management of patiens with SLE. Therefore, premature interruption of estrogen (the primary female sex hormone) production may give rise to a higher risk of cardiovascular disease, osteoporosis and infertility, among other estrogen deficiency-related symptoms. Amenorrhea is the most common menstrual disorder in SLE and is associated with disease activity, stress and drugs used.
Cyclophosphamide is the immunosuppressive agent of choice for the treatment of various complications of SLE and, therefore, is the factor most highly associated with ovarian insufficiency. Gonadal toxicity (damage to sex glands) should be of great concern in premenopausal women who take cyclophosphamide. The frequency of ovarian insufficiency in SLE patients treated with this drug ranges from 11 to 59% in different studies and depends on the dose used, the age of the patient and methodological differences.
The reproduction potential of male patients is impaired by the disease directly in the testicular tissue or by immunosuppressive therapy. Infertility is an important issue for them nowadays due to better prognosis and quality of life. The evaluation of male subjects should rely on careful medical history, complete physical examination, semen analysis and sexual hormone profile. Although semen analysis is considered the hallmark of male infertility evaluation, standard seminal parameters do not detect abnormalities in up to 20% of sub-fertile males. The routine measurements do not reveal seminal defects at molecular levels that might be induced by reactive oxygen species, which are associated with male infertility.
Autoimmunity also affects fertility by the presence of ASA (anti-sperm antibodies). Immunologic infertility is characterized by the presence of antibodies against spermatozoa (sperm cells) in the serum and/or in the seminal plasma or on the sperm surface. The presence of multiple ASA can lead to the immobilization and/or agglutination (clumping) of spermatozoa, which blocks sperm-egg interaction. They can also prevent implantation or arrest embryo development. In SLE patients ASA have been found in up to 42% of the patients. Lastly, aneuploidies (abnormal cell divisions in the process of sperm cell maturation) are frequent and may also contribute for fertility impairment in SLE patient’s; therefore karyotype (examination of sperm cells‘ chromosomes) should be evaluated to complete the fertility analysis of these patient’s, especially in those with severally compromised spermatogenesis.