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

Anti-β2-glycoprotein I/HLA-DR antibody in infertility

To evaluate whether anti-β2-Glycoprotein I/HLA-DR (anti-β2GPI/HLA-DR) antibody is associated with pathophysiology of infertility, 224 women with infertility were enrolled from July 2020 to December 2021 in this prospective study. The serum levels of anti-β2GPI/HLA-DR antibody (normal < 73.3 U) were determined in 224 women with infertility. Backgrounds, causes and clinical factors were compared between women with and without anti-β2GPI/HLA-DR antibody. Forty (17.9 %) of the 224 women tested positive for anti-β2GPI/HLA-DR antibody. The prevalence of endometriosis was higher in women with anti-β2GPI/HLA-DR antibody than in women without the antibody (32.5 %, 13/40 vs. 17.4 %, 32/184; P = 0.048). Logistic regression analyses revealed that, among clinical factors and diseases, endometriosis was associated with anti-β2GPI/HLA-DR antibody positivity in infertile women (adjusted-odds ratio [OR] 3.01, 95 % confidence interval [CI] 1.30-6.99; P = 0.010). Twenty-three (15.5 %) of 148 women who underwent assisted reproductive technology (ART) tested positive for anti-β2GPI/HLA-DR antibody. The prevalence of recurrent implantation failure (RIF) defined as three or more implantation failures following in vitro fertilization and embryo transfers was higher in women with ART who tested positive for the antibody (43.5 %, 10/23) than in women with ART who tested negative (20.8 %, 26/125; P = 0.032). Logistic regression analyses revealed that RIF was associated with anti-β2GPI/HLA-DR antibody positivity in women with ART (adjusted-OR 2.92, 95 % CI 1.05-8.11; P = 0.040). Anti-β2GPI/HLA-DR antibody may be associated with the pathophysiology of infertility, endometriosis and RIF; and can be a potential therapeutic target in infertility.

Obstetric management of the most common autoimmune diseases: A narrative review

Historically, women with an autoimmune disease (AD) could not get pregnant due to infertility frequently linked to the medical condition or because the pregnancy was contraindicated, as it could harm the mother and the future child. Sometimes, pregnancy was contraindicated because the medication needed to control the AD could not be given during pregnancy. All these items are no longer true nowadays. Fertility treatments have advanced, obstetric care is better, and the medical treatments of autoimmune diseases have progressed, so women with any kind of AD are encouraged to get pregnant, and their presence in obstetric clinics is arising. This is challenging for the obstetricians, as to be sure that these pregnancies are safe for the mother and the future child, the obstetricians need to know the natural evolution of these conditions, the impact of pregnancy and postpartum on the illness, and the impact of the AD in the pregnancy. In this narrative review, we aim to make a brief resume of the obstetric management of the most common diseases (Systemic lupus erythematosus, antiphospholipid syndrome, the Anti-Ro/SSA and Anti-La/SSB antigen-antibody systems, rheumatoid arthritis, Sjögren's syndrome and Undifferentiated systemic rheumatic disease and overlap syndromes).

Antiphospholipid antibodies in women with recurrent embryo implantation failure: A systematic review and meta-analysis

OBJECTIVE

Antiphospholipid antibodies (aPL) are related to poor pregnancy outcomes, but their effect on embryo implantation is unclear. We aimed to assess the prevalence of different aPL in women with recurrent implantation failure (RIF).

METHODS

We searched studies in PubMed (MEDLINE), Scopus and Cochrane Library. Quality of studies was scored by the Newcastle-Ottawa Scale and risk of bias assessment by items described in RevMan5 software. Statistical analyses were made using random-effects model and presented as pooled Odds Ratio (OR), 95% confidence interval (CI). Heterogeneity was assessed by I²% and D²%.

RESULTS

This systematic review and meta-analysis included 17 studies and showed a high degree of variability in aPL positivity in RIF. In the latter, the risk of bias assessment suggested unclear bias on study performance with a median sample size and interquartile range for RIF patients and fertile women of 96 (57-417) and 100 (60.5-202.5), respectively. Among the criteria aPL, IgG anticardiolipin autoantibodies (OR 5.02, 95% CI [1.95, 12.93]) were associated with RIF. Within the non-criteria aPL, anti-β2 glycoprotein I-IgA (OR 64.8, 95% CI [9.74, 431.0]), and antiphosphatidylglycerol-IgG and IgM (OR 10.74, 95% CI [5.25, 22.0]; OR 4.26, 95% CI [1.76,10.31]; respectively) were associated with RIF, too.

CONCLUSIONS

Anticardiolipin-IgG is a prevalent autoantibody in women with RIF. Three other non-criteria aPL, aβ2GP I-IgA, aPG-IgG and aPG-IgM also present a positive rate in RIF. Overall, these results advise about testing them as indicators of RIF risk in women seeking IVF treatment.

Serum antiphospholipid antibody status may not be associated with the pregnancy outcomes of patients undergoing in vitro fertilization

BACKGROUND

Antiphospholipid syndrome (APS) is an autoimmune disease that is associated with recurrent pregnancy loss. It is still controversial whether the presence of antiphospholipid antibodies (aPL) in the serum of patients with in vitro fertilization-embryo transfer (IVF-ET) has a negative effect on the outcomes. In view of the discrepancies, a meta-analysis of the published data was performed to explore the relationship of aPL and IVF-ET outcomes.

METHODS

We searched for all published articles indexed in PubMed, Web of Science, and Cochrane Library, which were retrieved up to April, 2021. A total of 921 studies were yielded, of which 6 finally met the inclusion criteria. We carried out the meta-analysis by pooling results of these studies with Review Manager 5.3 software. The effect index was measured with 95% confidence intervals (CIs) of the relative risks (RRs).

RESULTS

Six eligible studies were included in this meta-analysis, involving 3214 patients. Our results showed that positive aPL was not associated with decreased clinical pregnancy rate (RR 0.97; 95% CI 0.91-1.04). There was no correlation between positive aPL and increased miscarriage risk (RR 1.22; 95% CI 0.94-1.58). Only 5 of the 6 studies referred to live birth rate, but still no association was found between them (RR 0.95; 95% CI 0.81-1.11).

CONCLUSIONS

The results showed that the presence of positive aPL neither decreased clinical pregnancy rate and live birth rate, nor increased miscarriage rate in women undergoing IVF, which is differed from the opinion of clinical practice. More prospective studies with high quality and larger sample size are needed to evaluate the relationship between positive aPL and outcomes of IVF-ET.

Recurrent Implantation Failure-Is It the Egg or the Chicken?

Recurrent implantation failure (RIF) is an undefined, quite often, clinical phenomenon that can result from the repeated failure of embryo transfers to obtain a viable pregnancy. Careful clinical evaluation prior to assisted reproduction can uncover various treatable causes, including endocrine dysfunction, fibroid(s), polyp(s), adhesions, uterine malformations. Despite the fact that it is often encountered and has a critical role in Assisted Reproductive Technique (ART) and human reproduction, RIF’s do not yet have an agreed-on definition, and its etiologic factors have not been entirely determined. ART is a complex treatment with a variable percentage of success among patients and care providers. ART depends on several factors that are not always known and probably not always the same. When confronted with repeated ART failure, medical care providers should try to determine whether the cause is an embryo or endometrium related. One of the most common causes of pregnancy failure is aneuploidy. Therefore, it is likely that this represents a common cause of RIF. Other RIF potential causes include immune and endometrial factors; however, with a very poorly defined role. Recent data indicate that the possible endometrial causes of RIF are very rare, thereby throwing into doubt all endometrial receptivity assays. All recent reports indicate that the true origin of RIF is probably due to the “egg”.

Antiphospholipid antibodies and pregnancy outcome of assisted reproductive treatment: A systematic review and meta-analysis

PROBLEM

Antiphospholipid antibodies (aPLs) are a group of autoantibodies associated with a variety of pregnancy complications, but the impact of aPL on the outcomes of assisted fertility treatment (ART) is controversial. This systematic review and meta-analysis were designed to explore the association between aPL and ART outcomes and to explore in which stages does aPL play a role.

METHOD OF STUDY

PubMed and Cochrane database were systematically retrieved, and odds ratios (ORs) or risk ratios (RRs) with 95% confidence intervals (CIs) were calculated in a random-effect model or fixed-effect model according to the heterogenicity assessed by the Cochran Q and I²  statistic test. Of 246 records identified by the search, 10 case-control studies and 13 cohort studies that explored the association between aPL and in vitro fertilization (IVF) and/or intracytoplasmic sperm injection (ICSI) were analyzed.

RESULTS

The results showed that aPL positive rate was higher in females who failed in IVF/ICSI than those who succeeded in IVF/ICSI (OR: 3.62, 95% CI: 1.95-6.74). This study also indicated that females positive for aPL have a higher miscarriage rate (RR: 1.68, 95% CI: 1.24-2.28) than those negative for aPL, but live birth rate, biochemical pregnancy rate, and clinical pregnancy rate were similar between two groups (RR: 1.01, 95% CI: 0.91-1.12; RR: 1.18, 95% CI: 0.57-2.43 and RR: 0.95, 95% CI: 0.80-1.13).

CONCLUSIONS

There was higher aPL prevalence in females with adverse IVF/ICSI outcomes. It seems that aPL mainly affects the miscarriage rate, but has little effect on live birth rate, biochemical pregnancy rate, and clinical pregnancy rate. Routine detection of aPL before IVF/ICSI treatment is meaningful.

The Pathophysiology of Hypercoagulability and Infertility

Alongside an interplay of a multitude of factors, attainment of a favorable pregnancy outcome is predicated on successful implantation, which in itself is a complex process anchored by balanced interchange with the hemostatic system. Among other etiologies, failure of implantation can result in infertility, and lead affected couples to consider assisted reproductive technology (ART) in an effort to fulfill their desire for procreation. Given the critical role of the hemostatic system in the process of implantation, documentation of a hypercoagulable state during controlled ovarian stimulation in the context of in vitro fertilization, as well as the potential association of its derangement in the setting of thrombophilia, with infertility, ART, ovarian hyperstimulation syndrome, and failure of implantation are explored. Additionally, current evidence addressing the relationship between ART and thromboembolism is examined, as is the role of therapy with heparin and aspirin to decrease thrombotic risk and improve ART-related pregnancy outcomes. Evidence-based recommendations from relevant professional societies are summarized.

Antiphospholipid antibodies levels and potential effects on in-vitro fertilization in a large cohort of infertile Syrian women

Background

Obstetric morbidities represent a common hallmark manifestation of antiphospholipid syndrome (APS), with the recurrent loss of pregnancy as the main complication. The presence of antiphospholipid antibodies (APA) and its potential impact have not been established yet in infertile women seeking assisted reproduction technologies in Syria.

This study aims to determine the prevalence of anticardiolipin antibodies (aCL) and lupus anticoagulation (LAC) and their association with age and the In vitro fertilization (IVF) outcomes in a large sample of Syrian women.

Materials and methods

The electronic patients’ records were screened and relevant data extraction was performed retrospectively. The study included 876 women who had IVF between January 2012 and January 2020 in a tertiary care hospital.

Results

The prevalence of APA among the included women was less than 1%. Only 5 patients had positive APA. No correlation was found between the APA levels and age. Additionally, the APA did not have an impact on neither the IVF outcomes nor the number of IVF cycles.

Conclusion

the added value of APS antibodies’ screening could be considered very modest when compared to its financial burden on patients since it has a very low prevalence in women having IVF.

•

Obstetric morbidities are a hallmark manifestation of antiphospholipid syndrome.

•

The prevalence of APS in Syrian women having IVF was less than 1%.

•

No correlation was found between the APA levels and age.

•

The APA had no impact on the IVF outcomes or the number of IVF cycles.

•

Screening of APA constitutes a financial burden on patients more than its benefit.

Using Deep Learning in a Monocentric Study to Characterize Maternal Immune Environment for Predicting Pregnancy Outcomes in the Recurrent Reproductive Failure Patients

Recurrent reproductive failure (RRF), such as recurrent pregnancy loss and repeated implantation failure, is characterized by complex etiologies and particularly associated with diverse maternal factors. It is currently believed that RRF is closely associated with the maternal environment, which is, in turn, affected by complex immune factors. Without the use of automated tools, it is often difficult to assess the interaction and synergistic effects of the various immune factors on the pregnancy outcome. As a result, the application of Artificial Intelligence (A.I.) has been explored in the field of assisted reproductive technology (ART). In this study, we reviewed studies on the use of A.I. to develop prediction models for pregnancy outcomes of patients who underwent ART treatment. A limited amount of models based on genetic markers or common indices have been established for prediction of pregnancy outcome of patients with RRF. In this study, we applied A.I. to analyze the medical information of patients with RRF, including immune indicators. The entire clinical samples set (561 samples) was divided into two sets: 90% of the set was used for training and 10% for testing. Different data panels were established to predict pregnancy outcomes at four different gestational nodes, including biochemical pregnancy, clinical pregnancy, ongoing pregnancy, and live birth, respectively. The prediction models of pregnancy outcomes were established using sparse coding, based on six data panels: basic patient characteristics, hormone levels, autoantibodies, peripheral immunology, endometrial immunology, and embryo parameters. The six data panels covered 64 variables. In terms of biochemical pregnancy prediction, the area under curve (AUC) using the endometrial immunology panel was the largest (AUC = 0.766, accuracy: 73.0%). The AUC using the autoantibodies panel was the largest in predicting clinical pregnancy (AUC = 0.688, accuracy: 78.4%), ongoing pregnancy (AUC = 0.802, accuracy: 75.0%), and live birth (AUC = 0.909, accuracy: 89.7%). Combining the data panels did not significantly enhance the effect on prediction of all the four pregnancy outcomes. These results give us a new insight on reproductive immunology and establish the basis for assisting clinicians to plan more precise and personalized diagnosis and treatment for patients with RRF.

Recurrent Implantation Failure-update overview on etiology, diagnosis, treatment and future directions

Recurrent implantation failure (RIF) refers to cases in which women have had three failed in vitro fertilization (IVF) attempts with good quality embryos. The definition should also take advanced maternal age and embryo stage into consideration. The failure of embryo implantation can be a consequence of uterine, male, or embryo factors, or the specific type of IVF protocol. These cases should be investigated to determine the most likely etiologies of the condition, as this is a complex problem with several variables. There are multiple risk factors for recurrent implantation failure including advanced maternal age, smoking status of both parents, elevated body mass index, and stress levels. Immunological factors such as cytokine levels and presence of specific autoantibodies should be examined, as well as any infectious organisms in the uterus leading to chronic endometritis. Uterine pathologies such as polyps and myomas as well as congenital anatomical anomalies should be ruled out. Sperm analysis, pre-implantation genetic screening and endometrial receptivity should be considered and evaluated, and IVF protocols should be tailored to specific patients or patient populations. Treatment approaches should be directed toward individual patient cases. In addition, we suggest considering a new initial step in approach to patients with RIF, individualized planned activities to activate the brain's reward system in attempt to improve immunological balance in the body.

Impact of presence of antiphospholipid antibodies on in vitro fertilization outcome

Objective

To investigate prevalence of antiphospholipid antibody (APA) in Korean infertile women undergoing the first in vitro fertilization (IVF) treatment and to evaluate the influence of APA on the subsequent IVF outcomes.

Method

Two hundred nineteen infertile women who destined the first IVF were prospectively enrolled in 2 infertility centers. Male factor or uterine factor infertility and women with past or current endocrine or immunologic disorders were completely excluded. Plasma concentration of lupus anticoagulant was measured by clot-based method, and anticardiolipin antibody (IgG/IgM), and anti-β2-glycoprotein 1 antibody (IgG/IgM) was measured by enzyme-linked immunosorbent assay method before starting ovarian stimulation for IVF.

Results

APA was positive in 13 women (5.9%). Lupus anticoagulant was positive in 2 women (0.9%), anticardiolipin antibody was positive in 7 women (3.2%), and anti-β2-glycoprotein 1 antibody was positive in 4 women (1.8%). In 193 women entering embryo transfer, clinical characteristics and stimulation outcomes were comparable between APA-positive (n=12) and APA-negative group (n=181). The clinical pregnancy rate (66.7% vs. 45.9%), ongoing pregnancy rate (58.3% vs. 37.0%), and miscarriage rate (12.5% vs. 19.3%) were all similar between APA-positive and APA-negative group.

Conclusion

The prevalence of APA is low in Korean infertile women undergoing the first IVF cycle, and the presence of APA appears to neither decrease their first IVF success nor increase abortion rate.

In Vitro Fertilization in 37 Women with Systemic Lupus Erythematosus or Antiphospholipid Syndrome: A Series of 97 Procedures

OBJECTIVE

To compile and assess data about complication and success rates for in vitro fertilization (IVF) of women with systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS). To date, such data are sparse.

METHODS

This retrospective study described women with SLE and/or APS who have had at least 1 IVF cycle.

RESULTS

Thirty-seven women with SLE (n = 23, including 8 with antiphospholipid antibodies), SLE with APS (n = 4), or primary APS (n = 10) underwent 97 IVF procedures. For 43% of cases, the infertility was female in origin, for 19% male, 14% mixed, and 24% unexplained. No women had premature ovarian insufficiency because of cyclophosphamide. Median age at IVF was 34 years (range 26-46). The median number of IVF cycles was 2.6 (1-8). Patients were treated with hydroxychloroquine (72%), steroids (70%), azathioprine (3%), aspirin (92%), and/or low molecular weight heparin (62%). There were 27 (28%) pregnancies, 23 live births among 26 neonates (3 twin pregnancies), 2 miscarriages, and 2 terminations for trisomy 13 and 21. Six spontaneous pregnancies occurred during the followup. Finally, 26 women (70%) delivered at least 1 healthy child. Complications occurred in or after 8 IVF cycles (8%): SLE flares in 4 (polyarthritis in 3 and lupus enteritis in 1) and thromboembolic events in 4 others. One SLE flare was the first sign of previously undiagnosed SLE. Poor treatment adherence was obvious in 2 other flares and 2 thromboses. No ovarian hyperstimulation syndrome was reported.

CONCLUSION

These preliminary results confirm that IVF can be safely and successfully performed in women with SLE and/or APS.

Local and systemic factors and implantation: what is the evidence?

Significant progress has been made in the understanding of embryonic competence and endometrial receptivity since the inception of assisted reproductive technology. The endometrium is a highly dynamic tissue that plays a crucial role in the establishment and maintenance of normal pregnancy. In response to steroid sex hormones, the endometrium undergoes marked changes during the menstrual cycle that are critical for acceptance of the nascent embryo. There is also a wide body of literature on systemic factors that impact assisted reproductive technology outcomes. Patient prognosis is impacted by an array of factors that tip the scales in her favor or against success. Recognizing the local and systemic factors will allow clinicians to better understand and optimize the maternal environment at the time of implantation. This review will address the current literature on endometrial and systemic factors related to impaired implantation and highlight recent advances in this area of reproductive medicine.

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.

Antiphospholipid antibodies and infertility

Since the late 1980s some publications have proposed that antiphospholipid antibodies (aPL) may have some relationship with infertility, considering reported deleterious effects that aPL exert on trophoblast proliferation and growth. Although not included in current classification criteria for antiphospholipid syndrome, many physicians investigate for aPL in patients with a history of infertility, including antibodies not listed in classification criteria, and most of those patients will receive anticoagulant therapy if any of those antibodies have a result considered positive. A review of literature was conducted searching for studies that investigated the association of aPL and infertility and if aPL positivity alters in vitro fertilization (IVF) outcome. The definition of infertility, routine work-up to exclude other causes of infertility, definition of IVF failure as inclusion criteria and control populations were heterogeneous among studies. Most of them enrolled women over 40 years of age, and exclusion of other confounding factors was also inconsistent. Of 29 studies that assessed aPL positivity rates in infertile women, the majority had small sample sizes, implying a lack of power, and 13 (44.8%) reported higher frequency of aPL in infertile patients compared to controls, but most of them investigated a panel of non-criteria aPL tests, whose clinical significance is highly controversial. Only two studies investigated all three criteria tests, and medium-high titer of anticardiolipin cut-off conforming to international guidelines was used in one study. Considering IVF outcome, there was also disparity in this definition: few studies assessed the live birth rate, others the implantation rate. Of 14 publications that addressed the relationship between aPL and IVF outcome, only two described a detrimental effect of these autoantibodies. In conclusion, available data do not support an association between aPL and infertility, and aPL positivity does not seem to influence IVF outcome. Well-designed clinical studies recruiting women with a clear diagnosis of infertility and a high-risk aPL profile should be performed to test whether clinically relevant aPL do-or not-exert an effect on human fertility.

Antiphospholipid Antibodies and Antiphospholipid Syndrome during Pregnancy: Diagnostic Concepts

Antiphospholipid syndrome (APS) comprises of a wide spectrum of clinical and obstetric manifestations linked to the presence of antiphospholipid antibodies (aPL). APS was described in the context of lupus, and later as an isolated syndrome or primary APS. The presence of aPL, especially the lupus anticoagulant test, is associated with adverse pregnancy outcomes, such as fetal death, recurrent early miscarriages, pre-eclampsia, and placental insufficiency, but does not seem to influence infertility. High quality scientific data to support these associations, however, are lacking, and controversies arise about the definition of positive aPL (low vs medium-high titers) or even the definition of the adverse events. This review discusses APS classification criteria and the current debate about it.

[In vitro fertilization and systemic lupus erythematosus or antiphospholipid syndrome: An update]

Fertility is not impaired in systemic lupus erythematosus or antiphospholipid syndrome, but, similarly to the general population, these patients may undergo in vitro fertilization. This type of treatment increases the risk of lupus flare, thrombosis, and ovarian hyperstimulation syndrome. This review will focus on in vitro fertilization in systemic lupus erythematosus or antiphospholipid syndrome. Literature data are relatively scant with only 3 reported studies. The first one included 17 patients and 63 cycles of induction ovulation/in vitro fertilization leading to 25 % of lupus flare, no thrombosis, and 3 % of ovarian hyperstimulation syndrome. The second study included 10 patients and 40 cycles of in vitro fertilization showing 31 % of lupus flare, no thrombosis and no ovarian hyperstimulation syndrome. The last one included 34 patients and 83 procedures of in vitro fertilization leading to 8 % of flares, 5 % of thrombosis and no ovarian hyperstimulation syndrome. Interestingly, in this last study, half of the complications were explained by poor adherence to treatment. These data are reassuring but it is important to remember that in vitro fertilization should be scheduled and carefully supervised in the same way as the high-risk pregnancies occurring in these patients.

Antiphospholipid antibodies in women undergoing in vitro fertilization treatment: clinical value of IgA anti-β2glycoprotein I antibodies determination

Implantation failure could be related to antiphospholipid antibodies (aPL). We retrospectively analyzed the usefulness of aPL determination in women undergoing IVF. Conventional aPL of the antiphospholipid syndrome, lupus anticoagulant (LA), anticardiolipin antibodies (aCL), anti-β2glycoprotein I (aβ2GPI) antibodies, and IgG and IgM isotypes as well as IgA isotype were analyzed in women presenting with at least two implantation failures after in vitro fertilization (IVF). In a population of 40 IVF patients, a total prevalence of 20% (8/40) of aPL was found, significantly different from that of the control population (100 healthy blood donors, P < 0.0005). Among the panels of aPL tested, aβ2GPI IgA antibodies were the most prevalent (62.5% 5/8), significantly higher in IVF patients (12.5%, 5/40) than in controls (1%, 1/100) (P = 0.01). No difference according to the numbers of IVF attempts and success of embryo implantation was found between aPL positive and negative IVF patients. In contrast, no accomplished pregnancy with full-term live birth was observed in aPL positive IVF patients. Altogether our data led us to propose aPL assessment, in particular aβ2GPI IgA antibodies, in support of IVF treated women. In a perspective way, an early aPL detection could be the basis for defining novel therapeutic strategy.

Obstetric antiphospholipid syndrome: a recent classification for an old defined disorder

Obstetric antiphospholipid syndrome (APS) is now being recognized as a distinct entity from vascular APS. Pregnancy morbidity includes >3 consecutive and spontaneous early miscarriages before 10weeks of gestation; at least one unexplained fetal death after the 10th week of gestation of a morphologically normal fetus; a premature birth before the 34th week of gestation of a normal neonate due to eclampsia or severe pre-eclampsia or placental insufficiency. It is not well understood how antiphospholipid antibodies (aPLs), beyond their diagnostic and prognostic role, contribute to pregnancy manifestations. Indeed aPL-mediated thrombotic events cannot explain the obstetric manifestations and additional pathogenic mechanisms, such as a placental aPL mediated complement activation and a direct effect of aPLs on placental development, have been reported. Still debated is the possible association between aPLs and infertility and the effect of maternal autoantibodies on non-vascular manifestations in the babies. Combination of low dose aspirin and unfractionated or low molecular weight heparin is the effective treatment in most of the cases. However, pregnancy complications, in spite of this therapy, can occur in up to 20% of the patients. Novel alternative therapies able to abrogate the aPL pathogenic action either by interfering with aPL binding at the placental level or by inhibiting the aPL-mediated detrimental effect are under active investigation.

14th International Congress on Antiphospholipid Antibodies Task Force report on obstetric antiphospholipid syndrome

Pregnancy morbidity is one of the clinical manifestations used for classification criteria of antiphospholipid syndrome (APS). During the 14th International Congress on Antiphospholipid Antibodies (aPL), a Task Force with internationally-known experts was created to carry out a critical appraisal of the literature available regarding the association of aPL with obstetric manifestations present in actual classification criteria (recurrent early miscarriage, fetal death, preeclampsia and placental insufficiency) and the quality of the evidence that treatment(s) provide benefit in terms of avoiding recurrent adverse obstetric outcomes. The association of infertility with aPL and the effectiveness of the treatment of patients with infertility and positive aPL was also investigated. This report presents current knowledge and limitations of published studies regarding pregnancy morbidity, infertility and aPL, identifying areas that need better investigative efforts and proposing how critical flaws could be avoided in future studies, as suggested by participants of the Task Force. Except for fetal death, there are limitations in the quality of the data supporting the association of aPL with obstetric complications included in the current APS classification criteria. Recommended treatments for all pregnancy morbidity associated to APS also lack well-designed studies to confirm its efficacy. APL does not seem to be associated with infertility and treatment does not improve the outcomes in infertile patients with aPL. In another section of the Task Force, Dr. Jane Salmon reviewed complement-mediated inflammation in reproductive failure in APS, considering new therapeutic targets to obstetric APS (Ob APS).

Obstetrical antiphospholipid syndrome: from the pathogenesis to the clinical and therapeutic implications

Antiphospholipid syndrome (APS) is an acquired thrombophilia with clinical manifestations associated with the presence of antiphospholipid antibodies (aPL) in patient plasma. Obstetrical APS is a complex entity that may affect both mother and fetus throughout the entire pregnancy with high morbidity. Clinical complications are as various as recurrent fetal losses, stillbirth, intrauterine growth restriction (IUGR), and preeclampsia. Pathogenesis of aPL targets trophoblastic cells directly, mainly via proapoptotic, proinflammatory mechanisms, and uncontrolled immunomodulatory responses. Actual first-line treatment is limited to low-dose aspirin (LDA) and low-molecular weight heparin (LMWH) and still failed in 30% of the cases. APS pregnancies should be a major field in obstetrical research, and new therapeutics are still in progress.

Persistent antiphospholipid antibodies do not contribute to adverse pregnancy outcomes

OBJECTIVE

To determine whether women with persistent aPL (>12 weeks apart on at least two separate occasions) without a history of thrombosis or adverse pregnancy outcome had the same adverse pregnancy outcomes as those with obstetric APS or unmatched controls.

METHODS

This was a case-control study between 2005 and 2011 where we identified 73 women with persistent aPL and coincidentally the same number with obstetric APS. Unmatched controls were identified from low-risk clinics (ratio 1:4). Women with multiple pregnancies, fetal anomalies, SLE, thrombotic APS and other thrombophilias were excluded.

RESULTS

Cases and controls were demographically similar, with the exception of younger controls with fewer medical comorbidities. aPL profiles were similar between aPL and APS. In women with aPL, risk of APS-type complications (odds ratio 1.3; 95% CI 0.6, 2.9) and birthweight distribution (median birthweight on a customized centile was 50.8, interquartile range 26.4-68.9; P < 0.05) were similar to controls. These findings persisted even after adjustment for maternal age and medical comorbidities.

CONCLUSION

Women with persistent aPL on aspirin had pregnancy outcomes that were similar to controls. These data suggest that in the absence of other risk factors, women with aPL do not need intense antenatal surveillance or modified management in pregnancy.

Aspirin and heparin to improve live birth rate in IVF for unexplained implantation failure?

The data concerning use of aspirin and/or heparin in IVF failure patients is reviewed. A number of methodological and biological problems are identified. A strategy to achieve reliable conclusions is explained.

Aspirin and heparin as adjuvants during IVF do not improve live birth rates in unexplained implantation failure

This study tested the hypothesis that using aspirin and/or heparin as adjuvants in IVF improves the treatment outcome. This retrospective cohort-control study recruited 234 consecutive subjects aged ≤ 44 years who had previously had one or more unsuccessful IVF cycle. All underwent IVF using conventional protocols. The study group received aspirin and/or heparin post embryo transfer until the day of pregnancy test or until 12 weeks of pregnancy. The control group did not receive adjuvant treatment. The outcome measures were live birth, clinical pregnancy and miscarriage rates. The outcomes were compared by chi-squared test and relative-risk analysis. Analysis was performed in 206 subjects. There was no statistically significant difference in the live birth rate (35.0%, 36/103 versus 47.6%, 49/103), clinical pregnancy rate (40.8%, 42/103 versus 53.4%, 55/103) and miscarriage rate (14.3%, 6/42 versus 10.9%, 6/55) between the study group and the control group. The data in this study show that low-dose aspirin and/or heparin as adjuvant therapies during IVF do not improve live birth rates in an unselected group of subfertile women who have previously had one or more unexplained implantation failure following IVF.

The correlation of autoantibodies and uNK cells in women with reproductive failure

There is conflicting evidence on the role of autoimmune disorders in reproductive failure, including recurrent miscarriage (RM) and recurrent implantation failure (RIF), after in vitro fertilisation (IVF). Several commonly studied autoimmune markers in women with reproductive failure include antiphospholipid antibodies (APAs), thyroid peroxidase antibodies (TPA) and uterine natural killer (uNK) cells. However, there have not been any studies that have examined the correlation of these markers in women with reproductive failure. To determine if women who tested positive for autoantibodies (APA and thyroid peroxidase antibodies) have significantly higher uNK cell numbers than women who tested negative for these antibodies, the percentage of stromal cells that stained positive for CD56 was identified by immunocytochemistry in endometrial biopsies from 42 women with unexplained RM (29 women tested negative for autoantibodies and 13 women tested positive for autoantibodies) and 40 women with unexplained RIF (30 women tested negative for autoantibodies and 10 women tested positive for autoantibodies). Biopsies were obtained on days LH+7 to LH+9. There was no significant difference in uNK cell numbers between women with unexplained RM who tested negative and those who tested positive for autoantibodies. Similarly, there was no significant difference in uNK cell numbers between women with unexplained RIF who tested negative and those who tested positive for autoantibodies. In women with reproductive failure the presence of autoantibodies does not appear to affect the numbers of uNK cells in the endometrium around the time of implantation.

An efficient infertility evaluation

The biological clock is a major adversary to human reproduction. Not only does fecundity wane with time, but so does an infertility patient's emotional reserve. Therefore, a well-organized approach to evaluating, treating, and referring patients to subspecialty centers when necessary is critical to optimally manage infertility. The initial infertility evaluation has undergone evidence-based improvements in efficiency and has demonstrated that less testing has given more useful knowledge.

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

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

Successful pregnancy after rituximab in a women with recurrent in vitro fertilisation failures and anti-phospholipid antibody positive

We report a case of successful pregnancy after rituximab in a patient with a history of in vitro fertilisation (IVF) failures and positive anti-cardiolipin antibody (ACA). Following a course of rituximab, her ACA became negative and she successfully conceived with IVF treatment. This is the first case in literature describing the use of rituximab therapy in this clinical scenario.

Is there a role of autoimmunity in implantation failure after in-vitro fertilization?

PURPOSE OF REVIEW

The process of implantation involves the interaction of the human blastocyst and the uterine epithelium. Several autoimmune factors have been implicated to have an influence on implantation failure.

RECENT FINDINGS

Recent studies have investigated the role of autoimmune factors in implantation in women undergoing in-vitro fertilization. Antiphospholipid antibodies are identified more frequently in women undergoing in-vitro fertilization, but their presence does not appear to influence the outcome of pregnancy, miscarriage, or live birth rates. Antithyroid antibodies are commonly found in women of reproductive age, but implantation rates and miscarriage rates are not altered when women have normal thyroid function. Antinuclear antibodies may be a marker for underlying autoimmune disease when coupled with certain signs and symptoms, but low-titer antibodies do not influence in-vitro fertilization outcome. Antisperm antibodies are more often associated with fertilization failure when found in high titers in seminal plasma, in sperm, or in the mucosal immune system of women. Antisperm antibodies are uncommon but most often associated with ovarian hypofunction.

SUMMARY

Implantation is characterized by the interaction of two immunologically and genetically distinct tissues. During implantation, local and systemic immune factors, cytokines, and growth factors may interact with adhesion molecules and other matrix-associated proteins, glycoproteins, and peptides.

Ovarian stimulation for ovulation induction and in vitro fertilization in patients with systemic lupus erythematosus and antiphospholipid syndrome

OBJECTIVE

To review the current evidence regarding the relationship between systemic lupus erythematosus (SLE) and antiphospholipid syndrome and female infertility, as well as the risks associated with ovarian stimulation for ovulation induction and IVF. To establish, based on this information, guidelines for safe and successful assisted reproductive technology (ART).

DESIGN

A MEDLINE computer search was performed to identify relevant articles.

RESULT(S)

Systemic lupus erythematosus and antiphospholipid syndrome are not related to infertility, except for cases of amenorrhea accompanying severe flares, renal insufficiency-related hypofertility, and ovarian failure secondary to cyclophosphamide (CTX) therapy. The most threatening conditions in affected women undergoing ovarian stimulation are lupus flares and thrombosis, with the latter being especially associated with the occurrence of an overt ovarian hyperstimulation syndrome (OHSS). Friendly ovarian stimulation, single embryo transfer, avoidance of OHSS, administration of coadjuvant therapy, and use of natural E(2) or P through a nonoral route may constitute the safest approach. Systemic lupus manifested in acute flares, badly controlled arterial hypertension, pulmonary hypertension, advanced renal disease, severe valvulopathy or heart disease, and major previous thrombotic events are situations on which to discourage ART, especially due to the high risk of complications for both mother and fetus during pregnancy and puerperium.

CONCLUSION(S)

Ovarian stimulation for ovulation induction and IVF seems to be safe and successful in well-selected women with SLE and antiphospholipid syndrome.

Pregnancy and catastrophic antiphospholipid syndrome

Antiphospholipid syndrome (APS) is clearly related to maternal morbidity. The most characteristic feature is pregnancy loss; however, several other serious complications had been reported including fetal growth restriction, uteroplacental insufficiency, fetal distress, pre-eclampsia, and HELLP syndrome. Herein, we review the different aspects of obstetric APS features, with special emphasis on its life-threatening variant known as catastrophic APS (Asherson's syndrome) and its relationship with a thrombotic microangiopathy such as HELLP syndrome.

Anticoagulant therapy and pregnancy

Low dose aspirin therapy is one of the anticoagulant treatments used during pregnancy. Anticoagulant agents may be useful for several disorders, such as recurrent miscarriage, pre-eclampsia, fetal growth restriction and infertility. However, it is unclear whether anticoagulant therapy can increase the live birth rate in all of these cases. Recent data suggest that a low-dose aspirin and heparin combination therapy is effective in the prevention of recurrent pregnancy loss in women with antiphospholipid syndrome. Thrombogenic diseases, for example, protein C deficiency, protein S deficiency, factor XII deficiency and hyperhomocysteinemia, may cause pregnancy loss. The etiology of recurrent miscarriage is often unclear and may be multifactorial, with much controversy regarding diagnosis and treatment. Although 70% of recurrent pregnancy losses are unexplained, anticoagulant therapy is effective in maintaining pregnancy without antiphospholipid antibody syndrome. We conclude that a low-dose aspirin and heparin combination therapy can be useful for unexplained cases of recurrent pregnancy loss without antiphospholipid antibody syndrome. (Reprod Med Biol 2008; 7: 1-10).