Intravenous immunoglobulin (IVIG) therapy for immunologic abortion

Efficacy of intravenous immunoglobulin in the treatment of recurrent spontaneous abortion: A systematic review and meta-analysis

OBJECTIVE

We aimed to evaluate the efficacy of IVIG in the treatment with patients with recurrent spontaneous abortion (RSA).

METHODS

PubMed, Embase, Web of science, Cochrane library were searched for randomized controlled (RCTs) about effect of IVIG on RSA from inception to August 20, 2021. Values of standardized mean differences (SMD) were determined for continuous outcomes.

RESULTS

A total of 15 articles involving 902 patients were included in meta-analysis. Compared with the control group, IVIG can increase the live birth rate of recurrent spontaneous abortion patients [OR = 3.06, 95%CI (1.23, 7.64, P = .02]. However, recurrent abortion was divided into primary and secondary abortion for subgroup analysis, and there was no statistical difference. Besides, IVIG can also increase the expression in peripheral blood CD3+[OR = .4, 95%CI(-2.47, 3.15, P = .81],CD4+[OR = 1.16, 95%CI(-4.60, 6.93, P = .69], and a decrease in the expression of CD8+[OR = -1.78, 95%CI(-5.30, 1.75, P = .32], but there is no statistical significance.

CONCLUSIONS

IVIG can significantly increase the live birth rate of recurrent spontaneous abortion. However, the evidence needs further verification and the curative effect is uncertain. It is necessary to further explore the pathogenesis of recurrent abortion and the mechanism of IVIG in the treatment of recurrent spontaneous abortion. Besides, more high-quality randomized controlled trials suitable for population, race, dosage and timing of IVIG in the treatment of recurrent abortion are needed to confirm its effectiveness, and effective systematic evaluation is also needed to evaluate its use benefit.

Clinical effect of lymphocyte immunotherapy on patients with unexplained recurrent spontaneous abortion

Introduction

Lymphocyte immunotherapy (LIT) is believed to be a viable treatment for unexplained recurrent spontaneous abortion (URSA), but its effect remains controversial. This study aims to investigate the clinical effect of LIT in patients with URSA and clarify the factors that may influence the outcome of LIT.

Methods

This study included a total of 704 URSA patients, of which 444 patients accepted LIT treatment. URSA patients that did not accept LIT served as control group. Clinical characteristics were collected and analyzed between LIT and control group. The blocking antibody was tested before and after LIT. The outcome of LIT treatment was recorded. Logistic regression analysis was applied to evaluate the independent predictors of LIT success.

Results

After LIT treatment, 77.9% (346/444) of USRA patients turned to BA positive, and the conversion rate elevated with increased LIT (p < .001). LIT significantly improved the pregnancy rate and live birth rate in USRA patients (65.3% vs. 29.6%, p < .001; 80.3% vs. 50.6%, p < .001). Multivariate regression analysis suggested that younger maternal age and positive BA were independent predictors of LIT success.

Conclusion

LIT effectively induced the production of BA, and improved pregnancy rate and live birth rate in URSA patients. Our findings supported LIT as a beneficial treatment for URSA.

Modulatory effect of intravenous immunoglobulin on Th17/Treg cell balance in women with unexplained recurrent spontaneous abortion

Recurrent spontaneous abortion (RSA) is a growing problem worldwide. In a majority of cases, the cause remains unknown but there is increasing evidence that immunologic factors play an important role. Intravenous immunoglobulin (IVIg) therapy has been proposed to have immune modulatory effects and therefore been applicable for the treatment of patients with RSA. Although its efficacy is still controversial, several recent studies suggest that IVIg treatment may improve pregnancy outcomes. CD4⁺ T cells and their related cytokines play an important role in maternal-fetal immune regulation, and an imbalance of Th17/Treg cell ratio has been proposed as a cause for RSA. We review the scientific evidence supporting a modulatory effect of IVIg on Th17/Treg cell balance and discuss the potential mechanisms how IVIg might enhance Treg cells function. We propose that correction of Th17/Treg cell dysregulation could be one of the mechanisms that can explain the positive therapeutic effects of IVIg therapy. Consequently, selecting patients with abnormal Th17/Treg cell ratios could increase the success of IVIg therapy.

Effect of Intravenous immunoglobulin on Th1 and Th2 lymphocytes and improvement of pregnancy outcome in recurrent pregnancy loss (RPL)

BACKGROUND

Women with elevated natural killer (NK) cell frequency and function during pregnancy, suffer from recurrent pregnancy loss (RPL). In the present study, the possible effect of intravenous immunoglobulin (IVIG) administration on Th1 and Th2 cell frequency, cytokine secretion, and expression of transcription factors is compared between RPL patients and control group.

MATERIALS AND METHODS

Totally, 44 women with a history of RPL (32 women as treated group and 12 as control group) were enrolled in the study. The frequency of Th1 and Th2 lymphocytes, the expression of transcription factors related to these cells and the serum levels of associated cytokines were assessed by flowcytometry, real-time PCR and ELISA, respectively. All, assessments were performed both before and after treatment with IVIG.

RESULTS

A significant reduction in Th1 lymphocyte frequency, transcription factor expression and cytokine levels were observed in IVIG-treated group, while all the above parameters indicated a significant increase for Th2 lymphocytes. Th1/Th2 ratio decreased significantly (p value<0.0001) at the end of treatment and 28 out of 32 (87.5%) women in IVIG-treated group had live birth in comparison with 5 out of 12 (41.6%) in untreated group.

CONCLUSION

IVIG administration proves to be an efficient therapeutic strategy which is able to enhance the success rate of pregnancy through a shift in Th2 responses. Furthermore, IVIG presents efficacy for the treatment of reproduction failures especially in subjects with immune cell abnormalities and increased NK cell level and function.

Intravenous immunoglobulin treatment increased live birth rate in a Spanish cohort of women with recurrent reproductive failure and expanded CD56(+) cells

PROBLEM

Natural killer (NK, CD3(-)CD56(+)/CD16(+)) and NKT-like cells (CD3(+)CD56(+)/CD16(+)) activity is considered among the key factors for reproductive success. In the absence of immunological screening, beneficial effects of intravenous immunoglobulin (IVIG) in preventing recurrent reproductive failure (RRF) have not been reported. Here, we analyse the IVIG influence on pregnancy success in women with RRF and circulating NK or/and NKT-like cells expansion.

METHOD OF STUDY

One hundred fifty-seven women with previous recurrent miscarriage and/or recurrent implantation failure after in vitro fertilization were consecutively studied. Sixty-four patients with CD56(+) cell expansion, no apparent underlying disease and who maintained their desire to conceive were selected. Forty of them received IVIG during pregnancy.

RESULTS

Overall, the clinical pregnancy rate for the women under IVIG therapy was 92.5% and the live birth rate was 82.5%. Significantly lower pregnancy and live birth rates (25% and 12.5%, respectively) were observed for the patients with recurrent pregnancy loss and NK/NKT-like cells expansion without IVIG. After three cycles of IVIG, NK cell percentages decreased significantly and these values persisted throughout gestation.

CONCLUSION

Intravenous immunoglobulin therapy for women with RRF and NK or NKT-like cell expansion was a safe and beneficial therapeutic strategy that associated with high clinical pregnancy and live birth rates.

Low circulating CD4(+) CD25(+) Foxp3(+) T regulatory cell levels predict miscarriage risk in newly pregnant women with a history of failure

PROBLEM  The purpose of this study was to determine whether quantification of peripheral blood Treg cell levels could be used as an indicator of miscarriage risk in newly pregnant women with a history of immunologic reproductive failure. METHOD OF STUDY  Fifty-four pregnant women with a history of immunologic infertility and/or pregnancy loss were retrospectively evaluated (mean age: 36.7 ± 4.9 years, 2.8 ± 2.5 previous miscarriages; 1.5 ± 1.9 previous IVF failures). Twenty-three of these women experienced another first trimester miscarriage, and 31 of these women continued their current pregnancies past 12 weeks ('pregnancy success'). The following immunologic parameters were assessed in the first trimester: NK cell 50:1 cytotoxicity, CD56(+)  16(+)  CD3(-) (NK), CD56(+)  CD3(+) (NKT), TNFα/IL-10, IFNγ/IL-10, CD4(+)  CD25(-) Foxp3(+) , total CD4(+)  Foxp3(+) (CD4(+ ) CD25(+)  Foxp3 plus CD25(- ) Foxp3(+) ), and CD4(+)  CD25(+)  Foxp3(+) levels. RESULTS  Patients with successful ongoing pregnancies experienced a mean (CD4(+)  CD25(+)  Foxp3(+) ) 'Treg' level of 0.72 ± 0.52%, while those that miscarried in the first trimester experienced a mean Treg level of 0.37 ± 0.29% (P = 0.005). Markers not significantly different between the loss and success groups were NK 50:1 cytotoxicity (P = 0.63), CD56(+)  16(+)  3(+) NK cells (P = 0.63), CD56(+)  3(+)   NKT (P = 0.30), TNFα(+) IL-10(+) (P = 0.13), IFNg(+) IL-10(+) (P = 0.63), and CD4(+)  25(-)  Foxp3(+) cells (P = 0.10), although total CD4(+)  Foxp3(+) levels remained significant (P = 0.02) and CD4(+)  25(+) Foxp3(+) showed the most significant difference (P = 0.005). Mean day of blood draw was 49.2 ± 36.1 days pregnant (median 39.0 days). In addition, patients with a low Treg level (<0.7%) in the first trimester experienced a significantly lower ongoing pregnancy rate than those with a higher Treg level (>0.7%) in the first trimester [44% (15/34) versus 80% (16/20); P = 0.01]. Of the 18 successful pregnancies with sequential Treg results, 85% (11/13) showed a T-regulatory-cell-level increase (mean Treg change 0.33 ± 0.32), while only 40% (2/5) of the failed pregnancies showed a Treg increase (mean Treg change -0.08 ± 0.28; P = 0.02). CONCLUSIONS  From these data, we propose that CD4(+)  CD25(+)  Foxp3(+) T regulatory cells may serve as a superior pregnancy marker for assessing miscarriage risk in newly pregnant women. Larger follow-up studies are needed for confirmation.

CD3-CD56+CD16+ natural killer cells and improvement of pregnancy outcome in IVF/ICSI failure after additional IVIG-treatment

PROBLEM

The purpose of this retrospective, observational study was to investigate whether additional treatment with intravenous immunoglobulin (IVIG) increased the rate of successful pregnancies after repeated implantation failure (RIF). The retrospective data were compared with data of patients without IVIG-therapy from the meta-analysis of Clark et al.

METHOD OF STUDY

A total of 188 women with 226 treatment cycles between 2007 and 2009 were evaluated for IVIG therapy. The percentage of NK cells was measured two times before a new embryo transfer (only women with NK cell percentages >12% were included) and after embryo transfer at a positive pregnancy test.

RESULTS

In comparison with the meta-analysis of Clark et al., we observed a pregnancy rate of 50.5%, an implantation rate of 21% and a miscarriage rate of 16.8%. In 42%/IVIG- patient or 34.9%/embryo transfer, we observed a live born baby. The live born rate per embryo was 16.6%. In accordance with the study of Kwak et al., we indicate a decrease in the NK cells in patients with improved pregnancy outcome.

CONCLUSION

In a subgroup of RIF-patients with high level of CD56(+) CD16(+) NK-cells the additional application of IVIG leads to a favourable pregnancy outcome.

Is intravenous immunoglobulins (IVIG) efficacious in early pregnancy failure? A critical review and meta-analysis for patients who fail in vitro fertilization and embryo transfer (IVF)

PROBLEM

Intravenous Immunoglobulins (IVIG) are widely used off label in the treatment of early reproductive failure. As IVIG is expensive, and may have side-effects, evidence of efficacy is needed. Previous results have suggested that the pre-conception treatment of primary recurrent abortion patients might be effective, but the data set has been too small for adequate statistical power. More recently it has been suggested that IVIG may improve the success rate of in vitro fertilization and embryo transfer (IVF) in patients with prior IVF failures, but clinical trials have given conflicting results that need explanation. Systematic reviews generating inconclusive results have focused on methodological rigor to the exclusion of biological plausibility.

METHODS

Review of current basic science of design, measurement, and evaluation of clinical trials and basic science mechanisms providing a rationale for treatment. Meta-analysis of published randomized controlled and cohort-controlled trials (updated with two unpublished data sets) evaluating IVIG treatment in IVF failure patients. Live birth rate was used as the most relevant endpoint. The ability of different sources of IVIG to suppress natural killer (NK) cell activity was determined using a standard (51)Cr-release assay in vitro.

RESULTS AND CONCLUSIONS

Meta-analysis of three published randomized controlled trials (RCTs) of IVIG in IVF failure patients shows a significant increase in the live birth rate per woman (p = 0.012; Number Needed to Treat for 1 additional live birth, NNT = 6.0 women). Using live birth rate per embryo transferred, and adding data from two cohort-controlled trials to the meta-analysis further supports this conclusion (overall p = 0.000015, NNT = 3.7 women). Relevant variables appear to include properties and scheduling of the IVIG, and selection of patients with abnormal immune test results. Different IVIG preparations vary significantly in their ability to suppress NK activity in vitro. A rationale for use of IVIG is provided by a review of mechanisms of IVIG action and mechanisms underlying failure of chromosomally normal embryos.

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.

Loss of Surface CD200 on Stored Allogeneic Leukocytes may Impair Anti-abortive EffectIn Vivo

PROBLEM

Prevention of spontaneous abortion by allogeneic mononuclear leukocyte immunotherapy has proven ineffective in the CBA x DBA/2 murine abortion model if the leukocytes are stored overnight before inoculation. The mechanism and generality of the phenomenon has not been elucidated.

METHODS

As prevention of recurrent abortion in the CBA x DBA/2 model requires allogeneic BALB/c lymphoid cells bearing paternal antigens and the tolerance-signaling molecule CD200 (OX-2), we evaluated effects of cell storage on cell surface CD200 expression using flow cytometry of fresh or stored cells stained with monoclonal anti-CD200 antibody. Release of putative CD200 molecules into culture supernatant during storage was tested by the ability of supernatants to block binding of anti-CD200 to freshly isolated cells. Similar studies were done using human peripheral blood mononuclear leukocytes. Possible binding of soluble CD200 to immunoglobulin G (IgG) molecules in plasma as a basis for the anti-abortive effect of intravenous immunoglobulin G (IVIG) was tested using the standard peripheral blood lymphocyte (PBL) natural killer (NK) cell lysis of (51)Cr-labeled K562 cells and monoclonal anti-human CD200 antibodies.

RESULTS

Loss of anti-abortive effect of BALB/c cells with overnight storage at 4 degrees C and blocking of protective effect of freshly isolated cells with anti-CD200 antibody was confirmed. Supernatants of stored cells acquired a low level of protective activity against abortion in the CBA x DBA/2 model. Cell surface CD200 was lost with overnight storage at 4 or 22 degrees C, and supernatants acquired the ability to block binding of anti-CD200 antibody to fresh cells. Similar results were obtained using human PBL. However, if cells were stored overnight in IgG containing plasma, binding was not blocked. Suppression of NK cell lysis by PBL was abrogated if anti-CD200 antibody was added to the assay.

CONCLUSIONS

Loss of the tolerance signal CD200 from allogeneic cells occurs with storage overnight, and their ability to protect against abortion is lost. CD200 appears to be shed into the supernatant, and may associate with IgG molecules rendering IVIG suppressive.

Shall We properly Re-examine the Status of Allogeneic Lymphocyte Therapy for Recurrent early Pregnancy Failure?

PROBLEM

How to evaluate immunological therapy advocated for recurrent spontaneous abortion and implantation failure. I was invited to comment on the opinion article of Chaouat (AJRI December 2003).

METHODS

A critical examination of key beliefs and application of the principles of evidence and logic utilizing current data.

RESULTS AND CONCLUSIONS

Although rationale has no bearing on efficacy of proposed treatments and is not sufficient justification for routine practice, insufficient attention to data concerning patient selection, insufficient attention to treatment methodology, and lack of full disclosure in some clinical trials needs to be corrected. A more systematic collection of follow-up data is needed.