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Krog MC, Flachs EM, Kolte AM, de Jager W, Meyaard L, Christiansen OB, Steffensen R, Vomstein K, Garred P, Nielsen HS. Angiogenic factors and the lectin pathway of complement in women with secondary recurrent pregnancy loss. J Reprod Immunol 2024; 163:104221. [PMID: 38447288 DOI: 10.1016/j.jri.2024.104221] [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: 07/06/2023] [Revised: 02/20/2024] [Accepted: 02/23/2024] [Indexed: 03/08/2024]
Abstract
The poor remodeling of placental spiral arteries seen in preeclampsia is also discussed to contribute to recurrent pregnancy loss (RPL) preceded by abnormal angiogenesis and excessive complement activation. Low levels of Mannose-binding-lectin (MBL), a pattern recognition molecule (PRM) of the lectin pathway, have been found in women with RPL. We propose that pregnancy loss is connected to defective angiogenesis with reperfusion damage in the placenta and decreased levels of PRM in the lectin pathway in women with RPL. In this cohort study, we investigate the angiogenic factors and the lectin complement pathway in early pregnancy and their time-dependent relationship with pregnancy outcomes in 76 women with secondary RPL (sRPL) who have at least four prior pregnancy losses and a live birth. We evaluated levels of Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), Vascular Endothelial Growth Factor (VEGF), soluble fms-like tyrosine kinase-1 (sFlt-1), and the PRMs, MBL, ficolin-1, -2, -3 and an additional soluble PRM, Pentraxin-3, during the 5th, 6th, and 7th gestational weeks. Our results showed that, compared to live births, pregnancies that ended in loss were associated with elevated VEGF levels and decreased levels of the Ang-2/Ang-1 ratio. Also, increasing levels of ficolin-2 were significantly associated with pregnancy loss, with MBL showing no association. Our research suggests that women with sRPL may have inadequate placentation with impaired angiogenesis in pregnancies ending in a loss.
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Affiliation(s)
- M C Krog
- The Recurrent Pregnancy Loss Unit, the Capital Region, Copenhagen University Hospitals, Rigshospitalet and Hvidovre Hospital, Kettegård Alle 30, Hvidovre 2650, Denmark; The Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Blegdamsvej 3B, Copenhagen 2200, Denmark.
| | - E M Flachs
- The Department of Occupational and Environmental Medicine, Copenhagen University Hospital, Bispebjerg Hospital, Bispebjerg Bakke 23F, Copenhagen 2400, Denmark
| | - A M Kolte
- The Recurrent Pregnancy Loss Unit, the Capital Region, Copenhagen University Hospitals, Rigshospitalet and Hvidovre Hospital, Kettegård Alle 30, Hvidovre 2650, Denmark
| | - W de Jager
- Multiplex Core Facility, Laboratory of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584 CX, the Netherlands
| | - L Meyaard
- Multiplex Core Facility, Laboratory of Translational Immunology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584 CX, the Netherlands
| | - O B Christiansen
- Centre for Recurrent Pregnancy Loss of Western Denmark, Department of Obstetrics and Gynecology, Aalborg University Hospital, Reberbansgade 15, Aalborg 9000, Denmark; Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, Aalborg 9000, Denmark
| | - R Steffensen
- Department of Clinical Immunology, Aalborg University Hospital, Urbansgade 32, Aalborg 9000, Denmark
| | - K Vomstein
- The Recurrent Pregnancy Loss Unit, the Capital Region, Copenhagen University Hospitals, Rigshospitalet and Hvidovre Hospital, Kettegård Alle 30, Hvidovre 2650, Denmark; Department of Obstetrics and Gynecology, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre 2650, Denmark
| | - P Garred
- The Department of Clinical Immunology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Blegdamsvej 3B, Copenhagen 2200, Denmark; The Laboratory of Molecular Medicine, Department of Clinical Immunology, Section 7631, Copenhagen University Hospital, Rigshospitalet, Ole Maaløesvej 26, Copenhagen 2200, Denmark
| | - H S Nielsen
- The Recurrent Pregnancy Loss Unit, the Capital Region, Copenhagen University Hospitals, Rigshospitalet and Hvidovre Hospital, Kettegård Alle 30, Hvidovre 2650, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Blegdamsvej 3B, Copenhagen 2200, Denmark; Department of Obstetrics and Gynecology, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre 2650, Denmark
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Yang X, Mu F, Zhang J, Yuan L, Zhang W, Yang Y, Wang F. Reproductive factors and subsequent pregnancy outcomes in patients with prior pregnancy loss. BMC Pregnancy Childbirth 2024; 24:219. [PMID: 38528474 PMCID: PMC10964557 DOI: 10.1186/s12884-024-06422-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/14/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND At present, individualized interventions can be given to patients with a clear etiology of pregnancy loss to improve the subsequent pregnancy outcomes, but the current reproductive status of the patient cannot be changed. The aim of this study was to investigate the association between female reproductive status and subsequence pregnancy outcome in patients with prior pregnancy loss (PL). METHODS A prospective, dynamic population cohort study was carried out at the Second Hospital of Lanzhou University. From September 2019 to February 2022, a total of 1955 women with at least one previous PL were enrolled. Maternal reproductive status and subsequent reproductive outcomes were recorded through an electronic medical record system and follow-up. Logistic regression was used to evaluate the association between reproductive status and the risk of subsequent reproductive outcomes. RESULTS Among all patients, the rates of subsequent infertility, early PL, late PL, and live birth were 20.82%, 24.33%, 1.69% and 50.77% respectively. In logistic regression, we found that age (OR 1.08, 95% CI 1.04-1.13) and previous cesarean delivery history (OR 2.46, 95% CI 1.27-4.76) were risk factors for subsequent infertility in patients with PL. Age (OR 1.06, 95% CI 1.03-1.10), age at first pregnancy (OR 1.06, 95% CI 1.03-1.10), BMI (OR 1.06, 95% CI 1.02-1.11), previous PL numbers (OR 1.18, 95% CI 1.04-1.57) and without pre-pregnancy intervention (OR 1.77, 95% CI 1.35-2.24) were risk factors for non-live birth. Age (OR 1.06, 95% CI 1.03-1.09), age at first pregnancy (OR 1.06, 95% CI 1.02-1.09), BMI (OR 1.07, 95% CI 1.02-1.11), previous PL numbers (OR 1.15, 95% CI 1.02-1.31) and without pre-pregnancy intervention (OR 2.16, 95% CI 1.65-2.84) were risk factors for PL. CONCLUSIONS The reproductive status of people with PL is strongly correlated with the outcome of subsequent pregnancies. Active pre-pregnancy intervention can improve the subsequent pregnancy outcome. TRIAL REGISTRATION This study was registered in the Chinese Clinical Trial Registry with the registration number of ChiCTR2000039414 (27/10/2020).
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Affiliation(s)
- Xin Yang
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China
| | - Fangxiang Mu
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China
| | - Jian Zhang
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China
| | - Liwei Yuan
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China
| | - Wei Zhang
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China
| | - Yanting Yang
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China
| | - Fang Wang
- Reproductive Medicine Center, Second Hospital of Lanzhou University, No.82, Cuiying Road, Chengguan District, Lanzhou, 730030, Gansu Province, China.
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Eliwa J, Papas RS, Kutteh WH. Expanding the role of chromosomal microarray analysis in the evaluation of recurrent pregnancy loss. J Reprod Immunol 2024; 161:104188. [PMID: 38171035 DOI: 10.1016/j.jri.2023.104188] [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: 09/30/2023] [Revised: 11/18/2023] [Accepted: 12/22/2023] [Indexed: 01/05/2024]
Abstract
Multiple factors contribute to recurrent pregnancy loss (RPL). This review highlights the latest international guidelines for RPL workup, including immunological testing, by the American Society for Reproductive Medicine (ASRM), the European Society of Human Reproduction and Embryology (ESHRE), and the Royal College of Obstetricians and Gynaecologists (RCOG). These three societies recommend testing for antiphospholipid syndrome. ESHRE and RCOG also recommend thyroid peroxidase antibody testing, whereas ASRM does not. All guidelines advise against testing of natural killer cells, cytokines, antinuclear antibodies, human leukocyte antigen (HLA) compatibility, anti-HLA antibodies, and anti-sperm antibodies. However, when following ASRM, ESHRE or RCOG diagnostic guidelines, over 50% of cases have no identifiable cause. Genetic testing of products of conception (POC) can improve our understanding of unexplained RPL as aneuploidy is a common cause of RPL. Based on studies reporting results from chromosomal microarray analysis (CMA) of POC, we propose a novel algorithm for RPL evaluation. The algorithm involves following evidence-based societal guidelines (published by ASRM, ESHRE, or RCOG), excluding parental karyotyping, in combination with CMA testing of miscarriage tissue. When utilizing this new evaluation algorithm, the number of unexplained cases of RPL decreases from over 50% to less than 10%. As a result, most patients are provided an explanation for their loss and healthcare costs are potentially reduced. Patients with an otherwise negative workup with euploid POC, are classified as "truly unexplained RPL". These patients are excellent candidates for enrollment in randomized, controlled trials examining novel immunological testing and treatment protocols.
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Affiliation(s)
- Jasmine Eliwa
- Division of Obstetrics and Gynecology, University of Tennessee Health Sciences Center-Memphis, Memphis, TN, USA
| | - Ralph S Papas
- Infertility Division, Obstetrics & Gynecology Department, St George Hospital - University Medical Center - University of Balamand, Beirut, Lebanon
| | - William H Kutteh
- Division of Obstetrics and Gynecology, University of Tennessee Health Sciences Center-Memphis, Memphis, TN, USA; Recurrent Pregnancy Loss Center, Fertility Associates of Memphis, Memphis, TN, USA.
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Das M, Patidar H, Singh M. Understanding trimester-specific miscarriage risk in Indian women: insights from the calendar data of National Family Health Survey (NFHS-5) 2019-21. BMC Womens Health 2024; 24:63. [PMID: 38263129 PMCID: PMC10804530 DOI: 10.1186/s12905-023-02838-7] [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: 02/21/2023] [Accepted: 12/09/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND The primary public health issue, especially in low- and middle-income countries, is early pregnancy loss driven by miscarriage. Understanding early pregnancy losses and the characteristics of mothers who have miscarriages is essential to creating effective reproductive health strategies. Thus, this study's primary goal is to delve into the factors which impact miscarriages that take place prior to and following the first 12 weeks of gestation. METHODS The bivariate analysis was employed to determine the frequency of miscarriages. The factors associated with miscarriages in the first (≤12 weeks) and second & above (> 12 weeks) trimesters of pregnancy were then examined using a generalised linear regression model, with 95% confidence intervals. Finally, we use ArcGIS to illustrate the prevalence of miscarriage in the districts of India. RESULTS Our result shows that miscarriages occur often in India (4.9%), with 23% of cases occurring in the first trimester (≤12 weeks). In our bivariate analysis, we identified several factors associated with a higher prevalence of miscarriages in India. It was found that mothers aged thirty years or older, residing in urban areas, with less than ten years of education, belonging to the richest wealth quantile, expressing a desire for more children, having no demand for contraception, and possessing no parity experienced a higher prevalence of miscarriage in total pregnancies in India. On the other hand, the generalised linear model's findings show that mothers who are thirty years of age or older, practise other religions, live in urban areas, are members of other castes, want more children, marry before the age of eighteen, and meet their contraceptive needs are more likely to have miscarriages in total pregnancy. However, there is a larger likelihood of miscarriage in the first trimester (≤12 weeks) for mothers who follow other religions, live in urban areas, are from Other Backward Class (OBC), get married before the age of eighteen, and fall into the middle and upper wealth quantiles. A mother is more likely to miscarriage in the second & above (> 12 weeks) trimesters if she is older than thirty, from other castes, wants more children, has moderate media exposure, marries before turning eighteen, meets her contraceptive needs, and does not feel the need for contraception. After accounting for socioeconomic characteristics, all results were statistically significant. CONCLUSIONS Given the substantial number of miscarriages in India, police need to improve planning and guidance in order to lower pregnancy loss due to miscarriage. Miscarriage rates may be significantly decreased by enhancing the availability and quality of reproductive health care infrastructure, particularly in rural areas.
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Affiliation(s)
- Milan Das
- International Institute for Population Sciences, Mumbai, India
| | | | - Mayank Singh
- International Institute for Population Sciences, Mumbai, India.
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Nørgaard-Pedersen C, Steffensen R, Kesmodel US, Christiansen OB. Maternal carriage of H-Y restricting HLA class II alleles is a negative prognostic factor for women with recurrent pregnancy loss after birth of a boy. J Reprod Immunol 2023; 156:103817. [PMID: 36753935 DOI: 10.1016/j.jri.2023.103817] [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: 11/28/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 01/26/2023]
Abstract
Immune system aberrations are suggested to be an important factor in the pathophysiology of unexplained secondary recurrent pregnancy loss (sRPL). The objective was to investigate if the sex ratio of the firstborn child in sRPL patients differs from the background population and whether the sex of the firstborn child has a negative impact on the pregnancy prognosis alone and/or in combination with carriage of male-specific minor histocompatibility (H-Y) restricting HLA class II alleles. From January 2016 to October 2022, 582 patients with unexplained RPL were admitted to the RPL Center of Western Denmark and continuously followed-up. HLA-DRB1 and -DQB1 typing was performed as part of the routine diagnostic work-up. In sRPL patients, a history of a firstborn boy was significantly more frequent than in the Danish background population and was associated with significantly lower odds of a successful reproductive outcome in the first pregnancy after admission compared to a firstborn girl (OR=0.41, 95% CI: 0.20-0.83, p = 0.014). The odds of a successful reproductive outcome were enhanced in patients carrying ≥ 1 H-Y-restricting HLA class II alleles with a first-born girl compared to a firstborn boy (OR=3.33, 95% CI: 1.40-7.88, p = 0.005), while no difference in successful reproductive outcome was seen in sRPL patients not carrying these alleles (OR=1.20, 95% CI: 0.33-4.43, p = 0.781). The sex ratio of children born after RPL was similar to the Danish background population. These findings confirm previous findings and suggests that a harmful immune response triggered by H-Y-antigen exposure during a previous pregnancy in preconditioned women may cause sRPL.
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Affiliation(s)
- C Nørgaard-Pedersen
- Centre for Recurrent Pregnancy loss of Western Denmark, Department of Obstetrics and Gynaecology, Aalborg University Hospital, Reberbansgade 15, 9000 Aalborg, Denmark; Department of Clinical Medicine, Søndre Skovvej 15, 9000 Aalborg, Denmark.
| | - R Steffensen
- Department of Clinical Immunology, Aalborg University Hospital, Urbansgade 32, 9000 Aalborg, Denmark.
| | - U S Kesmodel
- Centre for Recurrent Pregnancy loss of Western Denmark, Department of Obstetrics and Gynaecology, Aalborg University Hospital, Reberbansgade 15, 9000 Aalborg, Denmark; Department of Clinical Medicine, Søndre Skovvej 15, 9000 Aalborg, Denmark.
| | - O B Christiansen
- Centre for Recurrent Pregnancy loss of Western Denmark, Department of Obstetrics and Gynaecology, Aalborg University Hospital, Reberbansgade 15, 9000 Aalborg, Denmark; Department of Clinical Medicine, Søndre Skovvej 15, 9000 Aalborg, Denmark.
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Nørgaard-Pedersen C, Kesmodel US, Christiansen OB. Women with Recurrent Pregnancy Loss More Often Have an Older Brother and a Previous Birth of a Boy: Is Male Microchimerism a Risk Factor? J Clin Med 2021; 10:jcm10122613. [PMID: 34198508 PMCID: PMC8231851 DOI: 10.3390/jcm10122613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/03/2021] [Accepted: 06/10/2021] [Indexed: 01/08/2023] Open
Abstract
Known etiologic factors can only be found in about 50% of patients with recurrent pregnancy loss (RPL). We hypothesized that male microchimerism is a risk factor for RPL and aimed to explore whether information on family tree and reproductive history, obtained from 383 patients with unexplained RPL, was supportive of this hypothesis. The male:female sex ratio of older siblings was 1.49 (97:65) in all RPL patients and 1.79 (52:29) in secondary RPL (sRPL) patients, which differed significantly from the expected 1.04 ratio (p = 0.027 and p = 0.019, respectively). In contrast, the sex ratio of younger siblings was close to the expected ratio. Sex ratio of the firstborn child before sRPL was 1.51 (p = 0.026). When combined, 79.1% of sRPL patients had at least one older brother, a firstborn boy, or both. This differed significantly from what we expected based on the distribution of younger siblings and a general 1.04 sex ratio of newborns (p = 0.040). We speculate whether (s)RPL patients possibly acquired male microchimerism from older brother(s) and/or previous birth of boy(s) by transplacental cell trafficking. This could potentially have a detrimental impact on their immune system, causing a harmful response against the fetus or trophoblast, resulting in RPL.
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Affiliation(s)
- Caroline Nørgaard-Pedersen
- Centre for Recurrent Pregnancy Loss of Western Denmark, Department of Obstetrics and Gynaecology, Aalborg University Hospital, Reberbansgade 15, 9000 Aalborg, Denmark; (U.S.K.); (O.B.C.)
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
- Correspondence: ; Tel.: +45-41120267
| | - Ulrik Schiøler Kesmodel
- Centre for Recurrent Pregnancy Loss of Western Denmark, Department of Obstetrics and Gynaecology, Aalborg University Hospital, Reberbansgade 15, 9000 Aalborg, Denmark; (U.S.K.); (O.B.C.)
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Ole B. Christiansen
- Centre for Recurrent Pregnancy Loss of Western Denmark, Department of Obstetrics and Gynaecology, Aalborg University Hospital, Reberbansgade 15, 9000 Aalborg, Denmark; (U.S.K.); (O.B.C.)
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
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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: 32] [Impact Index Per Article: 10.7] [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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Odendaal J, Quenby S, Sammaritano L, Macklon N, Branch DW, Rosenwaks Z. Immunologic and rheumatologic causes and treatment of recurrent pregnancy loss: what is the evidence? Fertil Steril 2020; 112:1002-1012. [PMID: 31843070 DOI: 10.1016/j.fertnstert.2019.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 10/01/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Joshua Odendaal
- Division of Biomedical Sciences, Clinical Sciences Research Laboratories, Warwick Medical School, University of Warwick, Coventry, United Kingdom; Tommy's National Centre for Miscarriage Research, University Hospitals Coventry & Warwickshire, Coventry, United Kingdom
| | - Siobhan Quenby
- Division of Biomedical Sciences, Clinical Sciences Research Laboratories, Warwick Medical School, University of Warwick, Coventry, United Kingdom; Tommy's National Centre for Miscarriage Research, University Hospitals Coventry & Warwickshire, Coventry, United Kingdom
| | - Lisa Sammaritano
- Hospital for Special Surgery, New York, New York; Weill Cornell Medicine, New York, New York
| | - Nick Macklon
- London Womens Clinic, London, United Kingdom; ReproHealth Consortium, Zealand University Hospital, Koege, Denmark
| | | | - Zev Rosenwaks
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, New York.
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Mortensen LH, Cnattingius S, Gissler M, Klungsøyr K, Skjaerven R, Nybo Andersen AM, Nielsen HS. Sex of the first-born and obstetric complications in the subsequent birth. A study of 2.3 million second births from Denmark, Finland, Norway, and Sweden. Acta Obstet Gynecol Scand 2020; 99:1381-1386. [PMID: 32304226 DOI: 10.1111/aogs.13872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 03/31/2020] [Accepted: 04/11/2020] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Studies have shown associations between a first-born boy and increased risks of pregnancy loss, stillbirth, decreased birthweight, and preterm birth in subsequent pregnancies, but with limited precision. MATERIAL AND METHODS We examined associations between sex of the first-born and obstetric complications in second births. We calculated the relative risks (RR)s of preeclampsia/eclampsia, placental abruption, stillbirth, and preterm birth in approximately 2.3 million second births comparing women with a preceding first-born boy to those with a first-born girl using the Medical Birth Registries of Denmark, Finland, Norway, and Sweden 1980-2008. RESULTS In second births following a first-born boy rather than a girl, the RR was 4% higher for preeclampsia/eclampsia (RR = 1.04, 95% CI 1.02-1.06), 9% higher for placental abruption (RR = 1.09, 95% CI 1.05-1.13), 9% higher for stillbirth (RR = 1.09, 95% CI 1.04-1.14), and 8% higher for preterm birth (RR = 1.08, 95% CI 1.07-1.09). The population attributable risks ranged from 2% to 4.5%. CONCLUSIONS Male sex of the first-born is associated with small increases in risks of obstetric complications in the second birth. Exploration of the underlying mechanisms is needed to increase our knowledge and treatment options for these serious obstetric complications.
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Affiliation(s)
- Laust H Mortensen
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Sven Cnattingius
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Mika Gissler
- Finnish Institute for Health and Welfare, Helsinki, Finland.,Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Kari Klungsøyr
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Division for Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Rolv Skjaerven
- Division for Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway.,Center for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Anne-Marie Nybo Andersen
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Henriette S Nielsen
- Department of Obstetric and Gynecology, Hvidovre Hospital, University Hospital Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kaňková Š, Flegr J, Toman J, Calda P. Maternal RhD heterozygous genotype is associated with male biased secondary sex ratio. Early Hum Dev 2020; 140:104864. [PMID: 31500940 DOI: 10.1016/j.earlhumdev.2019.104864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies suggest that RhD positive heterozygotes express better health status than RhD positive homozygotes and especially RhD negative subjects. This also applies to pregnant women. According to the Trivers-Willard hypothesis, women in better physical condition should have more sons. AIM To test the hypothesis that RhD positive heterozygous mothers have a male-skewed sex ratio. STUDY DESIGN Cross-sectional study. The data was analysed using Chi-Square test for all women, separately for RhD positive and RhD negative women, and separately for primiparous and multiparous women. The effects of maternal weight as a continuous predictor and the RhD phenotype of newborn as a categorical predictor of newborn sex were evaluated by the generalized linear model (GLZ) separately for RhD positive and RhD negative women using binomial distribution and logit link function. OUTCOME MEASURES Clinical records comprised maternal weight before pregnancy, number of previous deliveries, sex of the newborn, maternal RhD phenotype, and RhD phenotype of the newborn. SUBJECTS We analysed data from 5655 women who gave birth between 2008 and 2012 in General University Hospital in Prague. RESULTS Secondary sex ratio was significantly higher (P = 0.028) in RhD positive mothers who had RhD negative newborns, i.e., in heterozygotes (SR = 1.23), than in RhD positive mothers who had RhD positive newborns, i.e., in a mixed population of heterozygotes and homozygotes (SR = 1.00), especially in primiparous women (P = 0.013; SR = 1.37 and 0.99 resp.). CONCLUSION The sex ratio at birth was significantly higher in RhD positive mothers who had RhD negative newborns than in RhD positive mothers who had RhD positive newborns.
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Affiliation(s)
- Šárka Kaňková
- Department of Philosophy and History of Science, Faculty of Science, Charles University, Prague CZ-128 44, Prague 2, Czech Republic.
| | - Jaroslav Flegr
- Department of Philosophy and History of Science, Faculty of Science, Charles University, Prague CZ-128 44, Prague 2, Czech Republic
| | - Jan Toman
- Department of Philosophy and History of Science, Faculty of Science, Charles University, Prague CZ-128 44, Prague 2, Czech Republic
| | - Pavel Calda
- Department of Obstetrics and Gynaecology, General University Hospital and First Faculty of Medicine, Charles University, Prague CZ-128 08, Prague 2, Czech Republic
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11
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Immunologic Abnormalities, Treatments, and Recurrent Pregnancy Loss: What Is Real and What Is Not? Clin Obstet Gynecol 2017; 59:509-23. [PMID: 27380207 DOI: 10.1097/grf.0000000000000215] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Recurrent pregnancy loss, depending on the definition, affects 1% to 3% of women aiming to have a child. Little is known about the direct causes of recurrent pregnancy loss, and the condition is considered to have a multifactorial and complex pathogenesis. The aim of this review was to summarize the evaluation and the management of the condition with specific emphasis on immunologic biomarkers identified as risk factors as well as current immunologic treatment options. The review also highlights and discusses areas in need of further research.
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12
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An altered endometrial CD8 tissue resident memory T cell population in recurrent miscarriage. Sci Rep 2017; 7:41335. [PMID: 28112260 PMCID: PMC5256279 DOI: 10.1038/srep41335] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/16/2016] [Indexed: 12/15/2022] Open
Abstract
When trying to conceive 1% of couples have recurrent miscarriages, defined as three or more consecutive pregnancy losses. This is not accounted for by the known incidence of chromosomal aneuploidy in miscarriage, and it has been suggested that there is an immunological aetiology. The endometrial mucosa is populated by a variety of immune cells which in addition to providing host pathogen immunity must facilitate pregnancy. Here we characterise the endometrial CD8-T cell population during the embryonic window of implantation and find that the majority of cells are tissue resident memory T cells with high levels of CD69 and CD103 expression, proteins that prevent cells egress. We demonstrate that unexplained recurrent miscarriage is associated with significantly decreased expression of the T-cell co-receptor CD8 and tissue residency marker CD69. These cells differ from those found in control women, with less expression of CD127 indicating a lack of homeostatic cell control through IL-7 signalling. Nevertheless this population is resident in the endometrium of women who have RM, more than three months after the last miscarriage, indicating that the memory CD8-T cell population is altered in RM patients. This is the first evidence of a differing pre-pregnancy phenotype in endometrial immune cells in RM.
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13
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Kolte AM, Steffensen R, Christiansen OB, Nielsen HS. Maternal HY-restricting HLA class II alleles are associated with poor long-term outcome in recurrent pregnancy loss after a boy. Am J Reprod Immunol 2016; 76:400-405. [PMID: 27600856 DOI: 10.1111/aji.12561] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/10/2016] [Indexed: 11/30/2022] Open
Abstract
PROBLEM Women with secondary recurrent pregnancy loss (RPL) after a boy have a reduced chance of live birth in the first pregnancy after referral if they carry HY-restricting HLA class II alleles, but long-term chance of live birth is unknown. METHODS OF STUDY Live birth was compared for 540 women with unexplained secondary RPL according to firstborn's sex and maternal carriage of HLA-DRB3*03:01, HLA-DQB1*05:01/02, HLA-DRB1*15, and HLA-DRB1*07. The groups were compared by Cox proportional hazard ratios. RESULTS For women with at firstborn boy, maternal carriage of HY-restricting HLA class II alleles decreased chance of live birth: 0 vs 1: hazard ratio 0.75 (95% CI 0.55-1.02); 0 vs 2: HR 0.62 (0.40-0.94). Carriage of HY-restricting HLA class II alleles decreased chance of live birth only if the firstborn was a boy: boy vs girl: HR 0.72 (95% CI 0.55-0.98). CONCLUSION Maternal carriage of HY-restricting HLA class II alleles decreases long-term chance of live birth in women with RPL after a boy.
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Affiliation(s)
- Astrid Marie Kolte
- Recurrent Pregnancy Loss Unit, Fertility Clinic 4071, University Hospital Copenhagen Rigshospitalet, København Ø, Denmark.
| | - Rudi Steffensen
- Department of Clinical Immunology, Aalborg University Hospital, Aalborg, Denmark
| | - Ole Bjarne Christiansen
- Recurrent Pregnancy Loss Unit, Fertility Clinic 4071, University Hospital Copenhagen Rigshospitalet, København Ø, Denmark.,Department of Gynecology and Obstetrics, Aalborg University Hospital, Aalborg, Denmark
| | - Henriette Svarre Nielsen
- Recurrent Pregnancy Loss Unit, Fertility Clinic 4071, University Hospital Copenhagen Rigshospitalet, København Ø, Denmark
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14
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Meuleman T, van Beelen E, Kaaja RJ, van Lith JMM, Claas FHJ, Bloemenkamp KWM. HLA-C antibodies in women with recurrent miscarriage suggests that antibody mediated rejection is one of the mechanisms leading to recurrent miscarriage. J Reprod Immunol 2016; 116:28-34. [PMID: 27172837 DOI: 10.1016/j.jri.2016.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 03/21/2016] [Indexed: 12/29/2022]
Abstract
HLA-C is the only polymorphic classical HLA I antigen expressed on trophoblast cells. It is known that higher incidence of C4d deposition on trophoblast cells is present in women with recurrent miscarriage. C4d is a footprint of antibody-mediated classical complement activation. Therefore, this study hypothesize that antibodies against HLA-C may play a role in the occurrence of unexplained consecutive recurrent miscarriage. Present case control study compared the incidence of HLA-C specific antibodies in 95 women with at least three consecutive miscarriages and 105 women with uneventful pregnancy. In the first trimester of the next pregnancy, presence and specificity of HLA antibodies were determined and their complement fixing ability. The incidence of HLA antibodies was compared with uni- and multivariate logistic regression models adjusting for possible confounders. Although in general a higher incidence of HLA antibodies was found in women with recurrent miscarriage 31.6% vs. in control subjects 9.5% (adjusted OR 4.3, 95% CI 2.0-9.5), the contribution of antibodies against HLA-C was significantly higher in women with recurrent miscarriage (9.5%) compared to women with uneventful pregnancy (1%) (adjusted OR 11.0, 95% CI 1.3-89.0). In contrast to the control group, HLA-C antibodies in the recurrent miscarriage group were more often able to bind complement. The higher incidence of antibodies specific for HLA-C in women with recurrent miscarriage suggests that HLA-C antibodies may be involved in the aetiology of unexplained consecutive recurrent miscarriage.
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Affiliation(s)
- T Meuleman
- Department of Obstetrics, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands.
| | - E van Beelen
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| | - R J Kaaja
- Department of Obstetrics and Gynaecology, Turku University, 20610 Turku, Finland
| | - J M M van Lith
- Department of Obstetrics, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| | - F H J Claas
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands
| | - K W M Bloemenkamp
- Department of Obstetrics, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands; Department of Obstetrics, Wilhelmina Children Hospital Birth Centre, Utrecht University Medical Centre, 3508 AB Utrecht, The Netherlands
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15
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James WH. Hypothesis: high levels of maternal adrenal androgens are a major cause of miscarriage and other forms of reproductive suboptimality. J Theor Biol 2014; 364:316-20. [PMID: 25264266 DOI: 10.1016/j.jtbi.2014.09.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/17/2014] [Accepted: 09/18/2014] [Indexed: 10/24/2022]
Abstract
A cause is proposed for several forms of reproductive suboptimality (viz foetal loss, preterm birth and low birth weight). The point is illustrated here in the case of miscarriage. I suggest that all these forms of reproductive suboptimality are partially caused by high levels of stress-related maternal adrenal androgens. The argument is supported by both experimental and epidemiological data.
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Affiliation(s)
- William H James
- The Galton Laboratory, Department of Genetics, Evolution and Environment, University College London, London, UK.
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16
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Recurrent miscarriage and birth sex ratio. Eur J Obstet Gynecol Reprod Biol 2014; 176:55-9. [PMID: 24666800 DOI: 10.1016/j.ejogrb.2014.02.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 02/07/2014] [Accepted: 02/15/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine the relationship between birth sex ratio and unexplained recurrent miscarriage (RM). STUDY DESIGN Retrospective, observational study including a total of 138 women with primary recurrent miscarriage (PRM) and 170 women with secondary recurrent miscarriage (SRM) in a tertiary referral recurrent miscarriage clinic between 1992 and 2010. The sex ratio of the first birth and subsequent birth were the main outcome measures. RESULTS In women with SRM: (i) The male:female sex ratio of the first stillbirth was 10:2, significantly (OR=4.76) higher than the male:female sex ratio of 1.05 among all births in UK. (ii) When the first born was a male, the male:female sex ratio of the subsequent birth was 21:35, significantly (OR=0.57) lower than the sex ratio among the general population. (iii) A male firstborn did not affect the chance of a subsequent live-birth. The findings did not apply to sex ratio in primary RM. CONCLUSION There was a subtle relationship between the sex of the first and subsequent births and secondary recurrent miscarriage, but not primary recurrent miscarriage.
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17
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Abstract
Women with unexplained recurrent pregnancy loss (RPL) represent a highly heterogeneous group of patients. Past studies have investigated systemic endocrine and immunologic mechanisms as potential causes for pregnancy loss in unexplained RPL, while exciting new work has focused on spermatozoal, embryonic, and endometrial characteristics to explain the regulation of implantation and subsequent pregnancy loss. In the clinical and research context, stratification of women with unexplained RPL according to whether they have a high probability of pathologic status will help select women who are most appropriate for further investigation and potential future treatment.
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Affiliation(s)
- Sotirios H Saravelos
- Department of Obstetrics and Gynaecology, St Mary's Campus, Imperial College London, Mint Wing, South Wharf Road, London W2 1PG, UK
| | - Lesley Regan
- Department of Obstetrics and Gynaecology, St Mary's Campus, Imperial College London, Mint Wing, South Wharf Road, London W2 1PG, UK.
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18
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Perchellet AL, Jasti S, Petroff MG. Maternal CD4⁺ and CD8⁺ T cell tolerance towards a fetal minor histocompatibility antigen in T cell receptor transgenic mice. Biol Reprod 2013; 89:102. [PMID: 24025737 DOI: 10.1095/biolreprod.113.110445] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Tolerance of the maternal immune system in pregnancy is important for successful pregnancy because the semiallogeneic fetus may be subject to antifetal responses. We examined maternal tolerance to the fetus using a murine system in which a model paternally inherited antigen, ovalbumin (OVA), is expressed exclusively in the fetus and placenta. By employing T cell receptor (TCR) transgenic mice specific for major histocompatibility complex class I- or class II-restricted epitopes of OVA (OT-I and OT-II) as mothers, we investigated the fate of fetus-specific CD8⁺ and CD4⁺ T cells, respectively, during gestation. Both OVA-specific CD8⁺ and CD4⁺ T cells displayed an activated phenotype in the peripheral lymphoid tissues of OVA-bred OT-I and OT-II mice, consistent with their encounter of fetal antigen. Whereas a small percentage of OVA-specific CD4⁺ T cells were deleted in the periphery and thymus of OVA-bred OT-II mice, with evidence of TCR downregulation in the remaining T cells, deletion and TCR downregulation were not observed in OVA-bred OT-I mice. Both CD4⁺ and CD8⁺ T cells upregulated inducible costimulator expression in response to the fetal antigen, but only CD4⁺ T cells consistently upregulated the inhibitory receptors programmed cell death 1 and cytotoxic T lymphocyte antigen-4. More regulatory T cells (Tregs) were present in pregnant OVA-bred than in WT-bred OT-II mice, revealing that Tregs expanded specifically in response to the fetal antigen. These data indicate that several mechanisms tolerize fetal antigen-specific maternal CD4⁺ T cells, whereas tolerance of fetal antigen-specific CD8⁺ T cells is less effective. The importance of these mechanisms is underscored by the finding that fetal loss occurs in OVA-bred OT-I but not OT-II mice.
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Affiliation(s)
- Antoine L Perchellet
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, Kansas
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19
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Evolution and the variation of mammalian sex ratios at birth: Reflections on Trivers and Willard (1973). J Theor Biol 2013; 334:141-8. [DOI: 10.1016/j.jtbi.2013.06.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 06/12/2013] [Accepted: 06/20/2013] [Indexed: 11/21/2022]
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20
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Blanchard R. A possible second type of maternal-fetal immune interaction involved in both male and female homosexuality. ARCHIVES OF SEXUAL BEHAVIOR 2012; 41:1507-1511. [PMID: 22350121 DOI: 10.1007/s10508-011-9896-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 12/06/2011] [Accepted: 12/06/2011] [Indexed: 05/31/2023]
Abstract
Recent research has found that the mothers of firstborn homosexual sons produce fewer subsequent offspring than do the mothers of firstborn heterosexual sons. It was hypothesized that a subset of mothers of firstborn homosexuals may be responsible for this finding. If there is a subset of mothers whose immune reactions cause their first male fetus to be homosexual and their subsequent fetuses to die, then their immune reactions should also cause their first male fetus to have a lower birth weight. This leads to the prediction that, within the population of firstborn homosexual men, those with no younger siblings should also tend to have lower birth weights. This prediction was tested using a previously published sample of 1,445 firstborn subjects: 929 heterosexual females, 47 homosexual females, 409 heterosexual males, and 60 homosexual males. The results showed that firstborn homosexuals with no younger siblings (i.e., only children) did have lower birth weights compared with all the other subjects, but the finding applied to firstborn lesbian women as well as firstborn gay men.
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Affiliation(s)
- Ray Blanchard
- Department of Psychiatry, University of Toronto, 250 College St., Toronto, ON, M5T 1R8, Canada.
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21
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Lissauer D, Piper K, Goodyear O, Kilby MD, Moss PAH. Fetal-specific CD8+ cytotoxic T cell responses develop during normal human pregnancy and exhibit broad functional capacity. THE JOURNAL OF IMMUNOLOGY 2012; 189:1072-80. [PMID: 22685312 DOI: 10.4049/jimmunol.1200544] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Tolerance of the semiallogeneic fetus presents a significant challenge to the maternal immune system during human pregnancy. T cells with specificity for fetal epitopes have been detected in women with a history of previous pregnancy, but it has been thought that such fetal-specific cells were generally deleted during pregnancy as a mechanism to maintain maternal tolerance of the fetus. We used MHC-peptide dextramer multimers containing an immunodominant peptide derived from HY to identify fetal-specific T cells in women who were pregnant with a male fetus. Fetal-specific CD8(+) T lymphocytes were observed in half of all pregnancies and often became detectable from the first trimester. The fetal-specific immune response increased during pregnancy and persisted in the postnatal period. Fetal-specific cells demonstrated an effector memory phenotype and were broadly functional. They retained their ability to proliferate, secrete IFN-γ, and lyse target cells following recognition of naturally processed peptide on male cells. These data show that the development of a fetal-specific adaptive cellular immune response is a normal consequence of human pregnancy and that unlike reports from some murine models, fetal-specific T cells are not deleted during human pregnancy. This has broad implications for study of the natural physiology of pregnancy and for the understanding of pregnancy-related complications.
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Affiliation(s)
- David Lissauer
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham B15 2TT, UK.
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22
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Abstract
BACKGROUND Recent data suggest that the chance of successfully maintaining a pregnancy may be influenced by the sex of previously born children. We explored a possible relation between sex of the first-born infant and the risk of preterm birth in the second pregnancy. METHODS Using data from the National Medical Birth Registries in Denmark 1980-2004 and Sweden 1980-2001, we selected all women whose first and second births were singleton and who had information on sex of first-born infant and gestational age for the second (Denmark, n = 393,686; Sweden, n = 603,282). Cox proportional hazards regression analysis was used to estimate the hazard ratio of preterm birth in the second pregnancy according to the sex of the first-born infant. RESULTS Compared with women whose first baby was a girl, women with boys had an increased risk of preterm birth in a second pregnancy (hazard ratio = 1.10 [95% confidence interval = 1.07-1.13]). This result was consistent in the 2 populations. The association was not confounded by maternal age, interpregnancy interval, or sex of the second infant or by maternal characteristics that do not vary from one pregnancy to the next. CONCLUSIONS Exposure to a male fetus may increase a woman's risk of preterm delivery in the next pregnancy. While the findings have no direct public health relevance, they may suggest new pathways by which preterm birth can occur.
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23
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Christiansen OB, Steffensen R, Nielsen HS. Anti-HY Responses in Pregnancy Disorders. Am J Reprod Immunol 2011; 66 Suppl 1:93-100. [DOI: 10.1111/j.1600-0897.2011.01038.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Nielsen HS, Witvliet MD, Steffensen R, Haasnoot GW, Goulmy E, Christiansen OB, Claas F. The presence of HLA-antibodies in recurrent miscarriage patients is associated with a reduced chance of a live birth. J Reprod Immunol 2011; 87:67-73. [PMID: 20605049 DOI: 10.1016/j.jri.2010.05.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 05/21/2010] [Accepted: 05/23/2010] [Indexed: 10/19/2022]
Abstract
Anti-paternal HLA-antibodies are considered a harmless phenomenon during most pregnancies, whereas their role in recurrent miscarriage (RM) patients is disputed. In contrast to primary RM, patients with secondary RM have carried a fetus to term pregnancy prior to a series of miscarriages, which increases the chance that allogeneic fetal cells appear in the maternal circulation. This study investigates the frequency of HLA-antibodies in secondary RM, primary RM patients and parous controls and analyzes whether the presence of HLA-antibodies in early pregnancy is associated with pregnancy outcome. Sera from women with secondary RM (n=56), primary RM (n=13) and parous controls (n=24) were tested for HLA-antibodies using an ELISA assay and complement dependent cytotoxicity. Samples were taken at gestational week 4-5 in 62 (90%) of the patients. HLA-antibodies were significantly more frequent in secondary RM patients with a boy prior to the miscarriages (62%) compared to secondary RM patients with a firstborn girl (29%, p=0.03), primary RM patients (23%, p=0.02) and parous controls (25%, p=0.005). Forty-one percent of HLA-antibody positive pregnant RM patients had a live birth compared to 76% of HLA-antibody negative RM patients, p=0.006 (adjusted OR: 0.22 (0.07-0.68), p=0.008). In conclusion, HLA-antibodies are significantly more frequent in secondary RM patients with a firstborn boy than in other RM patients and controls. The presence of these antibodies in early pregnancy is associated with a reduced chance of a live birth. Further exploring this association may increase our understanding of maternal acceptance of the fetal allograft.
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Affiliation(s)
- Henriette Svarre Nielsen
- The Fertility Clinic, University Hospital Copenhagen, Rigshospitalet, Fertility Clinic 4071, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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25
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Scherjon S, Lashley L, van der Hoorn ML, Claas F. Fetus specific T cell modulation during fertilization, implantation and pregnancy. Placenta 2011; 32 Suppl 4:S291-7. [PMID: 21592567 DOI: 10.1016/j.placenta.2011.03.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 03/28/2011] [Indexed: 02/07/2023]
Abstract
Recently there is an increasing interest in aspects of a more specific immunoregulation during pregnancy. Understanding these mechanism might have a broader application not only for reproductive immunology but also in general for biology and medicine. Especially the induction, already before conception, of feto-specific T cells with a possibly regulatory function gives a biological explanation of local immunotolerance at the maternal fetal interface, supporting the epidemiological evidence of a feto/paternal-specific immuneregulation. Understanding the expression of specific HLA-classes on trophoblast and the crosstalk of these antigens with various cell types, specifically modulated in the decidua, resulting in the secretion of cytokines and (angiogenic) chemokines has given us a more and more detailed understanding of this regulation. This regulation could be induced by fetal cells circulating in the mother (microchimerism) and from the interaction with fetal subcellular fractions as exosomes, but also from paternal antigens present in seminal fluid. Molecular interaction between paternal and fetal antigens and receptors in endometrium and the decidua are discussed. This review highlights besides uNK cells, especially the function of CD4+ and CD8+ T cells with a regulatory function in the context of recurrent miscarriage and pre-eclampsia. Besides HLA, also male-specific minor histocompatibility antigens and the genetic background for these pregnancy complications are discussed.
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Affiliation(s)
- S Scherjon
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands.
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26
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Abstract
BACKGROUND Approximately half recurrent miscarriage (RM) cases remain unexplained after standard investigations. Secondary RM (SRM) is, in contrast to primary RM, preceded by a birth, which increases the transfer of fetal cells into the maternal circulation. Mothers of boys are often immunized against male-specific minor histocompatibility (H-Y) antigens, and H-Y immunity can cause graft-versus-host disease after stem-cell transplantation. We proposed the H-Y hypothesis that aberrant H-Y immunity is a causal factor for SRM. METHODS This is a critical review of the H-Y hypothesis based on own publications and papers identified by systematic PubMed and EMBASE searches. RESULTS SRM is more common after the birth of a boy and the subsequent live birth rate is reduced for SRM patients with a firstborn boy. The male:female ratio of children born prior and subsequent to SRM is 1.49 and 0.76 respectively. Maternal carriage of HLA-class II alleles presenting H-Y antigens to immune cells is associated with a reduced live birth rate and increased risk of obstetric complications in surviving pregnancies in SRM patients with a firstborn boy. In early pregnancy, both antibodies against HLA and H-Y antigens are increased in SRM patients compared with controls. Presence of these antibodies in early pregnancy is associated with a lower live birth rate and a low male:female ratio in subsequent live births, respectively. Births of boys are also associated with subsequent obstetric complications in the background population. CONCLUSIONS Epidemiological, immunogenetic and immunological studies support the hypothesis that aberrant maternal H-Y immune responses have a pathogenic role in SRM.
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Affiliation(s)
- Henriette Svarre Nielsen
- The Fertility Clinic 4071, University Hospital Copenhagen, Blegdamsvej 9, Rigshospitalet, Copenhagen Ø, Denmark.
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27
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Petroff MG. Review: Fetal antigens--identity, origins, and influences on the maternal immune system. Placenta 2011; 32 Suppl 2:S176-81. [PMID: 21211836 DOI: 10.1016/j.placenta.2010.12.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 12/09/2010] [Accepted: 12/13/2010] [Indexed: 10/18/2022]
Abstract
Pregnancy induces priming of the maternal cellular and humoral immune systems. The paternally-inherited fetal antigens that influence maternal T and B cells include both major and minor histocompatibility antigens - the same antigens that are problematic in allotransplantation. Animal models have facilitated our understanding of the lymphocyte responses to fetal antigens, and our appreciation of the parallel response in pregnant women is increasing. The physiologic properties of the placenta as well as trafficking of cells between mother and fetus allow ample opportunity for sampling of fetal proteins by the maternal immune system. Here, the current state of knowledge of fetal antigen-specific lymphocyte responses in pregnancy is reviewed.
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Affiliation(s)
- M G Petroff
- Department of Anatomy & Cell Biology, University of Kansas Medical Center, Kansas City, KS 66160, USA.
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28
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Ooi PV, Russell N, O'Donoghue K. Secondary recurrent miscarriage is associated with previous male birth. J Reprod Immunol 2010; 88:38-41. [PMID: 21129780 DOI: 10.1016/j.jri.2010.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Revised: 10/25/2010] [Accepted: 10/28/2010] [Indexed: 11/17/2022]
Abstract
Secondary recurrent miscarriage (RM) is defined as three or more consecutive pregnancy losses after delivery of a viable infant. Previous reports suggest that a firstborn male child is associated with less favourable subsequent reproductive potential, possibly due to maternal immunisation against male-specific minor histocompatibility antigens. In a retrospective cohort study of 85 cases of secondary RM we aimed to determine if secondary RM was associated with (i) gender of previous child, maternal age, or duration of miscarriage history, and (ii) increased risk of pregnancy complications. Fifty-three women (62.0%; 53/85) gave birth to a male child prior to RM compared to 32 (38.0%; 32/85) who gave birth to a female child (p=0.002). The majority (91.7%; 78/85) had uncomplicated, term deliveries and normal birth weight neonates, with one quarter of the women previously delivered by Caesarean section. All had routine RM investigations and 19.0% (16/85) had an abnormal result. Fifty-seven women conceived again and 33.3% (19/57) miscarried, but there was no significant difference in failure rates between those with a previous male or female child (13/32 vs. 6/25, p=0.2). When patients with abnormal results were excluded, or when women with only one previous child were considered, there was still no difference in these rates. A previous male birth may be associated with an increased risk of secondary RM but numbers preclude concluding whether this increases recurrence risk. The suggested association with previous male birth provides a basis for further investigations at a molecular level.
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Affiliation(s)
- Poh Veh Ooi
- Anu Research Centre, Department of Obstetrics and Gynaecology, University College Cork, Cork University Maternity Hospital, Wilton, Cork, Ireland
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Markiewicz M, Siekiera U, Dzierzak-Mietla M, Zielinska P, Kyrcz-Krzemien S. The Impact of H-Y Mismatches on Results of HLA-Matched Unrelated Allogeneic Hematopoietic Stem Cell Transplantation. Transplant Proc 2010; 42:3297-300. [DOI: 10.1016/j.transproceed.2010.07.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Nielsen HS, Wu F, Aghai Z, Steffensen R, van Halteren AG, Spierings E, Christiansen OB, Miklos D, Goulmy E. H-Y antibody titers are increased in unexplained secondary recurrent miscarriage patients and associated with low male : female ratio in subsequent live births. Hum Reprod 2010; 25:2745-52. [PMID: 20823116 DOI: 10.1093/humrep/deq242] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The birth of a boy is significantly more common than a girl prior to secondary recurrent miscarriage (SRM) and is associated with a poorer chance of a subsequent live birth. Children born after SRM are more likely to be girls. High-titer antisera specific for male antigens (H-Y) have been shown to arrest development of male bovine embryos efficiently. We consequently questioned the role of H-Y antibodies in women with SRM. METHODS Serum samples from patients with unexplained SRM (n = 84), unexplained primary recurrent miscarriage (PRM) (n = 12) and healthy women (n = 37) were obtained. The samples were taken during pregnancy (gestational weeks 4-5) for 77 (80%) of the patients. Enzyme-linked immunosorbent assay was used to detect immunoglobulin G antibodies that specifically recognized any of the five recombinant H-Y proteins (EIF1AY, RPS4Y1, ZFY, DDX3Y and UTY) and their H-X homologs. RESULTS H-Y-specific antibodies were more frequent in SRM patients (46%) compared with female controls (19%, P = 0.004) and PRM patients (8%, P = 0.01). The presence of H-Y antibodies in early pregnancy was associated with a low male: female birth ratio among the subsequent live births, as only 12% of children born to H-Y antibody-positive patients were boys compared with 44% boys born to H-Y antibody negative patients (P = 0.03). CONCLUSIONS The high frequency of H-Y antibody-positive SRM patients and the association between the presence of these antibodies in early pregnancy and the low number of male offspring, suggest that maternal immune responses against H-Y antigens can cause pregnancy losses. Further exploring these mechanisms may increase our understanding of unexplained SRM.
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Affiliation(s)
- H S Nielsen
- The Fertility Clinic 4071, University Hospital Copenhagen, Blegdamsvej 9, Rigshospitalet, Copenhagen Ø, Denmark.
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Nielsen HS, Steffensen R, Lund M, Egestad L, Mortensen LH, Andersen AMN, Lidegaard O, Christiansen OB. Frequency and impact of obstetric complications prior and subsequent to unexplained secondary recurrent miscarriage. Hum Reprod 2010; 25:1543-52. [DOI: 10.1093/humrep/deq091] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Christiansen OB, Steffensen R, Nielsen HS. The impact of anti-HY responses on outcome in current and subsequent pregnancies of patients with recurrent pregnancy losses. J Reprod Immunol 2010; 85:9-14. [PMID: 20307907 DOI: 10.1016/j.jri.2009.12.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Revised: 12/02/2009] [Accepted: 12/15/2009] [Indexed: 01/06/2023]
Abstract
Women pregnant with a male fetus often generate cellular and humoral immune responses against male-specific minor histocompatibility (HY) antigens-however, the importance of these responses for pregnancy outcome is unclear. Epidemiologic studies have shown that the birth of a boy compared with a girl prior to a series of miscarriages significantly reduces the chance of a subsequent live birth and pregnancies with boys have an increased risk of placental abruption. This paper aims to review the current knowledge about the impact of anti-HY immunity on pregnancy outcome in terms of miscarriage and placental abruption. Our knowledge primarily comes from studies of the impact on pregnancy outcome of HLA class II alleles known to restrict CD4 T cell mediated anti-HY responses among 358 secondary recurrent miscarriage (SRM) patients and 203 of their children born prior to the miscarriages and investigation of these HLA alleles in 8 patients with recurrent severe placental abruptions. The chance of a subsequent live birth in SRM patients with firstborn boys compared to firstborn girls was significantly lower in women with HY-restricting HLA class II alleles [OR: 0.17 (0.1-0.4), p=0.0001]. Most patients with recurrent placental abruptions had firstborn boys and significantly more of these patients carried HLA haplotypes with HY-restricting class II alleles compared with controls (p=0.009). These findings are strongly indicative of aberrant maternal immune reactions against fetal HY antigens playing a role in recurrent miscarriage and placental abruption. We propose pathogenetic pathways for these conditions that in our view best explain the findings.
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Affiliation(s)
- Ole Bjarne Christiansen
- The Fertility Clinic 4071, University Hospital Copenhagen, Rigshospitalet, DK-2100 Copenhagen, Denmark.
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Abstract
During pregnancy there is transplacental traffic of fetal cells into the maternal circulation. Remarkably, cells of fetal origin can then persist for decades in the mother and are detectable in the circulation and in a wide range of tissues. Maternal CD8 T cell responses directed against fetal antigens can also be detected following pregnancy. However, the impact that the persistence of allogenic cells of fetal origin and the maternal immune response towards them has on the mother's health remains unclear and is the subject of considerable investigation. The potentially harmful effects of fetal microchimerism include an association with autoimmune disease and recurrent miscarriage. Beneficial effects that have been explored include the contribution of persistent fetal cells to maternal tissue repair. A link between fetal microchimerism and cancer has also been proposed, with some results supporting a protective role and others, conversely, suggesting a role in tumour development. The phenomenon of fetal microchimerism thus provokes many questions and promises to offer further insights not only into the biology of pregnancy but fields such as autoimmunity, transplantation biology and oncology.
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Nielsen HS, Steffensen R, Varming K, Van Halteren AG, Spierings E, Ryder LP, Goulmy E, Christiansen OB. Association of HY-restricting HLA class II alleles with pregnancy outcome in patients with recurrent miscarriage subsequent to a firstborn boy. Hum Mol Genet 2009; 18:1684-91. [DOI: 10.1093/hmg/ddp077] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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