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Mu F, Huo H, Wang M, Liu L, Wang F. Intravenous immunoglobulin improves live birth rates in patients with unexplained recurrent pregnancy loss. J Reprod Immunol 2024; 166:104322. [PMID: 39216166 DOI: 10.1016/j.jri.2024.104322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/21/2024] [Accepted: 08/24/2024] [Indexed: 09/04/2024]
Abstract
This real-world study aimed to assess the clinical efficacy and safety of intravenous immunoglobulin (IVIG) in treating unexplained recurrent pregnancy loss (uRPL) patients. A total of 238 patients with uRPL were enrolled in this retrospective study. According to the treatment, patients were assigned into treatment group (n=184, receiving IVIG+low molecular weight heparin [LMWH]) and control group (n=54, only LMWH). The primary outcome was the live birth rates (LBR) after 24 weeks of gestation. In addition, we performed subgroup analyses to assess the LBR in uRPL patients with age (≥30 years or <30 years), body mass index (BMI, 18-24 kg/m2 or ≥24 kg/m2), number of previous pregnancy losses (2 or ≥3), gestational week of first medication, and IVIG medication regimen during pregnancy. The LBR showed a significant increase after IVIG treatment compared to the control group (77.7 % vs. 53.7 %, P=0.001). Multivariable logistic regression indicated that IVIG was associated with increased LBR (aOR=4.383, 95 %CI 2.024-9.489). Besides, we observed a significantly lower incidence of decreased platelet count (1.6 % vs. 7.4 %, P=0.049) in the treatment group. Subgroup analyses showed that IVIG treatment was associated with improved LBR in uRPL patients with age of <30 years (aOR=4.012, 95 %CI 1.428-11.266), previous pregnancy losses ≥3 times (aOR=17.327, 95 %CI 2.525-118.921), and BMI of 18-24 kg/m2 (aOR=8.914, 95 %CI 2.985-26.618). IVIG treatment significantly improves the LBR in uRPL patients. These findings from real-world data provide evidence for the safety and efficacy of IVIG as a viable treatment for uRPL patients in clinical practice.
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Affiliation(s)
- Fangxiang Mu
- Department of Reproductive Medicine, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Huyan Huo
- Department of Reproductive Medicine, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Mei Wang
- Department of Reproductive Medicine, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Ling Liu
- Department of Reproductive Medicine, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Fang Wang
- Department of Reproductive Medicine, Lanzhou University Second Hospital, Lanzhou 730030, China.
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Ling Q, Xu J, Tian Y, Chen D, Mo C, Peng B. Effect of IVIG therapy on pregnant women with unexplained recurrent spontaneous abortion: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1381461. [PMID: 39205682 PMCID: PMC11349655 DOI: 10.3389/fendo.2024.1381461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
Objective To assess the effect of intravenous immunoglobulin (IVIG) therapy on unexplained recurrent spontaneous abortion (URSA). Methods We retrieved all randomized controlled trials (RCTs) related to the effect of IVIG therapy on URSA in the following databases: PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials before April 30, 2023, according to the PRISMA statement. The therapeutic effect of IVIG was measured by live birth rates. Quality assessment was conducted independently by two reviewers, based on the Newcastle-Ottawa scale. For the meta-analysis, we used odds ratios (random effects model and fixed effects model). The between-study heterogeneity was assessed by the Q test. Publication bias was assessed by funnel plots. Results A total of 12 studies with 751 participants were included in this meta-analysis. There was no statistical significance [OR = 1.07, 95%CI (0.65, 1.75), P=0.80] between the IVIG group and the non-IVIG group, including low molecular weight heparin (LMWH) plus low-dose aspirin (LDA), intralipid, multivitamins, albumin, and normal saline. A subgroup analysis was conducted according to the different treatment regimens of the non-IVIG group. Compared to the placebo group, including multivitamins, albumin, and saline, the live birth rate of the IVIG group is superior, but there was no statistical significance [OR =1.43, 95%CI (0.99, 2.07), P=0.05]. Another subgroup analysis was performed according to URSA with positive for antiphospholipid antibodies (aPLs). Results showed the live birth rate of IVIG on URSA with positive for aPLs is inferior to that of LMWH plus LDA [OR = 0.25, 95%CI (0.11, 0.55), P=0.0007]. Conclusions IVIG didn't increase the live birth rate of URSA compared to placebo. Conversely, compared with the IVIG, the LMWH plus LDA treatment schedule can increase the live birth rate of URSA with positive for aPLs.
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Affiliation(s)
- Qiao Ling
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Jinfeng Xu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yuan Tian
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Daijuan Chen
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chunheng Mo
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Bing Peng
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children of MOE, West China Second University Hospital, Sichuan University, Chengdu, China
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Yao Y, Ye Y, Chen J, Zhang M, Cai X, Zheng C. Maternal-fetal immunity and recurrent spontaneous abortion. Am J Reprod Immunol 2024; 91:e13859. [PMID: 38722063 DOI: 10.1111/aji.13859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 06/26/2024] Open
Abstract
Recurrent Spontaneous Abortion (RSA) is a common pregnancy complication, that has multifactorial causes, and currently, 40%-50% of cases remain unexplained, referred to as Unexplained RSA (URSA). Due to the elusive etiology and mechanisms, clinical management is exceedingly challenging. In recent years, with the progress in reproductive immunology, a growing body of evidence suggests a relationship between URSA and maternal-fetal immunology, offering hope for the development of tailored treatment strategies. This article provides an immunological perspective on the pathogenesis, diagnosis, and treatment of RSA. On one hand, it comprehensively reviews the immunological mechanisms underlying RSA, including abnormalities in maternal-fetal interface immune tolerance, maternal-fetal interface immune cell function, gut microbiota-mediated immune dysregulation, and vaginal microbiota-mediated immune anomalies. On the other hand, it presents the diagnosis and existing treatment modalities for RSA. This article offers a clear knowledge framework for understanding RSA from an immunological standpoint. In conclusion, while the "layers of the veil" regarding immunological factors in RSA are gradually being unveiled, our current research may only scratch the surface. In terms of immunological etiology, effective diagnostic tools for RSA are currently lacking, and the efficacy and safety of immunotherapies, primarily based on lymphocyte immunotherapy and intravenous immunoglobulin, remain contentious.
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Affiliation(s)
- Yao Yao
- Department of Pharmacy, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, China
| | - Yiqing Ye
- Department of Pharmacy, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, China
| | - Jia Chen
- School of Pharmacy, Hangzhou Medical College, Hangzhou, China
| | - Meng Zhang
- Department of Pharmacy, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, China
| | - Xiaoyu Cai
- Department of Pharmacy, Hangzhou First People's Hospital, Hangzhou, China
| | - Caihong Zheng
- Department of Pharmacy, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Hangzhou, China
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Yamada H, Deguchi M, Saito S, Takeshita T, Mitsui M, Saito T, Nagamatsu T, Takakuwa K, Nakatsuka M, Yoneda S, Egashira K, Tachibana M, Matsubara K, Honda R, Fukui A, Tanaka K, Sengoku K, Endo T, Yata H. High doses of intravenous immunoglobulin stimulate regulatory T cell and suppress natural killer cell in women with recurrent pregnancy loss. J Reprod Immunol 2023; 158:103977. [PMID: 37354783 DOI: 10.1016/j.jri.2023.103977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/28/2023] [Accepted: 06/09/2023] [Indexed: 06/26/2023]
Abstract
The aim was to evaluate whether natural killer (NK) cells and regulatory T (Treg) cells were involved in mechanisms underlying beneficial effects of a high dose of intravenous immunoglobulin (IVIG) on recurrent pregnancy losses (RPL) of unexplained etiology. In a double-blind, randomized, placebo-controlled trial of IVIG (400 mg/kg, for 5 days in 4-6 weeks of gestation) in women with RPL, blood samples were collected pre-infusion, one week after infusion (1 w), and eight weeks of gestation/when miscarried (8 w). Levels of NK and Treg cells in peripheral blood were compared between women with IVIG (n = 50) and placebo (n = 49), and between women with IVIG who gave live birth (n = 29) and those who had miscarriage with normal chromosome (n = 12). Effector Treg cell percentages in IVIG group at 1 w (mean 1.43 % vs. 1.03 %) and at 8 w (1.91 % vs. 1.18 %) were higher than those in placebo group (p < 0.01). Total Treg cell percentages in IVIG group at 1 w (4.75 % vs. 4.08 %) and at 8 w (5.55 % vs. 4.47 %) were higher than those in placebo group (p < 0.05). In women with live birth, total Treg cell percentages increased at 8 w (5.52 %, p < 0.001) compared with pre-infusion (4.54 %) and 1 w (4.47 %), while NK cell activity decreased at 1 w (20.18 %, p < 0.001) compared with pre-infusion (26.59 %). IVIG increased Treg cell percentages and suppressed NK cell activity very early in pregnancy, and these were associated with subsequent live birth. Stimulation of Treg cells and suppression of NK cell activity very early in pregnancy may be a mechanism of pharmacological effects of high dose IVIG.
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Affiliation(s)
- Hideto Yamada
- Center for Recurrent Pregnancy Loss, Teine Keijinkai Hospital, 1-40 Maeda 1-jho 12-chome Teine-ku, Sapporo, Japan.
| | - Masashi Deguchi
- Department of Obstetrics and Gynecology, Kobe University School of Medicine, 7-5-1 Kusunoki-cho Chuo-ku, Kobe, Japan
| | - Shigeru Saito
- Department of Obstetrics and Gynecology, The Toyama University, 2630 Sugitani, Toyama, Japan
| | - Toshiyuki Takeshita
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Mari Mitsui
- Division of Reproductive Medicine and Maternal Care, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
| | - Tsuyoshi Saito
- Department of Obstetrics and Gynecology, Sapporo Medical University, Minami 1-jo Nishi 17-chome, Chuo-ku, Sapporo, Japan
| | - Takeshi Nagamatsu
- Department of Obstetrics and Gynecology, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Koichi Takakuwa
- Niigata University, 1-757 Asahimachi-dori, Chuo-ku, Niigata, Japan
| | - Mikiya Nakatsuka
- Okayama University, Graduate School of Health Sciences, 2-5-1 Shikata, Kita-ku, Okayama, Japan
| | - Satoshi Yoneda
- Department of Obstetrics and Gynecology, The Toyama University, 2630 Sugitani, Toyama, Japan
| | - Katsuko Egashira
- Department of Obstetrics and Gynecology, Hamanomachi Hospital, 3-3-1 Nagahama, Chuo-ku, Fukuoka, Japan
| | - Masahito Tachibana
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Japan
| | - Keiichi Matsubara
- Department of Obstetrics and Gynecology, Ehime University School of Medicine, 454 Shitsukawa, Toon, Japan
| | - Ritsuo Honda
- Department of Obstetrics and Gynecology, Kumamoto University School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, Japan
| | - Atsushi Fukui
- Department of Obstetrics and Gynecology, Hyogo Medical University School of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Japan
| | - Kanji Tanaka
- Department of Obstetrics and Gynecology, Hirosaki University School of Medicine, 53 Honcho, Hirosaki, Japan
| | - Kazuo Sengoku
- Department of Obstetrics and Gynecology, Asahikawa Medical University, 1-1-1 Midorigaoka-higashi 2-jo, Asahikawa, Japan
| | - Toshiaki Endo
- Department of Obstetrics and Gynecology, Sapporo Medical University, Minami 1-jo Nishi 17-chome, Chuo-ku, Sapporo, Japan
| | - Hiroaki Yata
- Research & Development Division, Japan Blood Products Organization, 15F Tamachi Station Tower N 3-1-1 Shibaura, Minato-ku, Tokyo, Japan
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Banjar S, Kadour E, Khoudja R, Ton-Leclerc S, Beauchamp C, Beltempo M, Dahan MH, Gold P, Jacques Kadoch I, Jamal W, Laskin C, Mahutte N, Reinblatt SL, Sylvestre C, Buckett W, Genest G. Intravenous immunoglobulin use in patients with unexplained recurrent pregnancy loss. Am J Reprod Immunol 2023; 90:e13737. [PMID: 37491929 DOI: 10.1111/aji.13737] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/30/2023] [Accepted: 06/02/2023] [Indexed: 07/27/2023] Open
Abstract
PROBLEM Recurrent pregnancy loss (RPL) affects up to 4% of couples attempting to conceive. RPL is unexplained in over 50% of cases and no effective treatments exist. Due to the immune system's pivotal role during implantation and pregnancy, immune-mediated RPL may be suspected and immunomodulatory treatments like intravenous immunoglobulin (IVIg) have been administered but remain controversial. The goal of our study was to evaluate our center's 6 year-outcomes and to develop a framework for IVIg use in RPL. METHOD OF THE STUDY Retrospective, single-center cohort study. All patients having received IVIg for unexplained RPL at the McGill Reproductive Immunology Clinic (MRIC) from January 2014 to December 2020 were included if maternal age was <42 years, body mass index (BMI) < 35 kg/m2 , non-smoker and having had ≥3 consecutive RPL despite previous treatment with aspirin and progesterone. IVIg 0.6-0.8 g/kg was given prior to conception and monthly during pregnancy until 16-20 weeks' gestation. We compared IVIg treated patient's outcomes to a separate "natural history cohort". This cohort was composed of patients consulting at the McGill recurrent pregnancy loss clinic and the MRIC over a 2-year period (January 2020 to December 2021) with similar inclusion criteria as the treatment cohort but did not receive IVIg or other immunomodulatory treatments. The association of IVIg with outcomes (compared to no IVIg) was evaluated among the groups of patients with primary RPL and secondary RPL. The primary outcome was live birth rate (LBR), secondary outcomes included IVIg safety, obstetrical, and neonatal complications. RESULTS Among 169 patients with unexplained RPL that were included in the study, 111 had primary RPL (38 exposed to IVIg and 83 controls) and 58 had secondary RPL (nine exposed to IVIG and 49 controls). Among patients with primary RPL (n = 111), the LBR was 64.3% (18/28) among patient exposed to IVIg compared to 43.4% (36/83) in controls (p = 0.079); regression analysis adjusting for BMI and number of previous miscarriages showed benefit favoring the use of IVIg (OR = 3.27, CI 95% (1.15-10.2), p = 0.03) when evaluating for live birth. In the subgroup of patients with ≥5 previous RPL and primary RPL (n = 31), IVIg was associated with higher LBR compared to control (10/15 (66.7%) vs. 3/16 (18.8%); p = 0.0113) but not the in the sub-group of patients with <5 miscarriages and primary RPL (8/13 (61.5%) vs. 33/67 (49.3%); p = 0.548). IVIG treatment did not improve LBR in patients with secondary RPL in our study (3/9 (33.3%) vs. 23/49 (47%); p = 0.495). There were no serious adverse events in the IVIg treatment group, obstetrical/neonatal complications were similar between groups. CONCLUSION IVIg may be an effective treatment for patients with RPL if appropriately used in specific groups of patients. IVIg is a blood product and subject to shortages especially with unrestricted off-label use. We propose considering IVIg in well-selected patients with high order RPL who have failed standard medical therapy. Further mechanistic studies are needed to understand immune-mediated RPL and IVIg's mode of action. This will enable further refinement of treatment criteria and the development of standardized protocol for its use in RPL.
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Affiliation(s)
- Shorooq Banjar
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
- Division of Clinical Immunology and Allergy, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Einav Kadour
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Bnai-Zion Medical Center, Rishon-Le-Zion, Israel
- Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Rabea Khoudja
- Division of Clinical Immunology and Allergy, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | | | - Coralie Beauchamp
- Ovo Clinic, Montréal, Québec, Canada
- Obstetrics and Gynaecology Department, University of Montreal, Montreal, Quebec
| | - Marc Beltempo
- Division of Neonatology, Montreal Children's Hospital - McGill University Health Centre, Montreal, Québec, Canada
| | - Michael H Dahan
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Phil Gold
- Department of Allergy and Immunology, Montreal General Hospital, Montreal, Quebec, Canada
| | - Isaac Jacques Kadoch
- Ovo Clinic, Montréal, Québec, Canada
- Obstetrics and Gynaecology Department, University of Montreal, Montreal, Quebec
| | - Wael Jamal
- Clinique OVO, Montréal, Québec, Canada
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada
| | - Carl Laskin
- TRIO Fertility, Toronto, Ontario, Canada
- Deptartments of Medicine and Obstetrics & Gynecology, University of Toronto, Toronto, Canada
| | - Neal Mahutte
- The Montreal Fertility Centre, Montreal, Quebec, Canada
| | - Shauna Leigh Reinblatt
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
| | - Camille Sylvestre
- Ovo Clinic, Montréal, Québec, Canada
- Division of Reproductive Endocrinology and Infertility, University of Montreal, Montreal, Quebec, Canada
| | - William Buckett
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montréal, Québec, Canada
- McGill University Health Care Reproductive Center, Montreal, Quebec, Canada
| | - Genevieve Genest
- Division of Clinical Immunology and Allergy, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
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Cavalcante MB, Alcântara da Silva PH, Sampaio OGM, Câmara FEA, de Melo Bezerra Cavalcante CT, Barini R. The use of immunotherapies for recurrent miscarriage: An overview of systematic reviews and meta-analysis. J Reprod Immunol 2023; 158:103986. [PMID: 37413775 DOI: 10.1016/j.jri.2023.103986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/12/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023]
Abstract
Immunotherapies have been a treatment proposed for recurrent miscarriages (RMs). The use of immunotherapies remains not recommended in the management of couples with RM. This overview of systematic reviews and meta-analysis (SRs-MAs) aims to identify and evaluate the quality of SRs-MAs that studied the effectiveness of immunotherapies in the treatment of RM patients. SRs-MAs were searched in PubMed/Medline, Embase, and Web of Science. SRs-MAs were analyzed using AMSTAR-2, PRISMA 2020, Risk of Bias in Systematic (ROBIS), and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tools to evaluate the methodological quality, reporting quality, risk of bias, and evidence quality of included SRs-MAs, respectively. This review included 20 SRs-MAs that evaluated the following immunotherapies: intravenous immunoglobulin (13 publications), lymphocyte immunotherapy (6 publications), corticosteroids (3 publications), and lipid emulsion (1 publication). SRs-MAs were rated as high methodological, moderate, and critically low quality in 14 (70 %), 1 (5 %), and 5 (25 %) SRs-MAs and high reporting, moderate, and low quality in 13 (65 %), 4 (20 %), and 3 (5 %) SRs-MAs, respectively. The overall risk of bias revealed a low risk of bias for three-quarters of the SRs-MAs. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) analysis resulted in 23 outcomes, of which 4, 3, 5, and 11 results were of high, moderate, low, and very low quality, respectively. An improvement has been observed over the past few years in the quality of systematic reviews (SR)-MAs that have investigated the efficacy of intravenous immunoglobulin, lymphocyte immunotherapy, lipid emulsion therapy, and corticosteroids as a therapy for RM.
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Affiliation(s)
- Marcelo Borges Cavalcante
- Post Graduate Program in Medical Sciences, Universidade de Fortaleza (UNIFOR), Fortaleza, CE 60.811-905, Brazil; CONCEPTUS - Reproductive Medicine, Fortaleza, CE 60.170-240, Brazil.
| | | | - Olga Goiana Martins Sampaio
- Post Graduate Program in Medical Sciences, Universidade de Fortaleza (UNIFOR), Fortaleza, CE 60.811-905, Brazil
| | | | | | - Ricardo Barini
- Department of Obstetrics and Gynecology, Campinas University (UNICAMP), Campinas, SP 13.083-887, Brazil
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Yamada H, Deguchi M, Saito S, Takeshita T, Mitsui M, Saito T, Nagamatsu T, Takakuwa K, Nakatsuka M, Yoneda S, Egashira K, Tachibana M, Matsubara K, Honda R, Fukui A, Tanaka K, Sengoku K, Endo T, Yata H. Intravenous immunoglobulin treatment in women with four or more recurrent pregnancy losses: A double-blind, randomised, placebo-controlled trial. EClinicalMedicine 2022; 50:101527. [PMID: 35795714 PMCID: PMC9251568 DOI: 10.1016/j.eclinm.2022.101527] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/24/2022] [Accepted: 06/01/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There is no effective treatment for women with unexplained recurrent pregnancy loss (RPL). We aimed to investigate whether treatment with a high dose of intravenous immunoglobulin (IVIG) in early pregnancy can improve pregnancy outcomes in women with unexplained RPL. METHODS In a double-blind, randomised, placebo-controlled trial, women with primary RPL of unexplained aetiology received 400 mg/kg of IVIG daily or placebo for five consecutive days starting at 4-6 weeks of gestation. They had experienced four or more miscarriages except biochemical pregnancy loss and at least one miscarriage of normal chromosome karyotype. The primary outcome was ongoing pregnancy rate at 22 weeks of gestation, and the live birth rate was the secondary outcome. We analysed all women receiving the study drug (intention-to-treat, ITT) and women except those who miscarried due to fetal chromosome abnormality (modified-ITT). This study is registered with ClinicalTrials.gov number, NCT02184741. FINDINGS From June 3, 2014 to Jan 29, 2020, 102 women were randomly assigned to receive IVIG (n = 53) or placebo (n = 49). Three women were excluded; therefore 50 women received IVIG and 49 women received placebo in the ITT population. The ongoing pregnancy rate at 22 weeks of gestation (31/50 [62·0%] vs. 17/49 [34·7%]; odds ratio [OR] 3·07, 95% CI 1·35-6·97; p = 0·009) and the live birth rate (29/50 [58·0%] vs. 17/49 [34·7%]; OR 2·60, 95% CI 1·15-5·86; p = 0·03) in the IVIG group were higher than those in the placebo group in the ITT population. The ongoing pregnancy rate at 22 weeks of gestation (OR 6·27, 95% CI 2·21-17·78; p < 0·001) and the live birth rate (OR 4·85, 95% CI 1·74-13·49; p = 0·003) significantly increased in women who received IVIG at 4-5 weeks of gestation as compared with placebo, but these increases were not evident in women who received IVIG at 6 weeks of gestation. Four newborns in the IVIG group and none in the placebo group had congenital anomalies (p = 0·28). INTERPRETATION A high dose of IVIG in very early pregnancy improved pregnancy outcome in women with four or more RPLs of unexplained aetiology. FUNDING The Japan Blood Products Organization.
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Affiliation(s)
- Hideto Yamada
- Centre for Recurrent Pregnancy Loss, Teine Keijinkai Hospital, 1-40 Maeda 1-jho 12-chome Teine-ku, Sapporo, Japan
- Corresponding author at: Director of Centre for Recurrent Pregnancy Loss, Teine Keijinkai Hospital, 1-40 Maeda 1-jho 12-chome Teine-ku, Sapporo 006-8555, Japan.
| | - Masashi Deguchi
- Department of Obstetrics and Gynecology, Kobe University School of Medicine, 7-5-1 Kusunoki-cho Chuo-ku, Kobe, Japan
| | - Shigeru Saito
- Department of Obstetrics and Gynecology, the Toyama University, 2630, Sugitani, Toyama, Japan
| | - Toshiyuki Takeshita
- Department of Obstetrics and Gynecology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Mari Mitsui
- Division of Reproductive Medicine and Maternal Care, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan
| | - Tsuyoshi Saito
- Department of Obstetrics and Gynecology, Sapporo Medical University, Minami 1-jo Nishi 17-chome, Chuo-ku, Sapporo, Japan
| | - Takeshi Nagamatsu
- Department of Obstetrics and Gynecology, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Koichi Takakuwa
- Department of Obstetrics and Gynecology, Niigata University, 1-757 Asahimachi-dori, Chuo-ku, Niigata, Japan
| | - Mikiya Nakatsuka
- Okayama University, Graduate School of Health Sciences, 2-5-1 Shikata, Kita-ku, Okayama, Japan
| | - Satoshi Yoneda
- Department of Obstetrics and Gynecology, the Toyama University, 2630, Sugitani, Toyama, Japan
| | - Katsuko Egashira
- Department of Obstetrics and Gynecology, Kyushu University Graduate School of Medicine, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan
| | - Masahito Tachibana
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Japan
| | - Keiichi Matsubara
- Department of Obstetrics and Gynecology, Ehime University School of Medicine, 454, Shitsukawa, Toon, Japan
| | - Ritsuo Honda
- Department of Obstetrics and Gynecology, Kumamoto University School of Medicine, 1-1-1 Honjo, Chuo-ku, Kumamoto, Japan
| | - Atsushi Fukui
- Department of Obstetrics and Gynecology, Hirosaki University School of Medicine, 53,Honcho, Hirosaki, Japan
| | - Kanji Tanaka
- Department of Obstetrics and Gynecology, Hirosaki University School of Medicine, 53,Honcho, Hirosaki, Japan
| | - Kazuo Sengoku
- Department of Obstetrics and Gynecology, Asahikawa Medical University, 1-1-1 Midorigaoka-higashi 2-jo, Asahikawa, Japan
| | - Toshiaki Endo
- Department of Obstetrics and Gynecology, Sapporo Medical University, Minami 1-jo Nishi 17-chome, Chuo-ku, Sapporo, Japan
| | - Hiroaki Yata
- Research & Development Division, Japan Blood Products Organization, 15F Tamachi Station Tower N 3-1-1 Shibaura, Minato-ku, Tokyo, Japan
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8
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The impact of IVIG therapy on live birth rates in women with RPL: A systematic review and meta-analysis. GENE REPORTS 2022. [DOI: 10.1016/j.genrep.2021.101490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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9
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Kumar P, Marron K, Harrity C. Intralipid therapy and adverse reproductive outcome: is there any evidence? REPRODUCTION AND FERTILITY 2022; 2:173-186. [PMID: 35118388 PMCID: PMC8788620 DOI: 10.1530/raf-20-0052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/03/2021] [Indexed: 12/21/2022] Open
Abstract
Controversy exists regarding the benefits of intravenous intralipid therapy in patients with a poor reproductive history. It is frequently reported that there is no evidence to support the effectiveness, utility or safety for this treatment. While individual studies may be perceived as weak, a systematic review and meta-analysis were performed to determine if there is any advantage to patients. PubMed, Embase and Scopus searches were performed with the target populations being either recurrent pregnancy loss (RPL), or recurrent implantation failure (RIF) undergoing assisted reproductive technology (ART) and receiving intralipid infusions. These cohorts were compared with either placebo, no intervention or alternative treatments. The most relevant outcome measures were considered to be clinical pregnancy rate (CPR), live birth rate (LBR), implantation rate (IR) and miscarriage rate (MR). Twelve studies encompassing 2676 participants met the criteria for selection and were included and reviewed. Treatment of the target population with intralipid led to an improvement in IR (Odds Ratio (OR): 2.97, 2.05–4.29), pregnancy rate (OR: 1.64, 1.31–2.04), and LBR (OR: 2.36, 1.75–3.17), with a reduction in MR (OR: 0.2, 0.14–0.30). Although intravenous intralipid is not recommended as a routine treatment for recurrent miscarriage or implantation failure, there is enough data to suggest consideration in selected patients where routine testing is unremarkable, standard treatments have failed and immunological risk factors are present. The presence of abnormal uterine natural killer (uNK) cells needs more study as a target marker to determine those who could benefit.
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Affiliation(s)
- Parijot Kumar
- Beaumont Hospital, Dublin, Ireland.,RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Kevin Marron
- RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Conor Harrity
- Beaumont Hospital, Dublin, Ireland.,RCSI University of Medicine and Health Sciences, Dublin, Ireland.,ReproMed, Dublin, Ireland
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10
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Liu T, Guo X, Liao Y, Liu Y, Zhu Y, Chen X. Correlation Between the Presence of Antinuclear Antibodies and Recurrent Pregnancy Loss: A Mini Review. Front Endocrinol (Lausanne) 2022; 13:873286. [PMID: 35600596 PMCID: PMC9114698 DOI: 10.3389/fendo.2022.873286] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/29/2022] [Indexed: 12/15/2022] Open
Abstract
In the past decade, the incidence of recurrent pregnancy loss (RPL) has increased significantly, and immunological disorders have been considered as one of the possible causes contributing to RPL. The presence of antinuclear antibodies (ANAs) is regarded as a typical antibody of autoimmunity. However, the relationship between the presence of ANAs and RPL, the underlying mechanism, and the possible role of immunotherapy is still controversial. The aim of this mini review is to assess the association between ANAs and RPL and the effects of immunotherapy on pregnancy outcomes in women with positive ANAs and a history of RPL from the available data and to provide a relevant reference basis for clinical application in this group of women.
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Affiliation(s)
- Ting Liu
- Department of Obstetrics and Gynaecology, Shenzhen Baoan Women’s and Children’s Hospital, Jinan University, Shenzhen, China
| | - Xi Guo
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Ying Liao
- Department of Obstetrics and Gynaecology, Shenzhen Baoan Women’s and Children’s Hospital, Jinan University, Shenzhen, China
| | - Yingyu Liu
- Department of Obstetrics and Gynaecology, Shenzhen Baoan Women’s and Children’s Hospital, Jinan University, Shenzhen, China
| | - Yuanfang Zhu
- Department of Obstetrics and Gynaecology, Shenzhen Baoan Women’s and Children’s Hospital, Jinan University, Shenzhen, China
- *Correspondence: Yuanfang Zhu, ; Xiaoyan Chen, ;
| | - Xiaoyan Chen
- Department of Obstetrics and Gynaecology, Shenzhen Baoan Women’s and Children’s Hospital, Jinan University, Shenzhen, China
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
- *Correspondence: Yuanfang Zhu, ; Xiaoyan Chen, ;
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11
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Díaz-Hernández I, Alecsandru D, García-Velasco JA, Domínguez F. Uterine natural killer cells: from foe to friend in reproduction. Hum Reprod Update 2021; 27:720-746. [PMID: 33528013 DOI: 10.1093/humupd/dmaa062] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/15/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Recurrent miscarriage and pre-eclampsia are common reproductive disorders, but their causes are often unknown. Recent evidence has provided new insight into immune system influences in reproductive disorders. A subset of lymphocytes of the innate immune system known as uterine natural killer (uNK) cells are now recognized as fundamental to achieving embryo implantation and successful pregnancy, but were initially attributed a bad reputation. Indeed, immune therapies have been developed to treat the 'exaggerated' immune response from uNK cells. These treatments have been based on studies of peripheral blood natural killer (pbNK) cells. However, uNK cells and pbNK cells have different phenotypic and functional characteristics. The functions of uNK cells are closely related to their interactions with the extravillous trophoblast cells (EVTs) and spiral arteries, which underlie an essential role in regulating vascular function, controlling trophoblast invasion and promoting placental development. EVTs express MHC molecules of class I HLA-C/E/G/F, while uNK cells express, among other receptors, killer cell immunoglobulin-like receptors (KIRs) that bind to HLA-C or CD94/NKG2A inhibitory receptors, and then bind HLA-E. Associations of certain KIR/HLA-C combinations with recurrent miscarriage, pre-eclampsia, and foetal growth restriction and the interactions between uNK cells, trophoblasts and vascular cells have led to the hypothesis that uNK cells may play a role in embryo implantation. OBJECTIVE AND RATIONALE Our objective was to review the evolution of our understanding of uNK cells, their functions, and their increasingly relevant role in reproduction. SEARCH METHODS Relevant literature through June 2020 was retrieved using Google Scholar and PubMed. Search terms comprised uNK cells, human pregnancy, reproductive failure, maternal KIR and HLA-C, HLA-E/G/F in EVT cells, angiogenic cytokines, CD56+ NK cells, spiral artery, oestrogen and progesterone receptors, KIR haplotype and paternal HLA-C2. OUTCOMES This review provides key insights into the evolving conceptualization of uNK cells, from their not-so-promising beginnings to now, when they are considered allies in reproduction. We synthesized current knowledge about uNK cells, their involvement in reproduction and their main functions in placental vascular remodeling and trophoblast invasion. One of the issues that this review presents is the enormous complexity involved in studying the immune system in reproduction. The complexity in the immunology of the maternal-foetal interface lies in the great variety of participating molecules, the processes and interactions that occur at different levels (molecular, cellular, tissue, etc.) and the great diversity of genetic combinations that are translated into different types of responses. WIDER IMPLICATIONS Insights into uNK cells could offer an important breakthrough for ART outcomes, since each patient could be assessed based on the combination of HLA and its receptors in their uNK cells, evaluating the critical interactions at the materno-foetal interface. However, owing to the technical challenges in studying uNK cells in vivo, there is still much knowledge to gain, particularly regarding their exact origin and functions. New studies using novel molecular and genetic approaches can facilitate the identification of mechanisms by which uNK cells interact with other cells at the materno-foetal interface, perhaps translating this knowledge into clinical applicability.
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Affiliation(s)
| | - Diana Alecsandru
- Department of Immunology and Department of Reproductive Endocrinology and Infertility, Instituto Valenciano de Infertilidad-Madrid, Rey Juan Carlos University (IVI), Madrid 28023, Spain
| | - Juan Antonio García-Velasco
- Department of Immunology and Department of Reproductive Endocrinology and Infertility, Instituto Valenciano de Infertilidad-Madrid, Rey Juan Carlos University (IVI), Madrid 28023, Spain
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12
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Zhao H, Wei X, Yang X. A novel update on vitamin D in recurrent pregnancy loss (Review). Mol Med Rep 2021; 23:382. [PMID: 33760145 PMCID: PMC7986007 DOI: 10.3892/mmr.2021.12021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 02/15/2021] [Indexed: 12/20/2022] Open
Abstract
Recurrent pregnancy loss (RPL) is usually characterized as ≥3 miscarriages before 20 weeks of gestation. Patients with RPL may have autoimmune abnormalities or alloimmune problems. Vitamin D has a major function on the mechanism of immunomodulation at the maternal-fetal interface. However, whether vitamin D can be used as an effective method to treat patients with RPL requires investigation. It has been reported that vitamin D could prevent the occurrence of antiphospholipid syndrome (APS) by reducing the expression levels of anti-β2 glycoprotein and tissue factor in RPL cases with APS. In addition, there is an opposite relationship between vitamin D and thyroid peroxidase antibody levels in autoimmune thyroid disease cases with RPL. Vitamin D changes the ratio of T helper (Th) 1/Th2 and regulatory T cell/Th17 to a certain extent, as well as affects the activity of natural killer cells and the production of cytokines to reduce the incidence of RPL. The objective of the current review was to address the research progress of vitamin D in RPL in recent years, which could facilitate the use of vitamin D treatment to enhance the pregnancy outcome of RPL. Collectively, it was suggested that vitamin D may be used as an important and effective immunotherapeutic agent for patients with RPL.
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Affiliation(s)
- Haoyu Zhao
- Department of Hepatobiliary Surgery and Organ Transplant, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Xiaoqi Wei
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Xiuhua Yang
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
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13
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Saab W, Seshadri S, Huang C, Alsubki L, Sung N, Kwak-Kim J. A systemic review of intravenous immunoglobulin G treatment in women with recurrent implantation failures and recurrent pregnancy losses. Am J Reprod Immunol 2021; 85:e13395. [PMID: 33511656 DOI: 10.1111/aji.13395] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/22/2021] [Accepted: 01/23/2021] [Indexed: 11/28/2022] Open
Abstract
Over the last few decades, the advancement in reproductive technologies and protocols to improve embryo quality through culture techniques and genetic testing to eliminate chromosomally abnormal embryos resulted in better pregnancy rates and outcomes after fertility treatments. Unfortunately, some patients still struggle with recurrent implantation failures (RIFs) and recurrent pregnancy losses (RPLs). Immune etiologies have been attributed to play an important role in some of those patients. Maintaining a pre-conceptional anti-inflammatory environment for implantation and pregnancy continuation yields superior results. Intravenous immunoglobulin G (IVIG) treatment has been reported to enhance reproductive outcome in patients with RIF and RPL with immune dysregulations. In this systemic review, we analyzed outcomes of IVIG trials for RIF and RPL, its mechanism of action, dosing, administration, side-effects, and evidence for its use in women with RIF and RPL.
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Affiliation(s)
- Wael Saab
- Assisted Conception unit, The Centre for Reproductive and Genetic Health, London, UK
| | - Srividya Seshadri
- Assisted Conception unit, The Centre for Reproductive and Genetic Health, London, UK
| | - Changsheng Huang
- Reproductive Medicine and Immunology, Obstetrics and Gynecology, Clinical Sciences Department, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA.,Department of Traditional Chinese Medicine Rheumatology, Shenzhen Nanshan People's Hospital and The 6th Affiliated Hospital of Shenzhen University Health Science Center, Shenzhen, Guangdong, China
| | - Lujain Alsubki
- Reproductive Medicine and Immunology, Obstetrics and Gynecology, Clinical Sciences Department, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA.,Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Nayoung Sung
- Reproductive Medicine and Immunology, Obstetrics and Gynecology, Clinical Sciences Department, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA
| | - Joanne Kwak-Kim
- Reproductive Medicine and Immunology, Obstetrics and Gynecology, Clinical Sciences Department, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Vernon Hills, IL, USA
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14
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D'Mello RJ, Hsu CD, Chaiworapongsa P, Chaiworapongsa T. Update on the Use of Intravenous Immunoglobulin in Pregnancy. Neoreviews 2021; 22:e7-e24. [PMID: 33386311 DOI: 10.1542/neo.22-1-e7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intravenous immunoglobulin (IVIG) was first administered to humans in the 1980s. The mechanism of action of IVIG is still a subject of debate but the pharmacokinetics have been well characterized, albeit outside of pregnancy. IVIG has been used in pregnancy to treat several nonobstetrical and obstetrical-related conditions. However, current evidence suggests that IVIG use during pregnancy can be recommended for 1) in utero diagnosis of neonatal alloimmune thrombocytopenia; 2) gestational alloimmune liver disease; 3) hemolytic disease of the fetus and newborn for early-onset severe intrauterine disease; 4) antiphospholipid syndrome (APS) when refractory to or contraindicated to standard treatment, or in catastrophic antiphospholipid syndrome; and 5) immune thrombocytopenia when standard treatment is ineffective or rapid increase of platelet counts is needed. All recommendations are based on case series and cohort studies without randomized trials usually because of the rare prevalence of the conditions, the high incidence of adverse outcomes if left untreated, and ethical concerns. In contrast, IVIG therapy cannot be recommended for recurrent pregnancy loss, and the use of IVIG in subgroups of those with recurrent pregnancy loss requires further investigations. For non-obstetrical-related conditions, we recommend using IVIG as indicated for nonpregnant patients. In conclusion, the use of IVIG during pregnancy is an effective treatment in some obstetrical-related conditions with rare serious maternal side effects. However, the precise mechanisms of action and the long-term immunologic effects on the fetus and neonate are poorly understood and merit further investigations.
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Affiliation(s)
- Rahul J D'Mello
- Department of Obstetrics and Gynecology, Detroit Medical Center, Detroit, MI
| | - Chaur-Dong Hsu
- Department of Obstetrics and Gynecology and.,Department of Physiology, Wayne State University School of Medicine, Detroit, MI
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15
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Is there a Role of Intravenous Immunoglobulin in Immunologic Recurrent Pregnancy Loss? J Immunol Res 2020; 2020:6672865. [PMID: 33426092 PMCID: PMC7781684 DOI: 10.1155/2020/6672865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/15/2020] [Accepted: 12/22/2020] [Indexed: 01/01/2023] Open
Abstract
Recurrent pregnancy loss (RPL) commonly refers to three or more miscarriages that occur before 20 weeks of pregnancy. The immunological cause of RPL could be either an auto- or alloimmune-related event or both. Because of the discovery of immunological abnormalities in RPL patients in clinical practice, several immunomodulatory therapies were introduced to maintain the immune balance at the maternal-fetal interface. Intravenous immunoglobulin (IVIg) is one of the immunomodulators. In recent years, several studies have analyzed the therapeutic effect of IVIg on RPL patients with antiphospholipid syndrome (APS) or unexplained RPL. However, their results are controversial. IVIg can be used in RPL patients with APS who have previously failed in other treatments. It is recommended that IVIg infusion could be considered used before conception in RPL patients who have cellular immune abnormalities such as increased natural killer (NK) cell counts, NK cell cytotoxicity, or increased T helper (Th)1/Th2 ratio, depending on the cut-off values of each hospital. The aim of this review was to summarize the mechanisms, efficacy, pharmacokinetics, and side effects associated with passive immunization using IVIg in immunologic RPL, according to the literature published in recent years. We hope that more obstetricians will be able to understand the timing and indication of IVIg properly in immunologic RPL patients and effectively enhance pregnancy outcomes for mothers and neonates.
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16
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Woon EV, Day A, Bracewell-Milnes T, Male V, Johnson M. Immunotherapy to improve pregnancy outcome in women with abnormal natural killer cell levels/activity and recurrent miscarriage or implantation failure: A systematic review and meta-analysis. J Reprod Immunol 2020; 142:103189. [PMID: 32889304 DOI: 10.1016/j.jri.2020.103189] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/12/2020] [Indexed: 12/14/2022]
Abstract
There is a trend towards offering immunotherapy to women with unexplained reproductive failure based on abnormal Natural Killer (NK) cell levels. Previous systematic reviews evaluating immunotherapy usage have not focused on women with abnormal level of NK cells. To address the gap in literature, this systematic review aims to evaluate the efficacy of immunotherapy to improve pregnancy outcome in women with recurrent miscarriage (RM) or implantation failure (RIF) specifically selected based on abnormal levels and/or activity of NK cells. Six databases were searched for peer-reviewed studies following PRISMA guidelines. Risk of bias assessment was conducted using RoB2 for randomized controlled trials (RCT) and ROBINS-I for non-RCT. Of 1025 studies identified, seven studies on intravenous immunoglobulin (IVIG) (four), prednisolone (one), etanercept (one) and intralipid (one) were included. Meta-analysis of the non-RCT IVIG studies (557 participants; 312 intervention, 245 controls) showed livebirth in favour of intervention (RR 2.57; 95 % CI = 1.79-3.69; p < 0.05), however there were significant heterogeneity (I2 = 62 %) and moderate to severe risk of bias in these studies. Individual RCTs reported improved livebirth outcome in etanercept, intralipid and prednisolone and this was significant in the former two (p < 0.05). In conclusion, there may be some benefit of immunotherapy, but paucity of high quality evidence means that it is not possible to support the use of immunotherapy even when selected based on abnormal NK cell level/activity. Further research with application of scientifically validated immunological biomarkers in well-planned large scale RCTs will determine whether immunotherapy is beneficial in this subpopulation of women.
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Affiliation(s)
- Ee Von Woon
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive & Developmental Biology, Imperial College London, Chelsea and Westminster Hospital Campus, 369 Fulham Roadd, London, UK.
| | - Andrea Day
- Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital NHS Foundation Trust, West Middlesex University Hospital, Twickenham Road, Isleworth, London UK
| | - Timothy Bracewell-Milnes
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive & Developmental Biology, Imperial College London, Chelsea and Westminster Hospital Campus, 369 Fulham Roadd, London, UK
| | - Victoria Male
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive & Developmental Biology, Imperial College London, Chelsea and Westminster Hospital Campus, 369 Fulham Roadd, London, UK
| | - Mark Johnson
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive & Developmental Biology, Imperial College London, Chelsea and Westminster Hospital Campus, 369 Fulham Roadd, London, UK
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17
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Urban ML, Bettiol A, Serena C, Comito C, Turrini I, Fruttuoso S, Silvestri E, Vannacci A, Ravaldi C, Petraglia F, Emmi G, Prisco D, Mecacci F. Intravenous immunoglobulin for the secondary prevention of stillbirth in obstetric antiphospholipid syndrome: A case series and systematic review of literature. Autoimmun Rev 2020; 19:102620. [PMID: 32682986 DOI: 10.1016/j.autrev.2020.102620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of intravenous immunoglobulin (IVIg) in secondary prevention of pregnancy complications for patients with obstetric antiphospholipid syndrome (APS) and history of stillbirth. METHODS We described three cases of obstetric APS patients with history of stillbirth treated with IVIg in four pregnancies. In addition, we conducted a systematic literature review on the use of IVIg in obstetric APS with history of stillbirth. RESULTS Three patients with obstetric APS and history of stillbirth were treated with prophylactic IVIg, in addition to standard treatment (hydroxychloroquine, low-dose aspirin, low molecular weight heparin, and prednisone), in four pregnancies (three singleton and one twin). All pregnancies resulted in live healthy newborns. Long-term follow-up re-evaluations (24-53 months) did not shown any sign or symptom of active systemic disease, and the children were healthy. The systematic literature review retrieved only three cases of use of IVIg in obstetric APS patients with history of stillbirth. All three cases resulted in live healthy newborns. Only in one case, mild thrombocytopenia occurred during treatment, although this event was unlikely to be related to IVIg. CONCLUSION Our experience suggests that IVIg as secondary prevention of APS-related stillbirth is associated with good pregnancy and long-term outcomes, with no relevant safety concerns. However, the literature evidence on this topic is limited to few isolated cases, and further studies are needed to clarify which obstetric APS patients may benefit the most from IVIg.
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Affiliation(s)
- Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy; Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Caterina Serena
- Department of Biomedical, Experimental and Clinical Sciences-Division of Obstetrics and Gynaecology, University of Florence, Florence, Italy
| | - Chiara Comito
- Department of Biomedical, Experimental and Clinical Sciences-Division of Obstetrics and Gynaecology, University of Florence, Florence, Italy
| | - Irene Turrini
- Department of Biomedical, Experimental and Clinical Sciences-Division of Obstetrics and Gynaecology, University of Florence, Florence, Italy
| | - Silvia Fruttuoso
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Claudia Ravaldi
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Felice Petraglia
- Department of Biomedical, Experimental and Clinical Sciences-Division of Obstetrics and Gynaecology, University of Florence, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy.
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Federico Mecacci
- Department of Biomedical, Experimental and Clinical Sciences-Division of Obstetrics and Gynaecology, University of Florence, Florence, Italy
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18
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Kedzierska AE, Lorek D, Slawek A, Chelmonska-Soyta A. Tregitopes regulate the tolerogenic immune response and decrease the foetal death rate in abortion-prone mouse matings. Sci Rep 2020; 10:10531. [PMID: 32601347 PMCID: PMC7324366 DOI: 10.1038/s41598-020-66957-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 05/27/2020] [Indexed: 12/22/2022] Open
Abstract
The imbalance in immune tolerance may cause the variety of reproductive failures. An intravenous immunoglobulin infusion (IVIg) therapy is used to improve the live birth rate in women suffering from recurrent pregnancy loss, recurrent spontaneous abortions and recurrent implantation failures. However, the results of IVIg studies are still inconclusive as IVIg infusion in women suffering from pregnancy loss is sometimes ineffective. One of the mechanisms of action of this treatment is inhibition of B cells differentiation and expansion of Tregs and secretion of interleukin 10. It was proposed that immunomodulatory effects of IVIg may be attributed to tregitopes - self-IgG-derived epitopes present in the structure of immunoglobulins. Similarly to IVIg, tregitopes cause the expansion of Tregs and secretion of antigen-specific effector cytokine response. Here, we studied whether the administration of mouse tregitope 167 and/or 289 can prevent abortions in mouse abortion-prone mouse matings. We revealed that tregitopes reduce the foetal death rate. This may be driven by observed higher pool of peripheral Tregs, increased production of IL-10 by Tregs and Bregs and/or maintaining the tolerogenic phenotype of antigen-presenting cells. We believe that our findings may indicate a potential alternative to IVIg for therapeutic intervention in case of pregnancy failures.
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Affiliation(s)
- Anna Ewa Kedzierska
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland. .,Łukasiewicz Research Network - PORT Polish Center for Technology Development, Stablowicka 147 Str., Wroclaw, Poland.
| | - Daria Lorek
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | - Anna Slawek
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | - Anna Chelmonska-Soyta
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland.,Wroclaw University of Environmental and Life Sciences, Wroclaw, Poland
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19
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Cavalcante MB, Sarno M, Ricardo B. Recombinant human granulocyte-colony stimulating factor for all recurrent miscarriage patients or for a select group? Hum Reprod 2020; 34:2081-2083. [PMID: 31598676 DOI: 10.1093/humrep/dez147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/04/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- M B Cavalcante
- Department of Obstetrics and Gynecology, Fortaleza University, CONCEPTUS-Reproductive Medicine, Fortaleza-CE, Brazil
| | - M Sarno
- Department of Obstetrics and Gynecology, Federal University of Bahia, Salvador BA, Brazil
| | - B Ricardo
- Department of Obstetrics and Gynecology, Fortaleza University, CONCEPTUS-Reproductive Medicine, Fortaleza-CE, Brazil.,Department of Obstetrics and Gynecology, State University of Campinas, Campinas SP, Brazil
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20
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Ali S, Majid S, Niamat Ali M, Taing S. Evaluation of T cell cytokines and their role in recurrent miscarriage. Int Immunopharmacol 2020; 82:106347. [PMID: 32143004 DOI: 10.1016/j.intimp.2020.106347] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 02/08/2020] [Accepted: 02/23/2020] [Indexed: 01/03/2023]
Abstract
Recurrent miscarriage (RM) is defined as two or more consecutive pregnancy losses that affect approximately 5% of conceived women worldwide. RM is a multi-factorial reproductive problem and has been associated with parental chromosomal abnormalities, embryonic chromosomal rearrangements, uterine anomalies, autoimmune disorders, endocrine dysfunction, thrombophilia, life style factors, and maternal infections. However, the exact cause is still undecided in remaining 50% of cases. Immunological rejection of the embryo due to exacerbated maternal immune reaction against paternal embryonic antigens has been set forth as one of the significant reason for RM. The accurate means that shield the embryo during normal pregnancy from the attack of maternal immune network and dismissal are inadequately implicit. However, it is suggested that the genetically irreconcilable embryo escapes maternal immune rejection due to communication among many vital cytokines exuded at maternal-embryonic interface both by maternal and embryonic cells. Previous investigations suggested the Th1/Th2 dominance in altered immunity of RM patients, according to which the allogenic embryo flees maternal T cell reaction by inclining the Th0 differentiation toward Th2 pathway resulting into diminished pro-inflammatory Th1 immunity. However, recently pro-inflammatory Th17 cells and immunoregulatory Treg cells have been discovered as essential immune players in RM besides Th1/Th2 components. Cytokines are believed to develop a complicated regulatory network so as to establish a state of homeostasis between the semi-allogenic embryo and the maternal immune system. However, an adverse imbalance among cytokines at maternal-embryonic interface perhaps due to their gene polymorphisms may render immunoregulatory means not enough to re-establish homeostasis and thus may collapse pregnancy.
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Affiliation(s)
- Shafat Ali
- Cytogenetics and Molecular Biology Laboratory, Centre of Research for Development, University of Kashmir, 190006 Srinagar, J&K, India
| | - Sabhiya Majid
- Department of Biochemistry, Government Medical College, Srinagar, J&K, India
| | - Md Niamat Ali
- Cytogenetics and Molecular Biology Laboratory, Centre of Research for Development, University of Kashmir, 190006 Srinagar, J&K, India.
| | - Shahnaz Taing
- Department of Obstetrics and Gynaecology, Government Medical College Associated Lalla Ded Hospital, Srinagar, J&K, India
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21
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Immunotherapy for recurrent pregnancy loss. Best Pract Res Clin Obstet Gynaecol 2019; 60:77-86. [DOI: 10.1016/j.bpobgyn.2019.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 11/21/2022]
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22
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Di Nicuolo F, D'Ippolito S, Castellani R, Rossi ED, Masciullo V, Specchia M, Mariani M, Pontecorvi A, Scambia G, Di Simone N. Effect of alpha-lipoic acid and myoinositol on endometrial inflammasome from recurrent pregnancy loss women. Am J Reprod Immunol 2019; 82:e13153. [PMID: 31148259 DOI: 10.1111/aji.13153] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 04/05/2019] [Accepted: 05/24/2019] [Indexed: 12/22/2022] Open
Abstract
PROBLEM A significant increased expression/activation of one of the most well-characterized inflammasomes, the NAcht leucine-rich-repeat protein-3 (NALP-3), in the endometrium from idiopathic recurrent pregnancy loss women (RPL) has been previously found by our research group. We therefore, suggested this event as being one of the molecular mechanisms altering endometrial inflammatory status during early pregnancy. In the present research, we attempt to investigate whether molecules with anti-inflammatory activity, alpha-lipoic acid (ALA), and/or myoinositol affect the endometrial NALP-3 expression and activation. METHOD OF STUDY Women with a history of idiopathic RPL (n = 30) were included in the study and compared to a control group (n = 15). Endometrial tissues were collected by hysteroscopy during the mid-luteal phase. RPL women underwent a three-month prescription of tablets containing ALA plus myoinositol (Sinopol® ). After treatment, hysteroscopic biopsies were repeated in RPL patients. Inflammasome expression was evaluated by immunohistochemical and Western blot analysis. NALP-3 activation was studied by quantifying the secretion of both caspase-1 and interleukin (IL)-1ß and IL-18 through ELISA. In ex vivo experiments, the effects of each molecule on endometrial inflammasome were studied. RESULTS Sinopol® significantly reduced the RPL endometrial inflammasome expression and activation. ALA, but not myoinositol, significantly reduced the endometrial inflammasome expression and activity. CONCLUSION Our data suggest a role for ALA on RPL inflammasome. Understanding the mechanisms involved in RPL and the observation that specific molecules are able to interfere with such complex at the endometrium might provide new rational design approaches to a personalized evaluation of endometrial status and, ultimately, a targeted medicine.
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Affiliation(s)
- Fiorella Di Nicuolo
- Paolo VI International Scientific Institute, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Silvia D'Ippolito
- U.O.C. di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Roberta Castellani
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Esther Diana Rossi
- U.O.C. di Anatomia Patologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Valeria Masciullo
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Roma, Italia.,U.O.C. di Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Monia Specchia
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Marco Mariani
- Istituto di Sanità Pubblica, Sezione di Igiene, Università Cattolica Del Sacro Cuore, Roma, Italia
| | - Alfredo Pontecorvi
- Paolo VI International Scientific Institute, Università Cattolica del Sacro Cuore, Roma, Italia.,U.O.C di Endocrinologia e Diabetologia, Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Istituto di Patologia Medica, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Giovanni Scambia
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Roma, Italia.,U.O.C. di Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Nicoletta Di Simone
- U.O.C. di Ostetricia e Patologia Ostetrica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Roma, Italia
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23
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Treatment with intravenous immunoglobulin in patients with recurrent pregnancy loss: An update. J Reprod Immunol 2019; 133:37-42. [PMID: 31238263 DOI: 10.1016/j.jri.2019.06.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/09/2019] [Accepted: 06/14/2019] [Indexed: 02/02/2023]
Abstract
Intravenous immunoglobulin (IVIg) has a documented clinical effect in many autoimmune diseases and has so far been tested in >10 randomised controlled trials (RCTs) in women with recurrent pregnancy loss (RPL). The results of the RCTs have, however, been very divergent. In meta-analyses of all trials, no significant impact on live birth rate has been reported. In contrast, in sensitivity analyses, IVIg significantly increased live birth rates when initiated prior to conception and it had a borderline significant therapeutic effect in women with secondary RPL. Higher dosages of IVIg and serological signs of autoimmunity in the treated patients tended to increase the success rate after treatment. A follow-up study of patients from our recent RCT also supports a significant therapeutic effect in patients who had received IVIg before conception. The lessons learned from the published trials and meta-analyses should be incorporated in the design of future RCTs of IVIg in the treatment of RPL.
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24
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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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25
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Jafarzadeh S, Ahmadi M, Dolati S, Aghebati‐Maleki L, Eghbal‐Fard S, Kamrani A, Behrad B, Roshangar L, Jadidi‐Niaragh F, Yousefi B, Mehdipour M, Farzadi L, Yousefi M. Intravenous immunoglobulin G treatment increases live birth rate in women with recurrent miscarriage and modulates regulatory and exhausted regulatory T cells frequency and function. J Cell Biochem 2018; 120:5424-5434. [DOI: 10.1002/jcb.27821] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/12/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Sara Jafarzadeh
- Stem Cell Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Drug Applied Research Center, Tabriz University of Medical Sciences Tabriz Iran
| | - Majid Ahmadi
- Stem Cell Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Drug Applied Research Center, Tabriz University of Medical Sciences Tabriz Iran
| | - Sanam Dolati
- Aging Research Institute, Tabriz University of Medical Sciences Tabriz Iran
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
| | - Leili Aghebati‐Maleki
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
- Immunology Research Center, Tabriz University of Medical Sciences Tabriz Iran
| | - Shadi Eghbal‐Fard
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
| | - Amin Kamrani
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
| | - Behboud Behrad
- Reproductive Biology Department Tabriz University of Medical Sciences Tabriz Iran
| | - Leila Roshangar
- Stem Cell Research Center, Tabriz University of Medical Sciences Tabriz Iran
| | - Farhad Jadidi‐Niaragh
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
| | - Bahman Yousefi
- Department of Biochemistry and Laboratory Medicine Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
| | - Mahdi Mehdipour
- Stem Cell Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Reproductive Biology Department Tabriz University of Medical Sciences Tabriz Iran
| | - Laya Farzadi
- Reproductive Biology Department Tabriz University of Medical Sciences Tabriz Iran
| | - Mehdi Yousefi
- Drug Applied Research Center, Tabriz University of Medical Sciences Tabriz Iran
- Department of Immunology Faculty of Medicine, Tabriz University of Medical Sciences Tabriz Iran
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26
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Ahmadi M, Ghaebi M, Abdolmohammadi-Vahid S, Abbaspour-Aghdam S, Hamdi K, Abdollahi-Fard S, Danaii S, Mosapour P, Koushaeian L, Dolati S, Rikhtegar R, Oskouei FD, Aghebati-Maleki L, Nouri M, Yousefi M. NK cell frequency and cytotoxicity in correlation to pregnancy outcome and response to IVIG therapy among women with recurrent pregnancy loss. J Cell Physiol 2018; 234:9428-9437. [PMID: 30317625 DOI: 10.1002/jcp.27627] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/25/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Recurrent miscarriage (RM) has a multifactorial etiology mainly due to chromosomal abnormalities and immunological factors. Treating RM has remained to be a challenging issue and the role of intravenous immunoglobulin (IVIG) in treating RM is still controversial. MATERIALS AND METHODS This study aimed to evaluate the changes in natural killer (NK) cells' frequency and cytotoxicity in patients with RM who received the IVIG therapy. A total of 78 women with a history of three or more recurrent miscarriages were included and their peripheral blood was drawn in case of positive pregnancy test. On the same date, 400 mg/kg of IVIG was administrated intravenously in 38 women and it continued every four weeks through weeks 30-32 of gestation. The remaining 40 patients with RM were included to be the untreated control group. Then, the effects of IVIG on NK cell frequency, cytotoxic activity, and the expression of inhibitory and activating receptors in the patients with RM, pre and posttreatment were assessed. RESULTS NK cells percentage and cytotoxicity were significantly reduced in the IVIG-treated patients after 32 weeks of gestation (p < 0.0001). Expression levels of inhibitory receptors was increased, however, the expression levels of activating receptors were significantly decreased after the IVIG therapy. Pregnancy outcome after the treatment was significantly higher (86.8%) in the IVIG-treated patients than controls (45%; p = 0.0006). CONCLUSION Our results suggested that women with RM may benefit from IVIG as a therapeutic approach and the frequency and functional status of peripheral NK cells may serve as a valuable predictive factor of therapy response.
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Affiliation(s)
- Majid Ahmadi
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Student's Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahnaz Ghaebi
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samaneh Abdolmohammadi-Vahid
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sanaz Abbaspour-Aghdam
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kobra Hamdi
- Reproductive Biology Department, Tabriz University of Medical Sciences, Tabriz, Iran.,Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sedigheh Abdollahi-Fard
- Department of Gynecology, Eastern Azerbaijan ACECR ART Center, Eastern Azerbaijan Branch of ACECR, Tabriz, Iran
| | - Shahla Danaii
- Department of Gynecology, Eastern Azerbaijan ACECR ART Center, Eastern Azerbaijan Branch of ACECR, Tabriz, Iran
| | - Parisa Mosapour
- Department of Gynecology, Eastern Azerbaijan ACECR ART Center, Eastern Azerbaijan Branch of ACECR, Tabriz, Iran
| | - Ladan Koushaeian
- Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sanam Dolati
- Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Rikhtegar
- Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | | | - Mohammad Nouri
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Reproductive Biology Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Yousefi
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Reproductive Biology Department, Tabriz University of Medical Sciences, Tabriz, Iran
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27
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Muyayalo KP, Li ZH, Mor G, Liao AH. Modulatory effect of intravenous immunoglobulin on Th17/Treg cell balance in women with unexplained recurrent spontaneous abortion. Am J Reprod Immunol 2018; 80:e13018. [PMID: 29984444 DOI: 10.1111/aji.13018] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/18/2018] [Indexed: 12/15/2022] Open
Abstract
Recurrent spontaneous abortion (RSA) is a growing problem worldwide. In a majority of cases, the cause remains unknown but there is increasing evidence that immunologic factors play an important role. Intravenous immunoglobulin (IVIg) therapy has been proposed to have immune modulatory effects and therefore been applicable for the treatment of patients with RSA. Although its efficacy is still controversial, several recent studies suggest that IVIg treatment may improve pregnancy outcomes. CD4+ T cells and their related cytokines play an important role in maternal-fetal immune regulation, and an imbalance of Th17/Treg cell ratio has been proposed as a cause for RSA. We review the scientific evidence supporting a modulatory effect of IVIg on Th17/Treg cell balance and discuss the potential mechanisms how IVIg might enhance Treg cells function. We propose that correction of Th17/Treg cell dysregulation could be one of the mechanisms that can explain the positive therapeutic effects of IVIg therapy. Consequently, selecting patients with abnormal Th17/Treg cell ratios could increase the success of IVIg therapy.
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Affiliation(s)
- Kahinho P Muyayalo
- Family Planning Research Institute, Center for Reproductive Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhi-Hui Li
- Family Planning Research Institute, Center for Reproductive Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gil Mor
- Reproductive Immunology Unit, Department of Obstetrics Gynecology and Reproductive Science, Yale University School of Medicine, New Haven, Connecticut
| | - Ai-Hua Liao
- Family Planning Research Institute, Center for Reproductive Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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28
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Ediriwickrema LS, Chhadva P, Rodger DC, Ameri H, Rao NA. INTRAVENOUS IMMUNOGLOBULIN IN THE TREATMENT OF JUVENILE RETINITIS PIGMENTOSA-ASSOCIATED CYSTOID MACULAR EDEMA AND UVEITIS. Retin Cases Brief Rep 2018; 12:242-246. [PMID: 27828903 DOI: 10.1097/icb.0000000000000478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE To evaluate the efficacy of intravenous immunoglobulin in the treatment of cystoid macular edema and uveitis caused by juvenile retinitis pigmentosa in a woman interested in planning a pregnancy. METHODS Descriptive case report. A 25-year-old woman with retinitis pigmentosa presented with decreased visual acuity, interested in a second opinion. RESULTS Intravenous immunoglobulin therapy was begun at 2-week intervals. Visual acuity improved from 20/100 to 20/70 by 6 weeks, where it stabilized for the remaining year. Serial optical coherence tomography imaging revealed marked improvement in cystoid macular edema after 2 treatments of intravenous immunoglobulin at 2 weeks of follow-up, with complete resolution noted at 4 months, a finding that persisted at 1 year of follow-up. CONCLUSION Our findings support the use of intravenous immunoglobulin as a therapeutic option for the resolution of cystoid macular edema and management of uveitis secondary to juvenile retinitis pigmentosa.
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Affiliation(s)
- Lilangi S Ediriwickrema
- Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Priyanka Chhadva
- Department of Ophthalmology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Damien C Rodger
- Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Hossein Ameri
- Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Narsing A Rao
- Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, California
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29
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Rasmark Roepke E, Hellgren M, Hjertberg R, Blomqvist L, Matthiesen L, Henic E, Lalitkumar S, Strandell A. Treatment efficacy for idiopathic recurrent pregnancy loss - a systematic review and meta-analyses. Acta Obstet Gynecol Scand 2018; 97:921-941. [PMID: 29603135 DOI: 10.1111/aogs.13352] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 03/21/2018] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Medical treatment of women with idiopathic recurrent pregnancy loss is controversial. The objective was to assess the effects of different treatments on live birth rates and complications in women with unexplained recurrent pregnancy loss. MATERIAL AND METHODS We searched MEDLINE, Embase and the Cochrane Library, and identified 1415 publications. This systematic review included 21 randomized controlled trials regarding acetylsalicylic acid, low-molecular-weight heparin, progesterone, intravenous immunoglobulin or leukocyte immune therapy in women with three or more consecutive miscarriages of unknown cause. The study quality was assessed and data was extracted independently by at least two authors. RESULTS No significant difference in live birth rate was found when acetylsalicylic acid was compared with low-molecular-weight heparin or with placebo. Meta-analyses of low-molecular-weight heparin vs. control found no significant differences in live birth rate [risk ratio (RR) 1.47, 95% CI 0.83-2.61]. Treatment with progesterone starting in the luteal phase seemed effective in increasing live birth rate (RR 1.18, 95% CI 1.09-1.27) but not when started after conception. Intravenous immunoglobulin showed no effect on live birth rate compared with placebo (RR 1.07, 95% CI 0.91-1.26). Paternal immunization compared with autologous immunization showed a significant difference in outcome (RR 1.8, 95% CI 1.34-2.41), although the studies were small and at high risk of bias. CONCLUSION The literature does not allow advice on any specific treatment for idiopathic recurrent pregnancy loss, with the exception of progesterone starting from ovulation. We suggest that any treatment for recurrent pregnancy loss should be used within the context of a randomized controlled trial.
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Affiliation(s)
- Emma Rasmark Roepke
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Margareta Hellgren
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Lennart Blomqvist
- Department of Obstetrics and Gynecology, Southern Älvsborg Hospital, Borås, Sweden
| | - Leif Matthiesen
- Department of Obstetrics and Gynecology, Helsingborg Hospital, Lund University, Helsingborg, Sweden
| | - Emir Henic
- Reproductive Medicine Center, Skåne University Hospital, Malmö, Sweden
| | - Sujata Lalitkumar
- Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Annika Strandell
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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30
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Su N, Wang H, Zhang B, Kang Y, Guo Q, Xiao H, Yang H, Liao S. Maternal natural killer cell immunoglobulin receptor genes and human leukocyte antigen-C ligands influence recurrent spontaneous abortion in the Han Chinese population. Exp Ther Med 2018; 15:327-337. [PMID: 29387191 PMCID: PMC5769230 DOI: 10.3892/etm.2017.5406] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 10/30/2017] [Indexed: 02/05/2023] Open
Abstract
The underlying mechanism of recurrent spontaneous abortion (RSA) has remained elusive for many years. Several previous studies have suggested that the killer cell immunoglobulin receptor (KIR) gene family is associated with RSA, however, it is not clear exactly how. The present study detected KIR and human leukocyte antigen-C (HLA-C) genes in 110 Han Chinese women with unexplained RSA and 105 Han Chinese healthy females. The aim of the present study was to determine if certain genotypes were more susceptible to the occurrence of miscarriage. The frequency of KIR genes and different KIR haplotypes in the 2 groups demonstrated no statistical differences. However, in women who had miscarried ≥3 times, the frequency of KIR3DL1 was significantly reduced and the BB haplotype frequency was significantly higher compared with the control group. HLA-C2C2 was significantly increased in the KIR AB and KIR BB groups in the RSA groups compared with the control group. The women in the RSA group who had a homozygous HLA-C2C2 had a significantly higher frequency of the 2DS1 gene compared with the control group. The reduction of inhibitory gene and increased activation combinations may induce the activation of uterine natural killer cells, which may reduce the probability of fetal survival. To the best of our knowledge, the present study is the first report demonstrating the association between maternal KIR and HLA-C genes and RSA in women of a Han Chinese ethnicity. The present study revealed that females who miscarry ≥3 times may be used as selection criteria for RSA and so may exhibit higher research value.
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Affiliation(s)
- Ning Su
- Department of Obstetrics and Gynecology, People's Hospital of Zhengzhou University, Zhengzhou, Henan 450003, P.R. China
- Henan Medical Genetics Institute, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Hongdan Wang
- Henan Medical Genetics Institute, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Bowei Zhang
- International Office for Research and Development, Henan Red Cross Blood Center, Zhengzhou, Henan 450000, P.R. China
| | - Yiqing Kang
- International Office for Research and Development, Henan Red Cross Blood Center, Zhengzhou, Henan 450000, P.R. China
| | - Qiannan Guo
- Henan Medical Genetics Institute, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Hai Xiao
- Henan Medical Genetics Institute, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Hecai Yang
- International Office for Research and Development, Henan Red Cross Blood Center, Zhengzhou, Henan 450000, P.R. China
| | - Shixiu Liao
- Henan Medical Genetics Institute, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
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31
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Intravenous immunoglobulin (IVIG) treatment modulates peripheral blood Th17 and regulatory T cells in recurrent miscarriage patients: Non randomized, open-label clinical trial. Immunol Lett 2017; 192:12-19. [DOI: 10.1016/j.imlet.2017.10.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/07/2017] [Accepted: 10/09/2017] [Indexed: 12/17/2022]
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Immunologic Abnormalities, Treatments, and Recurrent Pregnancy Loss: What Is Real and What Is Not? Clin Obstet Gynecol 2017; 59:509-23. [PMID: 27380207 DOI: 10.1097/grf.0000000000000215] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Recurrent pregnancy loss, depending on the definition, affects 1% to 3% of women aiming to have a child. Little is known about the direct causes of recurrent pregnancy loss, and the condition is considered to have a multifactorial and complex pathogenesis. The aim of this review was to summarize the evaluation and the management of the condition with specific emphasis on immunologic biomarkers identified as risk factors as well as current immunologic treatment options. The review also highlights and discusses areas in need of further research.
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Recurrent Massive Perivillous Fibrin Deposition and Chronic Intervillositis Treated With Heparin and Intravenous Immunoglobulin: A Case Report. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:676-681. [DOI: 10.1016/j.jogc.2017.03.089] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/04/2017] [Accepted: 03/06/2017] [Indexed: 11/20/2022]
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Sha J, Liu F, Zhai J, Liu X, Zhang Q, Zhang B. Alteration of Th17 and Foxp3 + regulatory T cells in patients with unexplained recurrent spontaneous abortion before and after the therapy of hCG combined with immunoglobulin. Exp Ther Med 2017; 14:1114-1118. [PMID: 28810565 PMCID: PMC5526148 DOI: 10.3892/etm.2017.4574] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 04/18/2017] [Indexed: 12/02/2022] Open
Abstract
We conducted this study to investigate the effects of the combination therapy of human chorionic gonadotropin (hCG) plus immunoglobulin (IG) on the levels of T helper 17 (Th17) cells and Foxp3+ regulatory T cells (Treg) in patients with unexplained recurrent spontaneous abortion (URSA). Twenty pregnant women with URSA underwent combination therapy of hCG plus IG. Flow cytometry was performed to measure the proportions of Th17 and Treg cells before and after treatment. RT-PCR and ELISA were applied to detect the concentrations of interleukin (IL)-17, IL-6, IL-10, and transforming growth factor (TGF)-β1 in the peripheral blood. The therapy of hCG combined with IG may induce a decrease in the Th17/Treg ratio and the Treg bias, which may be beneficial for the maintenance of pregnancy. The levels of Th17 cells and related cytokines IL-17 and IL-6 decreased after the treatment (P<0.05). At the same time, levels of Treg cells and the related cytokines IL-10 and TGF-β1 increased (P<0.05). The Th17/Treg ratio decreased significantly after treatment. In conclusion, the occurrence of URSA may be associated with the Th17/Treg balance disorder, and correcting the disorder may be one of the mechanisms behind the efficacy of combination therapy for URSA.
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Affiliation(s)
- Jing Sha
- Department of Obstetrics and Gynecology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical College, Xuzhou, Jiangsu 221000, P.R. China
| | - Fumin Liu
- The Affiliated Hospital of Xuzhou Medical College, Xuzhou, Jiangsu 221000, P.R. China
| | - Jingfang Zhai
- Department of Obstetrics and Gynecology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical College, Xuzhou, Jiangsu 221000, P.R. China
| | - Xiaoyun Liu
- The Affiliated Hospital of Xuzhou Medical College, Xuzhou, Jiangsu 221000, P.R. China
| | - Qinglin Zhang
- Department of Obstetrics and Gynecology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical College, Xuzhou, Jiangsu 221000, P.R. China
| | - Bei Zhang
- Department of Obstetrics and Gynecology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical College, Xuzhou, Jiangsu 221000, P.R. China
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Natural killer cell activity in women with recurrent miscarriage: Etiology and pregnancy outcome. J Reprod Immunol 2017; 120:42-47. [DOI: 10.1016/j.jri.2017.04.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 02/16/2017] [Accepted: 04/11/2017] [Indexed: 11/19/2022]
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Sung N, Han AR, Park CW, Park DW, Park JC, Kim NY, Lim KS, Shin JE, Joo CW, Lee SE, Kim JW, Lee SK. Intravenous immunoglobulin G in women with reproductive failure: The Korean Society for Reproductive Immunology practice guidelines. Clin Exp Reprod Med 2017; 44:1-7. [PMID: 28428937 PMCID: PMC5395546 DOI: 10.5653/cerm.2017.44.1.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 02/03/2023] Open
Abstract
The task force of the Korean Society for Reproductive Immunology recommends intravenous immunoglobulin G treatment in women with reproductive failure, including recurrent pregnancy loss and/or repeated implantation failure, who show cellular immune factors such as abnormal natural killer cell levels, natural killer cell cytotoxicity, and/or type 1 T helper immunity.
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Affiliation(s)
- Nayoung Sung
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ae Ra Han
- Department of Obstetrics and Gynecology, Gangseo Mizmedi Hospital, Seoul, Korea
| | - Chan Woo Park
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Korea
| | - Dong Wook Park
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Korea
| | - Joon Cheol Park
- Department of Obstetrics and Gynecology, Keimyung University School of Medicine, Daegu, Korea
| | - Na Young Kim
- Department of Obstetrics and Gynecology, Gangnam Mizmedi Hospital, Seoul, Korea
| | | | | | | | - Seung Eun Lee
- Department of Obstetrics and Gynecology, Bundang CHA Medical Center, CHA University, Seongnam, Korea
| | | | - Sung Ki Lee
- Department of Obstetrics and Gynecology, Konyang University College of Medicine, Daejeon, Korea
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Perez EE, Orange JS, Bonilla F, Chinen J, Chinn IK, Dorsey M, El-Gamal Y, Harville TO, Hossny E, Mazer B, Nelson R, Secord E, Jordan SC, Stiehm ER, Vo AA, Ballow M. Update on the use of immunoglobulin in human disease: A review of evidence. J Allergy Clin Immunol 2016; 139:S1-S46. [PMID: 28041678 DOI: 10.1016/j.jaci.2016.09.023] [Citation(s) in RCA: 376] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 09/12/2016] [Accepted: 09/23/2016] [Indexed: 12/20/2022]
Abstract
Human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. Intravenous preparations have a number of important uses in the treatment of other diseases in humans as well, some for which acceptable treatment alternatives do not exist. We provide an update of the evidence-based guideline on immunoglobulin therapy, last published in 2006. Given the potential risks and inherent scarcity of human immunoglobulin, careful consideration of its indications and administration is warranted.
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Affiliation(s)
- Elena E Perez
- Allergy Associates of the Palm Beaches, North Palm Beach, Fla.
| | - Jordan S Orange
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Francisco Bonilla
- Department of Pediatrics, Clinical Immunology Program, Children's Hospital Boston and Harvard Medical School, Boston, Mass
| | - Javier Chinen
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Ivan K Chinn
- Department of Pediatrics, Section of Immunology Allergy and Rheumatology, Center for Human Immunobiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Tex
| | - Morna Dorsey
- Department of Pediatrics, Allergy, Immunology and BMT Division, Benioff Children's Hospital and University of California, San Francisco, Calif
| | - Yehia El-Gamal
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Terry O Harville
- Departments of Pathology and Laboratory Services and Pediatrics, University of Arkansas, Little Rock, Ark
| | - Elham Hossny
- Department of Pediatrics, Pediatric Allergy and Immunology Unit, Children's Hospital and Ain Shams University, Cairo, Egypt
| | - Bruce Mazer
- Department of Pediatrics, Allergy and Immunology, Montreal Children's Hospital and McGill University, Montreal, Quebec, Canada
| | - Robert Nelson
- Department of Medicine and Pediatrics, Division of Hematology and Oncology and Stem Cell Transplantation, Riley Hospital, Indiana University School of Medicine and the IU Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Elizabeth Secord
- Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Mich
| | - Stanley C Jordan
- Nephrology & Transplant Immunology, Kidney Transplant Program, David Geffen School of Medicine at UCLA and Cedars-Sinai Medical Center, Los Angeles, Calif
| | - E Richard Stiehm
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, Calif
| | - Ashley A Vo
- Transplant Immunotherapy Program, Comprehensive Transplant Center, Kidney Transplant Program, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Mark Ballow
- Department of Pediatrics, Division of Allergy & Immunology, University of South Florida, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg, Fla
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Dakhly DMR, Bayoumi YA, Sharkawy M, Gad Allah SH, Hassan MA, Gouda HM, Hashem AT, Hatem DL, Ahmed MF, El-Khayat W. Intralipid supplementation in women with recurrent spontaneous abortion and elevated levels of natural killer cells. Int J Gynaecol Obstet 2016; 135:324-327. [PMID: 27614789 DOI: 10.1016/j.ijgo.2016.06.026] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/13/2016] [Accepted: 08/21/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the efficacy of intralipid supplementation in women with recurrent spontaneous abortion (RSA) and elevated natural killer cell activity undergoing in vitro fertilization/intracytoplasmic sperm injection. METHODS Between February 10, 2013, and April 30, 2015, a double-blind randomized controlled study was conducted at a center in Egypt. Women with unexplained secondary infertility, RSA, and elevated levels of natural killer cells (>12%) were enrolled and randomly assigned to receive intralipid (2mL diluted at 20% in 250mL saline) or saline (250mL) infusion on the day of oocyte retrieval using random numbers and sealed envelopes. Patients and attending physicians were masked to group assignment. The infusions were repeated within 1week of a positive pregnancy test and then every 2weeks until the end of the first trimester. The primary outcome was chemical pregnancy 14days after embryo transfer. Analyses were by intention-to-treat. RESULTS Overall, 296 women were enrolled. Chemical pregnancy was recorded for 84 (58.3%) of 144 women in the intralipid group and 76 (50.0%) of 152 in the control group (P=0.129). CONCLUSION Intralipid supplementation did not increase frequency of chemical pregnancy. However, findings related to ongoing pregnancy and live birth should be investigated further. ClinicalTrials.gov:NCT01788540.
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Affiliation(s)
- Dina M R Dakhly
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt.
| | - Yomna A Bayoumi
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | - Mohamed Sharkawy
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | | | - Mohamed A Hassan
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | - Hisham M Gouda
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | - Ahmed T Hashem
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | - Dina L Hatem
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | - Mona F Ahmed
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | - Waleed El-Khayat
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
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Wang SW, Zhong SY, Lou LJ, Hu ZF, Sun HY, Zhu HY. The effect of intravenous immunoglobulin passive immunotherapy on unexplained recurrent spontaneous abortion: a meta-analysis. Reprod Biomed Online 2016; 33:720-736. [PMID: 27720163 DOI: 10.1016/j.rbmo.2016.08.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 08/19/2016] [Accepted: 08/30/2016] [Indexed: 10/21/2022]
Abstract
The aim of this study was to investigate the effect of passive immunotherapy using intravenous immunoglobulin (IVIG) on unexplained recurrent spontaneous abortion (RSA). Live birth rates were analysed and binary data were calculated using risk ratio and 95% confidence interval. Meta-analysis of 11 studies showed that the difference in the live birth rate between the IVIG treatment and placebo groups was on the margin of significance (RR = 1.25, 95% CI 1.00 to 1.56, P = 0.05). Both cumulative and trial sequential meta-analyses indicated potential beneficial effect of IVIG but the evidence was inconclusive. Subgroup analysis showed that the live birth rate in primary (RR = 0.88, 95% CI 0.71 to 1.07) and secondary (RR = 1.26, 95% CI 0.99 to 1.61) RSA patients was not significantly different between the IVIG and placebo groups. Live birth rate was significantly different when IVIG was administered before conception (RR = 1.67, 95% CI 1.30 to 2.14, P < 0.0001) but not after implantation (RR = 1.10, 95% CI 0.93 to 1.29). Evidence is insufficient to support the beneficial effects of IVIG on an unexplained RSA. Further high quality studies are needed to elucidate the effectiveness of IVIG.
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Affiliation(s)
- Si-Wei Wang
- Department of Pharmacy, The People's Hospital of Quzhou, 2 Zhongloudi Road, Quzhou, Zhejiang 324000, China
| | - Song-Yang Zhong
- Department of Pharmacy, The People's Hospital of Quzhou, 2 Zhongloudi Road, Quzhou, Zhejiang 324000, China.
| | - Li-Jun Lou
- Department of Pharmacy, The People's Hospital of Quzhou, 2 Zhongloudi Road, Quzhou, Zhejiang 324000, China
| | - Ze-Fu Hu
- Department of Pharmacy, The People's Hospital of Quzhou, 2 Zhongloudi Road, Quzhou, Zhejiang 324000, China
| | - Hua-Yu Sun
- Department of Pharmacy, The People's Hospital of Quzhou, 2 Zhongloudi Road, Quzhou, Zhejiang 324000, China
| | - Hai-Yan Zhu
- Department of Pharmacy, The People's Hospital of Quzhou, 2 Zhongloudi Road, Quzhou, Zhejiang 324000, China
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Diejomaoh MF, Bello Z, Al Jassar W, Jirous J, Karunakaran K, Mohammed AT. Consecutive successful pregnancies subsequent to intravenous immunoglobulin therapy in a patient with recurrent spontaneous miscarriage. Int Med Case Rep J 2015; 8:337-44. [PMID: 26715864 PMCID: PMC4686317 DOI: 10.2147/imcrj.s93159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Recurrent spontaneous miscarriage (RSM) has a multifactorial etiology, mainly due to karyotype abnormalities including balanced translocation, anatomical uterine disorders, and immunological factors, although in 50%–60% the etiology is unexplained. The treatment of RSM remains challenging, and the role of intravenous immunoglobulin (IVIG) in RSM is controversial. Case report Mrs HM, 37 years old, obstetric summary: P0+1+13+1, a known case of hypothyroidism/polycystic ovary syndrome, married to an unrelated 47-year-old man, presented to our RSM clinic in early January 2014 for investigation and treatment. She has had multiple failed in vitro fertilization trials and 13 first-trimester missed miscarriages terminating at 6–7 weeks, all without IVIG therapy. Her tenth pregnancy was spontaneous, managed in London, UK, with multiple supportive therapy and courses of IVIG starting from the third to the 30th week of pregnancy. The pregnancy ended at 36 weeks of gestation with a cesarean section and a live girl baby was delivered. Mrs HM had balanced translocation, 46XX t (7:11) (p10:q10). Preimplantation genetic diagnosis/intracytoplasmic sperm injection/in vitro fertilization was performed with embryo transfer on May 29, 2014, and resulted in a successful pregnancy. She was commenced immediately on metformin, luteal support, and IVIG therapy, started at 6 weeks of gestation and at monthly intervals until 30 weeks of gestation, and also received additional therapy. The pregnancy was monitored with ultrasound, progressed uneventfully until admission at 35 weeks of gestation, with mildly elevated liver enzymes and suspected fetal growth restriction. She was managed conservatively, and in the light of nonreassuring fetal status, a live female infant weighing 2.29 kg was delivered by emergency cesarean section on January 14, 2015, with an Apgar score of 8 and 9 and mild respiratory distress, and was admitted to the Special Care Baby Unit for intensive therapy. The mother and baby made satisfactory progress and were discharged on January 24, 2015. Conclusion Two consecutive successful pregnancies in Mrs HM with multiple causes of RSM treated with other medications and IVIG strongly suggest that IVIG has a positive role in RSM.
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Affiliation(s)
- Michael F Diejomaoh
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Kuwait University, Safat, Kuwait ; Maternity Hospital, Shuwaikh, Kuwait
| | | | - Waleed Al Jassar
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Kuwait University, Safat, Kuwait ; Maternity Hospital, Shuwaikh, Kuwait
| | | | | | - Asiya T Mohammed
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Kuwait University, Safat, Kuwait
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Abstract
Recurrent pregnancy loss (RPL) is a multifactorial condition. Approximately half of patients with RPL will have no explanation for their miscarriages. De novo chromosome abnormalities are common in sporadic and recurrent pregnancy loss. Testing for embryonic abnormalities can provide an explanation for the miscarriage in many cases and prognostic information. Regardless of the cause of RPL, patients should be reassured that the prognosis for live birth with an evidence-based approach is excellent for most patients. The authors review current evidence for the evaluation and treatment of RPL and explore the proposed use of newer technology for patients with RPL.
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Meng L, Lin J, Chen L, Wang Z, Liu M, Liu Y, Chen X, Zhu L, Chen H, Zhang J. Effectiveness and potential mechanisms of intralipid in treating unexplained recurrent spontaneous abortion. Arch Gynecol Obstet 2015; 294:29-39. [PMID: 26671484 DOI: 10.1007/s00404-015-3922-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 10/13/2015] [Indexed: 01/13/2023]
Abstract
AIM Abnormal natural killer (NK) cell activity has been suggested to be a high-risk factor associated with unexplained recurrent spontaneous abortion (URSA). Intralipid, like immunoglobulin, is able to lower the activity of NK cells, which has been reported to be useful for improving URSA outcomes in pregnancy. This study aimed to determine whether intralipid could be used as an alternative treatment to intravenous immunoglobulin (IVIG) which is expensive and has many side-effects. METHODS A prospective, randomized clinical trial was conducted from December 2010 to December 2012. Eligible participants were matched and sorted randomly into the intralipid and the IVIG group. The primary outcome was the rate of successful pregnancy. In addition, comparisons of peripheral NK cell activities were accessed by flow cytometry. Moreover, the effects of intralipid on trophoblasts were investigated using a Matrigel assay with the JEG-3 cell line. RESULTS Seventy-six patients in the intralipid group and 78 in the IVIG group completed the trial. There were no statistically significant differences in successful pregnancy rates between the two groups (92.1 vs 88.2 %, P = 0.415). The reduced NK cell concentrations revealed the cytotoxic effects of the treatments in both groups. The invasive ability of JEG-3 cells was inhibited during co-culture with patient PBMCs. However, the inhibitory effect could be alleviated if the patient PBMCs were stimulated with intralipid. CONCLUSIONS Intralipid can be used as an alternative treatment to IVIG for URSA, and its potential mechanism of action may occur by regulating NK cell function and promoting trophoblast invasion.
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Affiliation(s)
- Lili Meng
- Department of Gynecology and Obstetrics, The Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Yanjiang Road 107#, Guangzhou, 510060, Guangdong Province, China
| | - Jizong Lin
- Department of Hepatobiliary Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, China
| | - Libin Chen
- Department of Gynecology and Obstetrics, The Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Yanjiang Road 107#, Guangzhou, 510060, Guangdong Province, China
| | - Zhenhua Wang
- Department of Gynecology and Obstetrics, The Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Yanjiang Road 107#, Guangzhou, 510060, Guangdong Province, China
| | - Meilan Liu
- Department of Gynecology and Obstetrics, The Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Yanjiang Road 107#, Guangzhou, 510060, Guangdong Province, China
| | - Yukun Liu
- Department of Gynecology and Obstetrics, The Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Yanjiang Road 107#, Guangzhou, 510060, Guangdong Province, China
| | - Xin Chen
- Department of Gynecology and Obstetrics, The Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Yanjiang Road 107#, Guangzhou, 510060, Guangdong Province, China
| | - Liqiong Zhu
- Department of Gynecology and Obstetrics, The Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Yanjiang Road 107#, Guangzhou, 510060, Guangdong Province, China
| | - Hui Chen
- Department of Gynecology and Obstetrics, The Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Yanjiang Road 107#, Guangzhou, 510060, Guangdong Province, China.
| | - Jianping Zhang
- Department of Gynecology and Obstetrics, The Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Yanjiang Road 107#, Guangzhou, 510060, Guangdong Province, China.
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Nazari Z, Ghaffari J, Ebadi A. Comparison of the effect of aspirin and heparin with or without intravenous immunoglobulin in treatment of recurrent abortion with unknown etiology: A clinical study. J Nat Sci Biol Med 2015; 6:S17-21. [PMID: 26604612 PMCID: PMC4630756 DOI: 10.4103/0976-9668.166054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction and Objective: Abortion is the most common complication of pregnancy, defined as spontaneous expulsion of products of conception before 24 weeks of pregnancy or termination of pregnancy with a fetus weighing <500 g. The aim of this study was to compare the efficacy of intravenous immunoglobulin (IVIG) in combination regimens with aspirin and heparin versus aspirin and heparin combination alone in women with idiopathic recurrent abortion. Materials and Methods: This randomized, clinical trial was performed at Imam Khomeini Hospital in Sari-Iran between March 2010 and March 2013. Sixty people were randomly allocated into two groups. The control group was treated by subcutaneous enoxaparin 40 mg daily up to 24 weeks associated with aspirin 80 mg daily up to 37 weeks of gestation. The intervention group received IVIG 200 mg/kg monthly up to 24 weeks of gestation with enoxaparin and aspirin for the same therapeutic period and the same dose as the control group. Results: Three patients (10%) in the intervention group had abortion and 25 (90%) had live births with mean birth weight 3.5 ± 0.9 kg. Four patients (13%) in the control group had abortions, and 28 (87%) had live births with birth weight 3.4 ± 1.2 kg (P = 0.74). The difference was not statistically significant. Conclusions: It seems that employing the heparin and aspirin combination therapeutic regimen is appropriate for idiopathic abortions and avoids the high cost of IVIG use and its complications.
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Affiliation(s)
- Zeinab Nazari
- Obstetric and Gynecologist, Fellowship of Oncology, Department of Pediatrics, Mazandaran University of Medical Sciences, Sari, Iran
| | - Javad Ghaffari
- Associate Professor of Allergy and Clinical Immunology, Department of Pediatrics, Mazandaran University of Medical Sciences, Sari, Iran
| | - Aghdas Ebadi
- Obstetric and Gynecologist, Fellowship of Oncology, Department of Pediatrics, Mazandaran University of Medical Sciences, Sari, Iran
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Egerup P, Lindschou J, Gluud C, Christiansen OB. The Effects of Intravenous Immunoglobulins in Women with Recurrent Miscarriages: A Systematic Review of Randomised Trials with Meta-Analyses and Trial Sequential Analyses Including Individual Patient Data. PLoS One 2015; 10:e0141588. [PMID: 26517123 PMCID: PMC4627734 DOI: 10.1371/journal.pone.0141588] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 10/09/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Immunological disturbances are hypothesised to play a role in recurrent miscarriage (RM) and therefore intravenous immunoglubulins (IVIg) have been tested in RM patients. OBJECTIVES The objectives were to investigate the benefits and harms of IVIg versus placebo, no intervention, or treatment as usual in women with RM. SEARCH STRATEGY We searched the published literature in all relevant databases. SELECTION CRITERIA Randomised trials investigating IVIg versus placebo, no intervention, or treatment as usual in women with RM. DATA COLLECTION AND ANALYSIS We undertook meta-analyses of aggregated data and individual patient data using a two-step approach, and we conducted bias domain assessments and trial sequential analyses to assess the risks of systematic and random errors. MAIN RESULTS We identified 11 randomised clinical trials. No significant difference in the frequency of no live birth was found when IVIg was compared with placebo or treatment as usual (RR 0.92, 95% CI 0.75-1.12, p = 0.42). Trial sequential analysis showed that the required information size of 1,008 participants was not obtained. IVIg compared with placebo seems to increase the risk of adverse events. Subgroup analysis suggests that women with RM after a birth (secondary RM) seemed most likely to obtain a potential beneficial effect of IVIg (RR for no live birth 0.77, 95%CI 0.58-1.02, p = 0.06), however, trial sequential analysis showed that insufficient information is presently accrued. CONCLUSION We cannot recommend or refute IVIg in women with RM. IVIg should therefore be assessed in further randomised clinical trials with positive outcomes before any clinical use is considered.
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Affiliation(s)
- Pia Egerup
- The Fertility Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- * E-mail:
| | - Jane Lindschou
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Bjarne Christiansen
- The Fertility Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark
| | - ImmuReM IPD Study Group
- The Fertility Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark, Department of Obstetrics and Gynaecology, University Hospital Linköping, Linköping, Sweden
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Lee SK, Kim JY, Han AR, Hur SE, Kim CJ, Kim TH, Cho BR, Han JW, Han SG, Na BJ, Kwak-Kim J. Intravenous Immunoglobulin G Improves Pregnancy Outcome in Women with Recurrent Pregnancy Losses with Cellular Immune Abnormalities. Am J Reprod Immunol 2015; 75:59-68. [DOI: 10.1111/aji.12442] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/05/2015] [Indexed: 02/01/2023] Open
Affiliation(s)
- Sung Ki Lee
- Department of Obstetrics and Gynecology; Konyang University Hospital; Daejeon Korea
| | - Jee Yun Kim
- Department of Obstetrics and Gynecology; Konyang University Hospital; Daejeon Korea
| | - Ae Ra Han
- Department of Obstetrics and Gynecology; Konyang University Hospital; Daejeon Korea
| | - Sung Eun Hur
- Department of Obstetrics and Gynecology; Konyang University Hospital; Daejeon Korea
| | - Chul Jung Kim
- Department of Obstetrics and Gynecology; Konyang University Hospital; Daejeon Korea
| | - Tae Hyun Kim
- Department of Obstetrics and Gynecology; Konyang University Hospital; Daejeon Korea
| | - Bo Ra Cho
- Department of Obstetrics and Gynecology; Konyang University Hospital; Daejeon Korea
| | - Jae Won Han
- Department of Obstetrics and Gynecology; Konyang University Hospital; Daejeon Korea
| | - Sae Geul Han
- Department of Obstetrics and Gynecology; Konyang University Hospital; Daejeon Korea
| | - Baeg Ju Na
- Seoul Metropolitan Seobuk Hosptial; Seoul Korea
| | - Joanne Kwak-Kim
- Reproductive Medicine; Department of Obstetrics and Gynecology; Chicago Medical School at Rosalind Franklin University of Medicine and Science; North Chicago IL USA
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Tsur A, Hughes GC, Shoenfeld Y, Carp H. Interdisciplinary exchange of ideas: progestagens for autoimmunity, biologics for pregnancy complications. Immunol Res 2015; 61:31-4. [PMID: 25550090 DOI: 10.1007/s12026-014-8621-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In recent years, there has been a growing interest in the role of immune, alloimmune and autoimmune processes in the pathogenesis of spontaneous preterm birth and recurrent pregnancy loss. The association between an inflammatory response and preterm labor has been established. Indeed, many women suffering from preterm labor have elevated inflammatory markers such as tumor necrosis factor alpha, interleukin 6 and matrix metaloproeinase 8. The role of immune processes in the pathogenesis of recurrent pregnancy loss has also been widely researched. Progesterone induces many physiologic effects necessary for healthy pregnancy, and progestagens supplementation has been used as an approach to prevent preterm labor and recurrent pregnancy loss. Progestagens also have potent anti-inflammatory and immunomodulatory actions. Because preterm labor and recurrent pregnancy loss are associated with abnormal inflammation, progestagens may maintain healthy pregnancy through both endocrine and immunologic actions. These immunologic actions, such as suppression of Th1- and Th17-related responses, enhancement of regulatory T cell (Tregs) activity and suppression of inflammation, may also be involved in pregnancy-induced remission of certain autoimmune diseases such as rheumatoid arthritis (RA) and multiple sclerosis (MS). Accordingly, there is growing interest in the potential therapeutic role of progestagens in the treatment of MS and RA. In this review, we suggest that biologic autoimmune modulators, especially those which affect immune pathways similar to progestagens, may provide more potent and specific effects, and hence better results than progestagens, in preventing preterm labor and recurrent pregnancy loss.
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Affiliation(s)
- Abraham Tsur
- Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel,
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Effects of polyvalent immunoglobulins in patients with recurrent pregnancy loss and antibodies to the choriocarcinoma cell line JEG-3. Eur J Obstet Gynecol Reprod Biol 2015; 194:161-7. [PMID: 26407335 DOI: 10.1016/j.ejogrb.2015.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/21/2015] [Accepted: 09/03/2015] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The benefit of polyvalent immunoglobulins (IVIG) for patients with recurrent pregnancy loss (RPL) is controversially discussed. Anti-trophoblast antibodies as an expression of immune pathology have been associated with RPL. We investigated whether the antibody activity against the choriocarcinoma cell line JEG-3 in RPL patients is influenced in vitro by IVIG. STUDY DESIGN Sera of 110 unexplained RPL patients with positive anti-JEG-3 antibodies were coincubated with IVIG in different concentrations (10mg/ml, 20mg/ml, 40mg/ml). Coincubation with human albumin in identical concentrations served as control. Anti-JEG-3 reactivity was measured by using flow cytometry in comparisons with two in-house standards antibody probes of low and high reactivity as described before. Anti-JEG-3 reactivity above the 95% confidence interval of controls was defined as positive. RESULTS Incubating RPL sera with 10mg/ml IVIG significantly decreased anti-JEG-3 activity (p<0.001). Increasing IVIG concentration to 40mg/ml resulted in a slightly additionally reduction (p=0.42). In contrast, coincubation with albumin in identically concentrations did not affect anti-JEG-3 activity (p>0.40). CONCLUSION Coincubation with IVIG in vitro leads to a significant suppression of anti-JEG-3 activity in the sera of RPL patients.
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What is new in recurrent pregnancy loss?: best articles from the past year. Obstet Gynecol 2015; 125:1490-1492. [PMID: 26000521 DOI: 10.1097/aog.0000000000000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This month we focus on current research in recurrent pregnancy loss. Dr. Fox discusses five recent publications, and each is concluded with a "bottom line" that is the take-home message. The complete reference for each can be found in on this page, along with direct links to the abstracts.
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Chaiworapongsa T, Romero R, Korzeniewski SJ, Chaemsaithong P, Hernandez-Andrade E, Segars JH, DeCherney AH, McCoy MC, Kim CJ, Yeo L, Hassan SS. Pravastatin to prevent recurrent fetal death in massive perivillous fibrin deposition of the placenta (MPFD). J Matern Fetal Neonatal Med 2015; 29:855-62. [PMID: 25893545 DOI: 10.3109/14767058.2015.1022864] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Massive perivillous fibrin deposition of the placenta (MPFD) or maternal floor infarction (MFI) is a serious condition associated with recurrent complications including fetal death and severe fetal growth restriction. There is no method to evaluate the risk of adverse outcome in subsequent pregnancies, or effective prevention. Recent observations suggest that MFI is characterized by an imbalance in angiogenic/anti-angiogenic factors in early pregnancy; therefore, determination of these biomarkers may identify the patient at risk for recurrence. We report the case of a pregnant woman with a history of four consecutive pregnancy losses, the last of which was affected by MFI. Abnormalities of the anti-angiogenic factor, sVEGFR-1, and soluble endoglin (sEng) were detected early in the index pregnancy, and treatment with pravastatin corrected the abnormalities. Treatment resulted in a live birth infant at 34 weeks of gestation who had normal biometric parameters and developmental milestones at the age of 2. This is the first reported successful use of pravastatin to reverse an angiogenic/anti-angiogenic imbalance and prevent fetal death.
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Affiliation(s)
- Tinnakorn Chaiworapongsa
- a Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, MD and Detroit , MI , USA .,b Department of Obstetrics and Gynecology , Wayne State University , Detroit , MI , USA
| | - Roberto Romero
- a Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, MD and Detroit , MI , USA .,c Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , MI , USA .,d Department of Epidemiology and Biostatistics , Michigan State University , East Lansing , MI , USA .,e Department of Molecular Obstetrics and Genetics , Wayne State University , Detroit , MI , USA
| | - Steven J Korzeniewski
- a Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, MD and Detroit , MI , USA .,b Department of Obstetrics and Gynecology , Wayne State University , Detroit , MI , USA .,d Department of Epidemiology and Biostatistics , Michigan State University , East Lansing , MI , USA
| | - Piya Chaemsaithong
- a Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, MD and Detroit , MI , USA .,b Department of Obstetrics and Gynecology , Wayne State University , Detroit , MI , USA
| | - Edgar Hernandez-Andrade
- a Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, MD and Detroit , MI , USA .,b Department of Obstetrics and Gynecology , Wayne State University , Detroit , MI , USA
| | - James H Segars
- f Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda , MD , USA
| | - Alan H DeCherney
- f Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda , MD , USA
| | - M Cathleen McCoy
- g Perinatal Unit , Winchester Obstetrics and Gynecology, Winchester Medical Center , Winchester , VA , USA , and
| | - Chong Jai Kim
- a Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, MD and Detroit , MI , USA .,h Department of Pathology , University of Ulsan College of Medicine, Asan Medical Center , Seoul , Korea
| | - Lami Yeo
- a Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, MD and Detroit , MI , USA .,b Department of Obstetrics and Gynecology , Wayne State University , Detroit , MI , USA
| | - Sonia S Hassan
- a Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health , Bethesda, MD and Detroit , MI , USA .,b Department of Obstetrics and Gynecology , Wayne State University , Detroit , MI , USA
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Christiansen OB. Advances of intravenous immunoglobulin G in modulation of anti-fetal immunity in selected at-risk populations: science and therapeutics. Clin Exp Immunol 2015; 178 Suppl 1:120-2. [PMID: 25546787 DOI: 10.1111/cei.12536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- O B Christiansen
- Fertility Clinic 4071, Rigshospitalet, Copenhagen, Denmark; Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark
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