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Hajipour H, Nejabati HR, Latifi Z, Hamdi K, Bahrami-asl Z, Fattahi A, Nouri M. Lymphocytes immunotherapy for preserving pregnancy: Mechanisms and Challenges. Am J Reprod Immunol 2018; 80:e12853. [DOI: 10.1111/aji.12853] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/08/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- Hamed Hajipour
- Department of Reproductive Biology; Faculty of Advanced Medical Sciences; Tabriz University of Medical Sciences; Tabriz Iran
| | - Hamid Reza Nejabati
- Department of Biochemistry and Clinical Laboratories; Faculty of Medicine; Tabriz University of Medical Sciences; Tabriz Iran
| | - Zeinab Latifi
- Department of Biochemistry and Clinical Laboratories; Faculty of Medicine; Tabriz University of Medical Sciences; Tabriz Iran
| | - Kobra Hamdi
- Women's Reproductive Health Research Center; Tabriz University of Medical Sciences; Tabriz Iran
| | - Zahra Bahrami-asl
- Department of Reproductive Biology; Faculty of Advanced Medical Sciences; Tabriz University of Medical Sciences; Tabriz Iran
| | - Amir Fattahi
- Department of Biochemistry and Clinical Laboratories; Faculty of Medicine; Tabriz University of Medical Sciences; Tabriz Iran
- Women's Reproductive Health Research Center; Tabriz University of Medical Sciences; Tabriz Iran
| | - Mohammad Nouri
- Women's Reproductive Health Research Center; Tabriz University of Medical Sciences; Tabriz Iran
- Stem Cell and Regenerative Medicine Institute; Tabriz University of Medical Sciences; Tabriz Iran
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Egerup P, Kolte AM, Larsen EC, Krog M, Nielsen HS, Christiansen OB. Recurrent pregnancy loss: what is the impact of consecutive versus non-consecutive losses? Hum Reprod 2016; 31:2428-2434. [PMID: 27591241 DOI: 10.1093/humrep/dew169] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/31/2016] [Accepted: 06/08/2016] [Indexed: 12/21/2022] Open
Abstract
STUDY QUESTION Is there a different prognostic impact for consecutive and non-consecutive early pregnancy losses in women with secondary recurrent pregnancy loss (RPL)? SUMMARY ANSWER Only consecutive early pregnancy losses after the last birth have a statistically significant negative prognostic impact in women with secondary RPL. WHAT IS KNOWN ALREADY The risk of a new pregnancy loss increases with the number of previous pregnancy losses in patients with RPL. Second trimester losses seem to exhibit a stronger negative impact than early losses. It is unknown whether the sequence of pregnancy losses plays a role for the prognosis in patients with a prior birth. STUDY DESIGN, SIZE, DURATION This retrospective cohort study of pregnancy outcome in patients with unexplained secondary RPL included in three previously published, Danish double-blinded placebo-controlled trials of intravenous immunoglobulin (IvIg) conducted from 1991 to 2014. No other treatments were given. Patients with documented explained pregnancy losses (ectopic pregnancies and aneuploid miscarriages) were excluded. PARTICIPANTS/MATERIALS, SETTING, METHODS Of the 168 patients included in the trials, 127 had secondary RPL and experienced a subsequent live birth or unexplained pregnancy loss in the first pregnancy after giving informed consent to participate in the trials (the index pregnancy). Data analyzed by multivariate analysis included the independent variables age, the number of early pregnancy losses before and after the last birth, respectively and a second trimester pregnancy loss before or after the last birth, respectively. The outcome variable was unexplained loss in the index pregnancy. MAIN RESULTS AND THE ROLE OF CHANCE In patients with secondary RPL, both a late and each early loss before the last birth did not significantly influence the risk of a new pregnancy loss in the index pregnancy: incidence rate ratio (IRR) 1.31 (95% CI 0.62-2.77) and IRR 0.88 (95% CI 0.70-1.11), respectively. In contrast, the impact on risk of pregnancy loss conferred by a late and by each early pregnancy loss occurring after the birth was significant: IRR 2.15 (95% CI 1.57-2.94, P < 0.0001) and IRR 1.14 (95% CI 1.04-1.24, P = 0.002), respectively. LIMITATIONS, REASONS FOR CAUTION Of the patients, 48% were treated with IvIg, which could influence the results. However, allocation to IvIg was random and prognostic variables were equally distributed in IvIg and placebo-treated patients. WIDER IMPLICATIONS OF THE FINDINGS A birth in women with secondary RPL eradicates the negative prognostic impact of previous pregnancy losses and this finding is important for our understanding of the pathogenesis. It indicates that only consecutive pregnancy losses should count in the definition of RPL. STUDY FUNDING/COMPETING INTERESTS There was no particular funding for this study. The authors declare that there is no conflict of interest. TRIAL REGISTRATION NUMBER Not applicable for two of the included randomized controlled trials. For the last trial: Clinical.Gov NCT00722475.
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Affiliation(s)
- P Egerup
- Recurrent Pregnancy Loss Unit, Fertility Clinic 4071, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - A M Kolte
- Recurrent Pregnancy Loss Unit, Fertility Clinic 4071, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - E C Larsen
- Recurrent Pregnancy Loss Unit, Fertility Clinic 4071, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - M Krog
- Recurrent Pregnancy Loss Unit, Fertility Clinic 4071, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - H S Nielsen
- Recurrent Pregnancy Loss Unit, Fertility Clinic 4071, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - O B Christiansen
- Recurrent Pregnancy Loss Unit, Fertility Clinic 4071, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark .,Department of Obstetrics and Gynaecology, Aalborg University Hospital, Reberbansgade, DK-9000 Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Gleicher N. Graft-versus-host disease and immunologic rejection: implications for diagnosis and treatments of pregnancy complications. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.3.1.37] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Christiansen OB. Intravenous immunoglobulin in the prevention of recurrent spontaneous abortion: the European experience. Am J Reprod Immunol 1998; 39:77-81. [PMID: 9506205 DOI: 10.1111/j.1600-0897.1998.tb00338.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PROBLEM Clinical trials of the use of intravenous immunoglobulin (IvIg) in the treatment of recurrent spontaneous abortion (RSA) in Europe were reported and discussed. METHOD OF STUDY A search of the published literature, combined with our own published and unpublished results, was performed. RESULTS Two placebo-controlled trials have been concluded in Europe. One trial found high but equal success rates in both the IvIg and the placebo group. Another trial found that IvIg treatment may increase the success rate by 24% compared with placebo but that the result was not statistically significant, which might be due to the small number of patients. Reasons for the diverse results of the two trials were discussed. CONCLUSION More and larger placebo-controlled trials of IvIg treatment in RSA are needed before drawing definitive conclusions.
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Affiliation(s)
- O B Christiansen
- Department of Obstetrics and Gynecology, Aalborg Hospital, Denmark
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Gafter U, Sredni B, Segal J, Kalechman Y. Suppressed cell-mediated immunity and monocyte and natural killer cell activity following allogeneic immunization of women with spontaneous recurrent abortion. J Clin Immunol 1997; 17:408-19. [PMID: 9327341 DOI: 10.1023/a:1027372409361] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Spontaneous recurrent abortion (SRA) has been treated by means of immunization with paternal or third-party white blood cells, yet the immunological basis for SRA and for the role of immunization protocols in pregnancy outcome remains controversial. To elucidate this question, nine women with SRA were immunized with paternal mononuclear cells and studied before and 2 weeks after immunization. Seven women who became pregnant gave birth to live newborns. Secretion of the T helper 1 cytokines IL-2 and interferon-gamma by patients, mononuclear cells decreased, while production of IL-10 increased. The levels of natural killer and lymphokine-activated killer cell-mediated cytotoxicity were markedly decreased. Monocyte functions such as secretion of IL-1 alpha, tumor necrosis factor alpha, IL-6, and cytotoxic activity decreased concurrently with elevations in IL-10 and transforming growth factor beta secretion. Production of IL-12, a pivotal regulatory cytokine, decreased. Furthermore, B7/1 expression on patients' mononuclear cells was downregulated. This resulted in a decrease in monocyte costimulatory activity of purified T cells with soluble anti-CD3, paralleled by a decline in allogeneic proliferative responses. These results suggest that the improved pregnancy success rate in women with SRA following immunization may be partly related to suppression of cell-mediated immunity and monocyte and natural killer cell activity.
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Affiliation(s)
- U Gafter
- Department of Nephrology, Rabin Medical Center, Petah-Tikva, Israel
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Daher S, Fonseca F, Mattar R, Musatti CC, de Lima MG. Inhibitory serum factor of lymphoproliferative response to allogeneic cells in pregnancy. SAO PAULO MED J 1997; 115:1485-9. [PMID: 9595813 DOI: 10.1590/s1516-31801997000400006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION An inhibitory serum factor of mixed lymphocyte culture (MLC) has been associated with successful pregnancy after lymphocyte transfusion in women with unexplained recurrent spontaneous abortions (RSA). OBJECTIVE Investigate whether the inhibitory serum factor of MLC is essential for a successful pregnancy. METHOD Sera from 33 healthy pregnant women and from 40 women with RSA were assessed by a one-way MLC in which the woman's lymphocytes were stimulated with her partner's lymphocytes or with third party lymphocytes. RESULTS An inhibitory serum effect (inhibition > 50% as compared to normal serum) was detected in 45% of the pregnant women who had at least 1 previous parity, in 8% of the primigravidea, in 29% of those with one abortion and in 58% of those with more than one abortion. CONCLUSION MLC inhibitory serum factor does not seem to be an essential factor for pregnancy development. Therefore, it should not be considered as a parameter for the assessment of RSA patients.
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Affiliation(s)
- S Daher
- Pediatrics Department, Universidade Federal de São Paulo, EPM, Brazil
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Affiliation(s)
- C Ober
- Department of Obstetrics and Gynecology, University of Chicago, IL 60637, USA
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Coulam CB, Stephenson M, Stern JJ, Clark DA. Immunotherapy for recurrent pregnancy loss: analysis of results from clinical trials. Am J Reprod Immunol 1996; 35:352-9. [PMID: 8739453 DOI: 10.1111/j.1600-0897.1996.tb00493.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PROBLEM Up to 80% of unexplained recurrent spontaneous abortions (RSA) are thought to have an immunologic mechanism. Yet clinical trials using immunotherapy to treat women experiencing RSA have low treatment effects. The present study was undertaken to explain the low treatment effects. METHODS Results of clinical trials using allogeneic leukocyte immunization and intravenous (IV) immunoglobulin (Ig) are compared. The mechanisms of pregnancy loss are reviewed in light of data on frequency of karyotype abnormalities in trophoblast of failing pregnancies. RESULTS Results of two independent analyses using allogeneic leukocyte immunization as immunotherapy for all women with RSA revealed live birth ratios of 1.16 (P = 0.03) and 1.21 (P = 0.02). When the analysis was limited to primary aborters, the live birth ratio increased to 1.46 (P = 0.006). Live birth ratio after immunotherapy for all RSA using IVIg was 1.88 (P = 0.04). Because of low treatment effects, confounders to treatment success of maternal age and number of previous abortions were studied. Chromosomal abnormalities have been identified in 55% of concepti from RSA. The frequency of chromosomal abnormalities remained constant for up to six pregnancy losses. Women with a history of primary compared to secondary RSA had a higher frequency of karyotypically abnormal concepti (chi 2 = 4.54, P < 0.05). Risk factors for RSA also include number of previous losses. CONCLUSION Chromosomal abnormalities are a significant confounder when evaluating efficacy of immunotherapy for treatment of RSA. Some women with RSA have a high risk of recurrent chromosomal problems.
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Affiliation(s)
- C B Coulam
- Genetics and IVF Institute, Fairfax, VA 22031, USA
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Matzner W, Chong P, Xu G, Ching W. A comparison of flow cytometry and microcytotoxicity for the evaluation of alloimmune therapy in patients with recurrent spontaneous abortions. Am J Reprod Immunol 1995; 33:10-3. [PMID: 7619223 DOI: 10.1111/j.1600-0897.1995.tb01132.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
PROBLEM There is substantial data that support the efficacy of paternal leukocyte immunization (PLI) for the treatment of alloimmune mediated miscarriage; however, there is confusion regarding the laboratory test that should be performed to determine levels of maternal anti-paternal leukocyte antibodies (MAPLA). METHOD Popular methodologies employed include: 1) microcytotoxicity (MCX), 2) mixed lymphocyte culture (MLC), and 3) cell flow cytometry crossmatch (FCXM). Cell flow cytometry crossmatch correlates well with the more difficult MLC assay although the former proves the more sensitive study. This work compares the MCX assays with FCXM. The study group consisted of ten women who had a history of three or more spontaneous abortions (SABs). All ten had very low levels (< 10%) of MAPLA as measured by FCXM. Following PLI all subjects demonstrated elevated levels (> 50%) of MAPLA by FCXM. At 12 weeks gestation, sera were simultaneously measured for MAPLA by MCX and FCXM. RESULTS Although all ten patients had very high levels of MAPLA by FCXM during pregnancy, five of ten had antibodies to HLA Class I and two of ten had antibodies to HLA Class II paternal antigens by MCX. Furthermore, all patients who were positive by MCX to paternal Class I antigens were also positive to Class I antigens not seen in either parent. Both patients who were positive by MCX to paternal Class II antigens were also positive to maternal Class II antigens. Notable is that all ten women eventually delivered healthy infants. CONCLUSION Based on this preliminary study, the MCX assay is neither sensitive or reliable enough to determine the need and/or to monitor the effectiveness of PLI. Flow cytometry should be the modality of choice when determining the need for alloimmunotherapy and to monitor the effectiveness of treatment.
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Affiliation(s)
- W Matzner
- Reproductive Immunology Associates, Van Nuys, CA 91405, USA
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Ober C, Steck T, van der Ven K, Billstrand C, Messer L, Kwak J, Beaman K, Beer A. MHC class II compatibility in aborted fetuses and term infants of couples with recurrent spontaneous abortion. J Reprod Immunol 1993; 25:195-207. [PMID: 8207709 DOI: 10.1016/0165-0378(93)90063-n] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Maternal-fetal histocompatibility for alleles at HLA class II loci, HLA-DQA1 and HLA-DQB1, was examined in 40 abortuses and 31 liveborn children of 68 couples with a history of idiopathic recurrent spontaneous abortion (RSAB) who underwent leukocyte immunization prior to the index pregnancy. Significantly more couples with RSAB shared two HLA-DQA1 alleles as compared with fertile control couples (0.18 vs. 0.03, respectively; P = 0.031). There were no differences in HLA sharing between couples with RSAB who experienced a repeat abortion in the index pregnancy as compared with couples with RSAB who were delivered of a liveborn child. Non-significant deficits of abortuses who were compatible for alleles at the HLA-DQA1 (6 observed vs. 8.5 expected; P = 0.225) and the HLA-DQB1 (7 observed vs. 9.2 expected; P = 0.254) loci were observed. A significant deficit of HLA-DQA1 compatible liveborn children was observed (1 observed vs. 5.5 expected; P = 0.0069). The overall deficit of HLA-DQA1 compatible fetuses (7 observed vs. 14.0 expected; P = 0.0018) after approximately 8 weeks gestation suggests that HLA-DQA1 compatible fetuses may be aborted early in pregnancy, prior to the time when fetal tissue can be recovered for genetic studies.
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Affiliation(s)
- C Ober
- Department of Obstetrics and Gynecology, University of Chicago, IL 60637
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Aoki K, Kajiura S, Matsumoto Y, Yagami Y. Clinical evaluation of immunotherapy in early pregnancy with x-irradiated paternal mononuclear cells for primary recurrent aborters. Am J Obstet Gynecol 1993; 169:649-53. [PMID: 8372875 DOI: 10.1016/0002-9378(93)90638-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the beneficial effect of immunotherapy for the treatment of recurrent abortion. STUDY DESIGN We immunized 106 primary recurrent aborters, twice at around 5 and 7 weeks of gestation, with intradermal injection of approximately 100 to 200 million x-irradiated (50 Gy) paternal mononuclear cells. We injected another 38 primary recurrent aborters in the same manner with only 1 million such paternal cells, to examine the relationship between the paternal cell dose used for immunization and pregnancy outcome. RESULTS The pregnancy success rate (83.0%) in patients immunized with a large number of cells was significantly higher than that (55.3%) in those immunized with a small number of cells (p < 0.001). Furthermore, the frequency of twins in the former group was high (5.7%, five of 88). CONCLUSION This positive relationship between the paternal cell dose used for immunization in early pregnancy and the pregnancy outcome reflects the efficacy of this mode of immunotherapy for recurrent aborters.
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Affiliation(s)
- K Aoki
- Department of Obstetrics and Gynecology, Nagoya City University Medical School, Japan
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Maruyama T, Makino T, Sugi T, Iwasaki K, Ozawa N, Matsubayashi H, Nozawa S. Flow cytometric crossmatch and early pregnancy loss in women with a history of recurrent spontaneous abortions who underwent paternal leukocyte immunotherapy. Am J Obstet Gynecol 1993; 168:1528-36. [PMID: 8498439 DOI: 10.1016/s0002-9378(11)90794-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The purpose of our study was to evaluate the clinical significance of flow cytometric crossmatch in managing women with unexplained recurrent spontaneous abortions who have been immunized with paternal leukocytes. STUDY DESIGN Two-color flow cytometric crossmatch was performed after immunotherapy in 69 women with recurrent spontaneous abortions to detect maternal immunoglobulin G antibodies against paternal T lymphocytes. A positive flow cytometric crossmatch was determined by a > or = 20 channel increases (256 channel linear scale-log amplification) in the fluorescence intensity of the T-cell peak. We analyzed the clinical correlation between flow cytometric crossmatch results and subsequent pregnancy outcome in those patients using the Fisher exact test. RESULTS In 46 subsequent pregnancies among 69 immunized women the incidence of early subsequent pregnancy wastage was only 6 (17.1%) of 35 in flow cytometric crossmatch-positive patients and 7 (63.6%) of 11 in flow cytometric crossmatch-negative patients (p < 0.01). CONCLUSIONS These data indicate that a two-color T cell flow cytometric crossmatch predicts subsequent pregnancy outcome in patients undergoing immunotherapy for recurrent spontaneous abortion.
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Affiliation(s)
- T Maruyama
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo, Japan
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Gatenby PA, Cameron K, Simes RJ, Adelstein S, Bennett MJ, Jansen RP, Shearman RP, Stewart GJ, Whittle M, Doran TJ. Treatment of recurrent spontaneous abortion by immunization with paternal lymphocytes: results of a controlled trial. Am J Reprod Immunol 1993; 29:88-94. [PMID: 8329110 DOI: 10.1111/j.1600-0897.1993.tb00571.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PROBLEM It remains unclear whether maternal immunization with paternal lymphocytes prior to conception improves the reproductive outcome in women with recurrent abortion in whom all secondary causes have been excluded. METHOD A double-blind placebo controlled trial was instituted in women with unexplained recurrent spontaneous abortion, comparing immunization with 400 million paternal to 400 million maternal (autologous) lymphocytes. The groups were compared in a paired sequential trials chart, by logistic regression, and, in addition, a meta-analysis of this and other published trials was carried out. RESULTS The live birth rate among pregnancies in paired couples with paternal lymphocyte immunization was 68% compared to 47% in the women who received their own cells. The results bordered on, but did not achieve, statistical significance. The women in each group were thoroughly investigated to exclude known causes of recurrent pregnancy loss and appeared to have been well matched in all variables. Women with lymphocytotoxic antibodies against paternal lymphocytes were excluded. Unlike our previous study there was not association between the time to conception and the chance of a successful outcome. Indeed, the time to conception was relatively short, 12 wk in all groups. The meta-analysis supported an overall modest favorable experience with paternal cells. CONCLUSION The study is consistent with a general trend favoring paternal over maternal lymphocyte immunization but reinforces the need for larger multicenter controlled trials as well as more detailed biological study in humans to understand the nature of the maternal-fetal interface and its breakdown.
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Affiliation(s)
- P A Gatenby
- Department of Clinical Immunology, Royal Prince Alfred Hospital, Camperdown, Australia
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Coulam CB. Immunologic tests in the evaluation of reproductive disorders: a critical review. Am J Obstet Gynecol 1992; 167:1844-51. [PMID: 1471708 DOI: 10.1016/0002-9378(92)91785-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the clinical usefulness of immunologic assays proposed to assist in the diagnosis of alloimmune causes of recurrent spontaneous abortion. STUDY DESIGN Human leukocyte antigen typing, maternal antipaternal lymphocytotoxic antibody testing, and mixed lymphocyte culture assays were performed on 609 couples with recurrent spontaneous abortion, 92 infertile couples, and 43 fertile couples. The frequency of HLA antigen sharing and the presence of lymphocytotoxic antibodies and mixed lymphocyte culture inhibitors was compared among the populations. RESULTS Sharing of two or more HLA-A, HLA-B, HLA-C, or HLA-DR antigens was observed in 41% (252/609) couples with recurrent spontaneous abortion and in 34% (31/92) with infertility compared with 63% (27/43) of fertile couples. The frequency of lymphocytotoxic antibodies to paternal cells was significantly greater in the fertile population (27/143, 63%) (p < 0.0001) than in couples with recurrent spontaneous abortion (160/609, 26%) and in infertile couples (7/92, 8%). Mixed lymphocyte culture inhibitors were also more prevalent in sera from fertile women (19/43, 44%) compared with those with recurrent spontaneous abortion (122/609, 20%) and infertile women (4/92, 4%). CONCLUSION Human leukocyte antigen sharing does not predict pregnancy outcome, and the presence of lymphocytotoxic antibodies and mixed lymphocyte culture inhibitors is a function of the number and duration of pregnancies. More sensitive and specific assays are needed to identify alloimmunologic causes of reproductive disorders.
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Affiliation(s)
- C B Coulam
- Genetics & IVF Institute, Fairfax, VA 22031
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Cowchock FS, Smith JB. Predictors for live birth after unexplained spontaneous abortions: correlations between immunologic test results, obstetric histories, and outcome of next pregnancy without treatment. Am J Obstet Gynecol 1992; 167:1208-12. [PMID: 1442968 DOI: 10.1016/s0002-9378(11)91690-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Our objective was to determine whether results from tests for maternal serum antinuclear antibodies, cytotoxic antibodies to paternal lymphocytes, parental histocompatibility types, and blocking factors for maternal-paternal mixed lymphocyte reactions were predictive of pregnancy outcome without immunologic treatment. Pregnancy outcome data from 95 women with a history of unexplained recurrent spontaneous abortions who underwent immunologic tests at Jefferson Medical College were evaluated with multiple logistic regression analyses. The number of prior spontaneous abortions, history of another relevant diagnosis, parental sharing of one histocompatibility antigen, and maternal age were related to the outcome of the next pregnancy in women given no immunologic treatment (p = 0.05). No significant correlation was found between results from the immunologic tests or other history characteristics evaluated and outcome of the next pregnancy. The immunologic tests evaluated were not clinically useful predictors of pregnancy outcome.
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Affiliation(s)
- F S Cowchock
- Department of Medicine, Jefferson Medical College, Philadelphia, Pennsylvania
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Abstract
Many cases of habitual abortion have been assumed to be due to hyporesponsiveness to the spouse's antigens encountered in pregnancy. Immunization by paternal leukocytes has been used to potentiate the immune response and prevent further miscarriages. This treatment has been highly controversial in terms of efficacy, mode of action, and side effects. More recently immunoglobulin has been used as passive immunization for similar indications. In our experience immunotherapy is effective; 80% of patients have subsequent live births. The most significant results are seen in patients with five or more abortions, in whom 66% of subsequent pregnancies develop normally compared to 20% in a control group. We have used antipaternal complement-dependent antibody (APCA) production after immunization as a marker of immune response. APCA correlates with beneficial outcome in the next pregnancy. APCA may also be associated with cytokines, which may enhance embryonic and trophoblast development. Immunoglobulin may similarly provide the relevant antibodies or cytokines. At present a large scale meta-analysis is being performed to confirm or refute the efficacy of this treatment. This meta-analysis may resolve the controversy.
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Affiliation(s)
- H J Carp
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
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Smith JB, Cowchock FS, Lata JA, Hankinson BT. The number of cells used for immunotherapy of repeated spontaneous abortion influences pregnancy outcome. J Reprod Immunol 1992; 22:217-24. [PMID: 1453389 DOI: 10.1016/0165-0378(92)90044-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
One hundred and sixty-eight women were immunized on a single occasion with paternal mononuclear cells (MNC) for recurrent spontaneous abortion (RSA) and pregnancy outcomes were analysed with respect to the number of MNC given. The study was done in a prospective sequential fashion using all MNC recoverable from a unit of the spouse's blood and both patients and investigators were blinded as to the number of cells injected. Women receiving low and mid-range doses of MNC (58-305 x 10(6) and 308-567 x 10(6), respectively) had a significantly higher pregnancy success rate (57%) than those receiving the high (568-2677 x 10(6)) dose of MNC (41%). In 77 consecutive patients the diameter of the largest immediate skin flare reaction at the site of subcutaneous injection was recorded. No correlation was found between the skin flare response and the number of MNC injected. Our data suggest that a blinded trial of paternal MNC immunization comparing what appears to be optimum numbers of cells (100-550 million) to a low dose inoculum (e.g., 10 million), again noting the sizes of the skin flare reactions, might answer questions about efficacy and placebo effects of immunotherapy for RSA.
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Affiliation(s)
- J B Smith
- Department of Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107
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Hill JA. Immunological contributions to recurrent pregnancy loss. BAILLIERE'S CLINICAL OBSTETRICS AND GYNAECOLOGY 1992; 6:489-505. [PMID: 1446418 DOI: 10.1016/s0950-3552(05)80007-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- J A Hill
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Doherty RA, Stubblefield P, Dostal-Johnson DA, Day GJ. White blood cell immunization and anticardiolipin antibody levels in women with recurrent miscarriages. Fertil Steril 1992; 58:199-201. [PMID: 1624007 DOI: 10.1016/s0015-0282(16)55162-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
To determine whether WBC immunization stimulates production of anticardiolipin antibodies, anticardiolipin antibodies were measured before and 6 weeks after WBC immunization. Twenty-four non-pregnant women, who had had recurrent miscarriages for which a definitive cause could not be determined, were immunized with their partner's WBC. No significant differences in levels of anticardiolipin antibodies were detected between paired samples of sera obtained before and 6 weeks after WBC immunization. White cell immunization in nonpregnant women did not stimulate production of anticardiolipin antibodies.
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Affiliation(s)
- R A Doherty
- Foundation for Blood Research, Scarborough, Maine 04070-0190
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23
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Kwak JY, Gilman-Sachs A, Beaman KD, Beer AE. Autoantibodies in women with primary recurrent spontaneous abortion of unknown etiology. J Reprod Immunol 1992; 22:15-31. [PMID: 1522562 DOI: 10.1016/0165-0378(92)90003-m] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A group of 153 women with 3 or more recurrent spontaneous abortions (RSAs) with unknown etiology and 90 normal multigravida controls were evaluated for antibodies to phospholipids and nuclear antigens. We demonstrate that women with recurrent spontaneous abortions showed significantly higher incidence of antibodies to phospholipids than normal multigravida controls. In contrast, the incidence of antibodies to polynucleotides and histones was not different between these two groups. These findings suggest that antiphospholipid antibodies are either epiphenomena or causally related to recurrent spontaneous abortions.
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Affiliation(s)
- J Y Kwak
- Department of Obstetrics and Gynecology, UHS/The Chicago Medical School, Illinois 60064
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24
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Abstract
Results of recent, randomized, placebo-controlled clinical trials have raised questions about the efficacy of immunotherapy for recurrent spontaneous abortion (RSA). Most of the clinical trials have shown a 70% successful pregnancy rate with immunotherapy. The controversy comes from variations in success rates in the control populations, which have ranged from 29% to 76%. Explanations for these variations includes small sample sizes and heterogeneity by the populations studied as well as cointervention by the placebo. A meta-analysis has been proposed to investigate these explanations. Because the trials have largely used husband's leukocytes for immunization, alternative forms of immunotherapy have been sought. Two treatments that have been proposed but have not completed testing a randomized, placebo-controlled trials are intravenous immunoglobulin (IVIG) and immunization with seminal plasma. A safe and efficacious method is needed to treat recurrent spontaneous abortion; it is hoped that results of proposed studies will answer this controversy.
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Affiliation(s)
- C B Coulam
- Center for Reproduction and Transplantation Immunology, Indianapolis, Indiana
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25
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Kilpatrick DC. Cardiolipin antibody levels are not influenced by leukocyte immunotherapy in patients experiencing recurrent spontaneous abortion. Fertil Steril 1992; 57:328-30. [PMID: 1735483 DOI: 10.1016/s0015-0282(16)54839-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To confirm that leukocyte immunotherapy stimulates the production of cardiolipin antibodies and to relate changes to pregnancy outcome. PATIENTS Fifty patients with idiopathic recurrent abortion were studied. Thirty-six patients received injections of their partners' leukocytes; 14, injected with their own cells, served as controls. DESIGN Cardiolipin antibodies were measured a month before and after leukocyte immunization. Patients who became pregnant were immunized a second time in early pregnancy, and cardiolipin antibodies were again measured a month later. RESULTS Thirty-six patients immunized with their partners' leukocytes showed no appreciable change in cardiolipin antibody levels a month after vaccination. Twenty-nine of them subsequently became pregnant and were immunized again in early pregnancy: again, no change in cardiolipin antibody level was observed. There was no difference between the minority who aborted again and the majority who subsequently had successful pregnancies nor between those who responded to immunotherapy by producing cytotoxic antilymphocyte antibodies and those who did not. CONCLUSION Leukocyte immunotherapy does not stimulate cardiolipin antibody production in women with normal pretreatment levels of the autoantibody.
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Affiliation(s)
- D C Kilpatrick
- Department of Transfusion Medicine, Royal Infirmary, Edinburgh, Scotland
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26
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Cowchock S. What's a mother to do? Analysis of trials evaluating new treatments for unexplained recurrent miscarriages and other complaints. Am J Reprod Immunol 1991; 26:156-9. [PMID: 1840731 DOI: 10.1111/j.1600-0897.1991.tb00717.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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27
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Coulam CB, Clark DA. Report from the Ethics Committee for Immunotherapy, American Society for the Immunology of Reproduction. Am J Reprod Immunol 1991; 26:93-5. [PMID: 1768324 DOI: 10.1111/j.1600-0897.1991.tb00979.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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28
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Cauchi MN, Pepperell R, Kloss M, Lim D. Predictors of pregnancy success in repeated miscarriage. Am J Reprod Immunol 1991; 26:72-5. [PMID: 1768321 DOI: 10.1111/j.1600-0897.1991.tb00974.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Factors that may have a bearing on subsequent pregnancy success or failure in patients with recurrent abortion were examined in 165 women with a history of three or more consecutive miscarriages in the first trimester. The overall success rate was 67.9%. Factors that were found to correlate significantly with success rate were length of abortion history, total number of abortions, interval from last miscarriage to present pregnancy, and whether there was any degree of subfertility. Logistic regression analysis showed that the abortion x years index and maternal age accounted for all the variation observed in our data. Where all other known causes of abortions are excluded, recurrent aborters can be subdivided into two populations--namely, those with a relatively good prognosis characterized by a short abortion history and absence of subfertility problems, compared to those with a poor prognosis namely those with a long abortion history or presence of subfertility problems. These data clearly demonstrate major differences in success rates in women depending on the number of abortions and the length of abortion history (abortion x year index), particularly in women over the age of 30 years.
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Affiliation(s)
- M N Cauchi
- Royal Women's Hospital, Carlton, Melbourne, Australia
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29
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Abstract
The established association between a relatively specific group of autoantibodies binding negatively charged phospholipids and poor pregnancy outcome has advanced treatment options for women with this diagnosis. Evidence for an association between systemic autoimmune disorders and otherwise unexplained obstetric complications, in the absence of a documented antiphospholipid antibody(s), is reviewed. The existence of autoantibodies with other specificities that could be related to fetal wastage has been suggested by associations between poor obstetric histories and nonspecific serologic abnormalities observed in women with no clinical signs of an autoimmune disorder. Because signs and symptoms of vasospasm such as Raynaud's phenomenon or placental infarction have been observed in women with a history of unexplained fetal demise, a search for autoantibodies recognizing antigens common to trophoblastic and vascular cell surfaces is suggested.
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Affiliation(s)
- S Cowchock
- Department of Internal Medicine, Jefferson Medical College, Philadelphia, Pennsylvania 19107
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30
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Coulam CB, Faulk WP, McIntyre JA. Immunotherapy for recurrent spontaneous abortion and its analogies to treatment for cancer. Am J Reprod Immunol 1991; 25:114-9. [PMID: 1930637 DOI: 10.1111/j.1600-0897.1991.tb01077.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- C B Coulam
- Center for Reproduction and Transportation Immunology, Indianapolis, IN 46202
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31
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Clark DA, Daya S. Trials and tribulation in the treatment of recurrent spontaneous abortion. Am J Reprod Immunol 1991; 25:18-24. [PMID: 2029328 DOI: 10.1111/j.1600-0897.1991.tb01058.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- D A Clark
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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32
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Cauchi MN, Lim D, Young DE, Kloss M, Pepperell RJ. Treatment of recurrent aborters by immunization with paternal cells--controlled trial. Am J Reprod Immunol 1991; 25:16-7. [PMID: 2029327 DOI: 10.1111/j.1600-0897.1991.tb01057.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
A paired sequential trial was undertaken to establish whether paternal mononuclear cells improved the prognosis in couples with recurrent abortions. For this purpose, 10(7)-10(8) cells obtained from the blood of partners were injected intravenously, subcutaneously, and intra-dermally into women who had had three or more consecutive miscarriages with the same partner. Control women were given normal saline, injected in the same manner. The result of the sequential analysis showed that there was no significant beneficial effect of the cells compared to control. The overall success rate was 70% (32/46 couples). The success rate in patients given cells was 62% (13/21), while in those given saline it was 76% (19/25). While the overall success rate in this study compares with a number of other studies, we find an equally high success rate with non-immunized patients. We conclude that the value of immunization for the prevention of recurrent miscarriage has not been established.
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Affiliation(s)
- M N Cauchi
- Royal Women's Hospital, Melbourne, Australia
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