Immune testing in fertility practice: truth or deception?

Maternal history of recurrent pregnancy loss increases the risk for long-term pediatric respiratory morbidity of the offspring

BACKGROUND

While the etiology in many cases of recurrent pregnancy loss (RPL) is unclear, recent evidence suggests possible immunological dysfunction, which is also implicated in the pathophysiology of many pediatric respiratory diseases.

OBJECTIVE

We sought to investigate whether maternal history of RPL is associated with long-term respiratory morbidity of the offspring.

STUDY DESIGN

A population based cohort analysis was performed comparing the risk of long-term respiratory morbidity (up to the age of 18 years) of children born to mothers with and without a history of RPL (defined as two or more losses). Respiratory morbidity included hospitalizations involving a predefined set of ICD-9 codes, as recorded in the hospital medical records. Deliveries occurred between the years 1991 and 2014 in a tertiary medical center. A Kaplan-Meier survival curve was constructed to compare cumulative respiratory morbidity, and a Cox proportional hazards model was used to control for confounders.

RESULTS

During the study period, 242 187 newborns met the inclusion criteria; 5% (n = 12 182) of which were offspring to mothers with a history of RPL. Respiratory morbidity was significantly more common in the exposed group (6.0% vs 4.8%, P < .001). Specifically, offspring to mothers with a history of RPL had higher rates of obstructive sleep apnea and asthma (P < .05). The Kaplan-Meier survival curve exhibited a higher cumulative incidence of total respiratory morbidity in offspring of mothers with a history of RPL (Log rank P < .001). In the Cox regression, maternal history of RPL was independently associated with increased pediatric respiratory morbidity of the offspring with an adjusted hazard ratio of 1.24 (95 % confidence interval [95%CI], 1.15-1.34, P < .001).

CONCLUSION

Maternal history of RPL is associated with a higher risk of future pediatric respiratory morbidity of the offspring; possibly explained by a common immunological etiology.

Live birth and adverse birth outcomes in women with ulcerative colitis and Crohn's disease receiving assisted reproduction: a 20-year nationwide cohort study

OBJECTIVE

To examine the chance of live births and adverse birth outcomes in women with ulcerative colitis (UC) and Crohn's disease (CD) compared with women without inflammatory bowel disease (IBD) who have undergone assisted reproductive technology (ART) treatments.

METHODS

This was a nationwide cohort study based on Danish health registries, comprising all women with an embryo transfer during 1 January 1994 through 2013. The cohorts comprised 1360 ART treatments in 432 women with UC, 554 ART treatments in 182 women with CD and 148,540 treatments in 52,489 women without IBD. Our primary outcome was live births per ART treatment cycle. We controlled for multiple covariates in the analyses. Our secondary outcomes were adverse birth outcomes.

RESULTS

The chance of a live birth for each embryo transfer was significantly reduced in ART treatments in women with UC (OR=0.73, 95% CI 0.58 to 0.92), but not significantly reduced in the full model of ART treatments in women with CD (OR=0.77, 95% CI 0.52 to 1.14). Surgery for CD before ART treatment significantly reduced the chance of live birth for each embryo transfer (OR=0.51, 95% CI 0.29 to 0.91). In children conceived through ART treatment by women with UC, the OR of preterm birth was 5.29 (95% CI 2.41 to 11.63) in analyses including singletons and multiple births; restricted to singletons the OR was 1.80, 95% CI 0.49 to 6.62.

CONCLUSIONS

Our results suggest that women with UC and CD receiving ART treatments cannot expect the same success for each embryo transfer as other infertile women. Women with CD may seek to initiate ART treatment before needing CD surgery. Increased prenatal observation in UC pregnancies after ART should be considered.

Effect of 1,25(OH)2 vitamin D3 on cytokine production by endometrial cells of women with repeated implantation failure

Repeated implantation failure (RIF) is a worldwide health problem that imposes a great deal of cost on patients and health care system. Vitamin D(3) has been proposed to have positive impact on the process of implantation. The present study was performed to compare the effect of 1,25-dihydroxy vitamin D(3) (1,25(OH)(2)D(3)) on cytokine production by endometrial cells of women with RIF and healthy fertile controls. Whole endometrial cells (WECs) and endometrial stromal cells (ESCs) from RIF and normal fertile women were treated with 1,25(OH)(2)D(3). The levels of IL-10, TGF-β, IFNγ, Il-6, IL-8 and IL-17 in culture supernatants were assayed by ELISA. Also, ability of the cells from both groups to produce 1,25(OH)(2)D(3) was evaluated and compared. 1,25(OH)(2)D(3) down-regulated cytokine production in WECs from both groups except for IL-8 which was upraised. Similar trends were also observed in ESCs except up-regulation of TGF-β in RIF group. Endometrial cells of both groups had comparable capacity to produce 1,25(OH)(2)D(3). Based on the minimal differential immunoregulatory effect of vitamin D(3) on endometrial cells from RIF and control women, it may be suggested that circulating levels of maternal vitamin D(3) be the subject of further investigation.

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.

A systematic review of intravenous immunoglobulin for treatment of unexplained recurrent miscarriage

OBJECTIVE

To estimate whether intravenous immunoglobulin (IVIG) improves the probability of a live birth in women with unexplained recurrent miscarriage (RM).

DESIGN

A computerized search in Medline, Embase, Central, Ovid Medline In-Process, and Other Non-Indexed Citations Databases and randomized controlled trial (RCT) registries was performed. Abstracts of the American Society of Reproductive Medicine and European Society of Human Reproduction and Embryology annual meetings and reference lists of identified reports were searched.

SETTING

None.

PATIENT(S)

Women with unexplained primary (without a prior live birth) or secondary (subsequent to a live birth) RM.

INTERVENTION(S)

IVIG or placebo control intervention.

MAIN OUTCOME MEASURE(S)

Live birth rate per randomized woman.

RESULT(S)

Six relevant RCTs were identified including 272 women with unexplained RM. The overall odds ratio for live birth is 0.92, with a 95% confidence interval of 0.55-1.54, indicating a lack of a treatment effect with IVIG. Similarly, IVIG was not found to be beneficial when women with primary and secondary RM were analyzed separately.

CONCLUSION(S)

A beneficial effect of IVIG in treatment of RM was not observed. Given the absence of a proven mechanism of action, and the lack of a diagnostic algorithm to identify patients who are likely to benefit from such treatment, IVIG administration for treatment of recurrent miscarriage is not justified outside the context of properly designed RCTs.

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.

Unexplained infertility: does it really exist? Does it matter?

Unexplained infertility (UI) refers to a diagnosis made in couples in whom standard investigations including semen analysis, tests of ovulation and tubal patency are normal. It has been suggested that the term UI is unsustainable, as conditions such as endometriosis, tubal infertility, premature ovarian ageing and immunological infertility tend to be misdiagnosed as UI. In this debate, we present the view that, although scientifically unsatisfying, the diagnosis of UI is sustainable from a clinical and practical perspective. Given our present treatment options, further investigations leading to a more 'accurate' diagnosis is unlikely to change our management in these cases. Scientific curiosity must take second place to a more pragmatic approach, which takes into account the clinical and financial costs of making a more 'accurate' diagnosis.

Antiphospholipid antibodies and coagulation defects in women with implantation failure after IVF and recurrent miscarriage

Evaluation of patients with IVF implantation failure or recurrent miscarriage often frustratingly fails to elicit any particular cause for their problem. Testing for antiphospholipid antibodies or thrombophilia is commonly carried out, and interpretation of results in the light of the current evidence is extremely difficult. This paper reviews the purported pathogenetic mechanisms and clinical associations between both antiphospholipid antibodies and inherited thrombophilias, and reproductive failure. The current management strategies are also critically evaluated and recommendations are made for optimal, evidence-based clinical practice.

New insights into sexual functioning and fertility in rheumatic diseases

Sexuality is an often neglected area of quality of life in patients with rheumatic disease. Manifestations and symptoms of disease can impair sexual functioning, but this can be much improved by adequate intervention and counseling. Fertility is in general not reduced in rheumatic diseases, however, the time taken to achieve a pregnancy is often increased. An increased rate of pregnancy loss is observed in systemic lupus erythematosus and the antiphospholipid syndrome contributing to a reduced family size. Autoantibodies are present in most of the rheumatic diseases and can interfere with fertilization, implantation, embryonic development and placental function. Active disease disturbs the hypothalamic-pituitary-axis, giving rise to periods of gonadal dysfunction. Toxic effects of immunosuppressive drugs can induce transient or permanent gonadal failure in women and men.