A Further Exploration of the Impact of Antinuclear Antibodies onIn VitroFertilization-Embryo Transfer Outcome

Pregnant outcomes of patients with positive anticentromere antibodies receiving in vitro fertilization-embryo transfer

OBJECTIVES

To analyze the pregnant outcomes in patients with positive anti-centromere antibody (ACA) receiving in vitro fertilization (IVF) -embryo transfer (ET) and natural conception.

METHODS

A case-control study was used to retrospectively analyze the clinical data of 3955 patients who received in vitro fertilization-embryo transfer therapy and had the results of antinuclear antibody (ANA) spectrum at Zhejiang Provincial People's Hospital from June 2016 to June 2023. Patients with positive ACA and negative ACA were matched at a ratio of 1∶3 using propensity score matching. Embryo outcomes of IVF were compared between the two groups, and the impact of different fertilization methods and the use of immunosuppressants on pregnant outcomes were analyzed using self-matching analysis. The natural conception and disease progress were followed up for ACA-positive patients after IVF failure.

RESULTS

The ACA-positive patients accounted for 0.86% of all IVF patients (34/3955) and 2.51% of total ANA-positive IVF patients. Regardless of whether patients received conventional IVF (c-IVF) or intracytoplasmic sperm injection (ICSI), the ACA-positive group exhibited significant differences in oocyte maturity and fertilization compared to the ACA-negative group (both P<0.01). Moreover, the ACA-positive group had a decreased number of D3 suboptimal embryos and D3 optimal embryos (both P<0.05). In 5 cases of ACA-positive patients who underwent ICSI cycles, the double pronuclei rate did not increase compared to c-IVF cycles (P>0.05), and there was a decrease in the number of D3 high-quality embryos and D3 suboptimal embryos (both P<0.05). After 1-2 months of immunosuppressant treatment, 12 ACA-positive patients underwent c-IVF/ICSI again, and there were no changes in egg retrieval and fertilization before and after medication (both P>0.05), but there was an improvement in the 2PN embryo cleavage rate (P<0.05). The number of embryos transferred was similar between the ACA-positive and negative groups, but the ACA-positive group had significantly lower embryo implantation rate and clinical pregnancy rate compared to the ACA-negative group (both P<0.05), with no significant difference in miscarriage rate between the two groups (P>0.05). Twenty-seven ACA-positive patients attempted natural conception or artificial insemination after IVF failure, resulting in a total of 7 cases of clinical pregnancy.

CONCLUSIONS

Serum ACA positivity may disrupt oocyte maturation and normal fertilization processes, with no improvement observed with ICSI and immunosuppressant use. However, ACA-positive patients may still achieve natural pregnancy.

Anticentromere antibodies are the most potent antinuclear antibodies in reducing live birth outcomes after ICSI

RESEARCH QUESTION

How, and to what extent, do anticentromere antibodies (ACA) reduce live birth outcomes after ICSI?

STUDY DESIGN

Retrospective cohort study of infertile women aged 30-43 years who underwent ICSI between September 2016 and March 2021. Women with a history or current diagnosis of symptomatic connective tissue disease were excluded. Immunofluorescence staining detected antinuclear antibodies (ANA). Staining pattern and titre (cut-off, 1:160) were used to divide infertile women into three groups: positive for ACA (ACA+) (n = 28); positive for ANA other than ACA (ANA+) (n = 77); and negative for both ACA and ANA (control) (n = 3723).

RESULTS

Cumulative live birth rate (CLB) was lowest in ACA+ (7%, 31% and 46% in ACA+, ANA+ and control, respectively) (ACA+ versus control, P < 0.0001; ACA+ versus ANA+, P = 0.011; ANA+ versus control, P = 0.012). A small impairment in meiosis I and a larger impairment in meiosis II, fertilization and embryo cleavage caused the decrease. Multiple pronuclei formation increased (RR versus control, 5.33; 95% CI 4.26 to 6.65) and good-quality blastocyst development decreased (RR 0.34; 95% CI 0.22 to 0.53). Multiple logistic regression analysis showed that ACA was associated with CLB outcome (OR 0.08, 95% CI 0.02 to 0.36); the other four ANA staining patterns were not.

CONCLUSIONS

The effect of ACA on live birth outcomes is strongest after ICSI among ANA, primarily through the impairment of meiosis II and subsequent stages. Repeated ICSI failure and eggs with multiple pronuclei may warrant specific testing for ACA.

The Diagnostics and Treatment of Recurrent Pregnancy Loss

Recurrent pregnancy loss is a common problem in the reproductive age population of women. It can be caused by many different conditions. This problem is addressed in international guidelines that take a slightly different approach to its diagnosis and treatment. The guidelines used in this review mainly use the guidelines of the Royal College of Obstetricians and Gynaecologists (RCOG), American Society of Reproductive Medicine (ASRM) and European Society of Human Reproduction and Embryology (ESHRE). This review shows how much the approach to miscarriages has changed and how much more needs to be explored and refined. The review also addresses the topic of unexplained pregnancy loss, which continues to be a challenge for clinicians.

Association between antinuclear antibody and female infertility: A meta-analysis

Autoimmunity is reported involving in reproductive failures, and antinuclear antibody (ANA) positivity has been regarded as a typical feature of autoimmunity. Published studies on the association of ANA with reproductive failures including infertility are controversial. The aim of this meta-analysis was to analyse whether the presence of ANA positivity increases the risk of infertility in women. We searched the PubMed and Embase databases for relevant literature without any restrictions prior to April 28, 2021. All analyses were performed using the RevMan 5.3 software. Twelve studies with 2734 participants, including 1482 patients with infertility, met the inclusion and exclusion criteria. The total positivity rate of ANA was 23.8% (353/1482) in all infertile patients and 8.5% (107/1252) in the control group. Infertile females had a significantly higher ANA positivity rate than the control group (odds ratio [OR] = 2.90, 95% confidence interval [CI]: 1.72-4.87, I2 = 65%, P < .0001). Several subgroup analyses were performed to reduce the heterogeneity. ANA positivity was associated with female infertility in studies either performed by indirect immunofluorescence (OR = 2.26, 95% CI:1.67-3.06, P < .00001) or by ELISA (OR = 10.76, 95% CI:1.82-63.64, P < .00001). ANA was significantly associated with increased risk of women infertility either after the definite exclusion of individuals with autoimmune diseases (AID) or without exclusion [(OR = 1.99, 95% CI:1.29-3.06, P = .002), (OR = 2.76, 95% CI:1.56-4.88, P = .0005), respectively]. This meta-analysis provides a comprehensive overview of the prevalence of antinuclear antibodies (ANA) in infertile women and suggests that ANA positivity increases the risk of infertility.

Antinuclear antibodies positivity in women in reproductive age: From infertility to adverse obstetrical outcomes - A meta-analysis

This systematic review and meta-analysis were designed to identify possible correlations between isolated serum antinuclear antibody (ANA) and (i) infertility in the context of in-vitro fertilization (IVF), (ii) idiopathic recurrent pregnancy losses (RPL), and (iii) second/ third trimester pregnancy complications. We performed a systematic review and meta-analysis of the literature in PubMed Library database from inception to March 2022 following PRISMA guidelines. Our pooled results showed a lower pregnancy rate among ANA-positive women undergoing IVF/ICSI compared to ANA-negative women undergoing the same procedures (279/908 versus 1136/2347, random effect, odds ratio -OR- 0.50, 95% confidence interval -CI- 0.38-0.67, p 0.00001, I² = 58%). We also reported a higher miscarriage rate among ANA-positive compared to ANA-negative women (48/223 versus 109/999, random effect, OR: 3.25 95% CI: 1.57-6.76, p = 0.002, I² = 61%) and a lower implantation rate (320/1489 versus 1437/4205, random effect, OR: 0.51, 95% CI: 0.36-0.72, p = 0.0001, I² = 78%). Regarding RPL, pooled results demonstrated a higher prevalence of ANA-positivity in RPL women compared to controls (698/2947 versus 240/3145, random effect, OR: 3.22, 95% CI: 2.12-4.88, p 0.00001, I² 77%), either using > 2 or > 3 pregnancy losses threshold for defining RPL. Heterogeneity of reporting outcome did not allow a quantitative analysis and led to no clear demonstration of an effect of serum ANA on the incidence of stillbirth, preeclampsia and hypertensive disorders. In conclusion, the unfavorable effect of serum ANA was observed in women following IVF. Similarly, ANA were associated with the risk of RPL, while data were unconclusive in terms of late pregnancy complications.

A new insight into the impact of systemic lupus erythematosus on oocyte and embryo development as well as female fertility

Background

Systemic lupus erythematosus (SLE) is often associated with adverse reproductive outcomes. But it's currently unclear regarding the role of SLE in oocyte and embryonic development. Also, it's controversial whether SLE has an adverse effect on fertility. There is a lack of comprehensive understanding and assessment of fertility in patients with SLE.

Objective

This study was aim to investigate oocyte and embryonic development as well as ovarian reserve, and clinical outcomes in SLE patients during in vitro fertilization (IVF) treatment. By combining data on embryonic and gamete development in SLE patients, we hope to provide new insights into a comprehensive assessment of fertility in SLE patients.

Methods

In this study, we collected data from 34 SLE patients who were previously diagnosed and in remission for a total of 44 IVF cycles and matched 102 infertile women with a total of 148 IVF cycles by Propensity Score Matching (PSM) of 1:3 ratio. We then evaluated baseline characteristics, ovarian reserve, IVF laboratory outcomes, and clinical outcomes between the two groups.

Results

After PSM matching, baseline characteristics including age, infertility types, and duration, as well as infertility causes overall coincided between the two groups. Anti-müllerian hormone (AMH) was significantly lower in the SLE group vs comparison (1.9 vs. 3.3 ng/mL, P=0.001). The SLE group performed a significant reduction in available embryo rate (76.6% vs. 86.0%, P=0.001), good-quality blastocyst formation rate (35.1% vs. 47.0%, P=0.003), and blastocyst formation rate (51.0% vs. 67.7%, P=0.001) compared to the comparison. As for clinical outcomes, the implantation rate in the SLE group was notably lower (37.9% vs. 54.9%, P=0.022). The CLBR following every embryo-transfer procedure was distinctly lower (41.2% vs 64.7%, P=0.016) in the SLE group vs comparison. Also, the conservative and optimal CLBRs following every complete cycle procedure were significantly reduced in the SLE group vs the comparison (P=0.001, both).

Conclusion

Patients with SLE present worse outcomes in oocyte and embryonic development, thus yielding compromised female fertility and clinical pregnancy. Individualized fertility assessment and early fertility guidance are necessary for these special groups.

A Review of Roles of Uterine Artery Doppler in Pregnancy Complications

The invasion of trophoblasts into the uterine decidua and decidual vessels is critical for the formation of placenta. The defects of placentation are related to the etiologies of preeclampsia (PE), fetal growth restriction (FGR), and small-for-gestational age (SGA) neonates. It is possible to predict significant vascular events during pregnancy through uterine artery Doppler (UAD). From the implantation stage to the end of pregnancy, detecting changes in uterine and placental blood vessels can provide a favorable diagnostic instrument for pregnancy complications. This review aims to collect literature about the roles of UAD in pregnancy complications. We consider all relevant articles in English from January 1, 1983 to October 30, 2021. Predicting pregnancy complications in advance allows practitioners to carry out timely interventions to avoid or lessen the harm to mothers and neonates. Administering low-dose aspirin daily before 16 weeks of pregnancy can significantly reduce the incidence of pregnancy complications. From early pregnancy to late pregnancy, UAD can combine with other maternal factors, biochemical indicators, and fetal measurement data to identify high-risk population. The identification of high-risk groups can also lessen maternal mortality. Besides, through moderate risk stratification, stringent monitoring for high-risk pregnant women can be implemented, decreasing the incidence of adversities.

Undifferentiated Connective Tissue Disease in Pregnancy: A Topic Yet to be Explored

Undifferentiated connective tissue disease (UCTD) is characterized by signs and symptoms suggestive of a connective tissue disease (CTD), but not fulfilling criteria for a specific CTD. Although UCTD is probably the most common rheumatic disease diagnosed in pregnant women, data about disease course during pregnancy and perinatal outcomes are very limited. Compared to other CTDs, UCTD seems to have milder clinical manifestations in pregnancy. Its natural history is related to disease activity at conception. In fact, if the disease is in a state of remission or minimal activity at conception, pregnancy outcomes are generally good. On the contrary, patients who become pregnant in a moment of high disease activity and/or who have multiple antibodies positivity show an increased risk of disease flares, evolution to a definite CTD and obstetric complications, such as fetal growth restriction, preeclampsia and preterm birth. Therefore, a preconception assessment is essential in women with UCTD to evaluate maternal and fetal risks, to initiate interventions to optimize disease activity, and to adjust medications to those that are least harmful to the fetus. The aim of the present study was to review the available literature about pregnancy course, maternal and fetal outcomes and therapeutic approaches of pregnant women with UCTD.

Combined treatment of prednisone and hydroxychloroquine may improve outcomes of frozen embryo transfer in antinuclear antibody-positive patients undergoing IVF/ICSI treatment

BACKGROUND

The influence of anti-nuclear antibody (ANA) on induced ovulation was controversial, and the effect of prednisone plus hydroxychloroquine (HCQ) treatment on frozen embryo transfer outcomes of in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) for ANA-positive women was unclear.

METHODS

Fifty ANA-positive women and one-hundred ANA-negative women matched for age and anti-Mullerian hormone (AMH) were included from a Reproductive Medical Central of a University Hospital. Sixty-one oocytes pick-up (OPU) cycles in ANA+ group and one-hundred OPU cycles in ANA- group were compared; 30 frozen embryo transfer cycles without treatment and 66 with prednisone plus HCQ treatment among ANA-positive women were compared.

RESULTS

There was no statistical difference in number of retrieved oocytes (13.66 ± 7.71 vs 13.72 ± 7.23, p = .445), available embryos (5.23 ± 3.37 vs 5.47 ± 3.26, p = .347), high-quality embryos (3.64 ± 3.25 vs 3.70 ± 3.52, p = .832), and proportion of high-quality embryos (26.5% vs. 26.7%, p = .940). Biochemical pregnancy rate (33.3% vs. 68.2%, p < .05), clinical pregnancy rate (20.0% vs. 50.1%, p < .05), and implantation rate (5.6% vs. 31.8%, p < .05) were lower, and pregnancy loss rate (83.3% vs. 23.1%, p < .05) was higher in patients with treatment than no treatment.

CONCLUSION

The influence of ANA on number of retrieved oocytes, available embryos, high-quality embryos, and proration of high-quality embryos was not found. The treatment of prednisone plus HCQ may improve implantation rate, biochemical pregnancy rate, and clinical pregnancy rate, and reduce pregnancy loss rate in frozen embryo transfer outcomes for ANA-positive women.

The Effects of LIT and MLR-Bf on Immune Biomarkers and Pregnancy Outcomes in Women With Previous Early Recurrent Miscarriage: A Retrospective Study

Background: Immunological failure during pregnancy is considered one of the etiologies of recurrent miscarriage (RM). The decreased production of mixed lymphocyte reaction-blocking factors (MLR-Bf) may play a major role in this condition. Lymphocyte immunotherapy (LIT), which induces the production of MLR-Bf, has been used in treating RM patients since 1984. However, the effectiveness of LIT is currently being heatedly debated. In addition to that, possible changes to the maternal immune system upon induced MLR-Bf production by LIT remains unclear. Objectives: To explore the possible impacts that MLR-Bf may have on the expression of immune biomarkers and pregnancy outcomes, and deduce whether the prevention of miscarriages is possible with LIT or MLR-Bf in RM patients. Materials and Methods: Women with previous early RM (eRM) were enrolled in this retrospective study after they got pregnant again. LIT was implemented before pregnancy and during the first trimester. MLR-Bf and immune biomarkers were checked as the clinical routine. Patients were followed up until 12 gestational weeks. Levels of immune biomarkers and successful pregnancy rates were compared between MLR-Bf^- group and MLR-Bf⁺ group stratified by LIT. Independent associations between LIT, or MLR-Bf, and miscarriage were estimated. All data management and analysis were conducted using SPSS 20.0. Results: A total of 1,038 patients, 497 MLR-Bf^- (49 cases accepted LIT), and 541 MLR-Bf⁺(463 cases induced by LIT) were included in the study. Percentage of lymphocytes, the ratio of CD4+ T cells/lymphocytes, and levels of some rheumatoid biomarkers (anti-U1-nRNP, anti-SAA-52kd, and anti-CENOP B) were statistically higher in MLR-Bf⁺ group than in MLR-Bf^- group among women without LIT. With LIT treatment the successful pregnancy rate was statistically higher in MLR-Bf⁺ group than in MLR-Bf^- group (66.7% vs. 51.0%, P = 0.028) among women with LIT. Meanwhile, LIT was estimated to have an independent negative association with miscarriage. Conclusion: Upon LIT treament levels of immune biomarkers were different in women with and without MLR-Bf when stratified by whether they received LIT. Not MLR-Bf, but LIT, has an independent protective effect on miscarriage.

Anticentromere antibody induced by immunization with centromere protein a and Freund's complete adjuvant may interfere with mouse oocyte meiosis

BACKGROUND

Anticentromere antibody (ACA) is a member of the antinuclear antibody (ANA) family, and recent studies have found that ACA may be associated with oocyte maturation disorders; however, the possible mechanism behind this phenomenon remains unknown. We conducted this study to investigate whether ACA could penetrate into the living oocytes and interfere with oocyte meiosis in a mouse model.

METHODS

We divided mice into three groups: human recombinant centromere protein-A (human CENP-A, HA) and complete Freund's adjuvant (CFA) were used to immunize mice for the study group (HA + CFA), and mice injected with CFA (CFA group) or saline (Saline group), respectively, served as controls. After immunization, serum anti-CENP-A antibody was detected by indirect immunofluorescence assay (IIFT) and enzyme-linked immunosorbent assay (ELISA). Chromosome alignment and intracellular IgG localization in MI- and MII-stage oocytes were investigated by immunofluorescence analysis.

RESULTS

Positive ACAs were successfully induced by immunization with CENP-A and CFA, and results showed that the serum level of anti-CENP-A antibody was significantly higher in the HA + CFA group compared with the control groups. There was marked increase of chromosome misalignments in MI and MII oocytes in the HA + CFA group compared to the control groups. However, no oocytes from any of the three groups showed intracellular antibody immunofluorescence.

CONCLUSIONS

The development and maturation of oocytes were impaired in peripheral ACA positive mice, which exhibited severe chromosomal misalignments in metaphase meiosis; however, no evidence of ACAs entering the oocytes was observed, thus the underlying mechanism needs further exploration.

Immunological Risk Factors in Recurrent Pregnancy Loss: Guidelines Versus Current State of the Art

Around 1-5% of all couples experience recurrent pregnancy loss (RPL). Established risk factors include anatomical, genetic, endocrine, and hemostatic alterations. With around 50% of idiopathic cases, immunological risk factors are getting into the scientific focus, however international guidelines hardly take them into account. Within this review, the current state of immunological risk factors in RPL in international guidelines of the European Society of Reproduction and Embryology (ESHRE), American Society of Reproductive Medicine (ASRM), German/Austrian/Swiss Society of Obstetrics and Gynecology (DGGG/OEGGG/SGGG) and the Royal College of Obstetricians and Gynecologists (RCOG) are evaluated. Special attention was drawn to recommendations in the guidelines regarding diagnostic factors such as autoantibodies, natural killer cells, regulatory T cells, dendritic cells, plasma cells, and human leukocyte antigen system (HLA)-sharing as well as treatment options such as corticosteroids, intralipids, intravenous immunoglobulins, aspirin and heparin in RPL. Finally, the current state of the art focusing on both diagnostic and therapeutic options was summarized.

Immunization with CENP-C Causes Aberrant Chromosome Segregation during Oocyte Meiosis in Mice

Anticentromere antibodies (ACA) were associated with lower oocyte maturation rates and cleavage rates, while the mechanism was not clear. Aims of this study were to examine whether active immunization with centromere protein C could elicit the CENP-C autoantibody in mice and the impacts of the CENP-C autoantibody on oocyte meiosis. Mice were divided into two groups, one was the experimental group immunized with human centromere protein C and Freund's adjuvant (CFA), and the other was the control group injected with CFA only. Serum and oocytes of BALB/c mice immunized with human centromere protein C (CENP-C) in complete Freund's adjuvant (CFA) or injected with only CFA were studied for the development of the CENP-C antibody. Rates of germinal vesicle breakdown (GVBD), first polar body (Pb1) extrusion, abnormal spindle morphology, and chromosome misalignment were compared between the experimental group and the control group. The CENP-C antibody was only observed in serum and oocytes of mice immunized with the centromere protein C antigen. The first polar body (Pb1) extrusion rate was lower in the experimental group (P < 0.01). A higher percentage of spindle defects and chromosome congression failure were also detected in the experimental group (spindle defects: 64.67 ± 1.16% vs. 9.27 ± 2.28% control; chromosome misalignment: 50.80 ± 2.40% vs. 8.30 ± 1.16% control; P < 0.01 for both). Oocyte meiosis was severely impaired by the CENP-C antibody, which may be the main mechanism of adverse reproductive outcomes for ACA-positive women who have no clinical symptoms of any autoimmune diseases.

Association of prednisone and antinuclear antibodies with pregnancy outcomes in women with unexplained recurrent pregnancy loss

OBJECTIVE

To investigate the therapeutic role of prednisone in patients having unexplained recurrent pregnancy loss (URPL) with positivity of antinuclear antibodies (ANA) and the relationship between ANA titers, prednisone, and pregnancy outcomes.

METHODS

We included 202 women diagnosed as having URPL with positive ANA at titer of 1:80 or more. Among them, 159 patients receiving prednisone plus aspirin were included as group PA and the remaining 43 patients prescribed aspirin only served as group A. Live birth rates were considered as the primary outcome. Incidence rates of pregnancy complications and outcomes of the newborns were also compared. Additionally, the association between live birth and major clinical variables was studied.

RESULTS

Live birth rates were comparable between the two groups (93.1% versus 83.7%, P = 0.107). No significant differences were observed regarding the incidence rates of adverse pregnancy outcomes, other pregnancy complications and the fetal outcomes. Alteration of ANA titers after pregnancy compared with pre-conception results was the only significant variable associated with live birth.

CONCLUSION

Prednisone plus aspirin did not show improved therapeutic effects over aspirin alone in URPL patients with positive ANA. Variation of ANA titers was found to be a prognostic indicator of pregnancy outcomes in these patients.

Antinuclear antibodies in follicular fluid may reduce efficacy of in vitro fertilization and embryo transfer by invading endometrium and granular cells

PROBLEM

The mechanism(s) by which antinuclear antibodies (ANA) induce implantation failure are not clear, and little information regarding the function of autoantibodies in reproductive tissues is available.

METHODS OF STUDY

A total of 380 patients who underwent in vitro fertilization and embryo transfer (IVF-ET) were divided into control, serum positive, and follicular fluid (FF) positive groups based on the results of indirect immunofluorescence assay for ANA in the serum and FF. Immunofluorescence assay was performed to evaluate the existence of ANA in granular cells and endometrial tissues. Presence in FF of soluble apoptotic markers, including Bcl-2, Caspase-3, cleaved PARP, Cytochrome C, GAPDH, and p53, was assessed using magnetic bead based assays.

RESULTS

The patients in the FF positive group had the lowest numbers of retrieved oocytes, fertilizations, and high-quality embryos. The fertilization rate, and the proportion of two pronuclear (2PN) embryos in patients in the FF positive group were significantly lower than those in the other two groups. The FF positive group also had the lowest clinical pregnancy rate, and the highest early miscarriage rate. Granulosa cells and endometrial tissues in patients in the FF positive group were ANA positive. High levels of BCL-2, Caspase-3, Cytochrome C, GAPDH, and p53 were found in the FF of patients in the FF positive group.

CONCLUSIONS

Antinuclear antibodies in FF and endometrial tissues may cause imbalanced apoptosis, resulting in poor IVF-ET treatment outcomes. Local autoimmunity and cell apoptosis in reproductive tissues could be considered new therapeutic targets for improving IVF-ET treatment efficacy.

Antinuclear antibodies and recurrent miscarriage: Systematic review and meta-analysis

Studies have investigated the relationship between antinuclear antibodies (ANA) and recurrent miscarriage (RM). The objective of this paper is to evaluate the presence of ANA as a risk factor for spontaneous abortion in patients with RM. By considering the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis, the authors performed systematic review and meta-analysis by searching the databases of PubMed/Medline and SCOPUS. Review Manager, Version 5.3 performed the statistical analysis. Binary variables were analyzed by odds ratio (ORs) and 95% confidence interval (CI). The subgroup analysis compared the effect of different ANA titers. The authors analyzed the ANA patterns of immunofluorescence staining. Seven case-control studies were selected. The frequency of positive ANA was statistically higher in the RM group (20.6%, 288/1400) as compared to the control group (6.7%, 72/1080). The meta-analysis of the positive ANA showed a statistical difference between the two groups (OR 3.30, 95% CI 1.41-7.73; I²  = 87%, P = .006). Studies have revealed different frequencies of ANA patterns of immunofluorescence. This meta-analysis suggested that positive ANA might increase the risk of RM. However, it was not possible to conclude which ANA pattern of immunofluorescence staining is more frequent in the RM group.

The pathogenic role of autoantibodies in recurrent pregnancy loss

In the present manuscript, we review the recent research investigating the pathogenic association between most studied autoantibodies and recurrent pregnancy loss. Pregnancy loss represents a common obstetric complication occurring in about 15%-25% of all clinically recognized pregnancies. The recurrence of pregnancy loss identifies a distinct clinical entity, that is recurrent pregnancy loss (RPL), affecting about 2%-4% of couples. Several factors, including age, chromosomal abnormalities, uterine anomalies, thrombophilic disorders, endocrinopathies, hormonal and metabolic disorders, infections, sperm quality, and lifestyle issues, are involved in RPL. The role of autoantibodies in RPL is only partially determined. In some cases (antiphospholipid antibodies [aPL]), their involvement is well established. In other cases (anti-thyroid autoantibodies, antinuclear, anti-transglutaminase, and anti-endomysial antibodies), it is still debated, despite multiple, although not fully conclusive, evidences strongly suggest a possible involvement in RPL. Further extensive research is needed to definitively confirm or exclude their actual role.

Association of antinuclear antibody with clinical outcome of patients undergoing in vitro fertilization/intracytoplasmic sperm injection treatment: A meta-analysis

PROBLEM

Several recent studies have investigated the relationship between antinuclear antibodies (ANAs) and in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes. This meta-analysis evaluated the effect of ANA on clinical outcome for patients undergoing IVF/ICSI treatment.

METHOD OF STUDY

A systemic survey of the literature was performed using PubMed, EMBASE and the Cochrane Library databases, through January 2019. Evaluated outcomes included clinical pregnancy rate (CPR), miscarriage rate (MR) and implantation rate (IR). Relative risk ratio (RR) and 95% confidence intervals (95% CI) were used for dichotomous data. Meta-analyses were performed with Review Manager 5.3 software.

RESULTS

Eleven eligible studies were found. For IVF/ICSI cycles, compared with an ANA(-) group, infertile patients with ANA(+) had significantly reduced incidence of CPR (RR 0.66, 95% CI 0.56-0.79; I²  = 60%) and IR (RR 0.61, 95% CI 0.49-0.76; I²  = 75%), and had a higher MR (RR 1.81, 95% CI 1.40-2.36; I²  = 48%).

CONCLUSION

This study suggested that ANA might cause poor pregnancy outcomes for infertile women undergoing IVF/ICSI treatment.

The Impact of Autoantibodies on IVF Treatment and Outcome: A Systematic Review

The role of autoantibodies in in vitro fertilization (IVF) has been discussed for almost three decades. Nonetheless, studies are still scarce and widely controversial. The aim of this study is to provide a comprehensive systematic review on the possible complications associated to autoantibodies (AA) impeding the chances of a successful IVF cycle. An Embase, PubMed/Medline and Cochrane Central Database search was performed on 1 December 2018, from 2006 until that date. From the 598 articles yielded in the search only 44 relevant articles ultimately fulfilled the inclusion criteria and were qualitatively analyzed. Five subsets of results were identified, namely, thyroid related AA, anti-phospholipid antibodies, anti-nuclear antibodies, AA affecting the reproductive system and AA related to celiac disease. It may be implied that the majority of auto-antibodies exert a statistically significant effect on miscarriage rates, whereas the effects on clinical pregnancy and live birth rates differ according to the type of auto-antibodies. While significant research is performed in the field, the quality of evidence provided is still low. The conduction of well-designed prospective cohort studies is an absolute necessity in order to define the impact of the different types of autoantibodies on IVF outcome.

[Use of hydroxychloroquine and prednisone in the presence of serum autoimmunity in female infertility]

OBJECTIVE

Presence of non-specific autoimmunity (antinuclear antibodies without antigenic specificities and/or antiphospholipid antibodies without criteria of antiphospholipid syndrome) seems to be associated with unexplained female infertility. The objective is to study the characteristics of patients who undergone treatment for non-specific antibodies in Medically Assisted Procreation (MAP).

METHODS

Ten patients were prospectively followed at MAP center of Grenoble University Hospital. Patient characteristics were collected and evaluated. All patients had a consultation in internal medicine unit as well as an autoimmune assessment (antinuclear antibodies, APL especially) in search of defined autoimmune disease (exclusion criterion). The treatments undertaken were at clinician' discretion.

RESULTS

One patient received quadritherapy (heparin, platelet antiaggregant, prednisone and hydroxychloroquine), 5 received triple therapy, 3 had dual therapy, and one patient had prednisone only. The 10 patients had a pregnancy under treatment, 8 of which were completed without complications. The control of autoimmunity under treatment appears to show a decrease in serum antibody levels. Tolerance was good (delayed hypersensitivity to hydrochloroquine resulted in discontinuation of therapy in only one patient).

CONCLUSION

The presence of non-specific serum autoimmunity in a context of infertility appears to be pathogenic and immunomodulatory treatments are clinically and/or biologically effective. A prospective and interventional study with a larger number of patients is needed to assess the efficacy of such treatments in patients with unexplained infertility.

Association of serum autoantibodies with pregnancy outcome of patients undergoing first IVF/ICSI treatment: A prospective cohort study

The relevance of antiphospholipid (aPL), antinuclear (ANA) or antithyroid (ATA) antibodies in women undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) are controversial. The present study aims to investigate which autoantibodies are associated with the pregnancy outcome of patients undergoing first IVF/ICSI treatment. A total of 3763 IVF/ICSI patients were recruited from January to December 2015. Forty-five patients positive for aPL presenting adverse outcomes in their first cycle received low-dose aspirin treatment before the second transfer. Logistic regression analyses were performed to assess any association between autoantibodies and IVF/ICSI outcomes. The aCL-IgG was significantly associated with live birth rate (OR 0.58, 95% CI 0.36-0.96, p<0.05) and miscarriage rate (OR 2.04, 95% CI 1.23-3.40, p<0.01). The aCL-IgM was associated with miscarriage rate (OR 2.14, 95% CI 1.29-3.54, p<0.01). The aβ₂GPI-IgG was associated with implantation rate and clinical pregnancy rate (OR 0.61, 95% CI 0.24-0.96, p<0.05; OR 0.40, 95% CI 0.13-0.87, p<0.05, respectively). After the low-dose aspirin treatment, the live birth rate (37.0% vs. 19.1%, p<0.05) increased significantly in patients with positive for aPL. In contrary, the aβ₂GPI-IgM, ANA, anti-thyroglobulin (aTG) and anti-thyroperoxidase (aTPO) antibodies had no association with IVF/ICSI outcome. It is suggested that the presence of aCL-IgG, aCL-IgM and aβ₂GPI-IgG might exert a detrimental effect on IVF/ICSI outcomes. Low-dose aspirin treatment could be useful for patients positive for these antibodies. Therefore, it is suggested that these antibodies should be assessed prior to IVF/ICSI treatment.

Impacts of Anti-dsDNA Antibody on In Vitro Fertilization-Embryo Transfer and Frozen-Thawed Embryo Transfer

Our purpose is to explore whether anti-dsDNA antibody, which was demonstrated to enter living cells and induced apoptosis, could adversely affect reproductive outcomes. A total of 259 women receiving the in vitro fertilization-embryo transfer (IVF) cycle were enrolled in this study, including 52 women with positive ANA and anti-dsDNA (ANA+/anti-dsDNA+ group), 86 women with positive ANA and negative anti-dsDNA (ANA+/anti-dsDNA− group), and 121 women with negative ANA and anti-dsDNA (ANA−/anti-dsDNA− group). 136 nonpregnant women among 259 patients in the IVF-ET cycle were enrolled in the hormone replacement therapy frozen-thawed embryo transfer (HRT-TET) cycle. We compared basic characters and IVF outcomes among three groups in fresh embryo transfer and frozen-thawed embryo transfer cycle, respectively. The number of retrieved oocytes, available embryos, and high-quality embryos in the ANA+/anti-dsDNA+ group was lower than those in the other two groups in the fresh embryo transfer cycle. The rates of fertilization, implantation, and clinical pregnancy in the ANA+/anti-dsDNA+ group were the lowest, while the early miscarriage rate was the highest in the ANA+/anti-dsDNA+ group both in the fresh embryo transfer cycle and in the frozen-thawed embryo transfer cycle. Our data suggested that anti-dsDNA antibody may be the essential marker for defective oocytes or embryos in infertile women with any type of ANA.

Combined treatment of prednisone and aspirin, starting before ovulation induction, may improve reproductive outcomes in ANA-positive patients

LABELED PROBLEM

Antinuclear antibody (ANA) could cause reproductive failure. But treatment for women with antinuclear antibody was controversial.

METHODS

One hundred and thirty-three ANA+ women with one-time in vitro fertilization (IVF) implantation failure were divided into two groups randomly. The study group comprised 60 sero-positive for antinuclear antibody. These patients were treated with prednisone (10 mg/day) and aspirin (100 mg/day) starting 3 months before induction of ovulation in 60 IVF cycles. Seventy-three patients were included in untreated group.

RESULTS

Fertilization rate, pregnancy rate, and implantation rate were significantly higher in treatment group, while abortion rate was markedly higher in non-treatment group by randomized controlled trial. Same conclusions were also proved between cycles of 60 ANA+ women with therapy and their former cycles without any treatment.

CONCLUSION

Combined treatment of prednisone for immunosuppression and aspirin as an antithrombotic agent, starting 3 months before ovulation induction, may improve reproductive outcomes in ANA+ patients.

Uterine blood flow indices, antinuclear autoantibodies and unexplained recurrent miscarriage

OBJECTIVE

To study the correlation between 2D and 3D uterine flow indexes and the presence or the absence of antinuclear antibodies (ANA) in women with unexplained recurrent miscarriage (uRM).

METHODS

Fifty-two subjects (26 uRM and 26 control women) underwent 2D Doppler measurement of pulsatility index and resistance index of the uterine arteries in both the follicular and midluteal phase of the cycle. Additionally, 3D ultrasonography determination of vascularisation index, flow index, and vascularisation flow index was carried out with the aid of the VOCAL technique. Serum assay for the presence of ANA was performed in all women.

RESULTS

Pulsatility index of ANA+ uRM women was higher than that of ANA- uRM women and control ANA+ and ANAwomen, both in the follicular and in the midluteal phase of the cycle. Vascularisation index in ANA- uRM women was significantly higher than that in ANA+ control women. Flow index in uRM ANA+ women was significantly lower than that of each of the other groups.

CONCLUSION

ANA might be involved in uRM by determining an impairment in uterine blood flow hemodynamic, particularly in uterine blood flow intensity and uterine artery impedance.

Human IgG Antinuclear Antibodies Induce Pregnancy Loss in Mice by Increasing Immune Complex Deposition in Placental Tissue: In Vivo Study

PROBLEM

A threefold higher prevalence of antinuclear antibodies (ANA) has been reported in patients with recurrent pregnancy loss (RPL). Nevertheless, the role of ANA in reproductive failure is still unclear. The aim of this study was to investigate the role of ANA during early pregnancy in vivo.

METHOD OF STUDY

We used pregnant mice treated with immunoglobulin G (IgG) obtained from normal healthy subjects (NHS); ANA(+) sera of patients with RPL; and ANA(+) sera from women with uncomplicated pregnancies (HW). Placental immunohistochemical/immunofluorescence staining was performed to detect complement and immune complex deposition. ELISA was performed to evaluate complement levels.

RESULTS

ANA(+) IgG from RPL women significantly increased embryo resorption rate, reduced C3, and increased C3a serum levels compared to NHS IgG or ANA(+) -HW IgG. Increased C3 deposition and increased immune complex staining in placental tissues from mice treated with ANA(+) -RPL IgG fraction compared to NHS- and ANA(+) -HW-IgG-treated mice were found.

CONCLUSION

ANA(+) IgG injection in mice is able to induce fetal resorption and complement activation. The presence on placental tissues of immune complexes and complement fragments suggests the complement activation as a possible mechanism of placental damage.

A retrospective study on IVF/ICSI outcome in patients with anti-nuclear antibodies: the effects of prednisone plus low-dose aspirin adjuvant treatment

BACKGROUND

Anti-nuclear antibodies (ANA) are suspected of having relevance to adverse reproductive events.

METHODS

This study aims to investigate the potential effect of ANA on IVF/ICSI outcome and the therapeutic role of prednisone plus low-dose aspirin (P + A) adjuvant treatment in ANA + patients. The first IVF/ICSI cycles without P + A of sixty-six ANA + women were enrolled as the ANA + group, and the 233 first IVF/ICSI cycles of matched ANA- women served as the ANA- group. The ANA + group was divided into the Titre < =1:320 subgroup and the Titre > 1:320 subgroup. Twenty-one ANA + women with adverse outcomes in their first cycles (ANA + cycles without P + A) received P + A adjuvant treatment for three months before the second IVF/ICSI cycle (ANA + cycles with P + A). The clinical characteristics and the IVF/ICSI outcomes were compared, respectively, between 1) the ANA + group and the ANA- group, 2) the Titre < =1:320 subgroup and the Titre > 1:320 subgroup, and 3) the ANA + cycles without P + A and the ANA + cycles with P + A.

RESULTS

No significant differences were observed between each of the two-group pairs in the clinical characteristics. The ANA + group exhibited significantly lower MII oocytes rate, normal fertilisation, pregnancy and implantation rates, as well as remarkably higher abnormal fertilisation and early miscarriage rates. The Titre < =1:320 subgroup's IVF/ICSI outcomes were as poor as those of the Titre > 1:320 subgroup. After the P + A adjuvant treatment, the number of two pro-nuclei, perfect embryos and available embryos, and the implantation rate increased significantly.

CONCLUSIONS

These observations suggest that ANA could exert a detrimental effect on IVF/ICSI outcome that might not be titre-dependent, and P + A adjuvant treatment could be useful for ANA + patients. This hypothesis should be verified in further prospective randomised studies.

Preliminary investigation of the impact of anticentromere antibody on oocyte maturation and embryo cleavage

OBJECTIVE

To explore whether anticentromere antibody (ACA) is the most significant antibody among antinuclear antibodies (ANA), which adversely affect oocyte maturation, embryo cleavage, and pregnancy outcome in women undergoing an intracytoplasmic sperm injection program.

DESIGN

Retrospective, nested case-control study.

SETTING

Center for reproductive medicine, university hospital.

PATIENT(S)

A total of 187 women receiving the first intracytoplasmic sperm injection cycle were enrolled in this study, including 20 women with positive ACA and ANA (ACA[+]/ANA[+] group), 51 women with negative ACA and positive ANA(ACA[-]/ANA[+] group), and 116 patients with negative ACA and ANA (ACA[-]/ANA[-] group). Patients in the three groups were age-matched.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Percentages of germinal vesicle, metaphase I, and metaphase II oocytes, embryo cleavage rate, number of high-quality embryos, and rates of pregnancy and implantation.

RESULT(S)

The metaphase I oocyte percentage was markedly higher and the metaphase II oocyte percentage and the normal cleavage rate were significantly lower in the ACA[+]/ANA[+] group as compared with the ACA[-]/ANA[+] group. Furthermore, statistically significant differences were found in rates of pregnancy and implantation among the three groups. However, no significant difference was found between any two groups owing to the small sample size, except for a significantly lower implantation rate being found in the ACA[+]/ANA[+] group when compared with the ACA[-]/ANA[-] group.

CONCLUSION(S)

Our data suggest that ACA may be the essential marker for defective oocytes or embryos in infertile women with any type of ANA.