Cumulative pregnancy and live birth rates in women with antiphospholipid antibodies undergoing assisted reproduction

Infertility in systemic lupus erythematosus: what rheumatologists need to know in a new age of assisted reproductive technology

Fertility is often a concern for women with SLE. In addition to known indirect factors that influence the ability of a woman with SLE to become pregnant, such as cytotoxic agents, other medications, advanced age and psychosocial effects of the disease, direct disease-related factors are believed to influence fertility. These include diminished ovarian reserve, menstrual irregularities (a function of disease activity) and the presence of antiphospholipid antibodies. The question of whether SLE intrinsically affects fertility, however, remains unanswered. In this review, we address known factors affecting fertility, assess current data regarding a direct impact of SLE on fertility and evaluate potential disease-related risk factors. We focus primarily on studies measuring anti-Müllerian hormone and antral follicle count, the most widely measured markers of ovarian reserve. Our goal is to provide information to rheumatologists faced with counselling patients with SLE regarding their fertility, family planning and options for assisted reproductive technologies, which now include fertility preservation through oocyte cryopreservation.

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.

Antiphospholipid syndrome and infertility

Antiphospholipid syndrome is a systemic autoimmune disease associated with obstetric complications along with vascular events affecting multiple organ systems in patients having positive titers of antiphospholipid antibodies. Eight to 20% of infertility cases have an unknown cause, part of which could be due to antiphospholipid syndrome. Although still debatable, many studies have addressed the relation between reproductive failure and antiphospholipid antibodies through the relation between antiphospholipid antibodies and unexplained infertility as well as the effect of antiphospholipid antibodies on the outcome of in vitro fertilization–embryo transfer. Few studies and cases have associated the presence of antiphospholipid antibodies with male infertility, describing morphofunctional penile abnormalities and testicular infarction. There are not enough data to support the routine practice of testing antiphospholipid antibodies in patients with infertility.

Assisted reproductive technologies for women with rheumatic AID

Assisted reproductive technology (ART) procedures are safe for women with rheumatic autoimmune diseases (rAID) when illness is inactive. Medications incompatible with pregnancy should be replaced with alternative pregnancy-compatible medications months before planned ART procedures to allow time to verify the substitute medication's efficacy and tolerability. Medications compatible with pregnancy should be continued, as should anticoagulation (warfarin changed to low-molecular-weight heparin) before pregnancy begins. Protocols that provide details for specific medications are available. All patients with rAID should be screened for diagnosis-relevant organ system damage, and those intending to carry their own pregnancies must be tested for aPL and anti-Ro/La autoantibodies. Patients with organ damage and/or positive tests for aPL and anti-Ro/La should be counseled about fetal and maternal risks, including implications to the child and family of maternal disability or death. Sperm donors with rAID may need to discontinue medications. REI and physicians treating patients with rAID (usually rheumatologists) must work together to plan and accomplish ART.

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.

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.

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).

Thrombophilia and outcomes of assisted reproduction technologies: a systematic review and meta-analysis

Thrombophilia has been associated with pregnancy complications and recurrent miscarriage. The aim of this systematic review was to evaluate the controversial association between thrombophilia and failures of assisted reproduction technology (ART). A systematic search of the literature for studies reporting on thrombophilia in women undergoing ART up to April 2011 yielded 33 studies (23 evaluating anti-phospholipid antibodies, 5 inherited thrombophilia, and 5 both) involving 6092 patients. Overall, methodologic quality of the studies was poor. Combined results from case-control studies showed that factor V Leiden was significantly more prevalent among women with ART failure compared with fertile parous women or those achieving pregnancy after ART (odds ratio = 3.08; 95% confidence interval, 1.77-5.36). The prothrombin mutation, methylenetetrahydrofolate reductase mutation, deficiency of protein S, protein C, or anti-thrombin were all not associated with ART failure. Women with ART failure tested more frequently positive for anti-phospholipids antibodies (odds ratio = 3.33; 95% confidence interval, 1.77-6.26) with evidence of high degree of between-study heterogeneity (I2 = 75%; P < .00001). Prospective cohort studies did not show significant associations between thrombophilia and ART outcomes. Although case-control studies suggest that women experiencing ART failures are more frequently positive for factor V Leiden and anti-phospholipid antibodies, the evidence is inconclusive and not supported by cohort studies.

Implantation Failure, Etiology, Diagnosis and Treatment

Embryonic implantation is a complex interaction between the embryo and the endometrium. Despite great investigative effort this process is still obscure. Contrary to the great advancement in patient care, follicular recruitment, oocyte quality and aspiration, embryo quality, culture and cryopreservation, our understanding of the implantation process did not enhance as much, and the tools to intervene within this process are limited. The implantation of the transferred embryos still remains the major limiting factor in IVF. Here we will review the current literature on the maternal (uterine, hematologic, immunologic and others) and embryonic factors that are associated with repeated implantation failure (RIF) and describe the various therapeutic approaches to cope with them. In addition, we will present our conclusive recommendations on how to investigate and manage RIF based on the literature and our own experience.

Association of the leukemia inhibitory factor gene mutation and the antiphospholipid antibodies in the peripheral blood of infertile women

To characterize the impact of the potentially functional mutation--the G to A transition at the position 3400 of the leukemia inhibitory factor (LIF; a pluripotent cytokine that plays a central role in the control of the embryo implantation) gene that leads to the exchange of valine with methionine at codon 64 we evaluated the association of the LIF gene mutation and the levels of antiphospolipid antibodies (aPLs) in the peripheral blood of infertile women (the aPLs examination was part of our routine immunological test during the infertility check-up). Eight infertile mutation-positive women were diagnosed with idiopathic infertility (n=5) and endometriosis (n=3) and their levels of aPLs in serum were compared with 115 infertile women without any LIF gene mutation. Enzyme-linked immunosorbent assay was used for the detection of seven antiphospholipid antibodies; the results were statistically assessed by the Fisher's 2 by 2 exact test to evaluate the association of the LIF gene mutations and aPLs in serum of infertile patients. The presence of aPLs was significantly higher in our study group (100%) than in 30% of aPLs-positives in control infertile patients (p = 0.0035) which indicates that the aPLs are elevated in women with LIF gene mutations.

Investigation and treatment of repeated implantation failure following IVF-ET

Pregnancy rate following one cycle of IVF and ET can be as high as 60%. But even in the very successful units, some couples fail repeatedly. The causes for repeated implantation failure (RIF) may be because of reduced endometrial receptivity, embryonic defects or multifactorial causes. Various uterine pathologies, such as thin endometrium, altered expression of adhesive molecules and immunological factors, may decrease endometrial receptivity, whereas genetic abnormalities of the male or female, sperm defects, embryonic aneuploidy or zona hardening are among the embryonic reasons for failure of implantation. Endometriosis and hydrosalpinges may adversely influence both. In this mini review, we discuss the suggested methods for evaluation and treatment of RIF: repeated hysteroscopy, myomectomy, endometrial stimulation, immunotherapy, preimplantation genetic screening (PGS), assisted hatching, zygote intra-Fallopian transfer (ZIFT), co-culture, blastocyst transfer, cytoplasmic transfer, tailoring stimulation protocols and salpingectomy for hydrosalpinges.

Future directions of failed implantation and recurrent miscarriage research

Recurrent implantation failure is today the major reason for women completing several IVF/intracytoplasmic sperm injection attempts without having achieved a child, and is probably also the explanation for many cases of unexplained infertility. Most causes of recurrent miscarriage are still poorly elucidated, but from a theoretical point of view recurrent implantation failure and recurrent miscarriage are suggested to have partly overlapping causes. Recent research has indeed documented that both syndromes can be caused by the same embryonic chromosomal abnormalities and the same maternal endocrine, thrombophilic and immunological disturbances. Consequently, many treatments attempting to normalize these abnormalities have been tested or are currently used in women with both recurrent implantation failure and recurrent miscarriage. However, no treatment for the two syndromes is at the moment sufficiently documented to justify its routine use. In this review, an overview is given regarding present knowledge about causes that may be common for recurrent implantation failure and recurrent miscarriage, and suggestions are put forward for future research that may significantly improve understanding and treatment options for the syndromes.

Drug intervention in early pregnancy after assisted reproductive technology

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

Immune testing in fertility practice: truth or deception?

PURPOSE OF REVIEW

Much attention has been paid to the role of immunology in reproductive success or failure. Every step in the establishment of normal pregnancy has been implicated as a possible site of immune-mediated reproductive failure. The widespread testing of antiphospholipid, antinuclear, antithyroid, and antisperm antibodies, as well as generalized immune testing, have thus been employed to diagnose patients with otherwise unexplained infertility or recurrent pregnancy loss. Controversial data surrounding the widespread and variable use of immune testing in current fertility practice is reviewed to determine which tests are warranted based on sound scientific evidence. Because it is postulated that early miscarriage, when occult, could represent a failure of embryo implantation indistinguishable from unexplained infertility, this analysis of immune testing includes a discussion of patients with recurrent pregnancy loss.

RECENT FINDINGS

Despite the increased prevalence of abnormal immune testing associated with early reproductive failure, the most rigorous studies have not proven a cause and effect between these phenomena. There is wide variation and inconsistency regarding this association, depending upon which test(s) are employed, the study methodology used, and the patient population under study. The significance of selected immunological test abnormalities associated with early reproductive failure is uncertain.

SUMMARY

Great variability exists in identifying candidates for immune testing, determining which tests to order, interpreting the test results, and offering immunologic treatments. This review argues that the use of widespread immune testing in clinical practice can not be supported by existing data. The resulting therapies are similarly of unconfirmed benefit and may cause harm.

Antiphospholipid antibodies in implantation failures

PROBLEM

The amino phospholipids (PL), phosphatidylserine (PS) and phosphatidylethanolamine (PE) are distributed asymmetrically in the plasma membranes of eucaryotic cells. This arrangement involves active transport of PS and PE from the outer to inner membrane leaflet by an aminophospholipid translocase (flipase). Cell activation, injury and programmed cell death (apoptosis) cause collapse of the PS/PE asymmetry by activation of another enzyme system, scramblase. Unlike other cells, the developing trophoblast exteriorizes PS during its differentiation.

METHODS OF STUDY

An analysis of published and unpublished data.

RESULTS

The trophoblast is targeted by antiphospholipid antibodies (aPL), especially to PS (aPS). Cardiolipin is not present in the trophoblast plasma membrane, nonetheless, anticardiolipin (aCL) has been implicated in trophoblast pathology. The aPS and aCL are often crossreactive. Both animal and in vitro experimental models have shown monoclonal and polyclonal aPS and aCL to specifically destroy trophoblast, inhibit syncytium formation, halt human chorionic gonadatropin (hCG) production, and limit trophoblast invasion. Antibodies to PE (aPE) have not been well characterized, however, recent reports from several independent laboratories document that aPE are associated significantly with very early (embryonic) recurrent pregnancy loss (RPL). Umeda and coworkers have shown that during cytokinesis (late telophase) of Chinese hamster ovary (CHO) cells, formation of PE rafts in cleavage furrows is required for completion of cell division and formation of daughter cells. This raises the question whether aPE might interfere with implantation and cell division during embryogenesis.

CONCLUSIONS

A role for aPL in implantation failure and occult pregnancy loss constitutes the basis of this overview.

Antiphospholipid antibodies and infertility

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

Immunoglobulins and cytokines level in follicular fluid in relation to etiology of infertility and their relevance to IVF outcome

OBJECTIVE

The aims of the present study were to (i) determine the presence and concentration of albumin fractions (alpha1, alpha2, beta, gamma), immunoglobulins (IgA, IgG, IgM) and cytokines [interleukin (IL)-6, IL-8, granulocyte-macrophage colony-stimulating factor (GM-CSF)] in periovulatory ovarian follicular fluid (FF) of in vitro fertilization (IVF) patients, (ii) examine the relationship between these parameters and the etiology of infertility as well as the IVF outcome and (iii) find out if these parameters in FF could be used as a predictive factor of IVF outcome.

DESIGN

The levels of albumin fractions, immunoglobulin and cytokines were measured from women who underwent IVF therapy for various indications and the results were compared between the patient groups and IVF outcome.

MATERIALS AND METHODS

Follicular fluid was obtained from 160 IVF patients. A total of 79 patients underwent controlled ovarian hyperstimulations (COH) either with follicle-stimulating hormone (FSH) or HMG. Whereas, the HMG was used for the second set of patients (n=81) - after down regulation with gondotropin-releasing hormone agonists (Gn-RHa) - the protein fractions were determined using electrophoresis separation. Immunoglobulins were measured using a commercial kits and the concentration of cytokines was determined by the highly sensitive enzyme-linked immunosorbent assay (ELISA) methods.

RESULTS

The stimulation regimens used have no effect on albumin (alpha1, alpha2, beta, gamma) and immunoglobulin (IgA, IgG, IgM) concentrations, as no significant difference was observed between the two groups. Besides, no specific relationship was found between the concentration of these investigated parameter in FF and etiology of infertility or fertilization, cleavage and pregnancy rate. Besides, there were no significant differences between the groups for any cytokine investigated. Moreover, there were no correlations between the concentration of IL-6, IL-8 and GM-CSF in FF and steroid hormone concentration in the blood at the day of oocytes retrieval or IVF outcome.

IN CONCLUSION

Total protein, albumin fraction, immunoglobulins and cytokines level in FF of patients undergoing COH for IVF therapy for various etiology of infertility could not be a useful parameter for predicting IVF outcome.

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.

Autoimmune factors in reproductive failure

The present review highlights recent studies that investigated the possible influences of autoimmune factors in reproductive success or failure. These factors include antiphospholipid antibodies, antithyroid antibodies, antinuclear antibodies, antisperm antibodies, and antiovarian antibodies. The majority of recent work has focused on these potential autoimmune factors; however, controversy still exists over indicated testing and treatment options. An association of antiphospholipid antibodies and recurrent pregnancy loss has been established, and treatment with subcutaneous heparin appears most efficacious. Other autoimmune factors are under investigation as markers of in-vitro fertilization failure. Limited data from treatment trials are presented.

Antiphospholipid syndrome and recurrent miscarriages

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