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Rheumatology Reproductive Health Program

The Rheumatology Reproductive Health Program (RRHP) of the Barbara Volcker Center for Women and Rheumatic Diseases (BVC) provides the highest quality of counseling and care to rheumatology patients with respect to contraception, fertility and pregnancy concerns. In addition to providing clinical care in this important area, the RRHP facilitates research and enhances physician and patient education.

Patients with rheumatology conditions, particularly systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), are at increased risk of maternal and fetal pregnancy complications. Specific disease diagnosis, disease-related damage, level of disease activity, medications, and certain autoantibodies may impact pregnancy. Considerations include:

  • Pre-pregnancy counseling to identify risk factors for poor outcomes and to allow appropriate interventions.
  • Women who have difficulty conceiving may require assisted reproductive techniques such as in vitro fertilization, and autoimmune rheumatic illnesses may impact the monitoring and/or therapy for these procedures.
  • Women with active or serious disease or those on teratogenic medications should avoid pregnancy and require guidance on which forms of contraception are safe and effective for their specific condition.

pregnant woman talking to reproductive health specialist

 

Patient Care, Research and Education

The RRHP is the result of the BVC’s longtime interest and expertise in the area of reproductive health issues. The structure formalizes the reproductive health counseling and management that HSS physicians have provided for many years and coordinates the care between rheumatologists, obstetrician- gynecologists, maternal fetal medicine physicians and reproductive endocrine and infertility specialists.

Our program goals focus on the following:

  • Patient Care: We provide timely and high-quality counseling and care to rheumatology patients in respect to contraception, fertility and pregnancy issues.
  • Research: We work to further research in the field of reproductive health in rheumatology patients by maintaining a program registry and pursuing individual research projects.
  • Education: Ongoing lectures and conferences increase knowledge and awareness of reproductive health management in rheumatology patients among physicians, and educate patients regarding reproductive health concerns specific to their diagnoses and various situations.

Meet the Team

Multispecialty Collaborating Physicians

The RRHC works closely with these specialists from Weill Cornell Medicine. Patients contacting a physician for referral services are advised to verify that the physician participates with their health insurance.

Family Planning / Gynecology

Maternal Fetal Medicine

Reproductive Endocrinology and Infertility

Cardiology

Hematology/Oncology

Nephrology

Patient Resources and Articles

Our physician experts on reproductive health and rheumatic disease have written or edited these articles intended for patients looking for more information. If you have any specific questions or needs, please contact your physician or schedule a consultation by calling 917.260.4499.

Research and Education

HSS physicians have a long history of involvement in landmark studies in this field, including the NEJM study by Dr. Lockshin and colleagues that established anticardiolipin antibody as a predictor of fetal distress in SLE patients (1), a large  case series demonstrating low rates of serious complications in SLE and APS patients undergoing in vitro fertilization (2), the SELENA study  which confirmed the safety of oral contraceptives and hormone replacement therapy in stable SLE patients without antiphospholipid antibodies (3), and the PROMISSE study which documented a low rate of flare in stable SLE patients during pregnancy and identified important risk factors for adverse outcomes (4).

RRHP rheumatologists have been integral to the development of the 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases that provides management recommendations to physicians for specific reproductive health issues including contraception, fertility treatments, pregnancy management, and medication use before, during and after pregnancy (5).

As educators, program staff provide regular lectures to:

  • fellows and attendings at HSS, Weill Cornell Medicine, and other institutions.
  • patient audiences across multiple institutions and groups (see Patient Articles)

For more information about research please visit:

  • HSS Clinical Trials listing for active research studies and trials
  • PubMed for a full list of published articles from our physicians

References

  1. Lockshin MD, Druzin ML, Goei S, Qamar T, Magid MS, Jovanovic L, Ferenc M. Antibody to cardiolipin as a predictor of fetal distress or death in pregnant patients with systemic lupus erythematosus. New England Journal of Medicine. 1985 Jul 18;313(3):152-6.
  2. Guballa N, Sammaritano L, Schwartzman S, Buyon J, Lockshin M. Ovulation induction and in vitro fertilization in lupus and antiphospholipid antibody syndrome. Arthritis Rheum 2000, 43:550-556.
  3. Petri M, Kim MY, Kalunian KC, Grossman J, Hahn BH, Sammaritano LR, Lockshin M, Merrill JT, Belmont HM, Askanase AD, McCune WJ. Combined oral contraceptives in women with systemic lupus erythematosus. New England Journal of Medicine. 2005 Dec 15;353(24):2550-8.
  4. Buyon JP, Kim MY, Guerra MM, Laskin CA, Petri M, Lockshin MD, Sammaritano L, Branch DW, Porter TF, Sawitzke A, Merrill JT. Predictors of pregnancy outcomes in patients with lupus: a cohort study. Annals of internal medicine. 2015 Aug 4;163(3):153-63.
  5. Sammaritano LR, Bermas BL, Chakravarty E, Chambers C, Clowse ME, Lockshin MD, et al. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis and Rheumatology, in press.

History of Reproductive Care at HSS

By Michael D. Lockshin MD

Dr. Michael Lockshin is the Director of the Barbara Volcker Center (BVC) at Hospital for Special Surgery (HSS). During his early years at HSS, he initiated the focus on care and research of reproductive health issues in rheumatology patients. Dr. Lockshin graduated from Harvard Medical School in 1963; did internal medicine residency at the Second (Cornell) Division, Bellevue Hospital and Memorial Hospital; and completed rheumatology fellowship at Columbia-Presbyterian Medical Center under Charles L. Christian. He moved to HSS in 1970; from 1989-97 he was Extramural Director then Acting Director, NIAMS, NIH. He returned to HSS in 1997 as Professor of Medicine and Obstetrics-Gynecology, Hospital for Special Surgery and Weill Cornell Medicine and Director, BVC. Here he describes the evolution of his interest and expertise in caring for reproductive issues in his patients, particularly those with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS).

The first patient death I witnessed was of a pregnant woman with SLE when I was a first-year medical student working on a summer research project. The standard practice at the Boston Lying-In Hospital (now the obstetrical unit of Brigham and Women’s Hospital) was to present such a patient at a staff conference, with discussion led by the reigning local expert, usually invited from outside. To my astonishment, no one was knowledgeable about this problem, so the chief resident reviewed the available literature instead. This was at a first-rate institution at a first-rate medical school. The memory of this case stays with me to the present day and is in part why I entered this field.

In the mid-1970s, I was a new faculty member at HSS and student health service at what is now Weill Cornell Medical College referred a first-year medical student to me because during a routine screening of new students she had a false positive test for syphilis, an abnormality associated with SLE. We now know this is a sign of antiphospholipid syndrome (APS), but it would be another decade until we make that determination. Citing the wisdom of the day, I told the student that she should not have children because pregnancy was very dangerous for women with lupus. She considered my medical advice unacceptable and challenged me to prove my assertion.

The prevailing rule was that because lupus would invariably flare, it was one of few absolute indications for terminating a pregnancy (before Roe v. Wade). This is an assertion I believed because of the patient I had seen more than a decade before. At the same time, a prominent Mexican rheumatologist was arguing that pregnancy would be possible if every patient were placed on at least 10 mg, and preferably 40 mg per day, of prednisone throughout her pregnancy (1).

The role of gender in autoimmune diseases

At HSS, we had already started to think about issues of gender in patients with autoimmune diseases (2). I responded to my current student/patient’s challenge about pregnancy safety by looking more deeply into the current medical literature, which I found seriously wanting. Women’s rights had become a prominent social issue, and women were more frequently rejecting their doctors’ recommendations. A number of our own patients had chosen pregnancy, so I decided to look at them systematically with Maurice Druzin, the new head of our high-risk pregnancy (maternal fetal medicine) unit, whom I had met through the case of a mutual pregnant patient whose child had a congenital heart block (3).

The first thing that we found was that the medical student had been correct to challenge us — pregnancy rarely caused lupus to flare (4). The next thing that we noticed was that the major driver of poor pregnancy outcome is the antiphospholipid antibody (the false positive test for syphilis) (5). This finding has stood the test of time. It is now considered to be the most treatable abnormality that threatens lupus pregnancy.

The discussion continues and the medical student that challenged us is now the mother of 6 and anticipating the birth of her twenty-third grandchild (email message, January 29, 2020).

Lisa Sammaritano, MD, joined HSS as a fellow in rheumatology in 1988 and then continued as a faculty member with special interest in reproductive health. In September 1989, I left HSS to join the National Institute of Arthritis and Musculoskeletal and Skin Diseases at the National Institutes of Health. From our first pregnancy-related paper in 1983 through 1990, our group published 23 papers on pregnancy in lupus. [SJ1] Working with Dr. Druzin, we established an informal relationship with the high-risk pregnancy clinic, and our practices at HSS became the go-to center for lupus pregnancy problems. While at NIH I co-chaired the first International Conference on Rheumatic Diseases in Pregnancy, in Jerusalem in 1992. These conferences have been held every 2-3 years since that time, with the 11th International Conference on Reproduction, Pregnancy and Rheumatic diseases scheduled for October 2020.

In 1997, the Volcker family founded the Barbara Volcker Center (BVC), and I returned to HSS as its director. HSS had continued its leadership in this field during my absence. Physicians at HSS participated as primary coinvestigators in the NIH-funded SELENA trials (safety of estrogen and oral contraceptive therapy in lupus patients; safety of estrogen and hormone replacement therapy in lupus patients) and as lead investigators in the new PROMISSE study (pregnancy outcomes in lupus and antiphospholipid syndrome patients).

We continued, now as the BVC, to clarify and expand our interest in the reproductive health field. A medical student on an elective rotation helped us to evaluate, and publish the first major paper on, ovulation induction and in vitro fertilization in lupus and antiphospholipid syndrome patients. That paper remains the classic reference on this topic (6). That same student is now an attending obstetrician/gynecologist at Weill Cornell Medicine.

HSS leadership in this field continues

Dr. Sammaritano edited and co-authored a textbook on contraception and pregnancy in rheumatic disease patients, published in 2014 (7). More recently, she chaired the ACR Reproductive Health Guidelines committee that, in 2020, set international standard for reproductive health care for patients with autoimmune rheumatic illnesses (8). BVC members participate in virtually all national and international groups that study this topic; at every national and international meeting, participate in, and often chair, workshops. In 2020 we are making formal our relationship with the Weill Cornell Medicine Department of Obstetrics and Gynecology and Center for Reproductive Medicine, creating a specialized  rheumatology reproductive health center based  within the BVC at HSS that includes collaborative projects on a variety of topics, seeking grant funding together, and working on a day-to-day basis to further improve reproductive health care for rheumatic disease patients.

References

  1. Mintz G, Niz J, Gutierrez G, Garcia-Alonso A, Karchmer S. J Rheumatol. Prospective study of pregnancy in systemic lupus erythematosus. Results of a multidisciplinary approach.1986 Aug;13(4):732-9.
  2. Inman RD, Jovanovic L, Markenson JA, Longcope C, Dawood MY, Lockshin MD: Systemic lupus erythematosus in men: genetic and endocrine features. Arch Intern Med 142: 1813‑1815, 1982
  3. Lockshin MD, Gibofsky A, Peebles CL, Gigli I, Fotino M, Hurwitz S: Neonatal lupus with heart block: family study of a patient with antiSSA and SSB antibodies. Arthritis Rheum 26: 210213, 1983
  4. Lockshin MD, Reinitz E, Druzin ML, Murrman M, Estes D: Lupus pregnancy: case control prospective study demonstrating absence of lupus exacerbation during or after pregnancy. Amer J Med 77: 893898, 1984
  5. Lockshin MD, Druzin ML, Goei S, Qamar T, Magid MS, Jovanovic L, Ferenc M: Antibody to cardiolipin predicts fetal distress or death in pregnant patients with systemic lupus erythematosus. New Engl J Med, 313: 152156, 1985
  6. Guballa N, Sammaritano L, Schwartzman S, Buyon J, Lockshin M. Ovulation induction and in vitro fertilization in lupus and antiphospholipid antibody syndrome. Arthritis Rheum 2000, 43:550-556.
  7. “Contraception and Pregnancy in Rheumatic Disease Patients.” Sammaritano LR and Bermas BL (eds). New York: Springer Science + Business Media, 2014.
  8. Sammaritano LR, Bermas B, Chakravarty EE, Chambers C, Clowse EB, Lockshin MD, et al. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases, Arthritis Rheum 2020 (in press)

Contact Us

The RRHP works in conjunction with the HSS Lupus and APS Center of Excellence. Patients looking for care from a rheumatologist specializing in reproductive health should call 917.260.4499.

Mailing Address:

Barbara Volcker Center for Women and Rheumatic Diseases
535 East 70th Street, 6th Floor
New York, NY 10021
Fax: 212.774.2258