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Abstract
Recurrent pregnancy loss is a distressing pregnancy disorder experienced by ~2.5% of women trying to conceive. Recurrent pregnancy loss is defined as the failure of two or more clinically recognized pregnancies before 20-24 weeks of gestation and includes embryonic and fetal losses. The diagnosis of an early pregnancy loss is relatively straightforward, although progress in predicting and preventing recurrent pregnancy loss has been hampered by a lack of standardized definitions, the uncertainties surrounding the pathogenesis and the highly variable clinical presentation. The prognosis for couples with recurrent pregnancy loss is generally good, although the likelihood of a successful pregnancy depends on maternal age and the number of previous losses. Recurrent pregnancy loss can be caused by chromosomal errors, anatomical uterine defects, autoimmune disorders and endometrial dysfunction. Available treatments target the putative risk factors of pregnancy loss, although the effectiveness of many medical interventions is controversial. Regardless of the underlying aetiology, couples require accurate information on their chances of having a baby and appropriate support should be offered to reduce the psychological burden associated with multiple miscarriages. Future research must investigate the pathogenesis of recurrent pregnancy loss and evaluate novel diagnostic tests and treatments in adequately powered clinical trials.
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Khalife D, Ghazeeri G, Kutteh W. Review of current guidelines for recurrent pregnancy loss: new strategies for optimal evaluation of women who may be superfertile. Semin Perinatol 2019; 43:105-115. [PMID: 30642578 DOI: 10.1053/j.semperi.2018.12.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The current evidence-based guidelines for the evaluation of recurrent pregnancy loss recommended by the American Society for Reproductive Medicine and by the European Society of Human Reproduction and Embryology are compared and contrasted in this review. The clinical use of either of these guidelines will result in a probable diagnosis for only half of the affected patients. New strategies for a full evaluation of recurrent pregnancy loss incorporating 24- chromosome microarary on the products of conception offer more explanations for patients and caregivers. This new algorithm should decrease the use of empiric, unproven treatments. Combining the results of genetic testing on the miscarriage tissue with the conventional diagnostic tests has made it possible to explain the etiology of pregnancy loss in more than 90% of the cases. This cost-saving strategy can decrease the emotional distress and frustration for both couples and physicians when it comes to management of recurrent pregnancy loss.
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Affiliation(s)
- Dalia Khalife
- Reproductive Endocrinology and Infertility Division, Department of Obstetrics and Gynecology, American University of Beirut Medical Center P.O. Box: 113-6044. Beirut, Lebanon
| | - Ghina Ghazeeri
- Reproductive Endocrinology and Infertility Division, Department of Obstetrics and Gynecology, American University of Beirut Medical Center P.O. Box: 113-6044. Beirut, Lebanon
| | - William Kutteh
- Clinical Professor of Reproductive Endocrinology Vanderbilt University School of Medicine; Consulting Gynecologist, Department of Surgery Director of Fertility Preservation St. Jude Children's Research Hospital; Managing Partner, Director of Recurrent Pregnancy Loss Center Fertility Associates of Memphis 80 Humphreys Center, Suite 307 Memphis, TN 38120-2363 Phone: 901-747-2229 FAX: 901-747-4446.
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The role of immunotherapy in in vitro fertilization: a guideline. Fertil Steril 2019; 110:387-400. [PMID: 30098685 DOI: 10.1016/j.fertnstert.2018.05.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 05/10/2018] [Indexed: 12/22/2022]
Abstract
Adjuvant immunotherapy treatments in in vitro fertilization (IVF) aim to improve the outcome of assisted reproductive technology (ART) in both the general ART population as well as subgroups such as patients with recurrent miscarriage or implantation failure. The purpose of this guideline is to evaluate the role of immunomodulating therapy in ART. Unfortunately, many of the evaluated therapies lack robust evidence from well-designed adequately powered randomized controlled trials to support their use. Immunotherapies reviewed in the present document are either not associated with improved live-birth outcome in IVF or have been insufficiently studied to make definitive recommendations.
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Affiliation(s)
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- American Society for Reproductive Medicine, Birmingham, Alabama
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Brezina PR. Genetic Screening and Early Recurrent Pregnancy Loss. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0207-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Brezina PR, Kutteh WH. Classic and cutting-edge strategies for the management of early pregnancy loss. Obstet Gynecol Clin North Am 2013; 41:1-18. [PMID: 24491981 DOI: 10.1016/j.ogc.2013.10.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
There are few conditions in medicine associated with more heartache to patients than recurrent pregnancy loss (RPL). The management of early RPL is a formidable clinical challenge for physicians. Great strides have been made in characterizing the incidence and diversity of this heterogeneous disorder, and a definite cause of pregnancy loss can be established in more than half of couples after a thorough evaluation. In this review, current data are evaluated and a clear roadmap is provided for the evaluation and treatment of RPL.
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Affiliation(s)
- Paul R Brezina
- Fertility Associates of Memphis, 80 Humphreys Center, Suite 307, Memphis, TN 38120, USA.
| | - William H Kutteh
- Fertility Associates of Memphis, 80 Humphreys Center, Suite 307, Memphis, TN 38120, USA
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Akhtar MA, Eljabu H, Hopkisson J, Raine-Fenning N, Quenby S, Jayaprakasan K. Aspirin and heparin as adjuvants during IVF do not improve live birth rates in unexplained implantation failure. Reprod Biomed Online 2013; 26:586-94. [PMID: 23518029 DOI: 10.1016/j.rbmo.2013.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 02/06/2013] [Accepted: 02/07/2013] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Muhammad A Akhtar
- Nottingham University Research and Treatment Unit in Reproduction (NURTURE), Division of Obstetrics and Gynaecology, School of Clinical Sciences, University of Nottingham, Nottingham, Nottinghamshire NG7 2UH, United Kingdom
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Xiao J, Xiong J, Zhu F, He L. Effect of prednisone, aspirin, low molecular weight heparin and intravenous immunoglobulin on outcome of pregnancy in women with antiphospholipid syndrome. Exp Ther Med 2012; 5:287-291. [PMID: 23251285 PMCID: PMC3524288 DOI: 10.3892/etm.2012.743] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 09/28/2012] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to evaluate the effect of traditional treatment (prednisone and aspirin) and comprehensive treatment [prednisone, aspirin, low molecular weight heparin (LMWH) and IVIg] on the pregnancy outcome, obstetric complications and fetal outcome in women with antiphospholipid syndrome (APS). In the present trial, we observed and evaluated 129 women with APS. Eighty-seven patients received traditional treatment and 42 patients received comprehensive treatment. In the traditional treatment group and comprehensive treatment group, the live birth rate was 83.91 and 97.62% (P<0.05), respectively, and the obstetric morbidity was 22.99 and 7.14% (P<0.05), respectively. The neonatal weight in the comprehensive treatment group was increased compared with the traditional treatment group (P<0.05), however, no differences were found in gestational age at delivery or preterm labor. Comprehensive treatment improved the result of gestation and reduced obstetric complications, and is a more effective treatment for APS than the traditional method using prednisone and aspirin.
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Affiliation(s)
- Jing Xiao
- Department of Gynecology and Obstetrics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, P.R. China
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Nardi FDS, Slowik R, Wowk PF, da Silva JS, Gelmini GF, Michelon TF, Neumann J, Bicalho MDG. Analysis of HLA-G polymorphisms in couples with implantation failure. Am J Reprod Immunol 2012; 68:507-14. [PMID: 23009094 DOI: 10.1111/aji.12001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 07/09/2012] [Indexed: 12/26/2022] Open
Abstract
PROBLEM HLA-G expression is related as an immune modulator of fetal-maternal tolerance, and its levels was correlated with pregnancy outcome. In a case-control study, we investigate the association between the genetic variability of the HLA-G gene and serum levels of soluble HLA-G in cases of embryo implantation failure. METHOD OF STUDY Forty couples with at least two unsuccessful fresh embryo transfers (implantation failure; IF) and 83 fertile couples with at least two successful pregnancies was genotyped by sequencing-based typing. HLA-G alleles were defined by nucleotide sequence variations at exon 2, 3, and 4, and the quantification of soluble HLA-G (sHLA-G) was performed by ELISA. RESULTS There was a significant difference between the HLA-G allelic distributions between IF couples and the control couples. The HLA-G*01:03:01 allele was increased in the IF couples. There were no significant differences in the serum levels of sHLA-G in the IF and control groups. CONCLUSION The results suggest that the distribution of HLA-G products may play a significant role in the modulation of maternal-fetal immune response.
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Affiliation(s)
- Fabiola da Silva Nardi
- Laboratory of Immunogenetics and Histocompatibility, Genetics Department, Universidade Federal do Paraná, Curitiba, Brazil
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Evaluation of serum antisperm antibodies in infertility. J Obstet Gynaecol India 2011. [DOI: 10.1007/s13224-011-0034-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Kling C, Schmutzler A, Wilke G, Hedderich J, Kabelitz D. Two-year outcome after recurrent implantation failure: prognostic factors and additional interventions. Arch Gynecol Obstet 2008; 278:135-42. [PMID: 18193252 PMCID: PMC6105261 DOI: 10.1007/s00404-007-0538-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2007] [Accepted: 12/10/2007] [Indexed: 11/28/2022]
Abstract
Objectives After recurrent implantation failure (RIF), empirical figures on further prospects are essential for counselling but difficult to estimate within single IVF centres due to high drop-out rates. Alternatively, couples referred to a tertiary unit for RIF were evaluated. Materials and methods Multi-centre 2-year observational trial of 1,174 eligible couples treated consecutively with adjuvant lymphocyte immunotherapy (LIT) in a university immunological department from 1999 to 2002 after three or more unsuccessful fresh embryo transfers. Acquisition of data was completed in 2005. Results With another 1.5 oocyte retrievals, delivery rate per couple depended on age (39.3% at <30 years, 16.9% at >39 years, P < 0.005). Prognosis was favourable when frozen embryo transfers had been conducted before (34.4 vs. 25.8%, P < 0.005). The outcome was slightly better in ICSI couples as compared to conventional IVF (31.0 vs. 24.8%, P < 0.05). Birth rates per fresh embryo transfer from the fourth to eighth retrieval were 17.4–18.3–15.0–12.9–12.9% (decline not significant). Apart from LIT, further additional interventions were given more often to couples who had had frozen embryo transfers before (49 vs. 40%, P < 0.005). Conclusions Female age and ovarian response are crucial for further IVF prognosis. Previous frozen embryo transfers indicate better chances. Couples with male factor infertility may benefit from intracytoplasmatic sperm injection (ICSI) because underlying female factors are less prevalent. Cycle rank had comparatively little impact. Additional interventions are preferentially offered to couples who have a favourable prognosis anyway. Their multiple use is common practice in RIF, but its value should be considered limited.
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Affiliation(s)
- Christiane Kling
- Institute of Immunology, University Medical Center Schleswig-Holstein, Michaelisstr. 5, 24105 Kiel, Germany.
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Vaquero E, Lazzarin N, Caserta D, Valensise H, Baldi M, Moscarini M, Arduini D. Diagnostic evaluation of women experiencing repeated in vitro fertilization failure. Eur J Obstet Gynecol Reprod Biol 2006; 125:79-84. [PMID: 16223559 DOI: 10.1016/j.ejogrb.2005.08.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2004] [Revised: 07/30/2005] [Accepted: 08/02/2005] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of the study was to propose a set of tests to clarify the diagnosis of repeated implantation failure in patients undergoing in vitro fertilization (IVF). STUDY DESIGN Fifty-nine patients with at least two unsuccessful IVF attempts were included in the study. Blood samples were evaluated for the presence of underlying thyroid abnormalities, antiphospholipid antibodies (aPL), increased levels of natural killer cells (NK), inherited thrombophilia and mouse embryo assay factor (MEA-f). The same tests were performed on 20 normal fertile control patients. RESULTS Seventy-six percent of IVF patients showed at least one abnormal result. This incidence was higher with respect to that found among control patients (45%). The prevalence of thyroid abnormalities, aPL and increased NK level was higher in IVF patients whereas no differences were observed in terms of prevalence of inherited thrombophilias and MEA-f. CONCLUSIONS A better understanding of reproductive failure mechanisms should allow an effective diagnostic flow chart and a focused therapeutic option for patients experiencing repeated IVF failure. With this objective in mind, our data provide two important results: thyroid abnormalities, aPL and increased NK levels are more prevalent in women experiencing IVF failure. No evidence was found for an association between inherited thrombophilia and MEA-f and failure to achieve pregnancy after IVF.
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Affiliation(s)
- Elena Vaquero
- Department of Obstetrics and Gynecology, Ospedale Fatebenefratelli, University of Rome Tor Vergata, Isola Tiberina, 00168 Rome, Italy.
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Vujisić S, Lepej SZ, Jerković L, Emedi I, Sokolić B. Antisperm Antibodies in Semen, Sera and Follicular Fluids of Infertile Patients: Relation to Reproductive Outcome afterIn VitroFertilization. Am J Reprod Immunol 2005; 54:13-20. [PMID: 15948768 DOI: 10.1111/j.1600-0897.2005.00274.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PROBLEM Data given in the literature, regarding the influence of antisperm antibodies (ASA) in the semen and/or sera on in vitro fertilization (IVF) procedure outcome are controversial. The aim of this study was to compare the prevalence of ASA in semen, peripheral blood and follicular fluid as well as to determine total immunoglobulin concentration in the serum and follicular fluid. Selected parameters were analyzed with regard to IVF outcome. METHOD OF STUDY The study enrolled 52 married couples. ASA in the semen was determined by direct immunobead mixed antiglobulin reaction (MAR Screen test), while in the peripheral blood and follicular fluid was determined by indirect immunobead MAR Screen test. Immunoglobulin (IgG, IgM and IgA) concentration in the follicular fluid and serum was determined by a liquid-phase immunoprecipitation assay with nephelometric end-point detection and analyzed with regard to IVF outcome. RESULTS Semen MAR test IgG was < 20% in 38 couples, and > 20% in 14 couples. Fertilization (73.2% versus 71.5%) and pregnancy rates (28.9% versus 28.57%) in both groups of patients were not significantly different. The results of direct and indirect MAR test were not associated with fertilization and pregnancy rates. Total serum IgG, IgM and IgA in infertile women were within normal ranges. Follicular fluid IgG was within normal values for serum samples, while IgA and IgM were decreased. CONCLUSION The presence of ASA on sperm or in the serum and follicular fluid was not associated with IVF outcome in the couples with good quality semen characteristic.
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Affiliation(s)
- Sanja Vujisić
- Department of Obstetrics and Gynecology, Medical School, University of Zagreb, Sveti Duh Hospital, Zagreb.
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Urman B, Yakin K, Balaban B. Recurrent implantation failure in assisted reproduction: how to counsel and manage. B. Treatment options that have not been proven to benefit the couple. Reprod Biomed Online 2005; 11:382-91. [PMID: 16176683 DOI: 10.1016/s1472-6483(10)60847-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The success of assisted reproduction, although gradually increasing over the years, is still less than satisfactory. Many couples have benefited from this treatment; however, many have also been left frustrated following multiple failed attempts. Couples who fail to conceive after multiple IVF/intracytoplasmic sperm injection (ICSI) treatments often seek treatment options that are new and that have not been offered before. Some of these include immunological testing and treatment, allogenic lymphocyte therapy, intratubal transfer of zygotes and embryos, blastocyst transfer, sequential embryo transfer, assisted hatching, co-cultures, and preimplantation genetic screening for aneuploidy. Although the evidence behind some of these is more robust, most suffer from lack of well designed randomized trials comparing them with other treatment options. Randomized studies are extremely difficult to conduct, as couples will resist being randomized into a treatment group where previously failed procedures will be repeated. In the mean time, assisted reproduction programmes should resist offering treatment options that are not evidence based, or at least they should share with the couple the information that is available and should stress that none of these is a panacea for their problem.
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Affiliation(s)
- Bulent Urman
- Assisted Reproduction Unit, American Hospital of Istanbul, Turkey.
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Kupka MS, Dorn C, Montag M, Felberbaum RE, van der Ven H, Kulczycki A, Friese K. Previous miscarriages influence IVF and intracytoplasmatic sperm injection pregnancy outcome. Reprod Biomed Online 2004; 8:349-57. [PMID: 15038904 DOI: 10.1016/s1472-6483(10)60916-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Previous conceptions are one predictor for the outcome of assisted reproductive technology procedures. Approximately 18-34% of clinical pregnancies following assisted reproduction procedures result in spontaneous abortion. The risk of such pregnancy loss is believed to increase with women's age, previous miscarriages and use of frozen-thawed embryos. This study analyses German IVF Registry data to examine the impact of previous miscarriages on the outcome of assisted reproduction procedures. The data set consists of a total of 174,909 assisted reproduction procedures performed between January 1998 and December 2000. Multiple logistic regression is used to assess the correlation between women's age, spousal/partner change, and infertility diagnosis. It is demonstrated that any previous miscarriage will increase the treatment-dependent miscarriage rate in assisted reproduction procedures. A significantly higher impact is shown for one previous miscarriage achieved by assisted reproduction procedures compared with spontaneous conception. Partner change is shown to have no specific impact on the treatment dependent miscarriage rate, whereas a statistically significant increase in miscarriages in all assisted reproduction procedures was found among women older than 34 years of age. Overall, the highest rate of treatment-dependent miscarriages was seen in assisted reproduction procedures with cryopreserved embryo transfer.
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Affiliation(s)
- M S Kupka
- University Medical Centre of Obstetrics and Gynaecology, University of Munich, Maistr. 11, D-80337 Munich, Germany.
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Lathi RB, Milki AA. Tissue sampling technique affects accuracy of karyotype from missed abortions. J Assist Reprod Genet 2002; 19:536-8. [PMID: 12484496 PMCID: PMC3455340 DOI: 10.1023/a:1020916003666] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To determine if careful specimen selection and washing of tissue from first trimester missed abortion products of conception specimens increases the sensitivity of routine cytogenetics in detecting aneuploidy. METHODS Retrospective review of cytogenetics results from tissue from dilation and curettage for missed abortion in a university fertility practice between 1998 and 2001. A technique of careful selection and washing of the specimen was implemented in July 1999. Results from before (n = 15) and after (n = 41) this change were compared. Cytogenetics reports from other physicians using the same laboratory were used for comparison (n = 59). RESULTS The percentage of 46XX results was significantly decreased in the test group when compared to historical and community controls: 29% vs. 73% and 56% respectively. The percentage of aneuploid results was significantly higher in the test group at 61% vs. 7% and 36% in the historical and community controls respectively. CONCLUSION Thorough separation and cleaning of villi prior to sending missed abortion specimens significantly increases sensitivity of conventional cytogenetics for detecting aneuploidy by decreasing maternal contamination.
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Affiliation(s)
- Ruth B Lathi
- Stanford University School of Medicine, California 94305, USA
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