The 2023 American College of Rheumatology (ACR) Convergence conference was held in November in San Diego, CA, with approximately 13,000 health care providers, clinicians, researchers, and patients from all over the world in attendance.
Just as medical treatments for rheumatic conditions have evolved over the past couple decades, so, too, has advancements in supporting fertility and family planning. When you have a rheumatic condition or other chronic condition that requires medication, the idea of starting a family requires you start with a lot of planning. For those with rheumatoid arthritis, lupus, or other rheumatic conditions, a diagnosis can come at a young age, well before you might be ready for a baby.
Lisa Sammaritano, MD, with the Hospital for Special Surgery and Weill Cornell Medicine, who played a key role in the development of the American College of Rheumatology (ACR) guidelines for managing reproductive health, presented information at the 2023 American College of Rheumatology Annual Meeting to demonstrate how the use of Assisted Reproductive Technologies (ART) can provide options for patients with rheumatic diseases to help them achieve their family planning goals, whether now or later on down the road, regardless of the reason for waiting.
Sammaritano started her presentation stating, “Age is the biggest factor impacting our patients’ ability to plan a family. How do we preserve the fertility for patients who defer pregnancy due to ongoing active disease or who are taking teratogenic medications?”
She discussed how Assisted Reproductive Technology (ART) may be the answer for some individuals, and shared some of the available technologies.
“Planned” oocyte (eggs) cryopreservation is a procedure that may help women avoid future infertility. “Freezing your eggs,” Sammaritano explained, used to be something encouraged for women who wanted to delay starting a family due to a career or delaying marriage. However, today, it is becoming an option offered to young women with cancer, known as “medical egg freezing.”
It can also be an option for patients with rheumatic diseases. Sammaritano provided scenarios for which oocyte cryopreservation or embryo cryopreservation (if patient has a partner) may be appropriate for rheumatic disease patient to preserve her fertility:
- During a period of disease inactivity, when not ready for pregnancy, but before another flare occurs.
- While disease is stable but still taking teratogenic medications
- Before fertility declines with age
- Before fertility declines with cyclophosphamide use
To retrieve oocytes, there’s typically a period of ovarian stimulation that must occur before oocyte retrieval. Ovarian stimulation can be followed by intrauterine insemination (IUI) or transvaginal oocyte retrieval. The oocytes can be frozen (oocyte cryopreservation), fertilized through in vitro fertilization (IVF) and (fresh) embryo transfer, or embryos can be cryopreserved and genetic testing can also be done.
To dive deeper into the topic of Assisted Reproductive Technology (ART) in patients with rheumatic diseases, H. Irene Su, MD MSCE, a reproductive endocrinologist in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California in San Diego, presented information about IVF and research related to embryo versus oocyte cryopreservation.
“Oocytes and embryos can be frozen for decades.” Su shared research comparing embryo banking to oocyte banking, stating “embryo banking has the highest likelihood of success” for live birth. This varies by age, with a 54% success rate for those under the age of 35, and 38% success rate for those between 35 to 37 years old.
There have been recent advances in oocyte banking which has improved the survival rate of the oocytes by 80% after thawing. This has become an option for patients with no partners at the time of egg freezing and no religious objections to embryos, per Su. But this still has challenges of its own, as success rates are unknown and then the question of what you do with embryos you don’t use arises. Do you discard, donate to research, or donate to someone else who wants to start a family?
Su says there are a lot of things that need to be considered before making decisions on which route to take when it comes to preserving fertility.
Of course, all these measures come at a high price tag. When you’re already overburdened with medical bills for your condition, having the financial ability to pay for fertility preservation is a challenge and yet another obstacle to overcome to access it. However, there could be some hope for those wanting to preserve their fertility if the timing isn’t right to plan for pregnancy.
Su shared information about the high costs of IVF. She stated the average cost for IVF is approximately $15,000 to $30,000 per IVF cycle, with a median cost of $19,000 for the procedure. The cost of surrogacy is $80,000 to $150,000. Access to these procedures can be cost prohibitive, Su says, especially when “the median income in this country is $76,000.”
“You should be aware, that now, more than ever, there’s insurance infertility coverage and there are 14 states currently have IVF benefits,” said Su.
While there are no federal mandates right now, she says there are some state health insurance mandates in 16 of the 50 states* and some employer voluntary coverage benefits available for medically indicated fertility preservation.
“Providers should be aware that they are improving health insurance benefits for IVF,” Su advised. “I think we can tailor IVF protocols for the needs of a rheumatic-musculoskeletal disease patient, in collaboration with rheumatology teams.”
Be sure to check your insurance plan to see if fertility preservation is covered in any way through your benefits.
If you’re of child-bearing age, it is important to have open and honest discussions with your rheumatologist and gynecologist about your family planning wants and needs. A referral could be given to a reproductive endocrinologist to discuss your options. Both your rheumatologist and reproductive endocrinologist will work together to determine safety of medications you can or cannot take and the timing of any fertility preservation procedures.
Just remember to keep all your specialty doctors on your health care team in the loop during the process, as it is vital to maintaining your health and planning for your future.
Speakers at ACR presentation:
Lisa Sammaritano, MD, with the Hospital for Special Surgery and Weill Cornell Medicine, played a key role in the development of the 2020 American College of Rheumatology Guidelines for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases.
Dr. Irene Su is a reproductive endocrinologist and reproductive epidemiologist in the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, and directs the clinical fertility preservation program.
*States with state health insurance mandates: California, Utah, Colorado, Montana, Texas, Louisiana, Illinois, Kentucky, New York, Maine, New Hampshire, Rhode Island, Maryland, Connecticut, New Jersey, and Delaware. States with active legislation: Pennsylvania, Massachusetts, and District of Columbia.
