Antiovarian antibodies and their effect on the outcome of assisted reproduction

Successful live birth after in vitro maturation treatment in a patient with autoimmune premature ovarian failure: a case report and review of the literature

OBJECTIVE

We report a successful live birth after oocytes in vitro maturation (IVM) and fresh embryo transfer in a patient with autoimmune premature ovarian failure (POF) and performed a review of the literature of livebirths obtained after oocytes IVM treatment in this indication.

METHODS

The patient was a 24-year-old woman with autoimmune POF diagnosed post-partum, who developed autoimmune polyglandular syndrome with serum anti-ovarian and anti-21-hydroxylase antibodies. The patient had typical symptoms of POF: secondary amenorrhea with hypoestrogenism, elevated gonadotropins and infertility; however, the serum anti-Müllerian hormone level and total antral follicle count remained normal. IVM of immature oocytes was performed after the administration of 150 IU highly purified human menopausal gonadotropin for three consecutive days and an injection of 10,000 IU human chorionic gonadotropin to trigger ovulation.

RESULTS

The six oocyte-cumulus complexes collected matured in vitro. After intracytoplasmic sperm injection (ICSI), five embryos were obtained. Pregnancy was achieved after the fresh transfer of two embryos and appropriate endometrial preparation. A normal female child was delivered following a 37-weeks pregnancy characterized by the onset of adrenal insufficiency and unstable diabetes.

CONCLUSIONS

We report a successful livebirth after IVM treatment in a patient with autoimmune premature ovarian failure (POF). Management of reproductive age women with autoimmune pathology requires fertility counseling. Early diagnosis of autoimmune POF is important for early conception and oocyte preservation, because the only other option at present is ovum donation.

The association of different auto-antibodies against ovarian tissues and gonadotropins and poor ovarian response in intracytoplasmic sperm injection cycles

This study aimed to assess the possible association between ovarian auto-antibodies and poor ovarian response to controlled ovarian hyperstimulation (COH) in patients undergoing intracytoplasmic sperm injection (ICSI) cycles. In total, 42 poor responders and 43 male factor subjects were enrolled in the study and underwent either a standard long gonadotropin-releasing hormone (GnRH) agonist or antagonist protocol. Anti-ovarian, anti-oocyte, anti-zona pellucida (anti-ZP) and anti-gonadotropin antibodies in their sera and follicular fluid (FF) were measured by an enzyme-linked immunosorbent assay technique (ELISA). The mean follicular fluid anti-oocyte antibody [ratio of optical density (OD) _sample/OD _Control] was significantly higher in poor responders compared to the normal group (2.40 ± 1.55 versus 1.72 ± 0.71, p = 0.012). The linear regression analysis showed an inverse correlation between FF anti-oocyte antibody concentrations and the number of: (i) retrieved oocytes (B = -1.212, r = -0.235, p = 0.030); (ii) mature oocytes (B = -1.042, r = -0.234, p = 0.031); (iii) embryos available (B = -0.713, r = -0.228, p = 0.036); and (iv) good quality embryos (B = -0.369, r = -0.229, p = 0.035). However, there were no significant differences between two groups in terms of FF and serum anti-ovarian, anti-gonadotropins and anti-ZP antibodies. The Pearson correlation analysis on 85 infertile patients showed a positive correlation between age and the levels of FF anti-oocyte antibody (r = 0.276, p = 0.010). This study demonstrated that FF anti-oocyte antibody could be associated with poor response to COH in ICSI cycles.

Ovulation Induction is a More Effective Stimulant on Antiovarian Antibody Production than In Vitro Fertilization

INTRODUCTION

Our aim in this study is to evaluate the effects of in vitro fertilization (IVF), including controlled ovarian hyperstimulation (COH) and the number of oocyte pick-up (OPU) procedures on the development of anti-ovarian antibodies (AOA).

METHODS

To evaluate the effects of IVF procedures, namely, COH and OPU, serum samples for measuring AOA concentration levels by enzyme-linked immunosorbent assay were collected on the third day of the menstrual cycle, at the end of the COH, and after OPU.

RESULTS

The AOA levels in IVF patients were significantly higher than the fertile control groups'. In the IVF group, neither COH nor OPU caused any increase in AOA levels when compared to the basal results. AOA levels were higher in patients with a history of 5-8 cycles of ovulation induction, before IVF treatment. There was no relationship between the basal AOA concentrations and the type of infertility, the etiology of infertility or the pregnancy outcomes, whereas there was a relationship between the AOA and the duration of infertility.

CONCLUSION

AOA levels of IVF patients were found to be higher than the fertile control groups'. AOA was found to be related to infertility in patients who had a longer duration of infertility and repeated ovulation induction procedures without IVF. COH and OPU during an IVF cycle did not cause an increase in AOA levels.

Autoantibodies to Heat-Shock Protein, HSPA5, and Epitope Spreading: High-Dose Dexamethasone Therapy Rescues Ovarian Function in Experimental Autoimmune Ovarian Insufficiency Mouse Model

PROBLEM

Role of autoantibodies to heat-shock protein 70 isoform, HSPA5, both alone or in combination with other antigenic peptides in epitope spreading and effect of high-dose dexamethasone to overcome this.

METHOD OF STUDY

Experimental autoimmune premature ovarian insufficiency mouse model generated by immunization with immunodominant epitopes of HSPA5 alone or in combination with other antigenic peptides. Two doses of dexamethasone treatment are given to the latter group. Immunosorbent assay and Western blot analysis were undertaken to detect cross-reactivity. Hormonal estimations, histological evaluation, and fertility studies were performed to assess treatment efficacy.

RESULTS

One of the immunodominant epitopes of HSPA5 led to epitope spreading. Of the two doses, 100 mg was more effective in rescuing fertility.

CONCLUSIONS

We postulate that the shared immunodominant peptide could be included in a peptide array to detect both HSAP5 and HSP90β autoantibodies for early diagnosis or prognosis of aPOI and customized glucocorticoid therapy for such subjects.

Immunization with ovarian autoantigens leads to reduced fertility in mice following follicular dysfunction

Immunoproteomics using sera of women with ovarian autoimmune diseases such as primary ovarian insufficiency and IVF embryo transfer recruits led to identification of three proteins namely alpha actinin 4 (α-ACTN4), heat-shock 70 protein 5 (HSPA5), and actin beta (ACTB). This study deals with the establishment of a peptide ELISA for screening sera of antiovarian antibody (AOA)-positive patients and further delves into understanding the role of these three proteins in ovarian autoimmunity in a mouse model. Using in silico approach, antigenic peptides of these proteins were identified and used for peptide ELISA. ELISA results indicated that AOA-positive sera showed reactivity with only specific peptides. The functional significance of the dominant peptides was studied by active immunization of female mice with these peptides. All immunized mice generated high antibody titers and profound effect on ovaries with few primordial (2.4±0.1, 2.4±0.2, and 2±0.1), primary (2.4±0.5, 1.7±0.3, and 2.4±0.3), preantral (2.3±0.5, 3.4±0.3, and 2.9±0.3), antral (0.9±0.2, 1.6±0.8, and 2.3±0.6) follicles, and corpora lutea (2.8±0.8, 2.9±1.7, and 4.6±2.3), and increased number of atretic follicles (5.5±0.4, 4.9±1.8, and 7.5±1.0) in ACTN4-, HSPA5-, and ACTB-immunized mice compared with control animals (3.0±0.2, 3.5±0.6, 3±0.1, 3.6±0.2, 4.7±0.3, and 1.5±0.3) respectively. These mice when mated with fertile male mice showed an overall 25–43% reduction in fertility compared with controls. The data clearly suggest that the dominant antigenic epitopes of the three proteins play critical role in fertility and could possibly be the key autoimmune targets. These epitopes could be used to develop a more specific and sensitive diagnostic test for women with ovarian autoimmune diseases and to design therapy for disease management for reinstatement of ovarian function.

Review on autoimmune reactions in female infertility: antibodies to follicle stimulating hormone

Female fertility can be affected by diseases or dysfunctions of reproductive tract, neuroendocrine system, and immune system. Reproductive autoimmune failure can be associated with overall activation of immune system or with immune system reactions specifically directed against ovarian antigens. Majority of the antiovarian autoantibodies are directed against β-subunit of follicle stimulating hormone (anti-FSH). This paper summarizes a current clinical classification of female infertility in the context of general activation of autoimmunity and antiovarian autoimmunity by describing serum anti-FSH. The presence of naturally occurring anti-FSH in healthy women will be discussed. In addition, the putative impairment of ovarian folliculogenesis in case of increased production of those antibodies in infertile women will be characterized.

Can anti-ovarian antibody testing be useful in an IVF-ET clinic?

OBJECTIVE

To establish importance of anti-ovarian antibodies (AOA) testing in infertile women.

DESIGN

A clinical reproductive outcome comparative study between two groups of women undergoing IVF-ET. Group 1 consists of women tested positive for AOA, put on corticosteroid therapy, reverted to AOA negative and then taken up for IVF-ET. Group 2 were seronegative for AOA.

SETTING

Major urban infertility reference centre and National research institute.

PATIENT(S)

Five hundred seventy infertile women enrolled for IVF-ET.

INTERVENTION(S)

AOA testing, corticosteroid therapy and IVF-ET/ICSI.

MAIN OUTCOME MEASURE(S)

Comparable clinical outcome and significance of AOA testing established.

RESULTS

AOA positive serum samples were sent periodically to re-investigate presence of AOA after corticosteroid therapy and women turned AOA negative were taken up for IVF-ET. Of the 70/138 women in group 1 who were treated with corticosteroids and turned seronegative for AOA, 22/70 were poor responders and needed donor oocyte-recipient cycles. Results demonstrated that fertilization and clinical pregnancy rates between both groups are comparable. Nevertheless, it is also observed that there is poor response to stimulation protocol, smaller number of oocytes retrieved and more spontaneous abortions in group 1 women. Hence not all outcomes following the treatment are comparable between the two groups. Usefulness of the test was established in two case studies.

CONCLUSIONS

AOA testing could be included in the battery of tests investigating and treating infertility.

A study of ovarian autotransplantation without vascular a pedicle in rats

PURPOSE

The study aimed to determine effects of FSH applications on follicle survival, development and hormone output and antigenicity of rat ovarian tissue autografts placed at subcutaneous or subperitoneal sites.

METHODS

A total of sixteen female rats were used in the study. The animals were divided into three groups. Ovaries were dissected and then transplanted under the peritoneum in the first group animals (n = 5) or under the skin in the second group animals (n = 6). And the animals in the third group (n = 5) were sham operated. Following operations, intramuscular injection of 8 IU of rhFSH were made daily to the animals in first and second groups from the first day of operation through thirty days. Vaginal irrigation samples were prepared daily from the animals for 30 days. The concentrations of serum estradiol and antiovarian antibodies in the blood were determined using ELISA on the last day of vaginal irrigations. Histopathological examination of the ovaries that were transplanted was made.

RESULTS

Results showed that cyclic variations were noticed in the samples of vaginal irrigation by day 30 in the animals of first and second groups. However, no significant differences were seen between groups. The concentration of blood serum estradiol was higher in the animals of first group. Decrease in numbers of primary follicles were found in the animals of second group and lesser corpus luteum were found in the animals of control group on the histopathological examinations of transplanted ovaries. All rats in the first and second groups were defined as seropositive for antiovarian antibodies. When the OD values were compared between first and second groups, it was identified that the OD values of rats in the first group was higher than it was seen in the second group.

CONCLUSION

The ovarian transplantation without vascular pedicle in rats is characterized by follicular hyperplasia endocrinologically functional. Being seropositive of all rats in first and second groups in terms of antiovarian antibodies is an indicator to these antibodies does not affect the functions of transplanted ovaries. It is believed that the highness of OD values in the group which is transplanted beneath the peritoneum is based on the highness of estradiol concentrations in these animals.

Corticosteroids in patients with antiovarian antibodies undergoing in vitro fertilization: a prospective pilot study

OBJECTIVE

Antiovarian autoantibodies (AOA) have been associated with reproductive failure, especially in in vitro fertilization (IVF) patients. Thus, the success rate of IVF might be improved by the use of corticosteroids. However, therapeutic trials with these drugs have yielded conflicting results, particularly because of heterogeneous inclusion criteria. Among women with previous IVF failure, we selected those who presented with a positive serum AOA assay, and analysed the efficacy of corticosteroids in improving the IVF outcome in these patients.

METHODS

One hundred patients with serum AOA detected by ELISA and at least two previously failed IVF attempts were selected. These patients underwent a further IVF cycle with 0.5 mg/kg prednisolone, started on the first day of the treatment cycle. In patients who became pregnant, corticosteroids were administered until the end of the first trimester of pregnancy and then progressively discontinued. AOA were assessed before and after oocyte retrieval. Clinical data of the corticosteroid-treated cycle were compared with data from the preceding IVF cycle for each patient.

RESULTS

No adverse effects resulting from corticosteroids were observed. Post oocyte retrieval antiovarian IgG were significantly lower in corticosteroid-treated attempts when compared with the preceding cycles. Twenty-six pregnancies resulted in the birth of 30 healthy children. The pregnancy rate, implantation rate, and live birth rate were 38.8%, 17.8%, and 26.5% respectively in prednisolone-treated cycles.

CONCLUSION

This study confirms the usefulness of corticosteroids in improving the success rate in a subset of patients with previous IVF failure and significant serum AOA levels.

[Ovarian autoimmunity and ovarian pathologies: antigenic targets and diagnostic significance]

The involvement of serum anti-ovarian autoantibodies (AOA) in ovarian pathology still remains controversial. In some cases of clinically patent ovarian failure, there seems to be a causal relationship between AOA and the ovarian disease. In patients with various organ-specific or systemic autoimmune diseases, or with unexplained, repeated reproductive failure, but otherwise normal ovarian function, it is even more difficult to determine the significance of AOA for several reasons: i) AOA recognize many different antigenic targets in the ovary ii) the antiovarian response may be transient or variable with time iii) the presence of AOA does not imply their aetiopathogenic role in the disease. The present paper reviews the clinical significance of AOA based on their ovarian targets as far as they have been identified until now.

Gonadal antibodies interfering with female reproduction

While the involvement of anti-ovarian antibodies (AOAs) is highly likely, yet still controversial, in patients with patent premature ovarian failure (POF), it is even more difficult--for several reasons--to ascertain the clinical significance of these antibodies in patients without obvious ovarian failure. First, AOAs form a heterogeneous group of antibodies recognizing several different antigenic targets such as granulosa and thecal cells, zona pellucida, oocyte cytoplasm, corpus luteum, as well as gonadotrophins and their receptors. Second, the detection of AOAs in various clinical situations does not readily imply a causal relationship between these antibodies and impaired ovarian function. Third, diagnostic tools for detecting AOAs and their molecular targets have to be improved to yield more reliable data and allow a better comprehension of the pathophysiology of AOAs. Preliminary results with immunosuppressive therapy in selected AOA patients have been encouraging, but randomized trials have to be performed.

[What are the antigenic targets in the ovary?]

The ovary can be the target of an autoimmune disease involving many different autoantigens. The clinical feature of this disease often results in premature ovarian failure or infertility and may be either isolated or associated with other autoimmune pathologies, especially with adrenal autoimmunity. The diagnosis of an autoimmune mechanism relies on the presence of anti-ovarian antibodies, whose prevalence is quite variable according to the different methods used to detect them, and to the different stages of the disease. In addition, their clinical significance is not always clear, as to their pathologic or epiphenomenal nature. However, the study of these autoantibodies has led to the identification of some of their antigenic targets which have to be known for a better understanding of the pathologic mechanisms involved. This paper reviews anti-steroid producing cells, anti-gonadotrophin receptor, anti-gonadotrophin, anti-corpus luteum, anti-zona pellucida and anti-oocyte antibodies.

Anticorps anti-ovaires et fécondation in vitro : cause ou conséquence ?

OBJECTIVES

To assess anti-ovarian antibodies (AOA) in serum samples at various times of in vitro fertilization (IVF) attempts to determine whether ovarian stimulation could result in the production of such autoantibodies in women.

PATIENTS AND METHODS

Prospective study on 134 patients and 138 IVF cycles using a classical long protocol. For each attempt, four serum samples were obtained, respectively, at the onset of downrelation (S1), end of downregulation (S13), after 7 days of follicular stimulation (S21) and the day of follicular puncture (SP). Five hundred and fifty two samples were tested with an enzyme-linked immunosorbent assay for three isotypes (IgG, IgA, IgM) of AOA.

RESULTS

In the whole group, mean concentrations of AOA for each isotype were compared group by group: S1-S13, S1-S21, S1-SP, S13-S21, S13-SP, S21-SP. Not any significant difference was observed whatever the isotype considered.

DISCUSSION AND CONCLUSION

This study shows the absence of influence of endogenous or exogenous ovarian stimulation by gonadotropins on anti-ovarian autoimmunity.

Ovarian autoimmune disease and ovarian autoantibodies

Detection of specific autoantibodies remains the most practical clinical and research marker of autoimmune disease. The lack of consensus on ovary specific antibodies as a marker for ovarian autoimmunity has clinical and research consequences. The objective of this review is to summarize the evidence for ovarian autoimmunity and the detection of ovary specific autoantibodies in humans. Evidence favors the presence of an autoimmune disease of the ovary. Ovarian autoantibodies are associated primarily with premature ovarian failure (POF) and unexplained infertility. Variations in detection of ovarian autoantibodies are likely to be due to study design elements such as antibody test format, antigen preparation, and criteria for study and comparison groups. In addition, multiple targets appear to be involved in ovarian autoimmunity including ovarian cellular elements and oocyte related antigens. Many studies only assess one target antigen, leaving individuals with ovarian autoimmunity unidentified. The next most significant advance in characterizing ovarian autoimmunity will be definitive identification of the specific antigens and development of standardized tests based on use of specific antigens.

Ovarian autoimmunity: greater frequency of autoantibodies in premature menopause and unexplained infertility than in the general population

The objective of this study was to: (1) assess the relative prevalence of ovarian, thyroid, nuclear, and cardiolipin antibodies associated with premature menopause and unexplained infertility and (2) compare ovarian and thyroid antibodies in premature menopause, unexplained infertility, and the general population. Autoantibodies were evaluated in women with premature menopause (n = 30), unexplained infertility with (n = 38) or without (n = 15) prior gonadotropin-induced ovulation, and normal cycling controls (n = 12) and in a population of women obtained from a blood bank (n = 53). Antibodies to ovary (OVAB), thyroid (THYAB; thyroid peroxidase and thyroglobulin), cardiolipin, and eight nuclear antigens were assessed by enzyme immunoassay. Organ-specific antibodies (ovary and thyroid) were present with significantly greater frequency than non-organ-specific antibodies (nuclear and cardiolipin) in premature menopause and unexplained infertility (60% (50/83) vs 16% (13/83) respectively; P < 0.0001). OVAB (53%, 44/83) were significantly more frequent than THYAB (30%, 25/83) in premature menopause and unexplained infertility (P = 0.0030). THYAB did not differ among all groups (P = 0.78). In premature menopause and treated or untreated unexplained infertility OVAB frequencies were 53, 61, and 33%, respectively, and were significantly more frequent than in the population (17%) (P = 0.0001). In unexplained infertility, individuals with no prior gonadotropin-induced ovulation had a lower frequency of OVAB than treated individuals (P = 0.07). The frequency distribution of optical density values for OVAB was significantly higher for premature menopause and unexplained infertility than for population or normal cycling women (P < 0.0001). Thus, only ovarian antibodies were significantly more frequent than other antibody markers of autoimmunity in premature menopause and unexplained infertility.