Assessment of ovarian reserve in reproductive age Indian women with lupus and determination of correlates of diminished reserve: results from a tertiary care centre

Background Fertility remains a controversial issue in women with systemic lupus erythematosus (SLE); it is largely preserved, though a subset experiences subfertility due to multiple interacting factors. Small studies on anti-mullerian hormone (AMH) as an ovarian reserve marker in SLE have yielded conflicting results; data on antral follicular count (AFC) and ovarian volume (OV) are sketchy. Potential ethno-geographic differences exist, but there is no data on ovarian reserve of Indian lupus patients. There is lack of clarity on the factors affecting ovarian reserve in SLE. Methods In this single-centre observational study, female SLE patients aged 18–45 years were tested for AMH, FSH, and estradiol at D2–D5 of menstrual cycle. Ultrasonographic assessment of AFC and OV was done in a subset. Age-specific nomograms of AMH and AFC of healthy fertile women were used for comparison. Proportion of patients with premature ovarian insufficiency (POI), early menopause, and those having low AMH (<1 ng/mL) were calculated. Clinico-immunological determinants of reduced ovarian reserve were identified through multivariable logistic regression. Results 168 lupus women [mean age 27(6.4) years] were included. 93(55%) were married. 120(72%) had regular menstrual cycles. 3(1.8%) had POI (at 21, 22, and 37 years of age), while an additional two (1.2%) had early menopause at 41 and 44 years. 82(49%) were found to have low AMH. Comparison with age-specific nomograms showed 64% patients had AMH and 47% had AFC less than the corresponding tenth centile of healthy fertile women. Multivariable regression showed higher age [OR = 1.12(1.05–1.20), p = 0.001], active disease [OR = 3.87(1.56–9.62), p = 0.004], menstrual irregularities [OR = 4.56(1.95–10.65), p < 0.001], and anti-Ro60 positivity [OR = 1.89(0.92–3.88), p = 0.08] independently predicted reduced AMH. There was no association with organ involvement (including nephritis), disease duration, anti-dsDNA, anti-Sm, or aPL positivity, or prior CYC use. Conclusions Prevalence of POI and early menopause in our study was found to be 1.8% and 1.2%, respectively. A high proportion (49%) of Indian SLE patients had evidence of low ovarian reserve in the absence of known risk factors. Higher age, active disease, menstrual irregularities, and anti-Ro60 positivity were found to be independently associated with diminished ovarian reserve. No association was found with prior CYC use, nephritis, or antiphospholipid antibodies.