The reproductive autoimmune failure syndrome

Pregnancy loss and the risk of rheumatoid arthritis in Chinese women: findings from the China Kadoorie biobank

Considering the female preponderance of rheumatoid arthritis (RA), and disease onset typically after the reproductive years, pregnancy and childbirth may play a role in the aetiology of the disease. Adverse outcomes of pregnancy have been found to precede the diagnosis of autoimmune diseases, including RA, but the evidence is scant and inconsistent. Therefore, we investigate whether pregnancy loss is associated with the risk of RA in Chinese women. Data from the China Kadoorie Biobank, conducted by the University of Oxford and the Chinese Centre for Disease Control and Prevention, of 299,629 Chinese women who had been pregnant were used. Multivariable logistic regression and stratified analyses were employed to analyse the association between types of pregnancy loss with the risk of RA. Pregnancy loss was significantly associated with increased risk of RA (OR 1.12, 95% CI 1.06–1.18), specifically, spontaneous (OR 1.11, 95% CI 1.03–1.20) and induced abortions (OR 1.11, 95% CI 1.06–1.17). There was no significant association between stillbirth and the risk of RA (OR 1.07, 95% CI 0.97–1.18). The risk of developing RA increases with the number of pregnancy losses: one loss confers an OR of 1.09 (95% CI 1.03–1.16), two an OR of 1.13 (95% CI 1.05–1.20), three or more an OR of 1.19 (95% CI 1.10–1.28) and OR of 1.06 (95% CI 1.03–1.08) for each additional. Spontaneous and induced abortions are associated with an increased risk of RA in Chinese women.

Immune determinants of endometrial receptivity: a biological perspective

Immune cells are essential for endometrial receptivity to embryo implantation and early placental development. They exert tissue-remodeling and immune regulatory roles-acting to promote epithelial attachment competence, regulate the differentiation of decidual cells, remodel the uterine vasculature, control and resolve inflammatory activation, and suppress destructive immunity to paternally inherited alloantigens. From a biological perspective, the endometrial immune response exerts a form of "quality control"-it promotes implantation success when conditions are favorable but constrains receptivity when physiological circumstances are not ideal. Women with recurrent implantation failure and recurrent miscarriage may exhibit altered numbers or disturbed function of certain uterine immune cell populations-most notably uterine natural killer cells and regulatory T cells. Preclinical and animal studies indicate that deficiencies or aberrant activation states in these cells can be causal in the pathophysiological mechanisms of infertility. Immune cells are, therefore, targets for diagnostic evaluation and therapeutic intervention. However, current diagnostic tests are overly simplistic and have limited clinical utility. To be more informative, they need to account for the full complexity and reflect the range of perturbations that can occur in uterine immune cell phenotypes and networks. Moreover, safe and effective interventions to modulate these cells are in their infancy, and personalized approaches matched to specific diagnostic criteria will be needed. Here we summarize current biological understanding and identify knowledge gaps to be resolved before the promise of therapies to target the uterine immune response can be fully realized.

Potential biomarkers of infertility associated with microbiome imbalances

PROBLEM

The aim of this study was to investigate the possible relationship between vaginal/rectal microbiome disbalances and miRNA expression with infertility.

METHOD OF STUDY

Observational, exploratory, preliminary study. A total of 287 multiple IVF failure infertile patients were recruited. Twenty fertile women, not IVF failure, were recruited as the control group. Swab samples were collected from the vagina and rectum. Microbial composition by NGS and miRNA expression by real-time PCR of vaginal and rectal samples was measured. Immunometabolic markers from blood (insulin, vitamin D, LDL-cholesterol, ANA, TPO, Tg, and ASCA antibodies) and saliva (sIgA) were analyzed.

RESULT(S)

Infertile patients showed a lower bacterial richness and increased Firmicutes/Bacteroidetes ratio at rectal level and an increased Lactobacillus brevis/Lactobacillus iners ratio in vaginal samples regarding the fertile group. In the same rectal swab samples, we found that miR-21-5p, which is associated with tight junction disruption and yeast overgrowth, is upregulated and that miR-155-5p, which is associated with inflammation, is overexpressed in the unexplained infertile group (*p < .05). These deregulated miRNAs were also upregulated in the vaginal samples from the same patients (*p < .05).

CONCLUSION

miRNAs could be potential biomarkers of the inflammatory impact of microbiome disbalances in unexplained infertile women.

Infertility in women with systemic autoimmune diseases

Infertility consists by definition in" failure to achieve a clinical pregnancy after 12 months or more of regular unprotected intercourse" while the term subfertility means a delay to achieve pregnancy. Several factors can contribute to infertility or subfertility in patients with systemic autoimmune diseases. The association of systemic autoimmune conditions with endometriosis, celiac disease and thyroid autoimmunity that are well known causes of infertility and/or subfertility need to be taken in consideration when difficulties in the onset of pregnancy is reported. The majority of the used antirheumatic drugs do not interfere with fertility. However, the use of cyclophosphamide, limited to severe disease, can provoke premature ovarian failure; to preserve fertility a preventive treatment is available. Nonsteroidal anti-inflammatory drugs can cause temporary infertility and corticosteroids are associated to a prolonged time to pregnancy in some rheumatic diseases. Data on the association of antiphospholipid antibodies (aPL) with infertility are still debated but in general an increased rate of aPL is described patients undergoing medically assisted reproductive techniques. In systemic lupus erythematosus aPL and other autoantibodies (i.e. anti-oocytes) can contribute to the infertility of some patients. Subfertility, rather than infertility, is observed in patients with rheumatoid arthritis; the particular physical conditions of these women can also account for this. Physicians should not forget the patients' age, that is mandatory in order to preserve their chance to have children.

Therapeutic Potential of Regulatory T Cells in Preeclampsia-Opportunities and Challenges

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.

The hidden world of anti-phospholipid antibodies and female infertility: A literature appraisal

Even though the association of anti-phospholipid antibodies (aPL) with infertility is debated, infertile women are commonly screened for aPL. To review evidence, a systematic PubMed search was conducted to retrieve papers addressing (i) the association between aPL and infertility, (ii) the positivity rate of criteria and non-criteria aPL in women with infertility, (iii) the association between aPL and assisted reproduction technologies (ART) outcome, (iv) the efficacy of medical treatments on ART outcome, and (v) the effects of ART on thrombotic risk. A total of 46 papers were considered; several limitations emerged: (i) wide heterogeneity in study populations, (ii) non-prospective design in 90% of studies, and (iii) aPL cutoffs not conforming to international guidelines in more than 75% of studies; aPL positivity not confirmed in 89% of studies. Most studies evinced an association between infertility and anti-β2GPI antibodies and almost all non-criteria aPL. The association rate with infertility was below 50% for lupus anti-coagulant, anti-cardiolipin antibodies (aCL), and anti-phosphatidic acid antibodies. According to our estimates, overall positivity rates of criteria and non-criteria aPL tests are 6% and 3% among infertile women, 1% and 2% among controls, respectively. A significant difference in the positivity rate of patients versus controls emerged for aCL only. Five of 18 studies reported a detrimental effect of aPL on ART outcome. Only one of the six studies assessing the effects of treatment on ART outcome among aPL-positive infertile women reported a benefit. All relevant studies reported no increase in the rate of thrombosis among aPL-positive women undergoing ART.

Gestational dermatosis shortly after implantation associated with parental class II HLA compatibility and maternal immune activation: preliminary report of a prospective case series

BACKGROUND

Pregnancy represents a semi-allograft, subject to similar immune responses as allogeneic organ transplants. Tolerance of pregnancy appears best with maximal class II HLA heterogeneity between mother and father, while compatibilities are associated with increased pregnancy loss and maternal autoimmunity. Tolerance abnormalities often involve skin reactions. Abnormalities in tolerance of the fetal graft may do the same.

OBJECTIVE

To define the characteristics of a newly described dermatosis in very early pregnancy.

METHODS

Prospective case series of 7 couples/12 clinical episodes.

RESULTS

The dermatosis was observed in 7 out of 285 women undergoing in vitro fertilization (IVF; 2.5%; 95% CI 0.66-4.26%) and in 12 out of 277 total IVF cycles reaching embryo transfer (4.3%; 95% CI 1.93-6.73%). Prior to IVF all women reported autoimmune clinically significant allergies. All but 1 couple demonstrated class II HLA compatibility. Two of 4 pregnancies miscarried. All rashes erupted within days from embryo implantation.

CONCLUSIONS

The 'implantation rash' reported here is uncommon but not rare. It may be the consequence of abnormal maternal immune responses to embryo implantation in women with prior immune activation, associated with class II HLA compatibility between parents. Further prospective studies are required to better define this condition.

Effects of anti-phospholipid antibodies on a human trophoblast cell line (HTR-8/SVneo)

Antibodies to phospholipids (aPL) have been shown to adversely affect trophoblast invasion in vivo and in vitro. HTR-8/SVneo cells derived from first trimester of pregnancy extravillous trophoblast were studied. Matrigel invasion assay, cytochemistry and cell-based enzyme-linked immunosorbant assay (ELISA) with aPL or normal IgG was used. Our data show that aPL at 100 microg/ml decrease invasiveness of HTR-8/SVneo cells to 60% of control (p<0.01), and this was also shown for primary cytotrophoblast (to 15.5% of control, p<0.001). aPL treatment caused a significant decrease in integrin alpha(1), alpha(5), and beta(1) proteins (86%, 84%, and 87%, respectively). We conclude that HTR-8/SVneo cell culture is a suitable model to study mechanisms of action of aPL on trophoblast, which in HTR-8/SVneo cells inhibit invasion by decreasing integrins alpha(5), alpha(1), and beta(1).

Recurrent pregnancy loss and inappropriate local immune response to sex hormones

PROBLEM

The cause of recurrent miscarriage is often unknown. Recurrent miscarriage may be associated with inappropriate responses to progesterone and estrogen. We examined whether the condition may be diagnosed by skin testing.

METHOD OF STUDY

In a longitudinal prospective study, the weal and flare reaction after intradermal injection of estradiol and progesterone was compared in 29 women with recurrent miscarriage to the response in 10 healthy women. Reactions were evaluated after 20 min, 24, and 48 hr and 5 days later.

RESULTS

Estrogen hypersensitivity was found in 23 patients, and progesterone hypersensitivity in 20 patients. No patient in the control group demonstrated sex hormone hypersensitivity.

CONCLUSION

Recurrent pregnancy loss may be associated with inappropriate local immune responses to sex hormones. Further research is necessary into the mechanisms of hypersensitivity to estrogen and progesterone and their interactions with other systems.

Prophylactic Therapy for Patients with Reproductive Failure Who were Positive for Anti-Phospholipid Antibodies

PROBLEM

To elucidate the efficacy of the treatment using a Japanese-modified Chinese herbal medicine, Sairei-to, and low-dose aspirin with or without a corticosteroid hormone for the patients with adverse pregnancy histories positive for anti-phospholipid antibodies.

METHOD OF STUDY

Fifteen cases positive for anti-phospholipid antibodies, who had experienced preterm delivery in which an extremely low birthweight infant (<1000 g) was born as a result of intrauterine growth restriction with or without severe preeclampsia, were treated with the medication according to the current protocol. Four cases with the same condition, who were treated with only low-dose aspirin, or without medication, were chosen as a control population. The pregnancy outcome was compared between the two groups.

RESULTS

The rate of patients in whom the next pregnancy continued until the 36th week of gestation or later was significantly higher in treated patients (80.0%) compared with the control population (0%).

CONCLUSIONS

In this series, we obtained case report data that Sairei-to may provide some benefit for patients with reproductive disorders positive for anti-phospholipid antibodies; however, randomized controlled trial evidence is needed before current treatment can be recommended.

Pregnancy loss and endometriosis: pathogenic role of anti-laminin-1 autoantibodies

Laminin-1 is a major multifunctional glycoprotein that forms an integral part of the scaffolding network of basement membranes, and is the earliest synthesized component during embryogenesis. This protein (alpha1beta1gamma1) plays an important role in basement membrane assembly and epiblast differentiation during embryonic development. Anti-laminin-1 autoantibodies are known to cause infertility and recurrent spontaneous abortion in animals. Recently, we reported that the presence of IgG anti-laminin-1 antibodies (Abs) in the blood is significantly associated with recurrent first-trimester miscarriages and subsequent negative pregnancy outcomes. Interestingly, these antibodies are also strongly associated with infertility, especially infertility caused by endometriosis. Laminin-alpha1, laminin-beta1, and laminin-gamma1 mRNAs were also detected in 90% of endometriotic lesions, and all laminin-alpha1, laminin-beta1, and laminin-gamma1 chains were localized to the basement membranes of glandular epithelium in endometriotic peritoneal lesions. ELISA showed specific reactivity of the autoantibodies to a particular region of the laminin-1 molecule, that is, the alpha1 chain G domain. IgM monoclonal anti-laminin-1 Abs, which we recently established, also recognized the G domain and cross-reacted with human alpha1 chain located in the basement membrane of the glandular epithelium of human endometrium. We also established an animal model that produced high titers of anti-laminin-1 Abs after immunization with mouse laminin-1. Anti-laminin-1 Abs from the immunized mice caused a higher fetal resorption rate with lower embryonic and placental weights. Thus, anti-laminin-1 Abs may be important in the development of autoimmune-mediated reproductive failures, and the assessment of the such antibodies may provide a novel means for noninvasive diagnosis of endometriosis.

Autoantibodies in Argentine women with recurrent pregnancy loss

PROBLEM

To determine the presence or absence of subclinical autoimmunity in Caucasian Argentine healthy women with first trimester recurrent pregnancy loss (RPL), the sera of 118 healthy women with a history of three or more consecutive abortions and 125 fertile control women without abortions and two children were analyzed for the presence of autoantibodies: immunoglobulin (Ig)G and IgM anticardiolipin, antinuclear (ANA), antismooth muscle (ASMA), antimitocondrial (AMA), antiliver-kidney-microsomal fraction (LKM), antigastric parietal cells (GPC), antineutrophil cytoplasmatic (ANCA) and antibodies antigliadin type IgA and IgG and IgA antitransglutaminase related with celiac disease (CD).

METHOD OF STUDY

ANA, ASMA, AMA, anti-LKM, antibodies to GPC and ANCA were determined by indirect immunofluorescence (IFI) and anticardiolipin, antigliadina and antitransglutaminase antibodies were measured by enzyme-linked immunosorbent assays (ELISA).

RESULTS

There was no significant difference between controls and patients with ANA, ASMA, AMA, LKM, ANCA and GPC. The prevalence of anticardiolipin antibodies in RPL was significantly higher than controls (P < 0,01) and the prevalence of positive antibodies for antigliadina type IgA and IgG and IgA antitransglutaminase in RPL was significantly higher than controls (P < 0.04).

CONCLUSION

We show that Caucasian Argentine women with RPL showed significantly higher incidence of anticardiolipin antibodies than normal controls and finally we recommended the screening of IgA and IgG antigliadina and IgA antitransglutaminase antibodies in pregnancy, because of the high prevalence of subclinical CD in RPL and the chance of reversibility through consumption of a gluten free diet.

Antiphospholipid antibodies and coagulation defects in women with implantation failure after IVF and recurrent miscarriage

Evaluation of patients with IVF implantation failure or recurrent miscarriage often frustratingly fails to elicit any particular cause for their problem. Testing for antiphospholipid antibodies or thrombophilia is commonly carried out, and interpretation of results in the light of the current evidence is extremely difficult. This paper reviews the purported pathogenetic mechanisms and clinical associations between both antiphospholipid antibodies and inherited thrombophilias, and reproductive failure. The current management strategies are also critically evaluated and recommendations are made for optimal, evidence-based clinical practice.

Relation between anatomical courses of the intramural portions of the uterine tubes and pelvic endometriosis

OBJECTIVE

Endometriosis may originate from implants of endometrium due to retrograde flow of menstrual blood. The flow may be stimulated by anatomical anomalies of uterine tubes or uterus. The aim of the study was to find links between anatomical courses of the intramural portions of the uterine tubes and endometriosis.

DESIGN

Retrospective comparative study.

SETTING

Academic hospital.

PATIENT(S)

Women (n = 227) operated on because of various gynecological indications.

INTERVENTION(S)

Total or subtotal abdominal hysterectomies.

MAIN OUTCOME MEASURE(S)

Pathological reports correlated with courses of the intramural parts of uterine tubes. To evaluate the intramural courses of uterine tubes, specimens were injected with barium sulfate and x-rayed.

RESULT(S)

The intramural portions were categorized into three patterns: straight, curved, or tortuous. Logistic regression identified the course of the intramural portion of the uterine tubes and the parity to be associated with endometriosis. Endometriosis was more frequent in women with straight courses and was infrequent in women with tortuous ones.

CONCLUSION(S)

We suggest that a tortuous course of the intramural portion of the uterine tubes constitutes a normal anatomical finding. It controls the retrograde flow of blood during menstruation and limits the possibility of developing endometriosis. Straight or curved intramural portions represent an anatomical abnormality that may predispose women to endometriosis.

Prognostic impact of anticardiolipin antibodies in women with recurrent miscarriage negative for the lupus anticoagulant

BACKGROUND

Anticardiolipin antibodies (ACA) are found with increased prevalence in women with unexplained recurrent miscarriage (RM) but their impact on future pregnancy outcome in lupus anticoagulant (LAC) negative patients needs better quantification.

METHODS

The impact of a repeatedly positive ACA test on the chance of live birth in the next pregnancy after adjustment for relevant prognostic factors was studied in 147 RM patients who had been included in placebo-controlled trials of immunotherapy. Patients with LAC were excluded and none of the patients received therapy with anticoagulation or prednisone.

RESULTS

60/147 patients (41%) were repeatedly ACA positive according to cut-off values derived from this study. The adjusted odds ratio (OR) for live birth among ACA positive patients was 0.36 (95% CI 0.2-0.7, P = 0.006). Using cut-off values derived from a normal population, the adjusted OR for live birth among ACA positive patients was 0.48 (95% CI 0.2-1.1, P = 0.10). Positivity for IgM ACA was found to be much stronger correlated to pregnancy outcome than IgG ACA.

CONCLUSIONS

In RM women not receiving anticoagulation or prednisone, the presence of ACA in the absence of LAC most likely reduces the chance of live birth by 36-48% compared with the absence of both ACA and LAC. This reduction is inferior to what has been reported from studies where no adjustments for prognostic variables were undertaken and LAC positive patients were included.

Drug intervention in early pregnancy after assisted reproductive technology

Implantation in humans is a complex, closely regulated, highly selective and relatively poorly understood process. Humans have the highest rate of miscarriage in mammals and various pharmacological manipulations have been used to minimize pregnancy losses in both spontaneous pregnancies and pregnancies resulting from assisted reproduction technology. The widespread application of protocols using numerous drugs in assisted reproduction treatment has led to an increasing number of pregnancies exposed to these drugs. The vast majority of these protocols have been based on data from a few observational and often retrospective clinical studies. This paper reviews the recent literature on drug interventions in early pregnancy after assisted reproduction treatment. It is concluded that there are still numerous issues about the safety of most drugs for both the women and their fetus. In many cases, the benefits are theoretical and the possible long-term side-effects are untested. There is an urgent need for more epidemiological studies and randomized controlled trials to explore the use, efficacy and side-effects of both old and new drugs in early pregnancy after assisted reproduction treatment.

A randomized, double-blind, placebo-controlled trial of heparin and aspirin for women with in vitro fertilization implantation failure and antiphospholipid or antinuclear antibodies

OBJECTIVE

To investigate whether heparin and low-dose aspirin increase the pregnancy rate in antiphospholipid antibody or antinuclear antibody-seropositive women with IVF implantation failure.

DESIGN

A double-blind, randomized, transfer-by-transfer of fresh or cryopreserved embryos, crossover trial.A hospital infertility clinic and associated IVF service.

PATIENT(S)

Women seropositive for at least one antiphospholipid (APA), antinuclear (ANA), or beta(2) glycoprotein I autoantibody and >or=10 embryos transferred without achieving pregnancy (n = 143).

INTERVENTION(S)

Subcutaneous unfractionated heparin (5000 IU b.i.d.) and aspirin (100 mg daily) (158 transfers of 296 embryos) or placebo (142 transfers of 259 embryos) from the day of embryo transfer.

MAIN OUTCOME MEASURE(S)

Fetal heart per embryo transferred (implantation rate).

RESULT(S)

There was no significant difference in pregnancy rates or implantation rates between treated and placebo cycles; for example, fetal hearts per embryo transferred implantation rates were 6.8% (20/296) and 8.5% (22/259), respectively, and the generalized estimating equation covariate adjusted relative pregnancy rate was 0.65 (95% confidence interval, 0.33-1.28). The implantation rate for seropositive trial participants (42/555, 7.6%) compared favorably with that for IVF implantation-failure patients continuing treatment outside the trial (147/3237, 4.5%).

CONCLUSION(S)

Heparin and aspirin did not improve pregnancy or implantation rates for APA-positive or ANA-positive patients with IVF implantation failure.

Antinuclear Autoantibodies, Complement Level, Hypergammaglobulinemia and Spontaneous Intrauterine Hematoma in Pregnant Women

PROBLEM

To examine the associative relationship among autoantibodies, C4 levels and intrauterine hematomas (IUH) in more detail than in the studies published earlier.

METHOD OF STUDY

We performed a retrospective study of 54 women with poor obstetric outcomes. Sera were screened for antinuclear antibodies (ANA), anti-DNA antibodies, antiphospholipid antibodies (aPL), and antithyroid antibodies. C4-complement and gammaglobulin levels were also monitored. We compared the main variables in IUH complicated pregnancy group with the risk pregnancy group without IUH. We also compared these variables in the IUH cases before and during IUH.

RESULTS

Eight IUH were detected. The average number of spontaneous losses for these eight women was 3.3 +/- 2.1 (range: 1-8). aPL was present in 100% of cases. ANAs and hypergammaglobulinemia were present in 50% of cases and low C4 in 87.5% of cases. After comparing these variables apart from C4 before and during IUH, we found no statistical differences. However, C4 was low in four patients before IUH and in seven patients during IUH (OR: 7.0; 95% CI: 0.57-86.33). When we compared autoantibodies apart from lupus anticoagulant (LAC) between the two groups, no differences were observed. However, seven of the eight (87.5%) patients with IUH were LAC positive whereas only 24 of the 46 patients (52.1%) were positive in the non-IUH group (OR: 6.42; 95% CI: 0.73-56.41). Rapid plasma reagin was present in 8/46 in the non-IUH group (16.7%) and 5/8 in the IUH group (62.5%) P < 0.015).

CONCLUSIONS

In women with poor obstetric histories, autoantibodies, especially antiphospholid antibodies, may play a role in the IUH development especially if low C4 and/or hypergammaglobulinemia are present.

Herbal factors in the treatment of autoimmunity-related habitual abortion

Deterioration in the balance of T helper-1 (Th1)/T helper-2 (Th2) during pregnancy may cause complications such as habitual abortion. Two types of immunity-related abortion are, at present, recognized. One is caused by autoimmune disorders as exemplified by the antiphospholipid antibody syndrome, in which the Th1/Th2 balance is excessively shifted to polarization of Th2. The other is caused by alloimmune fetal-maternal disorder, a condition associated with increased serum activity of Th1 cytokines. In Japan, herbal medicines such as Sairei-to (Sai) and Tokishakuyaku-san (Toki), which are prepared in granule forms and are manufactured, have been used in the treatment of these immunity-related habitual abortions and were reported to be clinically effective for these patients. The clinical effect of these herbal medicines can be explained by how they function in the maternal immune system. Sai and Toki enhance Th1 cytokine release from peripheral blood mononuclear cells (PBMCs) and might suppress the production of autoantibodies from B cells. However, Sai and Toki do not affect cytokine release from decidual mononuclear cells (DMCs), which are directly in contact with fetal trophoblasts. These herbal medicines might not enhance the killer activity of DMCs. Thus, the differential effects of Toki and Sai on the release of Th1/Th2 cytokines from PBMCs and DMCs may reveal the rationale for the use of these medicines in the treatment of autoimmunity-related habitual abortion.

Some thoughts on the reproductive autoimmune failure syndrome (RAFS) and Th-1 versus Th-2 immune responses

PROBLEM

The concept of immunologically induced reproductive failure has remained very controversial. Especially the question whether abnormal immune function can cause infertility has recently been subject to strong disagreement. This opinion piece is an attempt to reconcile difference of opinion by integrating clinical data from the human experience with well-established experimental models in animals.

METHOD OF STUDY

Review of published literature.

RESULTS

Experimental animal data, especially in the mouse, have suggested that normal pregnancy requires a switch to an immune response with T helper (Th)-2 preponderance. Recent data from the human experience suggest that infertility, repeated pregnancy loss and certain complications of pregnancy may be the consequence of abnormal Th-1 preponderance. In analogy, to animal models, immunologic reproductive failure in humans, may therefore not be the consequence of specific autoantibody abnormalities or natural killer (NK)-cell abnormalities, but the reflection of a misdirection of a more broadly based immune response.

CONCLUSIONS

Under such a model, both diagnosis and treatment of immunologically induced forms of reproductive failure require re-evaluation. Such a model, however, provides a satisfactory explanation for contradictory findings in the human experience that have led to strong disagreements among investigations.

Antiphospholipid antibodies and infertility

Antiphospholipid antibodies (aPL) are an established cause of recurrent pregnancy loss. As defective embryonic implantation is a common link between unexplained infertility and recurrent miscarriage, interest has focused on the potential relationship between aPL and implantation failure after in vitro fertilization and embryo transfer (IVF-ET). This review critically examines the published data to determine whether women undergoing IVF-ET should be routinely screened for aPL. Although most studies have reported an increased prevalence of aPL among women undergoing IVF-ET, prospective studies examining the effect of aPL on the outcome of IVF-ET demonstrate that these antibodies do not significantly affect either the implantation or ongoing pregnancy rates. The increased prevalence of aPL among women with infertility is therefore likely to be part of a generalized autoimmune disturbance associated with infertility. Hence routine screening for aPL among women undergoing IVF-ET is not warranted and therapeutic interventions should be used only in well designed randomized controlled trials.

Antiphospholipid syndrome and recurrent miscarriages

Sixty percent of recurrent spontaneous abortions are unexplained. Antiphospholipid syndrome is a multisystem disease with the predominant features of venous and arterial thrombosis, recurrent pregnancy loss, foetal death and the presence of antiphospholipid antibodies. Many epidemiological studies focus on antiphospholipid autoantibodies syndrome (APS) as a cause of recurrent spontaneous abortion (RSA). It is found that 7-25% of RSA would have APS as the main risk factor. 'Association not being synonymous with cause', the proportion of abortions due to the APS is difficult to estimate for several reasons: definition of recurrent abortion is variable, the assays for antiphospholipid antibodies are not well standardised, inclusion of patients in the study group according to the antibodies titre is author dependent. Recent studies suggest association of antiphospholipid antibodies syndrome not only with recurrent abortions but also with infertility. New mechanisms are described by which antiphospholipid antibodies could cause placental thrombosis and infarction, acting directly on the surface anticoagulant expressed on trophoblastic cells. Only lupus anticoagulant (LA) and anticardiolipin antibodies (aCL) assays are sufficiently standardised to be usable in routine. Testing for other antiphospholipid antibodies (aPLs) should remain investigational. Several treatments have been proposed: low doses of aspirin, low or immunosuppressive doses of corticosteroids, and preventive or effective dose of heparin, intravenous immunoglobulin.

Pregnancy outcome is not affected by antiphospholipid antibody status in women referred for in vitro fertilization

OBJECTIVE

To determine the prevalence of antiphospholipid (aPL) and anti-beta 2 glycoprotein I (anti-beta2-GPI) antibodies in women referred for IVF and to prospectively evaluate the effect of these antibodies on IVF outcome.

DESIGN

Prospective observational study.

SETTING

A university hospital and IVF unit.

PATIENT(S)

Three hundred eighty consecutive women referred for IVF.

INTERVENTION(S)

Blood samples taken before commencement of IVF cycles were tested for the presence of aPL (lupus anticoagulant [LA], anticardiolipin [aCL], and antiphosphatidyl serine antibodies [aPS]) and anti-beta2-GPI antibodies.

MAIN OUTCOME MEASURE(S)

Antibody prevalence, pregnancy rates, and live birth rates.

RESULT(S)

Of the total 380 women, 89 tested persistently positive for aPL (23.4%). None of 176 women tested for IgG aPS antibodies had a positive titer. Only 3.3% (11 of 329) tested positive for anti-beta2-GPI antibodies. Pregnancy rate, live birth rate, gestational age at delivery, and birth weight were not affected by aPL status.

CONCLUSION(S)

Although women referred for IVF have a high prevalence of aPL, these antibodies do not affect the outcome of treatment. Screening women undergoing IVF for aPL is not justified.

Studies on the HLA-DRB1 genotypes in Japanese women with severe pre-eclampsia positive and negative for anticardiolipin antibody using a polymerase chain reaction-restriction fragment length polymorphism method

The human leukocyte antigen (HLA)-DR genotype was determined in 54 Japanese women with severe pre-eclampsia in order to elucidate the relationship between HLA-DR antigen systems and pre-eclampsia. The patients were divided into two groups according to positivity for the anticardiolipin antibody (ACA), i.e. one patient group negative for ACA (n = 41) and the other patient group positive for ACA (n = 13). The frequency of each HLA-DRB1 allele in both groups was compared with that in 81 normally fertile Japanese women who had not experienced pre-eclampsia. The genotypes of HLA-DR antigens were determined using a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. The frequency of DRB1*04 and DRB1*0403 in the patient group positive for the ACA was significantly higher compared with that in the group of normal fertile women (P< 0.05). The frequency of each HLA-DRB1 allele was not significantly different between patient group with pre-eclampsia negative for ACA and group of normal fertile women. These results suggest a difference in the immunogenetic background between the patient groups with severe pre-eclampsia positive and negative for the ACA.

Suppressive effect of anticardiolipin antibody on the proliferation of human umbilical vein endothelial cells

OBJECTIVE

To determine whether sera that show a positive anticardiolipin test result have a suppressive effect on the proliferation of endothelial cells collected from human umbilical veins.

DESIGN

Retrospective in vitro study.

SETTING

University hospital outpatient clinic for the treatment of infertility.

PATIENT(S)

Thirteen patients with recurrent fetal miscarriages who were positive for anticardiolipin antibody and 14 patients with recurrent miscarriages who were negative for anticardiolipin antibody.

INTERVENTION(S)

Serum was obtained from each patient.

MAIN OUTCOME MEASURE(S)

Suppressive effect of the sera on the culture of human umbilical vein endothelial cells.

RESULT(S)

The proliferation of human umbilical vein endothelial cells decreased significantly in cultures that contained sera showing positive anticardiolipin antibody activity that had been collected from patients with recurrent fetal miscarriages.

CONCLUSION(S)

The results strongly suggest that anticardiolipin antibody has a suppressive effect on the proliferation of human umbilical vein endothelial cells.

Anti-cardiolipin antibody and anti-cardiolipin beta-2-glycoprotein I antibody in patients with recurrent fetal miscarriage

To elucidate the association between anticardiolipin antibody (aCL-Ab) or anti-cardiolipin beta-2-glycoprotein I-antibody (aCL-beta-2-GP I-Ab) and recurrent fetal miscarriage, the positive rates of aCL-Ab were assessed in 667 patients with recurrent fetal miscarriages and those of aCL-beta-2-GP I-Ab were assessed in 208 patients. The rates were then compared with the control group. The positive rate of aCL-Ab in the patients group (17.4%) was significantly higher than that in the control group (4.0%). The rate of aCL-Ab was especially high in patients who had experienced two or more fetal miscarriages including at least one or more intrauterine fetal deaths during the second or third trimester (41.3%). The positive rate of aCL-beta-2-GP I-Ab in patients with recurrent fetal miscarriage (3/208 cases, 1.4%) was not significantly different from the control group (0/100 cases, 0%). However, the rate of aCL-beta-2-GP I-Ab was significantly higher in patients who had experienced two or more fetal miscarriages including at least one or more intrauterine fetal deaths during the second or third trimester (8.3%) compared with the control group. In conclusion, the implication of aCL-Ab in the genesis of recurrent fetal miscarriage was confirmed. It was suggested that aCL-beta-2-GP I-Ab was associated with the generation of intrauterine fetal death, although it had little association with the genesis of recurrent fetal miscarriage during the first trimester.

Human leukocyte antigen class II genotype in patients with recurrent fetal miscarriage who are positive for anticardiolipin antibody

OBJECTIVE

To elucidate the relationship between human leukocyte antigen (HLA) class II genotypes and patients with recurrent fetal miscarriage who are positive for anticardiolipin antibody.

DESIGN

Prospective clinical study.

SETTING

Institutional practice at the outpatient clinic for infertility, Niigata University Medical Hospital.

PATIENT(S)

Patients with recurrent fetal miscarriage who were positive for anticardiolipin antibody and normal fertile women.

INTERVENTION(S)

Genomic DNA was extracted from peripheral mononuclear cells.

MAIN OUTCOME MEASURE(S)

Human leukocyte antigen class II genotype was determined using a polymerase chain reaction restriction fragment length polymorphism method.

RESULT(S)

The frequencies of DRB1*0403 and DRB1*0410 were significantly higher in the patient group than in the control group. The frequency of DRB1*04 also was significantly higher in the patient group. As for HLA-DQ genotype, the frequency of HLA-DQB1*0501 was significantly lower in the patient group.

CONCLUSION

Human leukocyte antigen systems appear to be involved in the genesis of antiphospholipid syndrome.

Antibodies to beta2 glycoprotein I are associated with in vitro fertilization implantation failure as well as recurrent miscarriage: results of a prevalence study

OBJECTIVE

To investigate whether antiphospholipid and related autoantibodies are associated with IVF implantation failure as well as with recurrent spontaneous miscarriage.

DESIGN

Prevalence study.

SETTING

University teaching hospital and associated IVF unit.

PATIENT(S)

Patients with at least three consecutive first-trimester miscarriages (n = 97), patients undergoing IVF who had at least 10 embryos transferred without any resulting clinical pregnancy (n = 105), fertile women (n = 106), and patients newly referred for IVF treatment (n = 52).

INTERVENTION(S)

Antibodies tested included lupus anticoagulant; immunoglobulin (Ig) G and IgM isotypes of each of anticardiolipin antibody, antiphosphatidylserine, antiphosphatidylethanolamine, and antiphosphatidylinositol; beta2 glycoprotein I antibodies; and antinuclear antibodies. Statistical analysis included chi2 and Fisher's exact tests for differences between groups, and multiple linear regression analysis and Spearman's nonparametric tests for relations between results.

MAIN OUTCOME MEASURE(S)

Seropositivity for autoantibodies tested.

RESULT(S)

Overall, 84 (23%) of the 360 samples tested positive for at least one autoantibody. Beta2 glycoprotein I IgM antibody and antinuclear antibody were significantly associated with both IVF implantation failure and recurrent miscarriage.

CONCLUSION(S)

Autoantibodies, particularly beta2 glycoprotein I antibodies and antinuclear antibodies, are associated with IVF implantation failure as well as with recurrent spontaneous abortion, although the mechanism is still unclear. The high seroprevalence of antibodies to beta2 glycoprotein I suggests that it may have an important role in autoimmune reproductive failure that needs to be explored further.

Alterations of lymphocyte subsets in patients with recurrent fetal wastage positive for antiphospholipid antibodies treated with Chinese herbal medicine

The alterations of peripheral blood lymphocyte subsets were sequentially analyzed in patients with recurrent fetal wastage who were treated with the Chinese herbal medicine, Sairei-to (Chan ling-Tan) for positive antiphospholipid antibodies to analyze the underlying mechanisms of the therapy. The titer of antiphospholipid antibodies was significantly decreased by administration of Sairei-to at one and two months after commencement of treatment and in the newly pregnant state compared with that before administration. The percentage of CD19-positive cells significantly decreased at two months after commencement of Sairei-to treatment and at the newly pregnant state compared with that before administration in successful pregnancies. The percentage of CD4-positive cells significantly increased two months after commencement of Sairei-to treatment compared with that before administration in both successful pregnancies and total cases. The CD4/CD8 ratio was increased significantly after two months administration of Sairei-to in both successful pregnancies and total cases. Thus, it is suggested that the administration of Sairei-to might induce the predominance of CD4-positive cells in parallel with the suppression of antiphospholipid antibodies. Moreover, the suppression of CD19-positive cells (B cells) was induced by administration of Sairei-to which might be involved in successful continuation of pregnancy in the patients.

Antiphospholipid antibodies associated with implantation failure after IVF/ET

PURPOSE

Our purpose was to determine the specific antiphospholipid antibodies (APAs) that should be evaluated to identify individuals at risk for implantation failure associated with reproductive autoimmune failure syndrome (RAFS).

METHODS

The prevalence of APAs among 312 women with implantation failure was compared with that of 100 fertile control women. To be included in the implantation failure group, each woman had to have had at least 12 embryos transferred without subsequent positive pregnancy test. Enzyme-linked immunoabsorbant assay was used to measure IgG, IgM, and IgA anticardiolipin, antiphosphatidyl ethanolamine, antiphosphatidyl inositol, antiphospatidic acid, anti-phosphatidyl glycerol, antiphosphatidyl choline, and antiphosphatidyl serine.

RESULTS

When the values for each of the seven APAs in three isotypes were compared between women with implantation failure and the control population, all of the APAs tested had a significantly higher frequency among women with implantation failure. Positive APAs were detected in 69 (22%) of the 312 women with implantation failure compared with 5 (5%) of the 100 control women (P < 0.0001). Anticardiolipin antibodies were found in 13 (4%) of the 312 women with implantation failure and none of the controls. Fifty-six (18%) of the 312 with implantation failure were negative for anticardiolipin antibodies but had positive values of other APAs.

CONCLUSIONS

A complete APA panel using seven isotypes is necessary for diagnosing implantation failure associated with RAFS. If only anticardiolipin antibody is measured, 4% (13/312) of the positive APAs are detected, and 81% (56/69) of women with implantation failure associated with RAFS will have the diagnosis missed.

Autoantibody screening for infertility: explaining the unexplained?

Several laboratories currently offer panels of serum autoantibody assays to screen women with unexplained infertility and those undergoing in vitro fertilization (IVF). Offering these tests implies that they have predictive value for the outcome of proposed infertility treatments such that the results of the testing would alter clinical management. Because screening for antiphospholipid antibodies adds expense to already costly procedures, it is an appropriate time to review the justification for the use of these panels.

Anti-endometrial autoantibodies in women with a diagnosis of infertility

PROBLEM

The purpose of this study was to investigate the frequency of anti-endometrial antibodies (AEA) in infertile women.

METHOD OF STUDY

Sera from fertile women (n = 6), and from patients with ovulatory dysfunction (n = 11), tubal obstruction (n = 9) and unexplained infertility (n = 5) were investigated for the presence of anti-endometrial membrane antibodies. We used two human endometrial cancer cell lines and human endometrial cells from gynecological biopsies as an antigenic source for analysis. The immunoenzymatic assay (ELISA) was performed with cultured endometrial cells in monolayers. Immunoblot analysis was performed with these two cell lines.

RESULTS

A good correlation between the response with each cell line and with human endometrial cells was obtained, indicating that the antigens analyzed were probably similar. Endometrial antibodies were detectable in a high percentage of women with tubal obstruction (77.8 and 66.7%, respectively) and ovulatory dysfunction (54.5 and 45.5%, respectively). Unexplained infertility showed anti-endometrial immunological response (40 and 60%, respectively). Some endometrial antigens in infertile women are the target for autoimmune response. The serum from a patient with tubal obstruction and ovulatory dysfunction showed two antigens by immunoblot, with molecular weights of 97 and 50 kDa.

CONCLUSION

The presence of anti-endometrial antibodies, detected by ELISA, is associated with infertility, mainly with ovulatory dysfunction and tubal obstruction. Some endometrial antigens may be involved in these two pathologies.

Chromosome analysis of aborted conceptuses of recurrent aborters positive for anticardiolipin antibody

OBJECTIVE

To elucidate the relationship between anticardiolipin antibody and recurrent abortion.

DESIGN

Prospective clinical study.

SETTING

Institutional practice in which patients with recurrent abortion were registered at the outpatient clinic for infertility of Niigata University Hospital.

PATIENT(S)

Five hundred sixty-one patients with recurrent abortions and 148 patients who were not recurrent aborters and who had experienced sporadic abortion.

INTERVENTION(S)

Aborted conceptuses for chromosome analyses were collected from the patients.

MAIN OUTCOME MEASURE(S)

The positive rate of anticardiolipin antibody was assessed in patients with recurrent abortion. Chromosome analyses of aborted conceptuses were performed in 10 patients with positive anticardiolipin antibody who had experienced another pregnancy that resulted in repeated abortion. Similar analyses of aborted conceptuses from 148 sporadic early abortions (controls) were performed.

RESULT(S)

The incidence of chromosome abnormalities in anticardiolipin antibody-positive recurrent aborters was 20.0% (2 of 10 cases), which was significantly lower than that of patients with sporadic abortion (60.1%, 89 of 148 cases).

CONCLUSION(S)

The low incidence of chromosome abnormalities in aborted conceptuses of patients with positive anticardiolipin antibody suggests that this antibody is strongly implicated in the genesis of recurrent abortions.

HLA antigens in patients with severe preeclampsia

The distribution of human leucocyte antigens (HLA) was analyzed in 35 patients with severe preeclampsia and compared with that in the general population in the Niigata district of Japan. The frequency of patients with HLA CW7 was significantly higher than that of the general population of this area (p < 0.05, Chi-square test). The frequency of those with HLA-DR6 (DR6, DR13 and DR14) was also significantly greater compared with the general population (P < 0.05, Chi-square test), while that of those with DR4 was significantly lower (P < 0.05, Chi-square test). The compatibility of HLA antigens in spouses was also analyzed in 20 patient couples and 26 normal fertile couples, and there was no significant difference. Thus it is suggested that HLA antigen systems might be involved in the genesis of preeclampsia.

Successful glucocorticoid treatment for patients with abnormal autoimmunity on in vitro fertilization and embryo transfer

PURPOSE

To analyze the effects of glucocorticoid treatment for patients with abnormal autoimmunity on IVF-ET outcomes, low-dose predonisolone or dexamethasone was administered in 51 IVF-ET cycles of 41 patients with positive antinuclear antibody (ANA), anti-DNA antibody, and/or lupus anticoagulant (LAC). Rates of clinical pregnancy and implantation in these patients were compared with those in 48 cycles without corticosteroid therapy. Autoantibody-negative patients were also treated with IVF-ET combined with (29 cycles) or without (57 cycles) glucocorticoid administration, and the pregnancy and implantation rates were investigated.

RESULTS

Without glucocorticoid treatment, the pregnancy rate per cycle and implantation rate per embryo in antibody-positive patients were 10.4 and 3.8%, respectively. Significant increases in pregnancy (35.3%) and implantation (13.2%) rates were observed with corticosteroid treatment. In antibody-negative patients, the rates of pregnancy and implantation showed no significant differences with versus without the glucocorticoid administration.

CONCLUSIONS

Our results indicate that because autoimmune abnormalities may be at least one cause of implantation failure following IVF-ET, the combined use of low-dose corticosteroid can be effective for autoantibody-positive women.

The use of intravenous immunoglobulin in recurrent pregnancy loss associated with combined alloimmune and autoimmune abnormalities

PROBLEM

Several studies have evaluated the effect of intravenous gammaglobulin (IVIG) in women with unexplained recurrent spontaneous abortions (RSA). Data regarding the underlying immunologic abnormalities in these patients is scant. This study reports the pregnancy outcome and immunologic changes observed in a large group of women with RSA associated with well-defined alloimmune and autoimmune abnormalities treated with IVIG.

METHODS

Thirty-five patients with three or more recurrent miscarriages were studied. None of the patients had identifiable alloimmune response to paternal lymphocytes. Twenty-four patients had anti-thyroid antibodies, ten patients had high levels of circulating immune complexes, and six patients had anti-cardiolipin antibodies. Five patients had Hashimoto's disease, one had immune thrombocytopenic purpura, and one had Crohn's disease. Twenty-three patients had more than one autoimmune abnormality. All patients received IVIG infusions (200-250 mg/kg) every 3 weeks during the first 8 months of pregnancy.

RESULTS

Twenty-eight patients (80%) had a successful pregnancy. Decrease of the level of autoantibodies and circulating immune complexes was observed in all patients who had a successful pregnancy. Only three of these patients developed measurable alloimmune response to paternal antigens.

CONCLUSIONS

This preliminary study suggests that IVIG may be of benefit to patients with recurrent pregnancy associated with combined alloimmune and autoimmune abnormalities. This benefit was seen in spite of lack of detectable correction of the alloimmune abnormality in the majority of patients.

Human autoantibodies recognizing human and mouse preimplantation stages

PROBLEM

To find out whether autoantibodies against human preimplantation stages are present in some human sera and, if so, whether the antibodies could be capable to affect the egg development and/or to trigger an activation of the complement system at the procedures of assisted conception.

METHODS

1. Immunohistochemistry on blots of human preimplantation stages. 2. Immunohistochemistry on paraffin sections of human and mouse preimplantation stages. 3. Culture of mouse morulae to analyze complement activation.

RESULTS

1. Some human sera contained autoantibodies against human preimplantation stages. 2. Human-mouse cross-reacting antibodies against preimplantation stages occurred. 3. Immune complexes, formed on mouse preimplantation stages, activated the complement systems in egg cultures, resulting in a damaging of the eggs.

CONCLUSION

The presence of natural autoantibodies to preimplantation stages may be associated with reproduction failure, caused by a direct effect by the autoantibodies and/or an activation of the uterine complement system by the immune complexes formed.

Detection of antiendometrial antibodies in patients with endometriosis by cell ELISA

PROBLEM

To determine whether infertile patients with endometriosis have serum antiendometrial antibodies.

METHODS

Sera from 40 infertile patients with or without endometriosis were tested by cell enzyme-linked immunosorbent assay (ELISA), in which endometrial cancer cells were used as endometrial antigens, and uterine cervix cancer cells as control antigens. As a negative control, eight healthy adult males were included. The level greater than the mean +/- 2 standard deviations (SD) of the male control group was judged positive.

RESULTS

The mean value of antiendometrial antibody level was significantly higher in patients with endometriosis than in those without endometriosis (ANOVA, P < 0.01). The frequency of antiendometrial antibody-positive patients was also higher in the former than in the latter (chi 2 test, P < 0.05). However, when uterine cervix cancer cells were used as antigens, no difference was observed in the mean antibody levels or in the positive rates between the two groups.

CONCLUSIONS

Endometriosis seems to be associated with autoantibody production against the endometrium-related antigen(s).

Treatment for patients with recurrent abortion with positive antiphospholipid antibodies using a traditional Chinese herbal medicine

Twelve patients with recurrent abortion who had shown positive antiphospholipid antibodies were treated through the administration of a Japanese modified traditional Chinese herbal medicine Sairei-To (Chan ling-Tang) The patients had experienced a total of 27 spontaneous abortions in their previous pregnancies and had no other pregnancy history except for one patient. The patients were treated with 9.0 g of Sairei-To per day before their next pregnancy. The positive value of antiphospholipid antibodies returned to negative in 9 patients out of 12 patients through the treatment. Out of 12 patients, in 10 patients, their new pregnancy continued uneventfully and delivered an offspring (Success rate: 83.3%). Thus, the current treatment was considered to be an effective therapy for patients with recurrent abortion who were found to be positive for antiphospholipid antibodies.