ARTICLE

Journal of Clinical Rheumatology and Immunology

Antiphospholipid Antibodies and Fertility: No Impact

on Ovarian Reserve in Premenopausal Women
Sciascia Savino1,2,a*, Radin Massimo1,3,a, Menegatti Elisa3, Barinotti Alice3, Sini Federica3,
Cecchi Irene1,3, Rubini Elena1,3, Foddai Silvia1,3, Roccatello Dario1,2
Center of Research of Immunopathology and Rare Diseases — Coordinating Center of Piemonte and Valle d’Aosta Network
1

for Rare Diseases, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy
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2
Nephrology and Dialysis Unit, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
3
School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Italy
Journal of Clinical Rheumatology and Immunology Downloaded from www.worldscientific.com

ABSTRACT
Objective: To investigate possible differences in levels of ovarian reserve between antiphospholipid antibodies (aPL) asymptomatic
carriers and antiphospholipid syndrome (APS) patients, by measuring the levels of anti-Müllerian hormone (AMH).
Methods: We enrolled 69 premenopausal women divided in 2 groups: a) patients with APS, either primary (PAPS) or secondary
(SAPS), according to the Sydney classification criteria; b) asymptomatic aPL carriers. Aged-matched premenopausal healthy
donors (HDs) were also recruited. Complete aPL testing was performed and AMH levels were measured using enzyme-linked
immunosorbent assay.
Results: Among the 69 patients included in the study, 22 were diagnosed with PAPS, 13 with SAPS, and 14 patients were asymptomatic
aPL carriers. No differences in AMH levels were observed among the three groups [mean AMH: PAPS 3.09 ng/ml ± 1.9 (range 1.02 -
7.1); SAPS 3.1 ng/ml ± 2.2 (range 1.1 - 7.6); aPL carriers 2.2 ng/ml ± 5.4 (range 1 - 6.3)] and between patients/aPL carriers and HDs
[mean AMH 2.82 ng/ml ± 2.9 (range 1 - 6.9)]. Any correlation between the global APS score (GAPSS) and AMH levels failed to be
found (rho = 0.31; p = 0.073).
Conclusion: With the limitations of the current study, as observed in women with APS, we confirm that ovarian reserve, assessed
with AMH levels, is not reduced in premenopausal women with isolated aPL positivity. Moreover, when granulating the aPL profile
in terms of risk assessment, using the GAPSS, no impact on fertility was observed.

Keywords: Antiphospholipid Syndrome; Antiphospholipid Antibodies; Anti-Müllerian Hormone; Pregnancy-Ovarian Reserve;

Fertility; Thrombosis.

INTRODUCTION both IgG and IgM; their positivity must be confirmed

Antiphospholipid syndrome (APS) is an autoimmune
disease which is characterised by the presence of
thrombosis and/or pregnancy morbidity (PM)
in association with the persistent positivity for
antiphospholipid antibodies (aPL) [1]. The current
classification criteria for APS include three laboratory
tests: lupus anticoagulant (LA), anticardiolipin (aCL)
and anti-β2 glycoprotein-I (aβ2GPI) antibodies,
at least twice, 12 weeks apart. PM in APS includes
unexplained recurrent early miscarriage, foetal death
and late obstetrical complications such as pre-eclampsia,
premature birth or foetal growth restriction associated
with placental insufficiency.
Over the last decade, the awareness of the link
between autoimmune conditions and reproductive
issues has grown enormously, in parallel with the

This is an Open Access article published by World Scientific Publishing Company. It is distributed under the terms of the Creative Commons Attribution-
NonCommercial-NoDerivatives 4.0 (CC BY-NC-ND) License which permits use, distribution and reproduction, provided that the original work is properly
cited, the use is non-commercial and no modifications or adaptations are made.
Received 12 January 2020; Accepted 8 March 2020; Published 13 April 2020
a
These authors contributed equally.
*Corresponding author: Sciascia Savino, MD, PhD, Center of Research of Immunopathology and Rare Diseases — Coordinating Center of Piemonte and Valle
d’Aosta Network for Rare Diseases, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Piazza del Donatore di Sangue 3,
10154, Turin, Italy, E-mail: savino.sciascia@unito.it
VOLUME 20 • NUMBER 1 • 2020 • 1–5
DOI: 10.1142/S2661341720500017

2050001.indd 1 09-04-2020 13:48:04

 ARTICLE

increase of the problem up to 25-40% in patients
affected by autoimmune-rheumatic diseases [2]. While
the direct association between the presence of specific
autoantibodies, such as aPL, and the development of
PM has been extensively proven, less is known about the
possible effects of these antibodies on fertility.
Moreover, while a few studies, both in vitro assays
and animal models as well as some clinical studies,
have investigated the potential role of aPL in fertility
[2], even less is known on the ovarian reserve in aPL
positive patients, especially in those without clinical
manifestations of the disease. The question of whether
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no previous history of thrombosis or PM (e.g., before
performing in vitro fertilization techniques).
Herewith, we aim to investigate possible differences
in levels of ovarian reserve between aPL asymptomatic
carriers and APS patients, either primary (PAPS) or
secondary (SAPS), by measuring the levels of anti-
Müllerian hormone (AMH).
MATERIAL AND METHODS
Patients
We enrolled 69 premenopausal women (as described
in Table 1) divided into two groups: a) asymptomatic

aPL per se can impact on fertility is still open, potentially aPL carriers and b) patients with APS (PAPS or SAPS)
Journal of Clinical Rheumatology and Immunology Downloaded from www.worldscientific.com

causing over-treating and unmotivated concerns, according to the Sydney classification criteria [3]. Aged-
especially when aPL are found in health subjects with matched premenopausal healthy donors (HDs) were

Table 1.  Demographic, clinical and laboratory characteristics of the patients

included in the study, divided according to their diagnosis.
PAPS SAPS aPL carriers
(n = 22) (n = 13) (n = 14)
Anagraphic and AMH testing

Mean age at AMH testing (years, S.D.) 38.1 (± 6.1) 36.3 (± 8.3) 33.5 (± 8.1)
Number of successful pregnancies 26 12 12
Mean AMH levels (ng/ml, S.D.) 3.1 (± 1.9) 3.1 (± 2.2) 2.2 (± 5.4)
Clinical manifestations of APS
Thrombosis (n, %) 18 (82%) 12 (92%) 0
Arterial thrombosis (n, %) 11 (50%) 8 (61%) 0
Venous thrombosis (n, %) 7 (32%) 5 (38%) 0
Obstetric APS (n, %) 9 (41%) 1 (8%) 0
Laboratory testing
LA positive (n, %) 18 (82%) 13 (100%) 12 (86%)
aCL (IgG/M) positive (n, %) 10 (45%) 7 (54%) 5 (36%)
anti-aβ2GPI (IgG/M) positive (n, %) 10 (45%) 6 (46%) 4 (29%)
Triple aPL positivity* 7 (32%) 5 (38%) 1 (7.1%)
aPS/PT (IgG/M) positive (n, %) 9 (41%) 7 (54%) 4 (29%)
Risk assessment

Mean GAPSS (n, S.D.) 9.6 (± 4.1) 11.5 (± 6.3) 5.4 (± 5)

Arterial hypertension (n, %) 6 (27%) 7 (54%) 3 (21%)
Hyperlipidaemia (n, %) 5 (23%) 5 (38%) 2 (14%)
Diabetes (n, %) 3 (95%) 1 (8%) 2 (14%)
PAPS — primary antiphospholipid syndrome; SAPS — secondary antiphospholipid syndrome; AMH — anti-Müllerian hormone;
S.D. — standard deviation; APS — antiphospholipid syndrome; aPL — antiphospholipid antibodies; LA — lupus anticoagulant;
aCL — anticardiolipin antibodies; anti-aβ2GPI — anti-β2Glycoprotein I antibodies; aPS/PT — ­­anti-phosphatidylserine/
prothrombin antibodies; GAPSS — global anti-phospholipid syndrome score.
*Triple aPL positivity is defined as concomitant positivity of LA, aCL and anti-aβ2GPI antibodies.

2050001.indd 2 09-04-2020 13:48:06


also recruited. Patients and aPL carriers were followed-
up in the outpatient clinic of the San Giovanni Bosco
Hospital (Turin, Italy).
Laboratory testing
The aPL profile, at the diagnosis, included aCL, LA,
aβ2GPI and anti-phosphatidylserine/prothrombin
(aPS/PT) antibodies.
The aCL, aβ2GPI, and aPS/PT (IgG and IgM) were
detected by commercial ELISA (Inova Diagnostics,
Inc., San Diego, CA, US) with cut-off of positivity
as defined at levels of aCL IgG/IgM or aβ2GPI IgG/
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IgM antibodies >40 GPL/MPL and of aPS/PT >30 U,
following manufacturer’s instructions. Plasma samples
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were tested for the presence of LA according to the
recommended criteria from the International Society
on Thrombosis and Haemostasis (ISTH) Subcommittee
on Lupus Anticoagulant/Phospholipid-Dependent
Antibodies [4,5]. aPL testing was confirmed for all
patients accordingly to the current laboratory Sydney
Criteria [3] after at least 12 weeks.
Subjects were tested for AMH levels, measured with
an enzyme-linked immunosorbent assay for quantitative
detection of human AMH (Bio-Techned®, Minneapolis,
Minnesota, USA) according to the manufacturer’s
instructions.
Global anti-phospholipid syndrome score
The Global APS Score (GAPSS) is a validated tool to
help stratifying patients for their risk of developing
clinical manifestations of the disease. Individual,
GAPSS was calculated for each patient/aPL carrier
as previously reported, by adding together all points
corresponding to the risk factors [6]. In brief, the
individual GAPSS corresponds to the sum of risk factors:
3 for hyperlipidaemia, 1 for arterial hypertension, 5 for
aCL (IgG/IgM), 4 for aβ2GPI (IgG/IgM), 3 for aPS/PT
(IgG/M) and 4 LA.
Statistical analysis
Categorical variables are presented as number (%) and
continuous variables are presented as mean (S.D.).
Categorical agreement and degree of linear association
was analyzed. The significance of baseline differences
was determined by ANOVA or the unpaired t-test, as
appropriate. Correlation analysis was performed with
Pearson correlation. A two-sided p-value <0.05 was
statistically significant. All statistical analyses were
performed using SPSS version 19.0 (IBM, Armonk, NY,
USA).
2050001.indd 3
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RESULTS
A total of 69 patients were included in this study. Thirty-
five patients were diagnosed with APS, and among
those, 30 patients presented with history of thrombosis
(19 with arterial and 12 with venous thrombotic events),
and 10 patients presented with history of PM. Twenty-
two patients were diagnosed with PAPS [mean age 38.1
(± 6.1) years], 13 patients had a concomitant diagnosis
of systemic lupus erythematosus and therefore were
classified as SAPS [mean age 36.3 (± 8.3) years], and
14 patients were asymptomatic aPL carriers [mean age
33.5 (± 8.1) years]. Forty age-matched HDs [mean age
34.5 (± 5.2) years] were also recruited. No demographic
statistical differences were observed between groups.
The number of successful pregnancies among all patients
was 50. Table 1 resumes the clinical and demographic
characteristics of the patients included in the study.
No differences in AMH levels were observed among
different groups of patients [mean AMH: PAPS 3.09 ng/
ml ± 1.9 (range 1.02 - 7.1); SAPS 3.1 ng/ml ± 2.2 (range
1.1 - 7.6); aPL carriers 2.2 ng/ml ± 5.4 (range 1 - 6.3);
ANOVA; p = 0.264] and between patients/aPL carriers
and HDs [mean AMH 2.82 ng/ml ± 2.9 (range 1 - 6.9);
t-test, p = 0.314]. The results of levels of AMH between
groups are illustrated in Figure 1 (Panel A).
As expected, APS patients presented with a higher
rate of aPL positivity and higher GAPSS score when
compared to asymptomatic aPL carriers (mean GAPSS
10.3 ± 5 vs. mean GAPSS 5.4 ± 5; t-test, p = 0.005).
When considering the possible correlation
between GAPSS, no significant statistical correlation
between GAPSS and AMH levels was found (Pearson
Correlation; rho = 0.31; p = 0.073). Figure 1 (Panel B)
shows the levels of the correlation analysis between
AMH levels and GAPSS.
DISCUSSION
While the management of women with APS is
supported by international recommendations, [7,8]
the management of women with aPL positivity but no
clinical feature of the disease is a matter of ongoing
debate. Women who have isolated aPL positivity, with no
prior pregnancy loss or thromboembolic phenomena,
do not fulfil the criteria for the diagnosis of APS. Albeit
evidence are heterogeneous, low dose of aspirin is often
used in this setting [9]. As a general consideration,
the best predictor of maternal and foetal outcome
in women with aPL is the previous obstetric history.
Where there is a previously normal obstetric history
09-04-2020 13:48:06
 ARTICLE
Figure 1.  Panel A. Levels of anti-Müllerian hormone between groups of patients. Panel B. Correlation analysis between levels of a­ nti-
Müllerian hormone and global anti-phospholipid syndrome score.
AMH — anti-Müllerian hormone; PAPS — primary antiphospholipid syndrome; SAPS — secondary antiphospholipid syndrome;
aPL+ — antiphospholipid antibodies carriers; GAPSS — global anti-phospholipid syndrome score.
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despite the presence of aPL, any future pregnancy is
likely to have a low risk of complications and women
should be reassured of this. Poor prognostic factors for
pregnant women with APS include the presence of LA,
and multiple aPL positivity.
AMH is currently considered the earliest and
most sensitive routine test to evaluate ovarian reserve,
because its level correlate inversely with chronological
age, its potential to reliably predict ovarian response
during assisted reproduction, as well as the time of onset
of menopause [10]. While levels of AMH were tested in
a small cohort by a recent study by Castillo-Martínez
et al. [11], that investigated 23 premenopausal women
with APS, reporting a normal ovarian reserve in this
population, this is the first study to our knowledge on
asymptomatic aPL carriers.
When considering this particular population,
the assessment of risk factors for adverse maternal
and foetal outcomes in women with aPL is crucial
for preconception counselling and for implementing
appropriate preventive strategies and patient-tailored
monitoring plan before and during pregnancy.
Scoring devices, such as the GAPSS, take into
account the combination of independent cardiovascular
risk factors and the aPL positivity profile and might
4
2050001.indd 4
help identifying patients with aPL who are at higher
risk for developing any clinical manifestations of APS
(thrombotic and/or PM [6]). Pre-pregnancy planning
should be offered to all women with APS, taking all
risk factors into consideration. It may be necessary to
recommend deferring pregnancy in order to improve
general health and reduce risk, such as the need for
weight loss, following an acute thrombotic event. To
date, patients with any known aPL positivity are advised
to a specialist when planning a pregnancy because of
the many possible aPL-related pregnancy complications
[9]. However, asymptomatic aPL carriers, as well as APS
patients, should be reassured that ovarian reserve is
comparable to matched aged HDs. Several other factors,
rather than aPL, such as age, organ involvement and
previous treatment (mainly cyclophosphamide) should
be the focus of the discussion when counselling a woman
looking for a pregnancy when exploring fertility issues.
This study has limitations that should be
acknowledged, mainly its retrospective nature that will
require prospective validation, the small sample size and
heterogeneity in age distribution of the populations.
In conclusion, with the limitations of the current
study (mainly sample size and its retrospective design),
as observed in woman with APS, we confirm that
09-04-2020 13:48:10

ovarian reserve, assessed with AMH circulating levels, is
not reduced in premenopausal women with isolated aPL
positivity. Moreover, even when granulating the aPL
profile in terms of risk assessment, using the GAPSS, no
impact on fertility was observed.
ACKNOWLEDGEMENTS
The Corresponding author takes responsibility for all
aspects of the reliability and freedom from bias of the
data presented and the discussed interpretation.
DECLARATION OF CONFLICTING
INTERESTS
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The author(s) declared no potential conflicts of interest
Journal of Clinical Rheumatology and Immunology Downloaded from www.worldscientific.com
with respect to the research, authorship, and/or
publication of this article.
FUNDING
The author(s) received no financial support for their
search, authorship, and/or publication of this article.
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