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Li JW, Xv H, Wan RT. Bibliometric analysis of the global trends in immune-related recurrent pregnancy loss research over the last two decades. J Obstet Gynaecol Res 2024; 50:828-841. [PMID: 38467350 DOI: 10.1111/jog.15907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/05/2024] [Indexed: 03/13/2024]
Abstract
PROBLEM A comprehensive analysis was conducted to explore the scientific output on immune-related recurrent pregnancy loss (RPL) and its key aspects. Despite the lack of clear explanations for most RPL cases, immune factors were found to play a significant role. METHOD OF STUDY The study utilized a bibliometric approach, searching the Web of Science Core Collection database for relevant literature published between 2004 and 2023. RESULTS The collected dataset consisted of 2228 articles and reviews, revealing a consistent increase in publications and citations over the past two decades. The analysis identified the United States and China as the most productive countries in terms of RPL research. Among the institutions, Fudan University in China emerged as the top contributor, followed by Shanghai Jiaotong University. Kwak-kim J was the most prolific author, while Christiansen Ob had the highest number of co-citations. The top 25 co-cited references on diagnosis, treatment, and mechanisms formed the foundation of knowledge in this field. By examining keyword co-occurrence and co-citations, the study found that antiphospholipid syndrome and natural killer cells were the primary areas of focus in immune-related RPL research. Additionally, three emerging hotspots were identified: chronic endometritis, inflammation, and decidual macrophages. These aspects demonstrated increasing interest and research activity within the field of immune-related RPL. CONCLUSIONS Overall, this comprehensive bibliometric analysis provided valuable insights into the patterns, frontiers, and focal points of global scientific output related to immune-related RPL.
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Affiliation(s)
- Jing-Wei Li
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou City, Guangdong Province, China
| | - Honglin Xv
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou City, Guangdong Province, China
| | - Ren-Tao Wan
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou City, Guangdong Province, China
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2
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Liu PC, Li JB, Huang YP, Zhang M, Yu SJ, Wu R. Overexpression of regulatory T cells in patients with unexplained recurrent pregnancy loss: friend or foe? Front Med (Lausanne) 2024; 10:1244424. [PMID: 38239620 PMCID: PMC10794536 DOI: 10.3389/fmed.2023.1244424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 12/14/2023] [Indexed: 01/22/2024] Open
Abstract
Background This study aimed to investigate the role of regulatory T cells in patients with unexplained recurrent pregnancy loss (URPL). Methods We retrospectively analyzed 136 women who had experienced two or more miscarriages before 24 weeks of gestation for no obvious reason from May 2018 to October 2021. The basic clinical data of the patients and expression of lymphocyte subsets such as regulatory T cells (Tregs) and natural killer cells (NKs) by flow cytometry were collected to explore the risk factors of pregnancy outcome in URPL patients. Results A total of 136 URPL patients were enrolled in this study. Eventually, 50 patients attained clinical pregnancy. The median age was 31.8 ± 4.6 years in patients with clinical pregnancy. The univariate and multivariate logistic regression analyses indicated that Tregs was associated with the pregnancy outcomes of patients with URPL (odds ratio 0.63, 95% confidence interval 0.50-0.80). More importantly, a U-shaped association was found between Tregs and pregnancy outcome (p < 0.001), with either higher or lower Tregs levels adversely affecting pregnancy outcome. Conclusion Tregs levels that are either too high or too low can harm pregnancy outcomes. It was expected to be a very promising quantitative biomarker for predicting pregnancy outcomes in URPL patients.
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Affiliation(s)
| | | | | | | | | | - Rui Wu
- Department of Rheumatology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
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3
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Mu F, Huo H, Wang M, Wang F. Omega-3 fatty acid supplements and recurrent miscarriage: A perspective on potential mechanisms and clinical evidence. Food Sci Nutr 2023; 11:4460-4471. [PMID: 37576058 PMCID: PMC10420786 DOI: 10.1002/fsn3.3464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/07/2023] [Accepted: 05/14/2023] [Indexed: 08/15/2023] Open
Abstract
Recurrent miscarriage (RM) affects approximately 1%-5% of couples worldwide. Due to its complicated etiologies, the treatments for RM also vary greatly, including surgery for anatomic factors such as septate uterus and uterine adhesions, thyroid modulation drugs for hyperthyroidism and hypothyroidism, and aspirin and low molecular weight heparin for antiphospholipid syndrome. However, these treatment modalities are still insufficient to solve RM. Omega-3 fatty acids are reported to modulate the dysregulation of immune cells, oxidative stress, endocrine disorders, inflammation, etc., which are closely associated with the pathogenesis of RM. However, there is a lack of a systematic description of the involvement of omega-3 fatty acids in treating RM, and the underlying mechanisms are also not clear. In this review, we sought to determine the potential mechanisms that are highly associated with the pathogenesis of RM and the regulation of omega-3 fatty acids on these mechanisms. In addition, we also highlighted the direct and indirect clinical evidence of omega-3 fatty acid supplements to treat RM, which might encourage the application of omega-3 fatty acids to treat RM, thus improving pregnancy outcomes.
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Affiliation(s)
- Fangxiang Mu
- Department of Reproductive MedicineLanzhou University Second HospitalLanzhouChina
| | - Huyan Huo
- Department of Reproductive MedicineLanzhou University Second HospitalLanzhouChina
| | - Mei Wang
- Department of Reproductive MedicineLanzhou University Second HospitalLanzhouChina
| | - Fang Wang
- Department of Reproductive MedicineLanzhou University Second HospitalLanzhouChina
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4
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Rezayat F, Esmaeil N, Rezaei A, Sherkat R. Contradictory Effect of Lymphocyte Therapy and Prednisolone Therapy on CD3 +CD8 +CD56 + Natural Killer T Population in Women with Recurrent Spontaneous Abortion. J Hum Reprod Sci 2023; 16:246-256. [PMID: 38045499 PMCID: PMC10688285 DOI: 10.4103/jhrs.jhrs_8_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 12/05/2023] Open
Abstract
Background Natural killer T (NKT) cells are influential immune cells in pregnancy failures, including recurrent spontaneous abortion (RSA). Different approaches are used for these disorders due to their effects on maternal immunomodulation. Aims In the present study, we compared the effects of two typical immunotherapies (lymphocyte immunotherapy [LIT] and low-dose prednisolone) on CD3+CD56+CD16+ and CD3+CD56+CD8+ cells as two distinct subsets of NKT cells in Women with RSA. Settings and Design This study was a comparative cohort study conducted from 2021 to 2022. One hundred and five women with RSA were distributed into three treatment groups randomly. Materials and Methods Fifty women in the group of low-dose prednisolone therapy, fifty women in the LIT group and five women without any treatment as the control group were included in the study. NK and NKT cell subsets were assessed using flow cytometry. Furthermore, the concentration of interferon-gamma (IFN-γ), transforming growth factor-beta (TGF-β) and interleukin-10 (IL-10) was measured quantitatively using the enzyme-linked immunosorbent assay technique. Statistical Analysis Used Normality and comparisons between study groups were performed by non-parametric unpaired Mann-Whitney, Kruskal-Wallis rank sum test, and one-way ANOVA. Results The percentage of CD56dim NK cells was increased after prednisolone therapy, while this population significantly decreased in the LIT group. In contrast to the LIT group, the administration of prednisolone increased CD3+CD8+CD56+ NKT cells (P < 0.0001), which is helpful for pregnancy. The effect of the investigated treatment approaches on the population of peripheral CD3+CD56+CD16+ NKT cells of women with RSA was not adequately significant. The same situation was also observed regarding the serum level of IFN-γ. However, a significant decrease in serum levels of IL-10 and TGF-β was observed after prednisolone therapy. Conclusion The lower capability of LIT in changing the population of NKT cells compared to prednisolone therapy may be due to its mechanism of action, which is related to the production of blocking antibodies. These treatment approaches had different effects on NKT cells, indicating that NKT cell population and function can be affected using LIT and prednisolone therapy distinctly. In addition, prednisolone therapy and LIT in women with normal serum levels of IFN-γ have no harmful effects in changing the production of this critical cytokine.
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Affiliation(s)
- Fatemeh Rezayat
- Department of Immunology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nafiseh Esmaeil
- Department of Immunology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abbas Rezaei
- Department of Immunology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Roya Sherkat
- Immunodeficiency Diseases Research Center, Isfahan, Iran
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5
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Raut MK, Raut MM. Role of lymphocyte immunization therapy (LIT) in repeated miscarriages - A review. Am J Reprod Immunol 2023; 89:e13629. [PMID: 36351029 DOI: 10.1111/aji.13629] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 08/20/2022] [Accepted: 09/16/2022] [Indexed: 11/11/2022] Open
Abstract
Recurrent Miscarriages are seen in 2%-5% of women and 50% of these are labelled as unexplained as no underlying cause is found in them. Various studies have explained possible alloimmune basis in these couples. Lymphocyte Immunization Therapy (LIT) was the earliest immunomodulatory method suggested in these cases. The efficacy of LIT was questioned by REMIS study in 1999 and subsequent Cochrane reviews. However, recent meta-analyses have shown that LIT is not only effective in the treatment of repeated miscarriages but it is also safe. Review of the odds ratio for live birth of various meta-analyses of studies in recurrent miscarriages has also shown that newer meta-analyses have shown higher odds ratios. The purpose of this paper is to put forward the current perspective of LIT in reproductive failure and bring forth the recent evidence. In addition, we share our experience with the use of LIT in women with recurrent pregnancy losses. However, large multicentric RCTs are required to further prove efficacy of LIT.
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Affiliation(s)
- Mohan K Raut
- Dr. Raut's Centre for Reproductive Immunology, Dr. Raut's Women's Hospital, Mumbai, India
| | - Mugdha M Raut
- Dr. Raut's Centre for Reproductive Immunology, Dr. Raut's Women's Hospital, Mumbai, India
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6
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Zhao QY, Li QH, Fu YY, Ren CE, Jiang AF, Meng YH. Decidual macrophages in recurrent spontaneous abortion. Front Immunol 2022; 13:994888. [PMID: 36569856 PMCID: PMC9781943 DOI: 10.3389/fimmu.2022.994888] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
Recurrent spontaneous abortion (RSA) is defined as two or more pregnancy loss, affecting the happiness index of fertility couples. The mechanisms involved in the occurrence of RSA are not clear to date. The primary problem for the maternal immune system is how to establish and maintain the immune tolerance to the semi-allogeneic fetuses. During the pregnancy, decidual macrophages mainly play an important role in the immunologic dialogue. The purpose of this study is to explore decidual macrophages, and to understand whether there is a connection between these cells and RSA by analyzing their phenotypes and functions. Pubmed, Web of Science and Embase were searched. The eligibility criterion for this review was evaluating the literature about the pregnancy and macrophages. Any disagreement between the authors was resolved upon discussion and if required by the judgment of the corresponding author. We summarized the latest views on the phenotype, function and dysfunction of decidual macrophages to illuminate its relationship with RSA.
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Affiliation(s)
| | | | | | | | | | - Yu-Han Meng
- Center of Reproductive Medicine, Affiliated Hospital of Weifang Medical University, Weifang, Shandong, China
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7
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Kowalczyk E, Kniotek M, Korczak-Kowalska G, Borysowski J. Progesterone-induced blocking factor and interleukin 4 as novel therapeutics in the treatment of recurrent pregnancy loss. Med Hypotheses 2022. [DOI: 10.1016/j.mehy.2022.110968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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8
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Eidizadeh A, Papert S, Valk J, Pollok-Kopp B, Goldmann M, Riggert J, Moltrecht R, Legler TJ. Adverse drug reactions following lymphocyte immunotherapy for the treatment of infertility: A retrospective study. J Obstet Gynaecol Res 2022; 48:2571-2582. [PMID: 35775609 DOI: 10.1111/jog.15348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/25/2022] [Accepted: 06/20/2022] [Indexed: 11/30/2022]
Abstract
AIM Unexplained infertility is a major burden for couples who want to have children. Lymphocyte immunotherapy (LIT) could be a therapeutic help for these couples. Although LIT has been carried out for decades, the data on the success of therapy are still controversial and there is hardly information on possible adverse drug reactions. METHODS In this study, we used a questionnaire to determine the frequency of local and systemic adverse drug reactions in our patients who were treated with LIT between 2017 and 2020 (n = 302). In addition, we asked about pregnancies and/or live births after LIT in a 2-year follow-up (n = 140). RESULTS Most of the patients reported the occurrence of mild local adverse drug reactions in a period of less than 4 weeks: Over 75% reported moderate erythema, itching or swelling, over 10% erythema, itching or swelling as more pronounced adverse drug reaction. Blistering was specified in 10% of the cases. Serious adverse drug reactions or adverse events were not described. In the follow-up, 69% of our patients stated a pregnancy after LIT, and 50% a life birth. CONCLUSIONS Overall, LIT represents a well-tolerated therapy for couples with unexplained infertility, however, more evidence is needed on the benefits.
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Affiliation(s)
- Abass Eidizadeh
- Institute for Clinical Chemistry/Interdisciplinary UMG Laboratory, University Medical Center Göttingen, Göttingen, Germany
| | - Susanne Papert
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Jakob Valk
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Beatrix Pollok-Kopp
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Monika Goldmann
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Joachim Riggert
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
| | | | - Tobias J Legler
- Department of Transfusion Medicine, University Medical Center Göttingen, Göttingen, Germany
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9
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Suchard MS, Martinson N, Malfeld S, de Assis Rosa D, Mackelprang RD, Lingappa J, Hou X, Rees H, Delany-Moretlwe S, Goldfein H, Ranchod H, Coetzee D, Otwombe K, Morris L, Tiemessen CT, Savulescu DM. Alloimmunity to Class 2 Human Leucocyte Antigens May Reduce HIV-1 Acquisition – A Nested Case-Control Study in HIV-1 Serodiscordant Couples. Front Immunol 2022; 13:813412. [PMID: 35401581 PMCID: PMC8987441 DOI: 10.3389/fimmu.2022.813412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
Enveloped viruses, including the Human Immunodeficiency Virus-1 (HIV), incorporate host proteins such as human leucocyte antigens (HLA) into their envelope. Pre-existing antibodies against HLA, termed HLA antibodies, may bind to these surface proteins and reduce viral infectivity. Related evidence includes macaque studies which suggest that xenoimmunization with HLA antigens may protect against simian immunodeficiency virus infection. Since HIV gp120 shows homology with class 2 HLA, including shared affinity for binding to CD4, class 2 HLA antibodies may influence HIV acquisition via binding to gp120 on the viral envelope. We conducted a nested case-control study on HIV serodiscordant couples, comparing the frequency of HLA antibodies among highly exposed persistently seronegative controls with those who went on to acquire HIV (HIV-seroconverters). We first performed low resolution HLA typing on 143 individuals who were HIV-infected at enrollment (index partners) and their corresponding sexual partners (115 highly exposed persistently seronegative individuals and 28 HIV-seroconverters). We then measured HLA class 1 and 2 antibodies in the highly exposed persistently seronegative individuals and HIV-seroconverters at early and late timepoints. We analyzed whether such antibodies were directed at HLA specificities of their HIV-infected index partners, and whether autoantibodies or complement-fixing class 2 HLA antibodies were present. Seventy-nine percent of highly exposed persistently seronegative individuals had HLA antibodies; 56% against class 1 and 50% against class 2 alleles. Half of the group of highly exposed persistently seronegative individuals, prior to seroconversion, expressed class 2 HLA antibodies, compared with only 29% of controls (p=0.05). HIV infection was a sensitizing event leading to de novo development of antibodies against HLA-A and HLA-B loci, but not against class 2 loci. HLA autoantibodies were present in 27% of highly exposed persistently seronegative individuals. Complement-fixing class 2 HLA antibodies did not differ significantly between highly exposed persistently seronegative individuals and seroconverters. In multivariable regression, presence of class 2 HLA antibodies at early timepoints was associated with reduced odds of HIV acquisition (odds ratio 0.330, confidence interval 0.112-0.976, p=0.045). These epidemiological data suggest that pre-existing class 2 HLA antibodies were associated with reduced odds of HIV acquisition.
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Affiliation(s)
- Melinda S. Suchard
- National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
- Chemical Pathology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- *Correspondence: Melinda S. Suchard,
| | - Neil Martinson
- Perinatal Health Research Unit (PHRU), University of The Witwatersrand, Johannesburg, South Africa
- Johns Hopkins University Centre for TB Research, Baltimore, MD, United States
| | - Susan Malfeld
- National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Debbie de Assis Rosa
- School of Molecular and Cell Biology, Faculty of Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Romel D. Mackelprang
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
| | - Jairam Lingappa
- Department of Global Health, University of Washington, Seattle, WA, United States
- Department of Medicine and Department of Paediatrics, University of Washington, Seattle, WA, United States
| | - Xuanlin Hou
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Helen Rees
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Sinead Delany-Moretlwe
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Hadassa Goldfein
- School of Molecular and Cell Biology, Faculty of Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Heena Ranchod
- National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
- Chemical Pathology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - David Coetzee
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Johannesburg, South Africa
| | - Kennedy Otwombe
- Perinatal Health Research Unit (PHRU), University of The Witwatersrand, Johannesburg, South Africa
- Epidemiology and Biostatistics Department, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lynn Morris
- National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
- Virology Department, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Caroline T. Tiemessen
- National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
- Virology Department, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Dana M. Savulescu
- National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
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10
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Understanding human immunity in idiopathic recurrent pregnancy loss. Eur J Obstet Gynecol Reprod Biol 2021; 270:17-29. [PMID: 35007974 DOI: 10.1016/j.ejogrb.2021.12.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 12/12/2021] [Accepted: 12/21/2021] [Indexed: 01/03/2023]
Abstract
Miscarriage, defined as the loss of a pregnancy before a viable gestation, affects 1 in 6 couples. Recurrent pregnancy loss (RPL), defined as two or more miscarriages, affects up to 1.9% of couples. The physical, psychological, and financial impact of miscarriage can be substantial. However, despite its multifactorial etiology, for up to 50% of couples a reason behind this condition cannot be identified, termed 'idiopathic RPL'. Much recent research has strived to understand this, with immune dysregulation being a source of particular interest. In this short review we summarize the current evidence on the complex role of the immune system both pre- and early post-conception in RPL. A key question is whether systemic peripheral blood markers, in particular natural killer cell and T cells, may be utilized to accurately predict and/ or diagnose those pregnancies at high risk of loss. Given the invasive nature of endometrial testing, identification of reliable peripheral immune biomarkers is particularly appealing. Clinical trials using potent immunomodulatory agents, including intravenous immunoglobulin, donor leukocyte immunization, and tumor necrosis factor (TNF)-α inhibitors, have been undertaken with the primary objective of preventing miscarriage in women with RPL. Standardisation of both diagnostic and prognostic immune cell testing assays is required to permit accurate identification of those women who may benefit from immunomodulation. Prompt clarification is required to meet the increasing expectation from couples and clinicians, as without these advancements women are at risk of exposure to potent immune-therapies and subsequent studies are at risk of failure, generating further controversy regarding the role of immune dysregulation in women with RPL. Through this review we highlight clear gaps in our current knowledge on immune activity in RPL.
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11
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Tao Y, Li Y, Zhang D, Xu L, Chen J, Sang Y, Piao H, Jing X, Yu M, Fu Q, Zhou S, Li D, Du M. Decidual CXCR4 + CD56 bright NK cells as a novel NK subset in maternal-foetal immune tolerance to alleviate early pregnancy failure. Clin Transl Med 2021; 11:e540. [PMID: 34709764 PMCID: PMC8516340 DOI: 10.1002/ctm2.540] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 07/12/2021] [Accepted: 08/06/2021] [Indexed: 01/15/2023] Open
Abstract
Natural killer (NK) cells preferentially accumulate at maternal-foetal interface and are believed to play vital immune-modulatory roles during early pregnancy and related immunological dysfunction may result in pregnant failure such as recurrent miscarriage (RM). However, the mechanisms underlying the establishment of maternal-foetal immunotolerance are complex but clarifying the roles of decidual NK (dNK) cells offers the potential to design immunotherapeutic strategies to assist RM patients. In this report, we analysed RNA sequencing on peripheral NK (pNK) and decidual NK cells during early pregnancy; we identified an immunomodulatory dNK subset CXCR4+ CD56bright dNK and investigated its origin and phenotypic and functional characteristics. CXCR4+ CD56bright dNK displayed a less activated and cytotoxic phenotype but an enhanced immunomodulatory potential relative to the CXCR4 negative subset. CXCR4+ CD56bright dNK promote Th2 shift in an IL-4-dependent manner and can be recruited from peripheral blood and reprogramed by trophoblasts, as an active participant in the establishment of immune-tolerance during early pregnancy. Diminished CXCR4+ dNK cells and their impaired ability to induce Th2 differentiation were found in RM patients and mouse models of spontaneous abortion. Moreover, adoptive transfer of CXCR4+ dNK cells to NK-deficient (Nfil3-/-) mice showed great therapeutic potential of CXCR4+ dNK via recovering the Th2/Th1 bias and reducing embryo resorption rates. The identification of this new dNK cell subset may lay the foundation for understanding NK cell mechanisms in early pregnancy and provide potential prognostic factors for the diagnosis and therapy of RM.
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MESH Headings
- Abortion, Habitual/blood
- Abortion, Habitual/immunology
- Abortion, Habitual/prevention & control
- Animals
- Decidua/immunology
- Disease Models, Animal
- Female
- Humans
- Immune Tolerance/immunology
- Killer Cells, Natural/immunology
- Male
- Mice
- Mice, Inbred BALB C
- Neural Cell Adhesion Molecules/blood
- Neural Cell Adhesion Molecules/genetics
- Neural Cell Adhesion Molecules/immunology
- Pregnancy
- Pregnancy Trimester, First
- Receptors, CXCR4/blood
- Receptors, CXCR4/genetics
- Receptors, CXCR4/immunology
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Affiliation(s)
- Yu Tao
- NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and GynecologyFudan University Shanghai Medical CollegeShanghaiChina
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghaiChina
- Department of Assisted ReproductionShanghai Ninth People's HospitalShanghai Jiao Tong University School of MedicineShanghaiPeople's Republic of China
| | - Yan‐Hong Li
- NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and GynecologyFudan University Shanghai Medical CollegeShanghaiChina
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghaiChina
| | - Di Zhang
- NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and GynecologyFudan University Shanghai Medical CollegeShanghaiChina
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghaiChina
| | - Ling Xu
- NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and GynecologyFudan University Shanghai Medical CollegeShanghaiChina
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghaiChina
| | - Jia‐Jia Chen
- NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and GynecologyFudan University Shanghai Medical CollegeShanghaiChina
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghaiChina
| | - Yi‐Fei Sang
- NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and GynecologyFudan University Shanghai Medical CollegeShanghaiChina
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghaiChina
| | - Hai‐Lan Piao
- NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and GynecologyFudan University Shanghai Medical CollegeShanghaiChina
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghaiChina
| | - Xue‐Ling Jing
- NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and GynecologyFudan University Shanghai Medical CollegeShanghaiChina
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghaiChina
| | - Min Yu
- NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and GynecologyFudan University Shanghai Medical CollegeShanghaiChina
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghaiChina
| | - Qiang Fu
- Department of ImmunologyBinzhou Medical CollegeYantaiPeople's Republic of China
| | - Sheng‐Tao Zhou
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE and State Key Laboratory of Biotherapy, Department of Obstetrics and Gynecology, West China Second University HospitalSichuan University and Collaborative Innovation CenterChengduPeople's Republic of China
| | - Da‐Jin Li
- NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and GynecologyFudan University Shanghai Medical CollegeShanghaiChina
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghaiChina
| | - Mei‐Rong Du
- NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Hospital of Obstetrics and GynecologyFudan University Shanghai Medical CollegeShanghaiChina
- Shanghai Key Laboratory of Female Reproductive Endocrine Related DiseasesShanghaiChina
- Department of Obstetrics and Gynecology, Guangzhou First People's Hospital, School of MedicineSouth China University of TechnologyGuangzhouChina
- State Key Laboratory of Quality Research in Chinese Medicine and School of PharmacyMacau University of Science and TechnologyMacauChina
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Günther V, Alkatout I, Meyerholz L, Maass N, Görg S, von Otte S, Ziemann M. Live Birth Rates after Active Immunization with Partner Lymphocytes. Biomedicines 2021; 9:biomedicines9101350. [PMID: 34680467 PMCID: PMC8533392 DOI: 10.3390/biomedicines9101350] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 09/23/2021] [Accepted: 09/26/2021] [Indexed: 12/30/2022] Open
Abstract
Although many potential causes have been established for recurrent implantation failure (RIF) and recurrent miscarriage (RM), about 50% of these remain idiopathic. Scientific research is focused on immunological risk factors. In the present study, we aim to evaluate live birth rates after immunization with paternal lymphocytes (lymphocyte immunotherapy (LIT)). This retrospective study consisted of 148 couples with a history of RM and/or RIF. The women underwent immunization with lymphocytes of their respective partners from November 2017 to August 2019. Fifty-five patients (43%) had live births. Stratified by indication (RM, RIF, combined), live birth rates in the RM and the combined group were significantly higher than that in the RIF group (53%, 59% and 33%, respectively, p = 0.02). The difference was especially noticeable during the first 90 days after immunization (conception rate leading to live births: 31%, 23% and 8% for RM, the combined group and RIF, respectively; p = 0.005), while there was no difference between groups during the later follow-up. LIT was associated with high live birth rates, especially in women with recurrent miscarriage. In view of the limited data from randomized studies, LIT cannot be recommended as routine therapy. However, it may be considered in individual cases.
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Affiliation(s)
- Veronika Günther
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 (House C), 24105 Kiel, Germany; (I.A.); (L.M.); (N.M.)
- University Fertility Center, Ambulanzzentrum gGmbH, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 (House C), 24105 Kiel, Germany;
- Institute for Transfusion Medicine and Transplant Center, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 (House 17), 24105 Kiel, Germany; (S.G.); (M.Z.)
- Institute for Transfusion Medicine and Transplant Center, University Hospitals Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160 (House 31), 23538 Lübeck, Germany
- Correspondence: ; Tel.: +49-(0)431-500-21401
| | - Ibrahim Alkatout
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 (House C), 24105 Kiel, Germany; (I.A.); (L.M.); (N.M.)
| | - Lisa Meyerholz
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 (House C), 24105 Kiel, Germany; (I.A.); (L.M.); (N.M.)
| | - Nicolai Maass
- Department of Obstetrics and Gynecology, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 (House C), 24105 Kiel, Germany; (I.A.); (L.M.); (N.M.)
| | - Siegfried Görg
- Institute for Transfusion Medicine and Transplant Center, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 (House 17), 24105 Kiel, Germany; (S.G.); (M.Z.)
- Institute for Transfusion Medicine and Transplant Center, University Hospitals Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160 (House 31), 23538 Lübeck, Germany
| | - Sören von Otte
- University Fertility Center, Ambulanzzentrum gGmbH, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 (House C), 24105 Kiel, Germany;
| | - Malte Ziemann
- Institute for Transfusion Medicine and Transplant Center, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 (House 17), 24105 Kiel, Germany; (S.G.); (M.Z.)
- Institute for Transfusion Medicine and Transplant Center, University Hospitals Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160 (House 31), 23538 Lübeck, Germany
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13
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Moving innovation to practice: an Ethics Committee opinion. Fertil Steril 2021; 116:331-336. [PMID: 33926716 DOI: 10.1016/j.fertnstert.2021.03.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 11/20/2022]
Abstract
The introduction of new strategies, tests, and procedures into clinical practice raises challenging ethical issues involving evaluation of evidence, balancing benefits and harms, supporting patient autonomy, avoiding conflict of interest, and promoting advances in health-care. The purpose of this document is to assist reproductive health practitioners as they introduce new interventions into the clinical care that they provide to patients. This document replaces the previously published document of the same name, last published in 2016.
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Vomstein K, Feil K, Strobel L, Aulitzky A, Hofer-Tollinger S, Kuon RJ, Toth B. Immunological Risk Factors in Recurrent Pregnancy Loss: Guidelines Versus Current State of the Art. J Clin Med 2021; 10:869. [PMID: 33672505 PMCID: PMC7923780 DOI: 10.3390/jcm10040869] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 02/06/2023] Open
Abstract
Around 1-5% of all couples experience recurrent pregnancy loss (RPL). Established risk factors include anatomical, genetic, endocrine, and hemostatic alterations. With around 50% of idiopathic cases, immunological risk factors are getting into the scientific focus, however international guidelines hardly take them into account. Within this review, the current state of immunological risk factors in RPL in international guidelines of the European Society of Reproduction and Embryology (ESHRE), American Society of Reproductive Medicine (ASRM), German/Austrian/Swiss Society of Obstetrics and Gynecology (DGGG/OEGGG/SGGG) and the Royal College of Obstetricians and Gynecologists (RCOG) are evaluated. Special attention was drawn to recommendations in the guidelines regarding diagnostic factors such as autoantibodies, natural killer cells, regulatory T cells, dendritic cells, plasma cells, and human leukocyte antigen system (HLA)-sharing as well as treatment options such as corticosteroids, intralipids, intravenous immunoglobulins, aspirin and heparin in RPL. Finally, the current state of the art focusing on both diagnostic and therapeutic options was summarized.
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Affiliation(s)
- Kilian Vomstein
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Katharina Feil
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Laura Strobel
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Anna Aulitzky
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Susanne Hofer-Tollinger
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
| | - Ruben-Jeremias Kuon
- Department of Gynecological Endocrinology and Fertility Disorders, Ruprecht-Karls University Heidelberg, Im Neuenheimer Feld 440, 69120 Heidelberg, Germany;
| | - Bettina Toth
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (K.F.); (L.S.); (A.A.); (S.H.-T.); (B.T.)
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15
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Canella PRBC, Barini R, Carvalho PDO, Razolli DS. Lipid emulsion therapy in women with recurrent pregnancy loss and repeated implantation failure: The role of abnormal natural killer cell activity. J Cell Mol Med 2021; 25:2290-2296. [PMID: 33544456 PMCID: PMC7933936 DOI: 10.1111/jcmm.16257] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 12/18/2022] Open
Abstract
Altered immune and/or inflammatory response plays an important role in cases of recurrent pregnancy loss (RPL) and repeated implantation failure (RIF). Exacerbation of the maternal immune response through increased NK cell activity and inflammatory cytokines can cause embryo rejection leading to abortion or embryo implantation failure. Immunosuppressors or immunomodulators can help or prevent this condition. Currently, lipid emulsion therapy (LET) has emerged as a treatment for RPL and RIF in women with abnormal NK cell activity, by decreasing the exacerbated immune response of the maternal uterus and providing a more receptive environment for the embryo. However, the mechanisms by which the intralipid acts to reduce NK cell activity are still unclear. In this review, we focus on the studies that conducted LET to treat patients with RPL and RIF with abnormal NK cell activity. We find that although some authors recommend LET as an effective intervention, more studies are necessary to confirm its effectiveness in restoring NK cell activity to normal levels and to comprehend the underlying mechanisms of the lipids action in ameliorating the maternal environment and improving the pregnancy rate.
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Affiliation(s)
| | - Ricardo Barini
- Department of Obstetrics and Gynecology, Campinas University (UNICAMP), Campinas, Brazil
| | | | - Daniela Soares Razolli
- Postgraduate Program in Health Sciences, São Francisco University, Bragança Paulista, Brazil
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Brand A, De Angelis V, Vuk T, Garraud O, Lozano M, Politis D. Review of indications for immunoglobulin (IG) use: Narrowing the gap between supply and demand. Transfus Clin Biol 2021; 28:96-122. [DOI: 10.1016/j.tracli.2020.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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17
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Is there a Role of Intravenous Immunoglobulin in Immunologic Recurrent Pregnancy Loss? J Immunol Res 2020; 2020:6672865. [PMID: 33426092 PMCID: PMC7781684 DOI: 10.1155/2020/6672865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/15/2020] [Accepted: 12/22/2020] [Indexed: 01/01/2023] Open
Abstract
Recurrent pregnancy loss (RPL) commonly refers to three or more miscarriages that occur before 20 weeks of pregnancy. The immunological cause of RPL could be either an auto- or alloimmune-related event or both. Because of the discovery of immunological abnormalities in RPL patients in clinical practice, several immunomodulatory therapies were introduced to maintain the immune balance at the maternal-fetal interface. Intravenous immunoglobulin (IVIg) is one of the immunomodulators. In recent years, several studies have analyzed the therapeutic effect of IVIg on RPL patients with antiphospholipid syndrome (APS) or unexplained RPL. However, their results are controversial. IVIg can be used in RPL patients with APS who have previously failed in other treatments. It is recommended that IVIg infusion could be considered used before conception in RPL patients who have cellular immune abnormalities such as increased natural killer (NK) cell counts, NK cell cytotoxicity, or increased T helper (Th)1/Th2 ratio, depending on the cut-off values of each hospital. The aim of this review was to summarize the mechanisms, efficacy, pharmacokinetics, and side effects associated with passive immunization using IVIg in immunologic RPL, according to the literature published in recent years. We hope that more obstetricians will be able to understand the timing and indication of IVIg properly in immunologic RPL patients and effectively enhance pregnancy outcomes for mothers and neonates.
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Kwak-Kim J, Ota K, Sung N, Huang C, Alsubki L, Lee S, Han JW, Han A, Yang X, Saab W, Derbala Y, Wang WJ, He Q, Liao A, Takahashi T, Cavalcante MB, Barini R, Bao S, Fukui A, Lédée N, Coulam C. COVID-19 and immunomodulation treatment for women with reproductive failures. J Reprod Immunol 2020; 141:103168. [PMID: 32603991 PMCID: PMC7291967 DOI: 10.1016/j.jri.2020.103168] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 06/11/2020] [Indexed: 12/19/2022]
Abstract
COVID-19 pandemic is affecting various areas of health care, including human reproduction. Many women with reproductive failures, during the peri-implantation period and pregnancy, are on the immunotherapy using immune modulators and immunosuppressant due to underlying autoimmune diseases, cellular immune dysfunction, and rheumatic conditions. Many questions have been raised for women with immunotherapy during the COVID-19 pandemic, including infection susceptibility, how to manage women with an increased risk of and active COVID-19 infection. SARS-CoV-2 is a novel virus, and not enough information exists. Yet, we aim to review the data from previous coronavirus outbreaks and current COVID-19 and provide interim guidelines for immunotherapy in women with reproductive failures.
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Affiliation(s)
- Joanne Kwak-Kim
- Reproductive Medicine and Immunology, Obstetrics and Gynecology, Clinical Sciences Department, Center for Cancer Cell Biology, Immunology and Infection, Chicago Medical School, Rosalind Franklin University of Medicine and Science, 830 West End Court, Vernon Hills, IL, 60061, USA.
| | - Kuniaki Ota
- Fukushima Medical Center for Children and Women, Fukushima Medical University, 1 Hikarigaoka, Fukushima City, Fukushima 960-1295, Japan
| | - Nayoung Sung
- Reproductive Medicine and Immunology, Obstetrics and Gynecology, Clinical Sciences Department, Center for Cancer Cell Biology, Immunology and Infection, Chicago Medical School, Rosalind Franklin University of Medicine and Science, 830 West End Court, Vernon Hills, IL, 60061, USA
| | - Changsheng Huang
- Reproductive Medicine and Immunology, Obstetrics and Gynecology, Clinical Sciences Department, Center for Cancer Cell Biology, Immunology and Infection, Chicago Medical School, Rosalind Franklin University of Medicine and Science, 830 West End Court, Vernon Hills, IL, 60061, USA; Traditional Chinese Medicine Department of Rheumatism, Huazhong University of Science and Technology Union Shenzhen Hospital, China
| | - Lujain Alsubki
- Reproductive Medicine and Immunology, Obstetrics and Gynecology, Clinical Sciences Department, Center for Cancer Cell Biology, Immunology and Infection, Chicago Medical School, Rosalind Franklin University of Medicine and Science, 830 West End Court, Vernon Hills, IL, 60061, USA; Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh. Saudi Arabia
| | - Sungki Lee
- Department of Obstetrics and Gynecology, Myuonggok Medical Research Center, Konyang University College of Medicine, Daejeon, South Korea
| | - Jae Won Han
- Department of Obstetrics and Gynecology, Myuonggok Medical Research Center, Konyang University College of Medicine, Daejeon, South Korea
| | - Aera Han
- Department of Obstetrics and Gynecology, MizMedi Hospital, Seoul, South Korea
| | - Xiuhua Yang
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, China
| | - Wael Saab
- The Centre for Reproductive & Genetic Health, 230-232 Great Portland St, Fitzrovia, London W1W 5QS, UK
| | - Youssef Derbala
- Obstetrics and Gynecology, Beaumont Hospital, Dearborn, Grosse Pointe, MI, USA
| | - Wen-Juan Wang
- Reproduction Medical Center, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, China
| | - Qiaohua He
- Department of Reproductive Medicine Center, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Henan Provincial People's Hospital of Henan University, Zhengzhou, Henan, 450003, China
| | - Aihua Liao
- Institute of Reproductive Health, Center for Reproductive Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Toshifumi Takahashi
- Fukushima Medical Center for Children and Women, Fukushima Medical University, 1 Hikarigaoka, Fukushima City, Fukushima 960-1295, Japan
| | - Marcelo Borges Cavalcante
- Department of Obstetrics and Gynecology, Fortaleza University (UNIFOR), Fortaleza, CE, Brazil; CONCEPTUS - Reproductive Medicine, Fortaleza, CE, Brazil
| | - Ricardo Barini
- Department of Obstetrics and Gynecology, Campinas University (UNICAMP), Campinas, SP, Brazil
| | - Shihua Bao
- Department of Reproductive Immunology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 201204, China
| | - Atsushi Fukui
- Department of Obstetrics and Gynecology, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan
| | - Nathalie Lédée
- MatriceLAB Innove, Pépinière Paris Santé Cochin, Hôpital Cochin, 29 rue du faubourg St Jacques, 75014 Paris, France; Centre d'assistance médicale à la procréation, Hôpital des Bluets, 4 rue Lasson, 75012, Paris, France
| | - Carolyn Coulam
- Clinical Immunology Laboratory, Rosalind Franklin University of Medicine and Science, North Chicago, 60064, IL, USA
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Guzman-Genuino RM, Hayball JD, Diener KR. Regulatory B Cells: Dark Horse in Pregnancy Immunotherapy? J Mol Biol 2020; 433:166596. [PMID: 32693108 DOI: 10.1016/j.jmb.2020.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 12/20/2022]
Abstract
There are many unanswered questions surrounding the function of immune cells and how they interact with the reproductive system to support successful pregnancy or contribute to pregnancy pathologies. While the role of immune cells such as uterine natural killer and dendritic cells, and more recently regulatory T cells has been established, the role of another major immune cell population, the B cell, and particularly the regulatory B cells, is relatively poorly understood. This review outlines what is known about B-cell subsets in the context of pregnancy, what constitutes a regulatory B cell and what role they may play, particularly during early pregnancy. Lastly, we discuss why immunotherapies for the treatment of pregnancy disorders is not widely progressed clinically and speculate on the potential of functional regulatory B cells as the basis of novel immunotherapeutic approaches for the treatment of immune-based pregnancy pathologies.
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Affiliation(s)
- Ruth Marian Guzman-Genuino
- Experimental Therapeutics Laboratory, University of South Australia Cancer Research Institute, Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - John D Hayball
- Experimental Therapeutics Laboratory, University of South Australia Cancer Research Institute, Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia; Robinson Research Institute and Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Kerrilyn R Diener
- Experimental Therapeutics Laboratory, University of South Australia Cancer Research Institute, Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia; Robinson Research Institute and Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia.
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Min Y, Wang X, Chen H, Yin G. The exploration of Hashimoto's Thyroiditis related miscarriage for better treatment modalities. Int J Med Sci 2020; 17:2402-2415. [PMID: 33029083 PMCID: PMC7532476 DOI: 10.7150/ijms.48128] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/21/2020] [Indexed: 12/25/2022] Open
Abstract
Hashimoto's thyroiditis (HT) is the most prevalent autoimmune thyroid disease (ATD) worldwide and is strongly associated with miscarriage and even recurrent miscarriage (RM). Moreover, with a deepening understanding, emerging evidence has shown that immune dysfunctions caused by HT conditions, including imbalanced subsets of CD4+ T-helper cells, B regulatory (Breg) cells, high expression levels of CD56dim natural killer (NK) cells, and cytokines, possibly play an important role in impairing maternal tolerance to the fetus. In recent years, unprecedented progress has been made in recognizing the specific changes in immune cells and molecules in patients with HT, which will be helpful in exploring the mechanism of HT-related miscarriage. Based on these findings, research investigating some potentially more effective treatments, such as selenium (Se), vitamin D3, and intravenous immunoglobulin (IVIG), has been well developed over the past few years. In this review, we highlight some of the latest advances in the possible immunological pathogenesis of HT-related miscarriage and focus on the efficacies of treatments that have been widely introduced to clinical trials or practice described in the most recent literature.
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Affiliation(s)
- Yu Min
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Rd, Yuzhong Dist, Chongqing 404100, China
| | - Xing Wang
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Rd, Yuzhong Dist, Chongqing 404100, China
| | - Hang Chen
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Rd, Yuzhong Dist, Chongqing 404100, China
| | - Guobing Yin
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital of Chongqing Medical University, No.74, Linjiang Rd, Yuzhong Dist, Chongqing 404100, China
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Eskandarian M, Moazzeni SM. Uterine Dendritic Cells Modulation by Mesenchymal Stem Cells Provides A Protective Microenvironment at The Feto-Maternal Interface: Improved Pregnancy Outcome in Abortion-Prone Mice. CELL JOURNAL 2019; 21:274-280. [PMID: 31210433 PMCID: PMC6582417 DOI: 10.22074/cellj.2019.6239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 01/31/2019] [Indexed: 02/05/2023]
Abstract
Objective Dendritic cells (DCs) as major regulators of the immune response in the decidua play a pivotal role in establishment and maintenance of pregnancy. Immunological disorders are considered to be the main causes of unexplained recurrent spontaneous abortions (RSAs). Recently, we reported that mesenchymal stem cells (MSCs) therapy could improve fetal survival and reduce the abortion rate in abortion-prone mice, although the precise mechanisms of this action are poorly understood. Since MSCs have been shown to exert immunomodulatory effects on the immune cells, especially DCs, this study was performed to investigate the capability of MSCs to modulate the frequency, maturation state, and phenotype of uterine DCs (uDCs) as a potential mechanism for the improvement of pregnancy outcome. Materials and Methods In this experimental study, adipose-derived MSCs were intraperitoneally administered to abortion-prone pregnant mice on the fourth day of gestation. On the day 13.5 of pregnancy, after the determination of abortion rates, the frequency, phenotype, and maturation state of uDCs were analyzed using flow cytometry. Results Our results indicated that the administration of MSCs, at the implantation window, could significantly decrease the abortion rate and besides, increase the frequency of uDCs. MSCs administration also remarkably decreased the expression of DCs maturation markers (MHC-II, CD86, and CD40) on uDCs. However, we did not find any difference in the expression of CD11b on uDCs in MSCs-treated compared to control mice. Conclusion Regarding the mutual role of uDCs in establishment of a particular immunological state required for appropriate implantation, proper maternal immune responses and development of successful pregnancy, it seems that the modulation of uDCs by MSCs could be considered as one of the main mechanisms responsible for the positive effect of MSCs on treatment of RSA.
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Affiliation(s)
- Maryam Eskandarian
- Department of Immunology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Seyed Mohammad Moazzeni
- Department of Immunology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran.Electronic Address:
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Sarno M, Cavalcante MB, Niag M, Pimentel K, Luz I, Figueiredo B, Michelon T, Neumann J, Lima S, Machado IN, Araujo Júnior E, Barini R. Gestational and perinatal outcomes in recurrent miscarriages couples treated with lymphocyte immunotherapy. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100036. [PMID: 31403124 PMCID: PMC6687386 DOI: 10.1016/j.eurox.2019.100036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/07/2019] [Accepted: 04/29/2019] [Indexed: 11/09/2022] Open
Abstract
Objective This study aims to elucidate which types of recurrent miscarriage (RM) patients experienced a livebirth after paternal lymphocyte immunotherapy (LIT) and to evaluate the perinatal outcome. Study design Retrospective analysis of a multicenter, observational study which enrolled 1096 couples with a history of two or more spontaneous miscarriages without any intercalated delivery. We conducted an intention-to-treat analysis of couples with RM treated with or without LIT regarding to gestational and perinatal outcomes. We compared groups by using the Student’s t-test or Kruskal–Wallis test, Fisher’s exact-test and χ2 test when appropriate. Results The success of gestation was significantly higher in the LIT group (60.1% vs. 33.1%; p < 0.001). A sub-analysis of four different immune disorder groups revealed a significantly higher success in the LIT group in all immune categories, except in patients who had autoantibodies positive. We observed no significant differences in perinatal outcomes such as gestational age at birth, preterm and extreme preterm birth, and birth weight in successful pregnancy in both groups. The success rate was significantly higher when LIT was administrated before and during pregnancy and only during pregnancy compared to only before pregnancy (p < 0.01). Conclusions Careful laboratory test phenotyping of RM patients may identify subgroups most likely to benefit and exclude those with little likelihood of benefit, and LIT during a pregnancy may significantly improve success rates.
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Affiliation(s)
- Manoel Sarno
- Department of Obstetrics and Gynecology, Federal University of Bahia (UFBA), Salvador, BA, Brazil
| | | | - Marla Niag
- Department of Obstetrics and Gynecology, Federal University of Bahia (UFBA), Salvador, BA, Brazil
| | - Kleber Pimentel
- Department of Obstetrics and Gynecology, Federal University of Bahia (UFBA), Salvador, BA, Brazil
| | - Ivana Luz
- Aloimune Reproductive Immunology Centre, Salvador, BA, Brazil
| | | | | | - Jorge Neumann
- Reproductive Immunology Centre, Porto Alegre, RS, Brazil
| | - Simone Lima
- Allovita Reproductive Immunology Centre, Campinas, SP, Brazil
| | | | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine-Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Ricardo Barini
- Department of Obstetrics and Gynecology, State University of Campinas (UNICAMP), Campinas, SP, Brazil
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Kieffer TEC, Laskewitz A, Scherjon SA, Faas MM, Prins JR. Memory T Cells in Pregnancy. Front Immunol 2019; 10:625. [PMID: 31001255 PMCID: PMC6455355 DOI: 10.3389/fimmu.2019.00625] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 03/08/2019] [Indexed: 12/20/2022] Open
Abstract
Adaptations of the maternal immune response are necessary for pregnancy success. Insufficient immune adaption is associated with pregnancy pathologies such as infertility, recurrent miscarriage, fetal growth restriction, spontaneous preterm birth, and preeclampsia. The maternal immune system is continuously exposed to paternal-fetal antigens; through semen exposure from before pregnancy, through fetal cell exposure in pregnancy, and through microchimerism after pregnancy. This results in the generation of paternal-fetal antigen specific memory T cells. Memory T cells have the ability to remember previously encountered antigens to elicit a quicker, more substantial and focused immune response upon antigen reencounter. Such fetal antigen specific memory T cells could be unfavorable in pregnancy as they could potentially drive fetal rejection. However, knowledge on memory T cells in pregnancy has shown that these cells might play a favorable role in fetal-maternal tolerance rather than rejection of the fetus. In recent years, various aspects of immunologic memory in pregnancy have been elucidated and the relevance and working mechanisms of paternal-fetal antigen specific memory T cells in pregnancy have been evaluated. The data indicate that a delicate balance of memory T cells seems necessary for reproductive success and that immunologic memory in reproduction might not be harmful for pregnancy. This review provides an overview of the different memory T cell subtypes and their function in the physiology and in complications of pregnancy. Current findings in the field and possible therapeutic targets are discussed. The findings of our review raise new research questions for further studies regarding the role of memory T cells in immune-associated pregnancy complications. These studies are needed for the identification of possible targets related to memory mechanisms for studies on preventive therapies.
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Affiliation(s)
- Tom E C Kieffer
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Anne Laskewitz
- Division of Medical Biology, Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Sicco A Scherjon
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Marijke M Faas
- Division of Medical Biology, Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jelmer R Prins
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Tsuda S, Nakashima A, Shima T, Saito S. New Paradigm in the Role of Regulatory T Cells During Pregnancy. Front Immunol 2019; 10:573. [PMID: 30972068 PMCID: PMC6443934 DOI: 10.3389/fimmu.2019.00573] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/04/2019] [Indexed: 12/14/2022] Open
Abstract
Semi-allogenic fetuses are not rejected by the maternal immune system because feto-maternal tolerance induced by CD4+CD25+FoxP3+ regulatory T (Treg) cells is established during pregnancy. Paternal antigen-specific Treg cells accumulate during pregnancy, and seminal plasma priming plays an important role in expanding paternal antigen-specific Treg cells in mouse models. Although paternal-antigen specific Treg cells have not been identified in humans, recent studies suggest that antigen-specific Treg cells exist and expand at the feto-maternal interface in humans. Studies have also revealed that reduction of decidual functional Treg cells occurs during miscarriage with normal fetal chromosomal content, whereas insufficient clonal expansion of decidual Treg cells is observed in preeclampsia. In this review, we will discuss the recent advances in the investigation of mechanisms underlying Treg cell-dependent maintenance of feto-maternal tolerance.
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Affiliation(s)
- Sayaka Tsuda
- Department of Obstetrics and Gynecology, University of Toyama, Toyama, Japan
| | - Akitoshi Nakashima
- Department of Obstetrics and Gynecology, University of Toyama, Toyama, Japan
| | - Tomoko Shima
- Department of Obstetrics and Gynecology, University of Toyama, Toyama, Japan
| | - Shigeru Saito
- Department of Obstetrics and Gynecology, University of Toyama, Toyama, Japan
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Robertson SA, Green ES, Care AS, Moldenhauer LM, Prins JR, Hull ML, Barry SC, Dekker G. Therapeutic Potential of Regulatory T Cells in Preeclampsia-Opportunities and Challenges. Front Immunol 2019; 10:478. [PMID: 30984163 PMCID: PMC6448013 DOI: 10.3389/fimmu.2019.00478] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/21/2019] [Indexed: 12/26/2022] Open
Abstract
Inflammation is a central feature and is implicated as a causal factor in preeclampsia and other hypertensive disorders of pregnancy. Inflammatory mediators and leukocytes, which are elevated in peripheral blood and gestational tissues, contribute to the uterine vascular anomalies and compromised placental function that characterize particularly the severe, early onset form of disease. Regulatory T (Treg) cells are central mediators of pregnancy tolerance and direct other immune cells to counteract inflammation and promote robust placentation. Treg cells are commonly perturbed in preeclampsia, and there is evidence Treg cell insufficiency predates onset of symptoms. A causal role is implied by mouse studies showing sufficient numbers of functionally competent Treg cells must be present in the uterus from conception, to support maternal vascular adaptation and prevent later placental inflammatory pathology. Treg cells may therefore provide a tractable target for both preventative strategies and treatment interventions in preeclampsia. Steps to boost Treg cell activity require investigation and could be incorporated into pregnancy planning and preconception care. Pharmacological interventions developed to target Treg cells in autoimmune conditions warrant consideration for evaluation, utilizing rigorous clinical trial methodology, and ensuring safety is paramount. Emerging cell therapy tools involving in vitro Treg cell generation and/or expansion may in time become relevant. The success of preventative and therapeutic approaches will depend on resolving several challenges including developing informative diagnostic tests for Treg cell activity applicable before conception or during early pregnancy, selection of relevant patient subgroups, and identification of appropriate windows of gestation for intervention.
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Affiliation(s)
- Sarah A. Robertson
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Ella S. Green
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Alison S. Care
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Lachlan M. Moldenhauer
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | | | - M. Louise Hull
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Women's and Children's Hospital, Adelaide, SA, Australia
| | - Simon C. Barry
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Gustaaf Dekker
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
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Li Y, Zhang D, Xu L, Dong L, Zheng J, Lin Y, Huang J, Zhang Y, Tao Y, Zang X, Li D, Du M. Cell-cell contact with proinflammatory macrophages enhances the immunotherapeutic effect of mesenchymal stem cells in two abortion models. Cell Mol Immunol 2019; 16:908-920. [PMID: 30778166 DOI: 10.1038/s41423-019-0204-6] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 01/21/2019] [Indexed: 02/08/2023] Open
Abstract
Mesenchymal stem cells (MSCs), which are pluripotent cells with immunomodulatory properties, have been considered good candidates for the therapy of several immune disorders, such as inflammatory bowel diseases, concanavalin A-induced liver injury, and graft-versus-host disease. The embryo is a natural allograft to the maternal immune system. A successful pregnancy depends on the timely extinction of the inflammatory response induced by embryo implantation, followed by the switch to a tolerant immune microenvironment in both the uterus and the system. Excessive infiltration of immune cells and serious inflammatory responses are triggers for embryo rejection, which results in miscarriage. Here, we demonstrated that adoptive transfer of MSCs could prevent fetal loss in a lipopolysaccharide (LPS)-induced abortion model and immune response-mediated spontaneous abortion model. The immunosuppressive MSCs alleviated excessive inflammation by inhibiting CD4 + T cell proliferation and promoting the decidual macrophage switch to M2 in a tumor necrosis factor-stimulated gene-6 (TSG-6)-dependent manner. Cell-to-cell contact with proinflammatory macrophages increased the TSG-6 production by the MSCs, thereby enhancing the suppressive regulation of T cells and macrophages. Moreover, proinflammatory macrophages in contact with the MSCs upregulated the expression of CD200 on the stem cells and facilitated the reprogramming of macrophages towards an anti-inflammatory skew through the interaction of CD200 with CD200R on proinflammatory macrophages. Therefore, the results demonstrate that a TSG-6-mediated paracrine effect, reinforced by cell-to-cell contact between MSCs and proinflammatory macrophages, is involved in the mechanism of MSC-mediated abortion relief through the induction of immune tolerance. Our study also indicates the potential application of MSCs in clinical recurrent miscarriages.
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Affiliation(s)
- Yanhong Li
- Laboratory for Reproductive Immunology, NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Hospital of Obstetrics and Gynecology, Fudan University Shanghai Medical College, Shanghai, China
| | - Di Zhang
- Laboratory for Reproductive Immunology, NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Hospital of Obstetrics and Gynecology, Fudan University Shanghai Medical College, Shanghai, China
| | - Ling Xu
- Laboratory for Reproductive Immunology, NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Hospital of Obstetrics and Gynecology, Fudan University Shanghai Medical College, Shanghai, China
| | - Lin Dong
- Department of Clinical Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji Zheng
- Department of Immunology, Medical College of Soochow University, Suzhou, Jiangsu, China
| | - Yikong Lin
- Laboratory for Reproductive Immunology, NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Hospital of Obstetrics and Gynecology, Fudan University Shanghai Medical College, Shanghai, China
| | - Jiefang Huang
- Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Jiao Tong University School of Medicine (SJTUSM) & Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Yanyun Zhang
- Key Laboratory of Stem Cell Biology, Institute of Health Sciences, Shanghai Jiao Tong University School of Medicine (SJTUSM) & Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, Shanghai, China
| | - Yu Tao
- Laboratory for Reproductive Immunology, NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Hospital of Obstetrics and Gynecology, Fudan University Shanghai Medical College, Shanghai, China
| | - Xingxing Zang
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Dajin Li
- Laboratory for Reproductive Immunology, NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Hospital of Obstetrics and Gynecology, Fudan University Shanghai Medical College, Shanghai, China
| | - Meirong Du
- Laboratory for Reproductive Immunology, NHC Key Lab of Reproduction Regulation (Shanghai Institute of Planned Parenthood Research), Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Hospital of Obstetrics and Gynecology, Fudan University Shanghai Medical College, Shanghai, China.
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Wojcieszek AM, Shepherd E, Middleton P, Lassi ZS, Wilson T, Murphy MM, Heazell AEP, Ellwood DA, Silver RM, Flenady V. Care prior to and during subsequent pregnancies following stillbirth for improving outcomes. Cochrane Database Syst Rev 2018; 12:CD012203. [PMID: 30556599 PMCID: PMC6516997 DOI: 10.1002/14651858.cd012203.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Stillbirth affects at least 2.6 million families worldwide every year and has enduring consequences for parents and health services. Parents entering a subsequent pregnancy following stillbirth face a risk of stillbirth recurrence, alongside increased risks of other adverse pregnancy outcomes and psychosocial challenges. These parents may benefit from a range of interventions to optimise their short- and longer-term medical health and psychosocial well-being. OBJECTIVES To assess the effects of different interventions or models of care prior to and during subsequent pregnancies following stillbirth on maternal, fetal, neonatal and family health outcomes, and health service utilisation. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (6 June 2018), along with ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (18 June 2018). SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-randomised controlled trials (qRCTs). Trials using a cluster-randomised design were eligible for inclusion, but we found no such reports. We included trials published as abstract only, provided sufficient information was available to allow assessment of trial eligibility and risk of bias. We excluded cross-over trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility and undertook data extraction and 'Risk of bias' assessments. We extracted data from published reports, or sourced data directly from trialists. We checked the data for accuracy and resolved discrepancies by discussion or correspondence with trialists, or both. We conducted an assessment of the quality of the evidence using the GRADE approach. MAIN RESULTS We included nine RCTs and one qRCT, and judged them to be at low to moderate risk of bias. Trials were carried out between the years 1964 and 2015 and took place predominantly in high-income countries in Europe. All trials assessed medical interventions; no trials assessed psychosocial interventions or incorporated psychosocial aspects of care. Trials evaluated the use of antiplatelet agents (low-dose aspirin (LDA) or low-molecular-weight heparin (LMWH), or both), third-party leukocyte immunisation, intravenous immunoglobulin, and progestogen. Trial participants were women who were either pregnant or attempting to conceive following a pregnancy loss, fetal death, or adverse outcome in a previous pregnancy.We extracted data for 222 women who had experienced a previous stillbirth of 20 weeks' gestation or more from the broader trial data sets, and included them in this review. Our GRADE assessments of the quality of evidence ranged from very low to low, due largely to serious imprecision in effect estimates as a result of small sample sizes, low numbers of events, and wide confidence intervals (CIs) crossing the line of no effect. Most of the analyses in this review were not sufficiently powered to detect differences in the outcomes assessed. The results presented are therefore largely uncertain.Main comparisonsLMWH versus no treatment/standard care (three RCTs, 123 women, depending on the outcome)It was uncertain whether LMWH reduced the risk of stillbirth (risk ratio (RR) 2.58, 95% CI 0.40 to 16.62; 3 trials; 122 participants; low-quality evidence), adverse perinatal outcome (RR 0.81, 95% CI 0.20 to 3.32; 2 trials; 77 participants; low-quality evidence), adverse maternal psychological effects (RR 1.00, 95% CI 0.07 to 14.90; 1 trial; 40 participants; very low-quality evidence), perinatal mortality (RR 2.58, 95% CI 0.40 to 16.62; 3 trials; 122 participants; low-quality evidence), or any preterm birth (< 37 weeks) (RR 1.01, 0.58 to 1.74; 3 trials; 114 participants; low-quality evidence). No neonatal deaths were reported in the trials assessed and no data were available for maternal-infant attachment. There was no clear evidence of a difference between the groups among the remaining secondary outcomes.LDA versus placebo (one RCT, 24 women)It was uncertain whether LDA reduced the risk of stillbirth (RR 0.85, 95% CI 0.06 to 12.01), neonatal death (RR 0.29, 95% CI 0.01 to 6.38), adverse perinatal outcome (RR 0.28, 95% CI 0.03 to 2.34), perinatal mortality, or any preterm birth (< 37 weeks) (both of the latter RR 0.42, 95% CI 0.04 to 4.06; all very low-quality evidence). No data were available for adverse maternal psychological effects or maternal-infant attachment. LDA appeared to be associated with an increase in birthweight (mean difference (MD) 790.00 g, 95% CI 295.03 to 1284.97 g) when compared to placebo, but this result was very unstable due to the extremely small sample size. Whether LDA has any effect on the remaining secondary outcomes was also uncertain.Other comparisonsLDA appeared to be associated with an increase in birthweight when compared to LDA + LMWH (MD -650.00 g, 95% CI -1210.33 to -89.67 g; 1 trial; 29 infants), as did third-party leukocyte immunisation when compared to placebo (MD 1195.00 g, 95% CI 273.35 to 2116.65 g; 1 trial, 4 infants), but these results were again very unstable due to extremely small sample sizes. The effects of the interventions on the remaining outcomes were also uncertain. AUTHORS' CONCLUSIONS There is insufficient evidence in this review to inform clinical practice about the effectiveness of interventions to improve care prior to and during subsequent pregnancies following a stillbirth. There is a clear and urgent need for well-designed trials addressing this research question. The evaluation of medical interventions such as LDA, in the specific context of stillbirth prevention (and recurrent stillbirth prevention), is warranted. However, appropriate methodologies to evaluate such therapies need to be determined, particularly where clinical equipoise may be lacking. Careful trial design and multicentre collaboration is necessary to carry out trials that would be sufficiently large to detect differences in statistically rare outcomes such as stillbirth and neonatal death. The evaluation of psychosocial interventions addressing maternal-fetal attachment and parental anxiety and depression is also an urgent priority. In a randomised-trial context, such trials may allocate parents to different forms of support, to determine which have the greatest benefit with the least financial cost. Importantly, consistency in nomenclature and in data collection across all future trials (randomised and non-randomised) may be facilitated by a core outcomes data set for stillbirth research. All future trials should assess short- and longer-term psychosocial outcomes for parents and families, alongside economic costs of interventions.
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Affiliation(s)
- Aleena M Wojcieszek
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)NHMRC Centre of Research Excellence in StillbirthLevel 3 Aubigny PlaceMater Health ServicesBrisbaneQueenslandAustralia4101
| | - Emily Shepherd
- The University of AdelaideRobinson Research Institute, Discipline of Obstetrics and Gynaecology, Adelaide Medical SchoolAdelaideSouth AustraliaAustralia
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSAAustralia
| | - Zohra S Lassi
- The University of AdelaideThe Robinson Research InstituteAdelaideSouth AustraliaAustralia5005
| | - Trish Wilson
- Trish Wilson Counselling61A Brecon CrescentBuderimQLDAustralia4556
| | - Margaret M Murphy
- University College CorkSchool of Nursing and MidwiferyBrookfield Health Sciences ComplexCollege RoadCorkIrelandT12 AK54
| | - Alexander EP Heazell
- University of ManchesterMaternal and Fetal Health Research Centre5th floor (Research), St Mary's Hospital, Oxford RoadManchesterUKM13 9WL
| | - David A Ellwood
- Griffith UniversitySchool of MedicineGold Coast CampusLevel 8, G40Gold CoastQueensland,Australia4216
| | - Robert M Silver
- University of UtahDivision of Maternal‐Fetal Medicine, Health Services Center30 North 1900 East SOM 2B200Salt Lake CityUtahUSA84132
| | - Vicki Flenady
- Mater Research Institute ‐ The University of Queensland (MRI‐UQ)NHMRC Centre of Research Excellence in StillbirthLevel 3 Aubigny PlaceMater Health ServicesBrisbaneQueenslandAustralia4101
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Pan X, Jiang J, Ma Q, Zhang J, Yang J, Chen W, Ding X, Fan Q, Guo Z, Xia Y, Xia S, Wu Z. Outbreak of HIV Infection Linked to Nosocomial Transmission, China, 2016-2017. Emerg Infect Dis 2018; 24:2141-2149. [PMID: 30457542 PMCID: PMC6256388 DOI: 10.3201/eid2412.180117] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
On January 25, 2017, a physician from ZC Hospital in Hangzhou, China, reported to the Zhejiang Provincial Center for Disease Control and Prevention that a potential HIV outbreak might have occurred during lymphocyte immunotherapy (LIT) performed at the hospital on December 30, 2016. We immediately began investigating and identified the index case-patient as an LIT patient's husband who donated lymphocytes for his wife's LIT and later screened HIV-reactive. Subsequent contamination by a technician resulted in the potential exposure of 34 LIT patients. Acute HIV infection was diagnosed in 5 persons. Phylogenetic analysis confirmed that the HIV-1 gag, pol, and env gene sequences from the index and outbreak-related cases had >99.5% similarity. Rapid investigation and implementation of effective control measures successfully controlled the outbreak. This incident provides evidence of a lapse in infection control causing HIV transmission, highlighting the need for stronger measures to protect patients from infectious disease exposure.
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Affiliation(s)
| | | | - Qiaoqin Ma
- These first authors contributed equally to this articleZhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China (X. Pan, J. Jiang, Q. Ma, J. Zhang, J. Yang, W. Chen, X. Ding, Q. Fan, Z. Guo, Y. Xia, S. Xia)
- National Center for AIDS/STD Control and Prevention, Beijing, China (Z. Wu)
- University of California, Los Angeles, California, USA (Z. Wu)
| | - Jiafeng Zhang
- These first authors contributed equally to this articleZhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China (X. Pan, J. Jiang, Q. Ma, J. Zhang, J. Yang, W. Chen, X. Ding, Q. Fan, Z. Guo, Y. Xia, S. Xia)
- National Center for AIDS/STD Control and Prevention, Beijing, China (Z. Wu)
- University of California, Los Angeles, California, USA (Z. Wu)
| | - Jiezhe Yang
- These first authors contributed equally to this articleZhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China (X. Pan, J. Jiang, Q. Ma, J. Zhang, J. Yang, W. Chen, X. Ding, Q. Fan, Z. Guo, Y. Xia, S. Xia)
- National Center for AIDS/STD Control and Prevention, Beijing, China (Z. Wu)
- University of California, Los Angeles, California, USA (Z. Wu)
| | - Wanjun Chen
- These first authors contributed equally to this articleZhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China (X. Pan, J. Jiang, Q. Ma, J. Zhang, J. Yang, W. Chen, X. Ding, Q. Fan, Z. Guo, Y. Xia, S. Xia)
- National Center for AIDS/STD Control and Prevention, Beijing, China (Z. Wu)
- University of California, Los Angeles, California, USA (Z. Wu)
| | - Xiaobei Ding
- These first authors contributed equally to this articleZhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China (X. Pan, J. Jiang, Q. Ma, J. Zhang, J. Yang, W. Chen, X. Ding, Q. Fan, Z. Guo, Y. Xia, S. Xia)
- National Center for AIDS/STD Control and Prevention, Beijing, China (Z. Wu)
- University of California, Los Angeles, California, USA (Z. Wu)
| | - Qin Fan
- These first authors contributed equally to this articleZhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China (X. Pan, J. Jiang, Q. Ma, J. Zhang, J. Yang, W. Chen, X. Ding, Q. Fan, Z. Guo, Y. Xia, S. Xia)
- National Center for AIDS/STD Control and Prevention, Beijing, China (Z. Wu)
- University of California, Los Angeles, California, USA (Z. Wu)
| | - Zhihong Guo
- These first authors contributed equally to this articleZhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China (X. Pan, J. Jiang, Q. Ma, J. Zhang, J. Yang, W. Chen, X. Ding, Q. Fan, Z. Guo, Y. Xia, S. Xia)
- National Center for AIDS/STD Control and Prevention, Beijing, China (Z. Wu)
- University of California, Los Angeles, California, USA (Z. Wu)
| | - Yan Xia
- These first authors contributed equally to this articleZhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China (X. Pan, J. Jiang, Q. Ma, J. Zhang, J. Yang, W. Chen, X. Ding, Q. Fan, Z. Guo, Y. Xia, S. Xia)
- National Center for AIDS/STD Control and Prevention, Beijing, China (Z. Wu)
- University of California, Los Angeles, California, USA (Z. Wu)
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Bender Atik R, Christiansen OB, Elson J, Kolte AM, Lewis S, Middeldorp S, Nelen W, Peramo B, Quenby S, Vermeulen N, Goddijn M. ESHRE guideline: recurrent pregnancy loss. Hum Reprod Open 2018; 2018:hoy004. [PMID: 31486805 PMCID: PMC6276652 DOI: 10.1093/hropen/hoy004] [Citation(s) in RCA: 413] [Impact Index Per Article: 68.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/05/2018] [Indexed: 12/19/2022] Open
Abstract
STUDY QUESTION What is the recommended management of women with recurrent pregnancy loss (RPL) based on the best available evidence in the literature? SUMMARY ANSWER The guideline development group formulated 77 recommendations answering 18 key questions on investigations and treatments for RPL, and on how care should be organized. WHAT IS KNOWN ALREADY A previous guideline for the investigation and medical treatment of recurrent miscarriage was published in 2006 and is in need of an update. STUDY DESIGN, SIZE, DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 31 March 2017 and written in English were included. Cumulative live birth rate, live birth rate and pregnancy loss rate (or miscarriage rate) were considered the critical outcomes. PARTICIPANTS/MATERIALS, SETTING, METHODS Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE The guideline provides 38 recommendations on risk factors, prevention and investigations in couples with RPL, and 39 recommendations on treatments. These include 60 evidence-based recommendations – of which 31 were formulated as strong recommendations and 29 as conditional – and 17 good practice points. The evidence supporting investigations and treatment of couples with RPL is limited and of moderate quality. Of the evidence-based recommendations, only 10 (16.3%) were supported by moderate quality evidence. The remaining recommendations were supported by low (35 recommendations: 57.4%), or very low quality evidence (16 recommendations: 26.2%). There were no recommendations based on high quality evidence. Owing to the lack of evidence-based investigations and treatments in RPL care, the guideline also clearly mentions investigations and treatments that should not be used for couples with RPL. LIMITATIONS, REASONS FOR CAUTION Several investigations and treatments are offered to couples with RPL, but most of them are not well studied. For most of these investigations and treatments, a recommendation against the intervention or treatment was formulated based on insufficient evidence. Future studies may require these recommendations to be revised. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in RPL, based on the best evidence available. In addition, a list of research recommendations is provided to stimulate further studies in RPL. One of the most important consequences of the limited evidence is the absence of evidence for a definition of RPL. STUDY FUNDING/COMPETING INTEREST(S) The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. J.E. reports position funding from CARE Fertility. S.L. reports position funding from SpermComet Ltd. S.M. reports research grants, consulting and speaker’s fees from GSK, BMS/Pfizer, Sanquin, Aspen, Bayer and Daiichi Sankyo. S.Q. reports speaker’s fees from Ferring. The other authors report no conflicts of interest. ESHRE Pages are not externally peer reviewed. This article has been approved by the Executive Committee of ESHRE.
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Affiliation(s)
| | - Ruth Bender Atik
- Miscarriage Association, 17 Wentworth Terrace, Wakefield WF1 3QW, UK
| | - Ole Bjarne Christiansen
- Aalborg University Hospital, Department of Obstetrics and Gynaecology Aalborg, Reberbansgade 15, Aalborg 9000, Denmark.,University Hospital Copenhagen, Rigshospitalet, Recurrent Pregnancy Loss Unit Kobenhavn, Fertility Clinic 4071Blegdamsvej 9, DK 2100 Kobenhavn, Denmark
| | - Janine Elson
- CARE Fertility Group, John Webster House, 6 Lawrence Drive, Nottingham NG8 6PZ, UK
| | - Astrid Marie Kolte
- University Hospital Copenhagen, Rigshospitalet, Recurrent Pregnancy Loss Unit Kobenhavn, Fertility Clinic 4071Blegdamsvej 9, DK 2100 Kobenhavn, Denmark
| | - Sheena Lewis
- School of Medicine, Obstetrics and Gynaecology, The Queens University of Belfast, Weavers Court Business Park, Linfield Road, Belfast, Northern Ireland BT12 5GH, UK
| | - Saskia Middeldorp
- Academic Medical Center, Department of Vascular Medicine Amsterdam, Meilbergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Willianne Nelen
- Radboudumc, Department of Obstetrics and Gynaecology Nijmegen, PO Box 9101, Nijmegen 6500 HB, The Netherlands
| | - Braulio Peramo
- Al Ain Fertility Clinic, Al Ain, 29 Street, Al Jimi PO Box 13844, Al Ain 13844, United Arab Emirates
| | - Siobhan Quenby
- University of Warwick, Division of Reproductive Health Clinical Science Laboratories, University Hospitals Coventry and Warwickshire, Coventry CV2 2DX, UK
| | | | - Mariëtte Goddijn
- Academic Medical Center, Center for Reproductive Medicine, Department of Obstetrics and Gynaecology, Amsterdam, Meilbergdreef 9, Amsterdam 1105 AZ, The Netherlands
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Günther V, Alkatout I, Junkers W, Maass N, Ziemann M, Görg S, von Otte S. Active Immunisation with Partner Lymphocytes in Female Patients Who Want to Become Pregnant - Current Status. Geburtshilfe Frauenheilkd 2018; 78:260-273. [PMID: 29576631 PMCID: PMC5862550 DOI: 10.1055/s-0044-101609] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/30/2017] [Accepted: 01/24/2018] [Indexed: 12/15/2022] Open
Abstract
Around 1 – 3% of all couples who try to have a child are affected by recurrent miscarriage. According to the WHO, recurrent miscarriage is defined as the occurrence of three or more consecutive miscarriages up to the 20th week of pregnancy. There are various causes of recurrent miscarriage; in many cases, the causes remain unclear, with the result that immunological factors are one of the possible causes discussed. For the motherʼs immune system, the embryo represents a semi-allogeneic transplant, as half of the embryoʼs genes are of paternal origin. In place of a conventional immune response, the embryo induces a secondary protection mechanism, which contributes to the successful implantation. When performing immunisation with partner lymphocytes, the patient receives an intradermal injection of her partnerʼs prepared lymphocytes into the volar side of the forearm in order to induce immunomodulation with a consequently increased rate of pregnancy and live birth. A prerequisite for this procedure is that all other possible causes of sterility have been ruled out in advance. Due to the highly heterogeneous nature of the data, a significant benefit as a result of the immunisation cannot yet be clearly proven. However, there are signs that the therapy may be effective when using lymphocytes that have been extracted as short a time beforehand as possible. Overall, the treatment represents a safe, low-risk procedure. Following a detailed informative discussion with the couple regarding the chances of success and following a detailed review of the indication and contraindications, immunisation with partner lymphocytes can be discussed with the couple on a case-by-case basis – provided that all other possible causes of sterility have been ruled out in advance.
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Affiliation(s)
- Veronika Günther
- Klinik für Gynäkologie und Geburtshilfe, UKSH Campus Kiel, Kiel, Germany
| | - Ibrahim Alkatout
- Klinik für Gynäkologie und Geburtshilfe, UKSH Campus Kiel, Kiel, Germany
| | - Wiebe Junkers
- Universitäres Kinderwunschzentrum, MVZ, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Nicolai Maass
- Klinik für Gynäkologie und Geburtshilfe, UKSH Campus Kiel, Kiel, Germany
| | - Malte Ziemann
- Institut für Transfusionsmedizin, UKSH Campus Kiel, Kiel, Germany.,Institut für Transfusionsmedizin, UKSH Campus Lübeck, Lübeck, Germany
| | - Siegfried Görg
- Institut für Transfusionsmedizin, UKSH Campus Kiel, Kiel, Germany.,Institut für Transfusionsmedizin, UKSH Campus Lübeck, Lübeck, Germany
| | - Sören von Otte
- Universitäres Kinderwunschzentrum, MVZ, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Han AR, Lee SK. Immune modulation of i.v. immunoglobulin in women with reproductive failure. Reprod Med Biol 2018; 17:115-124. [PMID: 29692668 PMCID: PMC5902469 DOI: 10.1002/rmb2.12078] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/09/2017] [Indexed: 12/11/2022] Open
Abstract
Background The mechanism of maternal immune tolerance of the semi‐allogenic fetus has been explored extensively. The immune reaction to defend from invasion by pathogenic microorganisms should be maintained during pregnancy. An imbalance between the immune tolerance to the fetus and immune activation to the pathogenic organisms is associated with poor pregnancy outcomes. This emphasizes that the immune mechanism of successful reproduction is not just immune suppression, but adequate immune modulation. Methods In this review, the action of i.v. immunoglobulin G (IVIg) on the immune system and its efficacy in reproductive failure (RF) was summarized. Also suggested is the indication of IVIg therapy for women with RF. Main findings (Results) Based on the mechanism of the immune regulation of IVIg and following confirmation of the immune modulation effects of it in various aberrant immune parameters in patients with RF, it is obvious that IVIg is effective in recurrent pregnancy losses and repeated implantation failures with immunologic disturbances. Conclusion The authors recommend IVIg therapy in patients with RF with aberrant cellular immunologic parameters, including a high natural killer cell proportion and its cytotoxicity or elevated T helper 1 to T helper 2 ratio, based on each clinic's cut‐off values. Further clinical studies about the safety of IVIg in the fetus and its efficacy in other immunologic abnormalities of RF are needed.
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Affiliation(s)
- Ae R Han
- Department of Obstetrics and Gynecology Gangseo Mizmedi Hospital Seoul South Korea.,Department of Obstetrics and Gynecology Eulji University College of Medicine Daejeon South Korea
| | - Sung K Lee
- Department of Obstetrics and Gynecology Konyang University College of Medicine Daejeon South Korea
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Kenny LC, Kell DB. Immunological Tolerance, Pregnancy, and Preeclampsia: The Roles of Semen Microbes and the Father. Front Med (Lausanne) 2018; 4:239. [PMID: 29354635 PMCID: PMC5758600 DOI: 10.3389/fmed.2017.00239] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/12/2017] [Indexed: 12/18/2022] Open
Abstract
Although it is widely considered, in many cases, to involve two separable stages (poor placentation followed by oxidative stress/inflammation), the precise originating causes of preeclampsia (PE) remain elusive. We have previously brought together some of the considerable evidence that a (dormant) microbial component is commonly a significant part of its etiology. However, apart from recognizing, consistent with this view, that the many inflammatory markers of PE are also increased in infection, we had little to say about immunity, whether innate or adaptive. In addition, we focused on the gut, oral and female urinary tract microbiomes as the main sources of the infection. We here marshall further evidence for an infectious component in PE, focusing on the immunological tolerance characteristic of pregnancy, and the well-established fact that increased exposure to the father's semen assists this immunological tolerance. As well as these benefits, however, semen is not sterile, microbial tolerance mechanisms may exist, and we also review the evidence that semen may be responsible for inoculating the developing conceptus (and maybe the placenta) with microbes, not all of which are benign. It is suggested that when they are not, this may be a significant cause of PE. A variety of epidemiological and other evidence is entirely consistent with this, not least correlations between semen infection, infertility and PE. Our view also leads to a series of other, testable predictions. Overall, we argue for a significant paternal role in the development of PE through microbial infection of the mother via insemination.
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Affiliation(s)
- Louise C. Kenny
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
- Department of Obstetrics and Gynecology, University College Cork, Cork, Ireland
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Douglas B. Kell
- School of Chemistry, The University of Manchester, Manchester, United Kingdom
- The Manchester Institute of Biotechnology, The University of Manchester, Manchester, United Kingdom
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Martini AE, Jasulaitis S, Fogg LF, Uhler ML, Hirshfeld-Cytron JE. Evaluating the Utility of Intralipid Infusion to Improve Live Birth Rates in Patients with Recurrent Pregnancy Loss or Recurrent Implantation Failure. J Hum Reprod Sci 2018; 11:261-268. [PMID: 30568356 PMCID: PMC6262661 DOI: 10.4103/jhrs.jhrs_28_18] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context Intralipid is used to improve clinical outcomes in patients with recurrent pregnancy loss (RPL) or recurrent implantation failure (RIF) with elevated natural killer (NK) cells. Data supporting this practice is conflicting but suggestive of minimal benefit. Aims The aims of this study are to determine if intralipid infusion improves live birth rates and if is a cost-effective therapy in the RPL/RIF population. Settings and Design This was a large REI private practice, retrospective cohort study. Subjects and Methods Charts of 127 patients who received intralipid from 2012 to 2015 were reviewed and compared to historical control data. T-tests and Chi-square analyses evaluated demographics and cycle statistics. Chi-square analyses assessed impact on clinical pregnancy and live birth rates. Cost analysis was performed from societal perspective with a one-way sensitivity analysis. Results Patients with live births were noted to have a higher average number of previous live births and were more likely to have had a frozen embryo transfer in the intralipid cycle in comparison to those with unsuccessful pregnancy outcomes. Neither clinical pregnancy nor live birth rates were significantly improved from baseline rates quoted in the literature (P = 0.12 and 0.80, respectively). Intralipid increased costs by $681 per live birth. If live birth rates were >40% using intralipid and <51% without intervention, neither strategy was favored. Conclusions Intralipid does not improve live birth rates and is not cost-effective for patients with RIF or RPL and elevated NK cells. This study supports the growing literature demonstrating the minimal benefit of screening for and treating elevated peripheral NK cells.
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Affiliation(s)
- Anne E Martini
- Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Louis F Fogg
- Fertility Centers of Illinois, Chicago, Illinois, USA
| | - Meike L Uhler
- Fertility Centers of Illinois, Chicago, Illinois, USA
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Kling C, Hedderich J, Kabelitz D. Fertility after recurrent miscarriages: results of an observational cohort study. Arch Gynecol Obstet 2017; 297:205-219. [PMID: 29038842 PMCID: PMC5762794 DOI: 10.1007/s00404-017-4532-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 09/12/2017] [Indexed: 11/24/2022]
Abstract
Purpose Recurrent pregnancy losses (RPL) are considered a pathological condition associated with heterogeneous laboratory and clinical findings, and are also linked to subfertility. We attempt to rank parameters derived from past history and diagnostic results with regard to the prognosis. Methods Observational trial on 719 consecutive couples who were referred to a tertiary immunological care centre (2006–2014) after three or more primary miscarriages. Information on past obstetric history and diagnostic procedures at baseline were correlated with cumulative pregnancy and delivery rates using Kaplan–Meier estimation, logistic regression and multivariate analysis. Results At baseline, median female age was 34.1 years, waiting time 3 years (1–17), number of preceding miscarriages 3 (3–9), 147 women (20.4%) had conceived at least once in ART or AIH cycles. After a median follow-up of 33.7 (1.7–123.0) months, 5-year pregnancy and delivery rates were 86.1 and 64.5%. Female age (< 35 years), waiting time (< 3 years) until baseline, tubal competence, and male factor fertility significantly correlated with favourable outcome (p < 0.001), while body mass index (> 29 kg/m2), number of preceding miscarriages (> 4), late miscarriages, preclinical losses and smoking revealed non-significant negative trends. Mode of conception until baseline (spontaneously or ART/AIH) and classification into idiopathic and non-idiopathic RPL showed no prognostic relevance. Conclusion Although in general, chances to conceive a child are retained after three or more miscarriages, factors related to subfertility of both partners have an important impact on the outcome. Therefore, prolonged time to pregnancy (> 6–9 months) should result in preventive gynaecological care from the first miscarriage on, so that fertility can be preserved as best as possible.
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Affiliation(s)
- Christiane Kling
- Institute of Immunology, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus 17, 24105, Kiel, Germany. .,MVZ Dr. Fenner and Colleagues, Bergstr. 14, 20095, Hamburg, Germany.
| | - Jürgen Hedderich
- Institute of Medical Statistics and Informatics, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus 31, 24105, Kiel, Germany
| | - Dieter Kabelitz
- Institute of Immunology, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3 Haus 17, 24105, Kiel, Germany
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El Hachem H, Crepaux V, May-Panloup P, Descamps P, Legendre G, Bouet PE. Recurrent pregnancy loss: current perspectives. Int J Womens Health 2017; 9:331-345. [PMID: 28553146 PMCID: PMC5440030 DOI: 10.2147/ijwh.s100817] [Citation(s) in RCA: 215] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Recurrent pregnancy loss is an important reproductive health issue, affecting 2%–5% of couples. Common established causes include uterine anomalies, antiphospholipid syndrome, hormonal and metabolic disorders, and cytogenetic abnormalities. Other etiologies have been proposed but are still considered controversial, such as chronic endometritis, inherited thrombophilias, luteal phase deficiency, and high sperm DNA fragmentation levels. Over the years, evidence-based treatments such as surgical correction of uterine anomalies or aspirin and heparin for antiphospholipid syndrome have improved the outcomes for couples with recurrent pregnancy loss. However, almost half of the cases remain unexplained and are empirically treated using progesterone supplementation, anticoagulation, and/or immunomodulatory treatments. Regardless of the cause, the long-term prognosis of couples with recurrent pregnancy loss is good, and most eventually achieve a healthy live birth. However, multiple pregnancy losses can have a significant psychological toll on affected couples, and many efforts are being made to improve treatments and decrease the time needed to achieve a successful pregnancy. This article reviews the established and controversial etiologies, and the recommended therapeutic strategies, with a special focus on unexplained recurrent pregnancy losses and the empiric treatments used nowadays. It also discusses the current role of preimplantation genetic testing in the management of recurrent pregnancy loss.
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Affiliation(s)
- Hady El Hachem
- Department of Reproductive Medicine, Ovo Clinic, Montréal, QC, Canada.,Department of Obstetrics and Gynecology, University of Montreal, Montréal, QC, Canada
| | - Vincent Crepaux
- Department of Obstetrics and Gynecology, Angers University Hopsital, Angers, France
| | - Pascale May-Panloup
- Department of Reproductive Biology, Angers University Hospital, Angers, France
| | - Philippe Descamps
- Department of Obstetrics and Gynecology, Angers University Hopsital, Angers, France
| | - Guillaume Legendre
- Department of Obstetrics and Gynecology, Angers University Hopsital, Angers, France
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36
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Matjila MJ, Hoffman A, van der Spuy ZM. Medical conditions associated with recurrent miscarriage-Is BMI the tip of the iceberg? Eur J Obstet Gynecol Reprod Biol 2017; 214:91-96. [PMID: 28494269 DOI: 10.1016/j.ejogrb.2017.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 05/02/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND In contrast to sporadic miscarriage, recurrent miscarriage (RM) is a rare entity which affects 1% of couples attempting conception. It is distressing for couples and healthcare professionals as the aetiology is unclear with limited treatment options. Apart from anti-phospholipid syndrome (APS), the strength of associations between RM and commonly investigated endocrine, autoimmune, thrombophilic and uterine structural abnormalities remains uncertain and variable. OBJECTIVES To assess the prevalence of commonly investigated medical conditions associated with RM. STUDY DESIGN A 9-year retrospective analysis of a prospectively collected database was conducted for 592 patients seen between 2008 and 2016, in tertiary level RM clinic in South Africa. RESULTS In this period, 592 patients were assessed. The mean age was 29.73±5.46 (mean±SD), gravidity 4.6±1.82 and parity 0.98±1.05. The mean number of miscarriages per patient was 3.34±1.63, of which two-thirds (61.3%) were in the first trimester, a third (33%) in the second trimester and intrauterine fetal deaths (IUFDs) constituted 6% of total losses. Of the 50% of patients with no identified associated disorders, 15% were unexplained (investigations complete but no associations found), 10% became pregnant during investigation (investigations incomplete) and 25% were lost to follow-up (investigations incomplete). Nearly forty percent (38%) of patients had an associated endocrine disorder (22% PCOS, 11% IGT, 3% Diabetes Mellitus and 2% Thyroid Dysfunction) and 10% a uterine factor (4% Cervical Incompetence, 2% Fibroids, 2% Synechiae and 2% Anomalies). APS and Thrombophilias constituted 3% and 2% of patients respectively. The BMI (mean±SD) amongst patients with Unexplained RM, PCOS and IGT were 28.85±5.95, 30.86±7.79 and 33.40±6.47 respectively. Patients with IGT had significantly higher mean BMI in comparison to those with Unexplained RM (p<0.0001)*** and PCOS (p<0.001)**. CONCLUSION PCOS, IGT and Type II Diabetes are all likely surrogates for elevated BMI and constitute 70% of those women with RM and identified associated medical disorders. In our population, BMI seems to have a substantial impact on recurrent pregnancy loss and future studies should interrogate its effect on recurrent miscarriage.
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Affiliation(s)
- Mushi J Matjila
- Department of Obstetrics and Gynaecology, Groote Schuur Hospital, Cape Town, 7937, South Africa; MRC/UCT Receptor Biology Unit, Institute of Infectious Disease and Molecular Medicine, Division of Medical Biochemistry, University of Cape Town, 7925, Cape Town, Western Cape, South Africa.
| | - Anne Hoffman
- Department of Obstetrics and Gynaecology, Groote Schuur Hospital, Cape Town, 7937, South Africa
| | - Zephne M van der Spuy
- Department of Obstetrics and Gynaecology, Groote Schuur Hospital, Cape Town, 7937, South Africa
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Cavalcante MB, Sarno M, Araujo Júnior E, Da Silva Costa F, Barini R. Lymphocyte immunotherapy in the treatment of recurrent miscarriage: systematic review and meta-analysis. Arch Gynecol Obstet 2017; 295:511-518. [PMID: 28004193 DOI: 10.1007/s00404-016-4270-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 12/09/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Recurrent miscarriage (RM) affects up to 2-3% of couples of reproductive age. There are several causes for this condition, including immunologic. The embryo is considered an allograft, subject to the rejection mechanisms of the maternal immune system. Immunotherapy involving immunization with lymphocytes is considered in cases of idiopathic RM. However, there is still no consensus regarding the efficacy and safety of this therapy. METHODS This systematic review and meta-analysis evaluated the data available in the literature regarding the efficacy and safety of the use of immunotherapy with lymphocytes in couples with history of RM. Searches in PubMed/Medline, SCOPUS, and Cochrane Library databases were conducted, using the following keywords: "recurrent miscarriage," "lymphocyte immunotherapy," and "meta-analysis." Statistical analyses were performed using Review Manager 5.3 (RevMan), version 5.3. RESULTS Six published meta-analysis were retrieved; two found no improvements in the rate of live births after the use of immunization with lymphocytes in the treatment of RM, and four found a beneficial effect of the use of immunotherapy with lymphocytes in cases of RM, with significant improvements in the rate of live births. CONCLUSION Data available in the literature supports the efficacy and safety of immunotherapy with lymphocytes in cases of RM without an identified cause.
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Affiliation(s)
| | - Manoel Sarno
- Department of Gynecology and Obstetrics, Bahia Federal University (UFBA), Salvador, BA, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine-São Paulo Federal University (EPM-UNIFESP), Rua Belchior de Azevedo, 156 apto. 111 Torre Vitoria, São Paulo, SP, Brazil.
| | - Fabricio Da Silva Costa
- Department of Obstetrics and Gynaecology, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, VIC, Australia
| | - Ricardo Barini
- Department of Obstetrics and Gynecology, State University of Campinas (UNICAMP), Campinas, SP, Brazil
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Abstract
BACKGROUND Miscarriage occurs in 10% to 15% of pregnancies. The traditional treatment, after miscarriage, has been to perform surgery to remove any remaining placental tissues in the uterus ('evacuation of uterus'). However, medical treatments, or expectant care (no treatment), may also be effective, safe, and acceptable. OBJECTIVES To assess the effectiveness, safety, and acceptability of any medical treatment for incomplete miscarriage (before 24 weeks). SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (13 May 2016) and reference lists of retrieved papers. SELECTION CRITERIA We included randomised controlled trials comparing medical treatment with expectant care or surgery, or alternative methods of medical treatment. We excluded quasi-randomised trials. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion, assessed risk of bias, and carried out data extraction. Data entry was checked. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included 24 studies (5577 women). There were no trials specifically of miscarriage treatment after 13 weeks' gestation.Three trials involving 335 women compared misoprostol treatment (all vaginally administered) with expectant care. There was no difference in complete miscarriage (average risk ratio (RR) 1.23, 95% confidence interval (CI) 0.72 to 2.10; 2 studies, 150 women, random-effects; very low-quality evidence), or in the need for surgical evacuation (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. For unplanned surgical intervention, we did not identify any difference between misoprostol and expectant care (average RR 0.62, 95% CI 0.17 to 2.26; 2 studies, 308 women, random-effects; low-quality evidence).Sixteen trials involving 4044 women addressed the comparison of misoprostol (7 studies used oral administration, 6 studies used vaginal, 2 studies sublingual, 1 study combined vaginal + oral) with surgical evacuation. There was a slightly lower incidence of complete miscarriage with misoprostol (average RR 0.96, 95% CI 0.94 to 0.98; 15 studies, 3862 women, random-effects; very low-quality evidence) but with success rate high for both methods. Overall, there were fewer surgical evacuations with misoprostol (average RR 0.05, 95% CI 0.02 to 0.11; 13 studies, 3070 women, random-effects; very low-quality evidence) but more unplanned procedures (average RR 5.03, 95% CI 2.71 to 9.35; 11 studies, 2690 women, random-effects; low-quality evidence). There were few data on 'deaths or serious complications'. Nausea was more common with misoprostol (average RR 2.50, 95% CI 1.53 to 4.09; 11 studies, 3015 women, random-effects; low-quality evidence). We did not identify any difference in women's satisfaction between misoprostol and surgery (average RR 1.00, 95% CI 0.99 to 1.00; 9 studies, 3349 women, random-effects; moderate-quality evidence). More women had vomiting and diarrhoea with misoprostol compared with surgery (vomiting: average RR 1.97, 95% CI 1.36 to 2.85; 10 studies, 2977 women, random-effects; moderate-quality evidence; diarrhoea: average RR 4.82, 95% CI 1.09 to 21.32; 4 studies, 757 women, random-effects; moderate-quality evidence).Five trials compared different routes of administration, or doses, or both, of misoprostol. There was no clear evidence of one regimen being superior to another. Limited evidence suggests that women generally seem satisfied with their care. Long-term follow-up from one included study identified no difference in subsequent fertility between the three approaches. AUTHORS' CONCLUSIONS The available evidence suggests that medical treatment, with misoprostol, and expectant care are both acceptable alternatives to routine surgical evacuation given the availability of health service resources to support all three approaches. Further studies, including long-term follow-up, are clearly needed to confirm these findings. There is an urgent need for studies on women who miscarry at more than 13 weeks' gestation.
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Affiliation(s)
- Caron Kim
- WHODepartment of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | | | | | - Martha Hickey
- The Royal Women's HospitalThe University of MelbourneLevel 7, Research PrecinctMelbourneVictoriaAustraliaParkville 3052
| | - Juan C Vazquez
- Instituto Nacional de Endocrinologia (INEN)Departamento de Salud ReproductivaZapata y DVedadoHabanaCuba10 400
| | - Lixia Dou
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Efficacy of Intrauterine Injection of Granulocyte Colony Stimulating Factor (G-CSF) on Treatment of Unexplained Recurrent Miscarriage: A Pilot RCT Study. J Reprod Infertil 2017; 18:379-385. [PMID: 29201668 PMCID: PMC5691254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Endometrium undergoes several changes in structure and cellular composition during pregnancy. Granulocyte Colony-stimulating Factor (GCS-F) is an important cytokine with critical role in embryo implantation and pregnancy. The aim of the present study was to evaluate the impact of intrauterine injection of G-CSF in patients who suffer from unexplained recurrent miscarriage (RM). METHODS In the present randomized clinical trial, a total of 68 patients were randomly allocated into two study groups including intrauterine G-CSF (n=23, 300 μg) injection and control group (n=27, no G-CSF injection). Eighteen out of 68 patients were excluded from the final analysis due to different reasons. All patients were in Ovulation Induction (I/O) cycle. In G-CSF group, intrauterine injection of G-CSF was done twice in the cycle. All enrolled patients were under 40 years old and had at least two unexplained pregnancy losses. Pregnancy was evaluated by titer of βhCG, presence of gestational sac (implantation) and fetal heart rate (clinical pregnancy) was assessed by vaginal ultrasonography. Student's T test and Mann-Whitney U were used for analysis. The p≤0.05 was determined as statistically significant. RESULTS No significant differences were observed between the two study groups when the rates of chemical pregnancy (26.1% vs. 29.6%, p=0.781), implantation (26.1% vs. 22.2%, p=0.750), clinical pregnancy (17.4% vs. 11.1%, p=0.689) and abortion (33% vs. 37.5%, p=0.296) were compared. CONCLUSION In our study, no significant difference was observed between the two study groups when the rates of chemical pregnancy, implantation, clinical pregnancy and abortion were compared.
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Etiologic characteristics and index pregnancy outcomes of recurrent pregnancy losses in Korean women. Obstet Gynecol Sci 2016; 59:379-87. [PMID: 27668201 PMCID: PMC5028645 DOI: 10.5468/ogs.2016.59.5.379] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/29/2016] [Accepted: 05/02/2016] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE The goal of this study was to evaluate the etiologies and clinical outcomes of Korean recurrent pregnancy loss (RPL) patients. And also, we investigated the differences between primary and secondary RPL patients, between two and three or more pregnancy losses. METHODS One hundred seventy eight women diagnosed as RPL were enrolled. We performed chromosomal analysis, thyroid stimulating hormone, prolactin, blood glucose, plasminogen activator inhibitor-1, natural killer cell proportion, anticardiolipin antibodies, antiphospholipid antibodies, lupus anticoagulant, anti-β2glycoprotein-1 antibodies, antinuclear antibody, protein C, protein S, antithrombin III, homocysteine, MTFHR gene, factor V Leiden mutation, and hysterosalphingography/hysteroscopic evaluation. RESULTS The mean age was 34.03±4.30 years, and mean number of miscarriages was 2.69±1.11 (range, 2 to 11). Anatomical cause (13.5%), chromosomal abnormalities (5.6%), and endocrine disorders (34.3%) were observed in RPL women. Elevated natural killer cell and antiphospholipid antibodies were observed in 43.3% and 7.3% each. Among of 178 women, 77 women were pregnant. After management of those women, live birth rate was 84.4% and mean gestational weeks was 37.63±5.12. Women with three or more RPL compared with women with two RPL had more common anatomical cause such as intrauterine adhesions and lower rates of spontaneous pregnancy. Compare with secondary RPL women, immunological abnormalities were more common in primary RPL. However, miscarriage rates were not different. CONCLUSION Immunological factor including autoimmune and alloimmune disorders was most common etiology of RPL. Inherited thrombophilia showed different patterns with other ethnic countries. Miscarriage rates were not different between primary and secondary RPL, or between two and three or more miscarriages group.
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Balogun OO, da Silva Lopes K, Ota E, Takemoto Y, Rumbold A, Takegata M, Mori R. Vitamin supplementation for preventing miscarriage. Cochrane Database Syst Rev 2016; 2016:CD004073. [PMID: 27150280 PMCID: PMC7104220 DOI: 10.1002/14651858.cd004073.pub4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Miscarriage is a common complication of pregnancy that can be caused by a wide range of factors. Poor dietary intake of vitamins has been associated with an increased risk of miscarriage, therefore supplementing women with vitamins either prior to or in early pregnancy may help prevent miscarriage. OBJECTIVES The objectives of this review were to determine the effectiveness and safety of any vitamin supplementation, on the risk of spontaneous miscarriage. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group Trials Register (6 November 2015) and reference lists of retrieved studies. SELECTION CRITERIA All randomised and quasi-randomised trials comparing supplementation during pregnancy with one or more vitamins with either placebo, other vitamins, no vitamins or other interventions. We have included supplementation that started prior to conception, periconceptionally or in early pregnancy (less than 20 weeks' gestation). DATA COLLECTION AND ANALYSIS Three review authors independently assessed trials for inclusion, extracted data and assessed trial quality. We assessed the quality of the evidence using the GRADE approach. The quality of evidence is included for numerical results of outcomes included in the 'Summary of findings' tables. MAIN RESULTS We included a total of 40 trials (involving 276,820 women and 278,413 pregnancies) assessing supplementation with any vitamin(s) starting prior to 20 weeks' gestation and reporting at least one primary outcome that was eligible for the review. Eight trials were cluster-randomised and contributed data for 217,726 women and 219,267 pregnancies in total.Approximately half of the included trials were assessed to have a low risk of bias for both random sequence generation and adequate concealment of participants to treatment and control groups. Vitamin C supplementation There was no difference in the risk of total fetal loss (risk ratio (RR) 1.14, 95% confidence interval (CI) 0.92 to 1.40, seven trials, 18,949 women; high-quality evidence); early or late miscarriage (RR 0.90, 95% CI 0.65 to 1.26, four trials, 13,346 women; moderate-quality evidence); stillbirth (RR 1.31, 95% CI 0.97 to 1.76, seven trials, 21,442 women; moderate-quality evidence) or adverse effects of vitamin supplementation (RR 1.16, 95% CI 0.39 to 3.41, one trial, 739 women; moderate-quality evidence) between women receiving vitamin C with vitamin E compared with placebo or no vitamin C groups. No clear differences were seen in the risk of total fetal loss or miscarriage between women receiving any other combination of vitamin C compared with placebo or no vitamin C groups. Vitamin A supplementation No difference was found in the risk of total fetal loss (RR 1.01, 95% CI 0.61 to 1.66, three trials, 1640 women; low-quality evidence); early or late miscarriage (RR 0.86, 95% CI 0.46 to 1.62, two trials, 1397 women; low-quality evidence) or stillbirth (RR 1.29, 95% CI 0.57 to 2.91, three trials, 1640 women; low-quality evidence) between women receiving vitamin A plus iron and folate compared with placebo or no vitamin A groups. There was no evidence of differences in the risk of total fetal loss or miscarriage between women receiving any other combination of vitamin A compared with placebo or no vitamin A groups. Multivitamin supplementation There was evidence of a decrease in the risk for stillbirth among women receiving multivitamins plus iron and folic acid compared iron and folate only groups (RR 0.92, 95% CI 0.85 to 0.99, 10 trials, 79,851 women; high-quality evidence). Although total fetal loss was lower in women who were given multivitamins without folic acid (RR 0.49, 95% CI 0.34 to 0.70, one trial, 907 women); and multivitamins with or without vitamin A (RR 0.60, 95% CI 0.39 to 0.92, one trial, 1074 women), these findings included one trial each with small numbers of women involved. Also, they include studies where the comparison groups included women receiving either vitamin A or placebo, and thus require caution in interpretation.We found no difference in the risk of total fetal loss (RR 0.96, 95% CI 0.93 to 1.00, 10 trials, 94,948 women; high-quality evidence) or early or late miscarriage (RR 0.98, 95% CI 0.94 to 1.03, 10 trials, 94,948 women; moderate-quality evidence) between women receiving multivitamins plus iron and folic acid compared with iron and folate only groups.There was no evidence of differences in the risk of total fetal loss or miscarriage between women receiving any other combination of multivitamins compared with placebo, folic acid or vitamin A groups. Folic acid supplementation There was no evidence of any difference in the risk of total fetal loss, early or late miscarriage, stillbirth or congenital malformations between women supplemented with folic acid with or without multivitamins and/or iron compared with no folic acid groups. Antioxidant vitamins supplementation There was no evidence of differences in early or late miscarriage between women given antioxidant compared with the low antioxidant group (RR 1.12, 95% CI 0.24 to 5.29, one trial, 110 women). AUTHORS' CONCLUSIONS Taking any vitamin supplements prior to pregnancy or in early pregnancy does not prevent women experiencing miscarriage. However, evidence showed that women receiving multivitamins plus iron and folic acid had reduced risk for stillbirth. There is insufficient evidence to examine the effects of different combinations of vitamins on miscarriage and miscarriage-related outcomes.
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Affiliation(s)
- Olukunmi O Balogun
- National Center for Child Health and DevelopmentDepartment of Health PolicyMedical Building No. 2, Hongo Campus2‐10‐1 OkuraTokyoTokyoJapan157‐8535
| | - Katharina da Silva Lopes
- National Center for Child Health and DevelopmentDepartment of Health PolicyMedical Building No. 2, Hongo Campus2‐10‐1 OkuraTokyoTokyoJapan157‐8535
| | - Erika Ota
- St. Luke's International University, Graduate School of Nursing SciencesGlobal Health Nursing10‐1 Akashi‐choChuo‐KuTokyoJapan104‐0044
| | - Yo Takemoto
- National Research Institute for Child Health and Development2‐10‐1 Okura, Setagaya‐kuTokyo157‐8535Japan
| | - Alice Rumbold
- The University of AdelaideThe Robinson Research InstituteGround Floor, Norwich Centre55 King William RoadAdelaideNTAustraliaSA 5006
| | - Mizuki Takegata
- National Center for Child Health and DevelopmentDepartment of Health PolicyMedical Building No. 2, Hongo Campus2‐10‐1 OkuraTokyoTokyoJapan157‐8535
| | - Rintaro Mori
- National Center for Child Health and DevelopmentDepartment of Health PolicyMedical Building No. 2, Hongo Campus2‐10‐1 OkuraTokyoTokyoJapan157‐8535
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Egerup P, Lindschou J, Gluud C, Christiansen OB. The Effects of Intravenous Immunoglobulins in Women with Recurrent Miscarriages: A Systematic Review of Randomised Trials with Meta-Analyses and Trial Sequential Analyses Including Individual Patient Data. PLoS One 2015; 10:e0141588. [PMID: 26517123 PMCID: PMC4627734 DOI: 10.1371/journal.pone.0141588] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 10/09/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Immunological disturbances are hypothesised to play a role in recurrent miscarriage (RM) and therefore intravenous immunoglubulins (IVIg) have been tested in RM patients. OBJECTIVES The objectives were to investigate the benefits and harms of IVIg versus placebo, no intervention, or treatment as usual in women with RM. SEARCH STRATEGY We searched the published literature in all relevant databases. SELECTION CRITERIA Randomised trials investigating IVIg versus placebo, no intervention, or treatment as usual in women with RM. DATA COLLECTION AND ANALYSIS We undertook meta-analyses of aggregated data and individual patient data using a two-step approach, and we conducted bias domain assessments and trial sequential analyses to assess the risks of systematic and random errors. MAIN RESULTS We identified 11 randomised clinical trials. No significant difference in the frequency of no live birth was found when IVIg was compared with placebo or treatment as usual (RR 0.92, 95% CI 0.75-1.12, p = 0.42). Trial sequential analysis showed that the required information size of 1,008 participants was not obtained. IVIg compared with placebo seems to increase the risk of adverse events. Subgroup analysis suggests that women with RM after a birth (secondary RM) seemed most likely to obtain a potential beneficial effect of IVIg (RR for no live birth 0.77, 95%CI 0.58-1.02, p = 0.06), however, trial sequential analysis showed that insufficient information is presently accrued. CONCLUSION We cannot recommend or refute IVIg in women with RM. IVIg should therefore be assessed in further randomised clinical trials with positive outcomes before any clinical use is considered.
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Affiliation(s)
- Pia Egerup
- The Fertility Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- * E-mail:
| | - Jane Lindschou
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Bjarne Christiansen
- The Fertility Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark
| | - ImmuReM IPD Study Group
- The Fertility Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark, Department of Obstetrics and Gynaecology, University Hospital Linköping, Linköping, Sweden
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Moffett A, Shreeve N. First do no harm: uterine natural killer (NK) cells in assisted reproduction. Hum Reprod 2015; 30:1519-25. [PMID: 25954039 PMCID: PMC4472320 DOI: 10.1093/humrep/dev098] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 04/07/2015] [Indexed: 01/22/2023] Open
Abstract
Natural killer (NK) cells are a type of lymphocyte circulating in peripheral blood named because of their effector functions in killing target cells. Immune cells that share similar phenotypic characteristics but are poor killers populate the uterine lining at implantation and during early pregnancy when the placenta is established. The functions of these uterine NK (uNK) cells are essentially unknown but available data point to a role in regulating placentation in concert with other elements of the decidua and invading trophoblast cells. Despite the lack of scientific rationale and advice from clinical governing bodies, such as the Human Fertilisation and Embryology Authority, an increasing range of tests and therapies are still offered to women undergoing IVF or attending recurrent miscarriage clinics based on the myth that uterine NK cells need suppressing to prevent damage to the embryo. New treatments can be introduced at whim with subsequent demands for expensive trials to prove/disprove their efficacy. The evidence that targeting uNK or peripheral blood NK cells assists women with recurrent pregnancy failure is lacking. Healthcare professionals and patients should very carefully evaluate the practice of immunomodulation to enhance pregnancy outcome. A discussion on how to move towards stricter regulation of immunotherapy in non-hospital settings is now needed because it is clear that the potential risks and costs of these therapies outweigh any benefits.
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Affiliation(s)
- Ashley Moffett
- Department of Pathology, University of Cambridge, Cambridge, UK Centre for Trophoblast Research, University of Cambridge, Cambridge, UK
| | - Norman Shreeve
- Centre for Trophoblast Research, University of Cambridge, Cambridge, UK Department of Obstetrics & Gynecology, University of Cambridge, Cambridge, UK
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Kwiatek M, Gęca T, Krzyżanowski A, Malec A, Kwaśniewska A. Peripheral Dendritic Cells and CD4+CD25+Foxp3+ Regulatory T Cells in the First Trimester of Normal Pregnancy and in Women with Recurrent Miscarriage. PLoS One 2015; 10:e0124747. [PMID: 25945787 PMCID: PMC4422710 DOI: 10.1371/journal.pone.0124747] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 03/05/2015] [Indexed: 12/04/2022] Open
Abstract
The development of pregnancy is possible due to initiation of immune response in the body of the mother resulting in immune tolerance. Miscarriage may be caused by the impaired maternal immune response to paternal alloantigens located on the surface of trophoblast and fetal cells. The aim of the study was to compare the population of circulating dendritic cells (DCs) and CD4+CD25+Foxp3+ regulatory T cells (TREGs) in the first trimester of a normal pregnancy and in women with recurrent miscarriage and an attempt to determine the relationship between these cells and the role they may play in human reproductive failures. The study was conducted in a group of 33 first trimester pregnant women with recurrent miscarriage and in a group of 20 healthy pregnant women in the first trimester of normal pregnancy. Among mononuclear cells isolated from peripheral blood, the populations of DCs and TREGs were assessed by flow cytometry. The percentage of myeloid DCs and lymphoid DCs showed no significant difference between study and control group. Older maternal age and obesity significantly reduced the pool of circulating myeloid and lymphoid DCs (R=-0.39, p=0.02). In miscarriages the percentage of circulating TREGs was significantly lower compared to normal pregnancies (p=0.003). Among the analysed factors the percentage of TREGs was the most sensitive and the most specific parameter which correlated with the pregnancy loss. The reduction in the population of circulating TREGs suggests immunoregulatory mechanisms disorder in a pregnancy complicated by miscarriage.
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Affiliation(s)
- Maciej Kwiatek
- Department of Obstetrics and Pathology of Pregnancy, Medical University of Lublin, Lublin, Poland
- * E-mail:
| | - Tomasz Gęca
- Department of Obstetrics and Pathology of Pregnancy, Medical University of Lublin, Lublin, Poland
| | - Arkadiusz Krzyżanowski
- Department of Obstetrics and Pathology of Pregnancy, Medical University of Lublin, Lublin, Poland
| | - Agnieszka Malec
- Department of Obstetrics and Pathology of Pregnancy, Medical University of Lublin, Lublin, Poland
| | - Anna Kwaśniewska
- Department of Obstetrics and Pathology of Pregnancy, Medical University of Lublin, Lublin, Poland
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Gao J, Deng G, Hu Y, Huang Y, Lu L, Huang D, Li Y, Zhu L, Liu X, Jin X, Luo S. Quality of reporting on randomized controlled trials on recurrent spontaneous abortion in China. Trials 2015; 16:172. [PMID: 25896786 PMCID: PMC4404269 DOI: 10.1186/s13063-015-0665-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 03/19/2015] [Indexed: 01/13/2023] Open
Abstract
Background Despite increasing numbers of RCTs done in China, detailed information on the quality of Chinese RCTs is still missing. The aim of this study was to assess the reporting quality of RSA RCTs and to identify significant predictors of reporting quality. Methods A literature review was conducted with the aim of identifying published RCTs on RSA conducted in China. In order to rate the report quality, we scored 1 for the item of CONSORT 2010 if it was reported and 0 if it was not stated or unclear. An overall quality score (OQS) with a range of 0–15 and a key methodological index score (MIS) with a range of 0–3 were calculated for each trial. Results A total of 98 relevant RCTs were included in the final analysis. The median OQS was 7, with a minimum of 1 and maximum of 12. The general level of OQS was not high, especially among ‘sample size,’ ‘baseline data,’ ‘outcomes and estimation,’ and ‘ancillary analyses,’ all of which had a positive rate of less than 10%. The median MIS was 1 with a minimum of 0 and maximum of 1. ‘Allocation concealment,’ ‘blinding,’ and ‘intention-to-treat analysis’ were mentioned in 1 (1%), 1 (1%) and 69 (70%) of the studies, respectively. In univariate analysis, funding was the only factor associated with an increased OQS. Specifically, the mean OQS increased by approximately 1.52 for manuscripts supported by funding (95% CI: 0.12 – 2.92; p = 0.03). With regard to the MIS, no association was found for any variable. Conclusion RCTs of RSA conducted in China need improvement in order to meet the level of “reporting quality” required by the CONSORT statement. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0665-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jie Gao
- Department of Gynecology, First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Gaopi Deng
- Department of Gynecology, First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Yunyun Hu
- Department of Gynecology, First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Yanxi Huang
- Department of Gynecology, First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Liming Lu
- Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, Guangdong, China.
| | - Dandan Huang
- Department of Anorectal, First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Yadi Li
- Department of Gynecology, First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Lin Zhu
- Department of Gynecology, First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Xiaojing Liu
- Department of Gynecology, First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Xin Jin
- Department of Anorectal, First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
| | - Songping Luo
- Department of Gynecology, First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.
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