Intravenous immunoglobulin preceding in vitro fertilization-embryo transfer for patients with repeated failure of embryo transfer

Endometrium Immunomodulation to Prevent Recurrent Implantation Failure in Assisted Reproductive Technology

After more than four decades of assisted reproductive technology (ART) practice worldwide, today more than 60% of women undergoing in vitro fertilization (IVF) treatments fail to become pregnant after the first embryo transfer and nearly 20% of patients are suffering from unexplained recurrent implantation failures (RIFs) and repeated pregnancy loss (RPL). The literature reported different causes of RIF–RPL, mainly multifactorial, endometrial and idiopathic. RIF remains a black box because of the complicated categorization and causes of this physio-pathological dysregulation of implantation and pregnancy process after ovarian stimulation. Many options were suggested as solutions to treat RIF–RPL with controversial results on their usefulness. In this article, we reviewed different possible therapeutic options to improve implantation rates and clinical outcomes. Based on our experience we believe that endometrium immunomodulation after intrauterine insemination of activated autologous peripheral blood mononuclear cells (PBMCs) or platelet-rich plasma (PRP) can be a promising therapeutic solution. On the other hand, peripheral lymphocyte balance typing, specific cytokines and interleukins profiling can be proposed as predictive biomarkers of implantation before embryo transfer.

Anti-phospholipid antibodies do not affect IVF success

The assessment of anti-phospholipid antibodies (APA) is not indicated among couples undergoing IVF, and therapy is not justified on the basis of existing data.

Update on Treatment of Immunologic Abortion with Low-dose Intravenous Immunoglobulin

PROBLEM

Recurrent spontaneous abortion associated with immunologic abnormalities has been termed immunologic abortion. Previously we showed that treatment with low-dose intravenous immunoglobulin (IVIG) appears to be beneficial for older women with immunologic abortion. We now report the results of IVIG treatment in a larger group of women with this disorder.

METHOD OF STUDY

A total of 99 women were prospectively evaluated for immunologic abortion, which was defined as three or more miscarriages and the presence of specific immunologic abnormalities. Prior to the next conception, patients were treated with IVIG at a dose of 0.2 g/kg. Once conception was achieved, IVIG treatment was continued on a monthly basis through 26-30 weeks of pregnancy.

RESULTS

The average age of the women was 37 years (range: 28-49), and the average number of miscarriages was 3.8 (range: 3-12). Of the 99 women, 72 received initial IVIG treatment, and 50 subsequently became pregnant. Of these women, 42 (84%) had a successful term pregnancy. Of the 27 women who refused IVIG therapy, 20 became pregnant and 18 (90%) miscarried. The difference in pregnancy success rate between the IVIG-treated and untreated groups was significant (P = 0.001). Four women had mild allergic reactions during IVIG infusion, and these reactions resolved when the IVIG brand was changed. Fetal abnormalities were not observed.

CONCLUSION

We conclude that low-dose IVIG therapy is safe and effective for older women with immunologic abortion.

Investigation and current management of recurrent IVF treatment failure in the UK

OBJECTIVE

To determine current practice in the management of recurrent in vitro fertilisation (IVF) treatment failure in licensed UK infertility centres.

DESIGN

National postal questionnaire study and literature review.

SETTING

University Hospital, Centre for Reproductive Medicine, Coventry, UK.

SAMPLE

Human Fertilisation and Embryology Authority licensed centres providing IVF/intracytoplasmic sperm injection (ICSI) in the UK (n = 79).

METHODS

A survey was designed that sought to determine how recurrent treatment failure was defined and which, if any, investigations were initiated. Furthermore, we asked which therapeutic options were subsequently recommended.

MAIN OUTCOME MEASURES

Definition of recurrent treatment failure. Investigations undertaken. Clinical or embryology changes recommended following recurrent treatment failure.

RESULTS

The response rate was 82%. The most common definition was three unsuccessful IVF cycles (range 2-6). Nineteen percent included frozen embryo replacements (FERs) in this figure. Anticardiolipin antibodies and lupus anticoagulant were the most frequent investigations suggested, followed by hysteroscopy and karyotype. A majority of centres would use a different treatment strategy in a subsequent cycle with blastocyst culture and assisted hatching being most popular.

CONCLUSIONS

The results of this survey suggest that there is considerable variation in the approach to investigation and management of recurrent IVF treatment failure in the UK, although in some areas (e.g. the definition) there was broad concordance. Not all of these approaches are evidence based.

Recurrent implantation failure in assisted reproduction: how to counsel and manage. B. Treatment options that have not been proven to benefit the couple

The success of assisted reproduction, although gradually increasing over the years, is still less than satisfactory. Many couples have benefited from this treatment; however, many have also been left frustrated following multiple failed attempts. Couples who fail to conceive after multiple IVF/intracytoplasmic sperm injection (ICSI) treatments often seek treatment options that are new and that have not been offered before. Some of these include immunological testing and treatment, allogenic lymphocyte therapy, intratubal transfer of zygotes and embryos, blastocyst transfer, sequential embryo transfer, assisted hatching, co-cultures, and preimplantation genetic screening for aneuploidy. Although the evidence behind some of these is more robust, most suffer from lack of well designed randomized trials comparing them with other treatment options. Randomized studies are extremely difficult to conduct, as couples will resist being randomized into a treatment group where previously failed procedures will be repeated. In the mean time, assisted reproduction programmes should resist offering treatment options that are not evidence based, or at least they should share with the couple the information that is available and should stress that none of these is a panacea for their problem.

Treatment of recurrent IVF failure and human leukocyte antigen similarity by intravenous immunoglobulin

This study sought to assess the efficacy of intravenous immunoglobulin (IVIg) in improving pregnancy rates and outcome, in a select group of patients with repeated IVF failure and human leukocyte antigen (HLA) similarity. Couples suffering from recurrent IVF failure, defined as at least seven attempts at embryo transfer with no successful implantations, who were found to share at least three HLA loci, and a negative cross-match test, were included in the study. The treatment consisted of two 30 g IVIg doses: one before oocyte retrieval, and a second as soon as a fetal pulse was identified on ultrasound. Ten couples comprised the study group. In total, these couples had undergone 98 IVF cycles with no successful pregnancies prior to initiation of the study. Following a total of 18 IVIg courses, seven women conceived, two women twice. Up to date, five women have delivered at least one live fetus, at 27 weeks or later. One woman is currently in the early third trimester of a twin pregnancy, and one woman had a late abortion at 19 weeks. The results suggest that couples with recurrent IVF failure and HLA similarity, may benefit from IVIg treatment.

Immunological testing and treatment in reproduction: frequency assessment of practice patterns at assisted reproduction clinics in the USA and Australia

BACKGROUND

The roles that alloimmunity and autoimmunity may play in reproductive failure, including recurrent pregnancy loss and failed IVF, have not been clearly established. To help define practice patterns, we investigated what tests clinicians in the USA and Australia were offering, to which patients (diagnostic groups) the tests were recommended, and in what situations immunological/anticoagulation treatment was advised.

METHODS

A five section survey was completed by senior physicians attending the annual national fertility society meetings in the USA and Australia. Results were tabulated and analysed.

RESULTS

Antiphospholipid antibody testing was offered to patients with recurrent pregnancy loss by almost all physicians surveyed. Patients with previous failure of IVF were tested much less often. Other immune tests (embryotoxic assay, natural killer cells and leukocyte antibodies) were ordered by none of the Australian participants and approximately 25% of the American participants. The use of immunotherapy and anticoagulation therapy for patients who tested positive for various immunological tests was also evaluated for frequency of use and reported secondary complications.

CONCLUSIONS

Large, well-structured studies examining the benefits of immunological evaluation and treatment are necessary before definite recommendations can be made.

Treatment of repeated unexplained in vitro fertilization failure with intravenous immunoglobulin: a randomized, placebo-controlled Canadian trial

OBJECTIVE

To evaluate the effect of intravenous immunoglobulin (IVIG) on pregnancy outcome in couples with repeated unexplained in vitro fertilization (IVF) failure.

DESIGN

Prospective, randomized, double blind, placebo-controlled clinical trial.

SETTING

A university-based and a free-standing IVF program.

PATIENT(S)

Fifty-one couples with a history of repeated unexplained IVF failure who were preparing for another fresh IVF cycle or replacement of cryopreserved embryos.

INTERVENTION(S)

Eligible women underwent a standard IVF stimulation using a long luteal phase GnRH analog protocol. Cryopreserved embryos were replaced after endometrial preparation with oral micronized estradiol and subsequent vaginal progesterone. The women were randomly selected to receive IVIG (500 mg/kg) or an equivalent volume of normal saline. The first infusion was given on the day of embryo transfer or during the preceding 72 hours. The second infusion was given 4 weeks later if a clinical pregnancy was confirmed by ultrasound.

MAIN OUTCOME MEASURE(S)

Live-birth rates.

RESULT(S)

Overall, the live-birth rates were 4/26 (15%) for the IVIG group and 3/25 (12%) for the placebo group (P=0. 52). There were 39 fresh IVF cycles, which yielded a clinical pregnancy rate of 28%, with live-birth rates of 4/21 (19%) for the IVIG group and 3/18 (17%) for the placebo group (P=0.59).

CONCLUSION(S)

In this randomized clinical trial, IVIG did not improve the live-birth rate in couples with repeated unexplained IVF failure, stringently defined by known determinants of IVF outcome.

Antibodies to phosphatidylethanolamine and phosphatidylserine are associated with increased natural killer cell activity in non-male factor infertility patients

Antiphospholipid antibodies (APA) have been identified in patients with recurrent pregnancy loss and IVF failure. Of these, antiphosphatidylethanolamine (aPE) and antiphosphatidylserine (aPS) may have special significance. A link between increased natural killer cell activity (NKa+) and trophoblast cell apoptosis has also been reported. This study was undertaken to determine how the APA profile was associated with peripheral NK cell activity. We evaluated 197 female IVF candidates for APA and NKa. Eighty-nine patients (45%) were APA+ and of these, 51 (57%) were aPE/aPS+. Fifty-four patients (27%) had increased NK cell activity. Some 51% of APA+ and 78% of aPE/aPS+ patients had increased NK cell activity compared with 8% and 13% when APA and aPE/aPS tested negative respectively (P: < 0.0001). Non-male factor infertility patients were APA+ and NKa+ in 57% and 34% of cases respectively, compared with 19% and 13% if a pure male factor was present. Some 88% of aPE/aPS+, non-male factor patients had increased NK cell activity, compared with 12% who tested aPE/aPS negative (P: < 0.0001) and 25% of aPE/aPS+, isolated male factor patients (P: < 0.0001). These findings establish a direct relationship between APA (specifically aPE/aPS) and increased peripheral NK cell activity among non-male factor infertility patients. It is possible that APA do not directly cause reproductive failure but rather function as markers or intermediaries for an underlying, abnormal activation of cellular immunity.

Successful treatment of immunologic abortion with low-dose intravenous immunoglobulin

OBJECTIVE

To evaluate the efficacy of low-dose intravenous immunoglobulin (IVIG) treatment in older women with immunologic abnormalities and recurrent spontaneous abortion (RSA), a condition referred to as immunologic abortion.

DESIGN

Prospective clinical trial.

SETTING

Outpatient referral practice.

PATIENT(S)

Forty-seven women were enrolled in the study. The mean age of the women was 37 years (range, 28-45 years), and the mean number of prior miscarriages was 3.7. Immunologic abnormalities included antiphospholipid antibodies (32%), antithyroid antibodies (53%), antinuclear antibodies (28%), antiovarian antibodies (2%), increased natural killer cells (40%), increased immunoglobulin (Ig)M level (28%), and increased CD4/CD8 T-cell ratio (15%). One patient had IgA deficiency, and three women had endometriosis. Thirty-one of the 47 patients (66%) had more than one immunologic abnormality.

INTERVENTION(S)

Treatment with IVIG at a dose of 0.2 g/kg within 2 weeks of attempted conception. Once conception was achieved, IVIG treatment was continued on a monthly basis at the same dose through 26-30 weeks of gestation.

MAIN OUTCOME MEASURE(S)

Successful pregnancy or recurrent abortion.

RESULT(S)

Of the 47 women, 36 received initial IVIG treatment, and 24 subsequently became pregnant. Of these women, 20 continued IVIG treatment through 26-30 weeks of gestation, and 19 (95%) had a successful term pregnancy. Four women discontinued IVIG therapy after 10-12 weeks of gestation, and 3 (75%) had a successful pregnancy outcome. Of the 11 women who refused IVIG therapy, 7 became pregnant, and all 7 miscarried. The difference in pregnancy success rate between the IVIG-treated and untreated groups was significant (P=.001). Three women had adverse reactions during the low-dose IVIG infusion, and these reactions resolved when the IVIG brand was changed. Fetal abnormalities were not observed.

CONCLUSION(S)

Low-dose IVIG therapy is beneficial for older women with immunologic abortion. The optimum duration of IVIG treatment in these women requires further study.

Antiphospholipid antibodies and in vitro fertilization success: a meta-analysis

OBJECTIVE

To evaluate whether the presence of antiphospholipid antibodies among women undergoing IVF affects the likelihood of IVF success.

DESIGN

A meta-analysis of seven eligible studies on antiphospholipid antibodies and IVF outcome.

MAIN OUTCOME MEASURE(S)

Odds ratios (ORs) and 95% confidence intervals (CIs) of an association between the presence of antiphospholipid antibodies and both clinical pregnancy and live birth from IVF.

RESULT(S)

There was no significant association between antiphospholipid abnormalities and either clinical pregnancy (OR 0.99; 95% CI 0.64-1.53) or live birth (OR 1.07; 95% CI 0.66-1.75) in IVF patients.

CONCLUSION(S)

The measurement of antiphospholipid antibodies is not warranted in patients undergoing IVF.