Cyclophosphamide Exposure in Pediatric Systemic Lupus Erythematosus Is Associated with Reduced Serum Anti-Müllerian Hormone Levels

To the Editor: The reproductive risk to girls with pediatric systemic lupus erythematosus (pSLE) of varying disease severity and medication exposure is not well established. Because 15%–20% of patients with SLE are diagnosed before age 19 years1, many young women with pSLE will be affected by disease complications throughout their reproductive years. Although infertility in SLE has been attributed mainly to use of cyclophosphamide (CYC)2,3, further studies are needed to clarify the relationship between disease severity, medication use, and ovarian dysfunction. Because the incidence of premature primary ovarian insufficiency (POI) after CYC exposure in patients with pSLE < 21 years of age is estimated at 0–11%3, biomarkers for morbidities, such as infertility, are important because they may change current treatment strategies. Anti-Müllerian hormone (AMH) is produced by granulosa cells of preantral and small antral follicles and has been identified as a sensitive biomarker of ovarian reserve. AMH concentrations are relatively stable throughout the menstrual cycle, are unaffected by hormonal contraceptives, and decline with advancing age, as does ovarian reserve/function4,5. Low to undetectable levels of AMH are found in women ages 25–46 years within 5 years of their final menstrual period, in cancer survivors exposed to chemotherapy and/or radiation therapy-induced follicle depletion, and in women with POI … Address correspondence to Dr. N.C. Douglas, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, New York Presbyterian Hospital–Columbia University Medical Center, 622 West 168th Street, PH 16-64, New York, NY 10032, USA. E-mail: nd2058{at}columbia.edu