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Sarkesh A, Sorkhabi AD, Ahmadi H, Abdolmohammadi-Vahid S, Parhizkar F, Yousefi M, Aghebati-Maleki L. Allogeneic lymphocytes immunotherapy in female infertility: Lessons learned and the road ahead. Life Sci 2022; 299:120503. [PMID: 35381221 DOI: 10.1016/j.lfs.2022.120503] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/12/2022] [Accepted: 03/22/2022] [Indexed: 02/07/2023]
Abstract
The endometrium is an essential tissue in the normal immunologic dialogue between the mother and the conceptus, which is necessary for the proper establishment and maintenance of a successful pregnancy. It's become evident that the maternal immune system plays a key role in the normal pregnancy's initiation, maintenance, and termination. In this perspective, the immune system contributes to regulating all stages of pregnancy, thus immunological dysregulation is thought to be one of the major etiologies of implantation failures. Many researchers believe that immune therapies are useful tactics for improving the live births rate in certain situations. Lymphocyte immunotherapy (LIT) is an active form of immunotherapy that, when used on the relevant subgroups of patients, has been shown in multiple trials to dramatically enhance maternal immunological balance and pregnancy outcome. The primary goal of LIT is to regulate the immune system in order to create a favorable tolerogenic immune milieu and tolerance for embryo implantation. However, there are a plethora of influential factors influencing its therapeutic benefits that merit to be addressed. The objective of our study is to discuss the mechanisms and challenges of allogeneic LIT.
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Affiliation(s)
- Aila Sarkesh
- Student's Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amin Daei Sorkhabi
- Student's Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hamid Ahmadi
- Department of Medical Biology and Central Electron Microscope Laboratory, Medical School, Pécs University, Pécs, Hungary
| | | | - Forough Parhizkar
- Student's Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; Stem Cell Research Center, Tabriz University of Medical Science, Tabriz, Iran
| | - Mehdi Yousefi
- Stem Cell Research Center, Tabriz University of Medical Science, Tabriz, Iran; Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leili Aghebati-Maleki
- Immunology 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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2
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Cavalcante MB, Sarno M, Barini R. Lymphocyte immunotherapy in recurrent miscarriage and recurrent implantation failure. Am J Reprod Immunol 2021; 85:e13408. [PMID: 33638199 DOI: 10.1111/aji.13408] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 02/23/2021] [Indexed: 12/22/2022] Open
Abstract
PROBLEM Lymphocyte immunotherapy (LIT) emerged in the early 1980s as a new therapeutic proposal for couples with a history of recurrent miscarriages (RM). However, in the early 2000s, the effectiveness of LIT was questioned. Recently, meta-analyses have observed the effectiveness and safety of LIT in treating couples with RM. Some studies evaluated the use of LIT in recurrent implantation failure (RIF) in in vitro fertilization cycles. METHODS This systematic and narrative review evaluated the data available in the literature regarding the efficacy and safety of the use of LIT. Searches in PubMed/Medline, Embase, and Cochrane Library databases were conducted, using the following keywords: "recurrent miscarriage," "lymphocyte immunotherapy," and "recurrent implantation failure". RESULTS This review describes the historical aspects of LIT and discusses its protocols, mechanisms of action, side effects, complications, and current evidence of the effectiveness in cases of reproductive failure. It also discusses the use of LIT during the COVID-19 pandemic and new immunological therapies. CONCLUSION In the vast majority of studies, the use of LIT for RM couples has shown an improvement in pregnancy outcomes. The most of the current studies that support the evidence are quasi-experimental, with few randomized, double-blind studies (Level of evidence III). However, the current evidence are not convincing for the use of LIT in RIF patients.
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Affiliation(s)
- Marcelo Borges Cavalcante
- Postgraduate Program in Medical Sciences, Fortaleza University (UNIFOR, Fortaleza, Brazil.,CONCEPTUS - Reproductive Medicine, Fortaleza, Brazil
| | - Manoel Sarno
- Department of Obstetrics and Gynecology, Federal University of Bahia (UFBA, Salvador, Brazil
| | - Ricardo Barini
- Department of Obstetrics and Gynecology, Campinas University (UNICAMP, Campinas, Brazil
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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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Günther V, Alkatout I, Junkers W, Maass N, Ziemann M, Görg S, von Otte S. Active Immunisation with Partner Lymphocytes in Female Patients Who Want to Become Pregnant - Current Status. Geburtshilfe Frauenheilkd 2018; 78:260-273. [PMID: 29576631 PMCID: PMC5862550 DOI: 10.1055/s-0044-101609] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/30/2017] [Accepted: 01/24/2018] [Indexed: 12/15/2022] Open
Abstract
Around 1 – 3% of all couples who try to have a child are affected by recurrent miscarriage. According to the WHO, recurrent miscarriage is defined as the occurrence of three or more consecutive miscarriages up to the 20th week of pregnancy. There are various causes of recurrent miscarriage; in many cases, the causes remain unclear, with the result that immunological factors are one of the possible causes discussed. For the motherʼs immune system, the embryo represents a semi-allogeneic transplant, as half of the embryoʼs genes are of paternal origin. In place of a conventional immune response, the embryo induces a secondary protection mechanism, which contributes to the successful implantation. When performing immunisation with partner lymphocytes, the patient receives an intradermal injection of her partnerʼs prepared lymphocytes into the volar side of the forearm in order to induce immunomodulation with a consequently increased rate of pregnancy and live birth. A prerequisite for this procedure is that all other possible causes of sterility have been ruled out in advance. Due to the highly heterogeneous nature of the data, a significant benefit as a result of the immunisation cannot yet be clearly proven. However, there are signs that the therapy may be effective when using lymphocytes that have been extracted as short a time beforehand as possible. Overall, the treatment represents a safe, low-risk procedure. Following a detailed informative discussion with the couple regarding the chances of success and following a detailed review of the indication and contraindications, immunisation with partner lymphocytes can be discussed with the couple on a case-by-case basis – provided that all other possible causes of sterility have been ruled out in advance.
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Affiliation(s)
- Veronika Günther
- Klinik für Gynäkologie und Geburtshilfe, UKSH Campus Kiel, Kiel, Germany
| | - Ibrahim Alkatout
- Klinik für Gynäkologie und Geburtshilfe, UKSH Campus Kiel, Kiel, Germany
| | - Wiebe Junkers
- Universitäres Kinderwunschzentrum, MVZ, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Nicolai Maass
- Klinik für Gynäkologie und Geburtshilfe, UKSH Campus Kiel, Kiel, Germany
| | - Malte Ziemann
- Institut für Transfusionsmedizin, UKSH Campus Kiel, Kiel, Germany.,Institut für Transfusionsmedizin, UKSH Campus Lübeck, Lübeck, Germany
| | - Siegfried Görg
- Institut für Transfusionsmedizin, UKSH Campus Kiel, Kiel, Germany.,Institut für Transfusionsmedizin, UKSH Campus Lübeck, Lübeck, Germany
| | - Sören von Otte
- Universitäres Kinderwunschzentrum, MVZ, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
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5
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Jiang C, Kong W, Wang Y, Ziai W, Yang Q, Zuo F, Li F, Wang Y, Xu H, Li Q, Yang J, Lu H, Zhang J, Wang J. Changes in the cellular immune system and circulating inflammatory markers of stroke patients. Oncotarget 2018; 8:3553-3567. [PMID: 27682880 PMCID: PMC5356903 DOI: 10.18632/oncotarget.12201] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 09/16/2016] [Indexed: 01/09/2023] Open
Abstract
This study was designed to investigate dynamic changes in the cellular immune system and circulating inflammatory markers after ischemic stroke. Blood was collected from 96 patients and 99 age-matched control subjects for detection of lymphocyte subpopulations and inflammatory markers. We observed decreases in B cells, Th cells, cytotoxic T cells, and NK cells and an increase in regulatory T (Treg) cells in stroke patients on days 1, 3, and 7. Serum levels of TNF-α, C-reactive protein (CRP), IL-4, IL-6, IL-10, IL-17, IL-23, and TGF-β increased, whereas serum level of IFN-γ decreased at all time points after stroke. Stroke patients with infection exhibited a similar tendency toward changes in some lymphocyte subpopulations and inflammatory markers as stroke patients without infection. After controlling for NIH Stroke Scale (NIHSS), we observed no differences in lymphocyte subpopulations between patients with anterior circulation stroke and those with posterior circulation stroke at any time point. The splenic volume correlated positively with the percentages of B cells, Th cells, and cytotoxic T cells, but negatively with Treg cells on day 3 after stroke. Infections were associated with splenic volume, leukocyte counts, percentage of Treg cells, and serum levels of CRP, IL-10, and IFN-γ on day 3. Lesion volume correlated positively with CRP, IL-6, and IL-23, but negatively with IFN-γ on day 3. The NIHSS showed a positive relation with IL-6 and IL-10 on day 3. Ischemic stroke has a profound effect on the systemic immune system that might explain the increased susceptibility of stroke patients to infection.
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Affiliation(s)
- Chao Jiang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Weixia Kong
- Department of Ultrasonography, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yuejuan Wang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wendy Ziai
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA.,Department of Neurology, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Fangfang Zuo
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Fangfang Li
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yali Wang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Hongwei Xu
- Department of Radiology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Qian Li
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Jie Yang
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Hong Lu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jiewen Zhang
- Department of Neurology, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jian Wang
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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6
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Cavalcante MB, Sarno M, Araujo Júnior E, Da Silva Costa F, Barini R. Lymphocyte immunotherapy in the treatment of recurrent miscarriage: systematic review and meta-analysis. Arch Gynecol Obstet 2017; 295:511-518. [PMID: 28004193 DOI: 10.1007/s00404-016-4270-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 12/09/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Recurrent miscarriage (RM) affects up to 2-3% of couples of reproductive age. There are several causes for this condition, including immunologic. The embryo is considered an allograft, subject to the rejection mechanisms of the maternal immune system. Immunotherapy involving immunization with lymphocytes is considered in cases of idiopathic RM. However, there is still no consensus regarding the efficacy and safety of this therapy. METHODS This systematic review and meta-analysis evaluated the data available in the literature regarding the efficacy and safety of the use of immunotherapy with lymphocytes in couples with history of RM. Searches in PubMed/Medline, SCOPUS, and Cochrane Library databases were conducted, using the following keywords: "recurrent miscarriage," "lymphocyte immunotherapy," and "meta-analysis." Statistical analyses were performed using Review Manager 5.3 (RevMan), version 5.3. RESULTS Six published meta-analysis were retrieved; two found no improvements in the rate of live births after the use of immunization with lymphocytes in the treatment of RM, and four found a beneficial effect of the use of immunotherapy with lymphocytes in cases of RM, with significant improvements in the rate of live births. CONCLUSION Data available in the literature supports the efficacy and safety of immunotherapy with lymphocytes in cases of RM without an identified cause.
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Affiliation(s)
| | - Manoel Sarno
- Department of Gynecology and Obstetrics, Bahia Federal University (UFBA), Salvador, BA, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine-São Paulo Federal University (EPM-UNIFESP), Rua Belchior de Azevedo, 156 apto. 111 Torre Vitoria, São Paulo, SP, Brazil.
| | - Fabricio Da Silva Costa
- Department of Obstetrics and Gynaecology, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, VIC, Australia
| | - Ricardo Barini
- Department of Obstetrics and Gynecology, State University of Campinas (UNICAMP), Campinas, SP, Brazil
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7
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Abdolmohammadi-Vahid S, Danaii S, Hamdi K, Jadidi-Niaragh F, Ahmadi M, Yousefi M. Novel immunotherapeutic approaches for treatment of infertility. Biomed Pharmacother 2016; 84:1449-1459. [DOI: 10.1016/j.biopha.2016.10.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/18/2016] [Accepted: 10/21/2016] [Indexed: 10/20/2022] Open
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8
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Liu Z, Xu H, Kang X, Wang T, He L, Zhao A. Allogenic Lymphocyte Immunotherapy for Unexplained Recurrent Spontaneous Abortion: A Meta-Analysis. Am J Reprod Immunol 2016; 76:443-453. [PMID: 27105633 DOI: 10.1111/aji.12511] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 03/20/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
- Zhilan Liu
- Department of Obstetrics and Gynecology; Ren Ji Hospital; School of Medicine; Shanghai Jiao Tong University; Shanghai China
| | - Haijing Xu
- Department of Obstetrics and Gynecology; Ren Ji Hospital; School of Medicine; Shanghai Jiao Tong University; Shanghai China
| | - Xiaomin Kang
- Department of Obstetrics and Gynecology; Ren Ji Hospital; School of Medicine; Shanghai Jiao Tong University; Shanghai China
| | - Tongfei Wang
- Department of Obstetrics and Gynecology; Ren Ji Hospital; School of Medicine; Shanghai Jiao Tong University; Shanghai China
| | - Liying He
- Department of Obstetrics and Gynecology; Ren Ji Hospital; School of Medicine; Shanghai Jiao Tong University; Shanghai China
| | - Aimin Zhao
- Department of Obstetrics and Gynecology; Ren Ji Hospital; School of Medicine; Shanghai Jiao Tong University; Shanghai China
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9
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Abstract
BACKGROUND Because immunological aberrations might be the cause of miscarriage in some women, several immunotherapies have been used to treat women with otherwise unexplained recurrent pregnancy loss. OBJECTIVES The objective of this review was to assess the effects of any immunotherapy, including paternal leukocyte immunization and intravenous immunoglobulin on the live birth rate in women with previous unexplained recurrent miscarriages. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 February 2014) and reference lists of retrieved studies. SELECTION CRITERIA Randomized trials of immunotherapies used to treat women with three or more prior miscarriages and no more than one live birth after, in whom all recognized non-immunologic causes of recurrent miscarriage had been ruled out and no simultaneous treatment was given. DATA COLLECTION AND ANALYSIS The review author and the two co-authors independently extracted data and assessed study quality for all studies considered for this review. MAIN RESULTS Twenty trials of high quality were included. The various forms of immunotherapy did not show significant differences between treatment and control groups in terms of subsequent live births: paternal cell immunization (12 trials, 641 women), Peto odds ratio (Peto OR) 1.23, 95% confidence interval (CI) 0.89 to 1.70; third-party donor cell immunization (three trials, 156 women), Peto OR 1.39, 95% CI 0.68 to 2.82; trophoblast membrane infusion (one trial, 37 women), Peto OR 0.40, 95% CI 0.11 to 1.45; or intravenous immunoglobulin, (eight trials, 303 women), Peto OR 0.98, 95% CI 0.61 to 1.58. AUTHORS' CONCLUSIONS Paternal cell immunization, third-party donor leukocytes, trophoblast membranes, and intravenous immunoglobulin provide no significant beneficial effect over placebo in improving the live birth rate.
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Affiliation(s)
- Luchin F Wong
- Intermountain HealthcareMaternal‐Fetal MedicineMurrayUtahUSA84132
- University of Utah Medical CentreDepartment of Obstetrics and GynaecologySalt Lake CityUtahUSA
| | - T Flint Porter
- Intermountain HealthcareMaternal‐Fetal MedicineMurrayUtahUSA84132
- University of Utah Medical CentreDepartment of Obstetrics and GynaecologySalt Lake CityUtahUSA
| | - James R Scott
- University of Utah Medical CentreDepartment of Obstetrics and GynaecologySalt Lake CityUtahUSA
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Coulam C, Clark D, Collins J, Scott J, Schlesselman J, Aoki K, Carp H, Cauchi M, Lim D, Christiansen O, Grunnet N, Cowchock S, Smith J, Daya S, Gatenby P, Cameron K, Gill T, Hin H, Georgieva R, Belchev D, Kilpatrick D, Liston W, Mowbray J, Underwood J, Parazzini F, Crosignani P, Rezenkoff M, Koyama FS. Worldwide Collaborative Observational Study and Meta-Analysis on Allogenic Leukocyte Immunotherapy for Recurrent Spontaneous Abortion1. Am J Reprod Immunol 2013. [DOI: 10.1111/j.1600-0897.1994.tb01095.x] [Citation(s) in RCA: 170] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Clark DA. ORIGINAL ARTICLE: Cell-Surface CD200 May Predict Efficacy of Paternal Mononuclear Leukocyte Immunotherapy in Treatment of Human Recurrent Pregnancy Loss. Am J Reprod Immunol 2008; 61:75-84. [DOI: 10.1111/j.1600-0897.2008.00665.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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12
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Clark DA. REVIEW ARTICLE: Immunological Factors in Pregnancy Wastage: Fact or Fiction. Am J Reprod Immunol 2008; 59:277-300. [DOI: 10.1111/j.1600-0897.2008.00580.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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13
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Clark DA. Should paternal leukocyte immunization be used in RPL? RECURRENT PREGNANCY LOSS 2007. [DOI: 10.3109/9780203931677.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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14
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Abstract
BACKGROUND Because immunological aberrations might be the cause of miscarriage in some women, several immunotherapies have been used to treat women with otherwise unexplained recurrent pregnancy loss. OBJECTIVES The objective of this review was to assess the effects of any immunotherapy, including paternal leukocyte immunization and intravenous immune globulin on the live birth rate in women with previous unexplained recurrent miscarriages. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group Trials Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2004, Issue 3), MEDLINE (1966 to September 2004) and EMBASE (1980 to September 2004). SELECTION CRITERIA Randomized trials of immunotherapies used to treat women with three or more prior miscarriages and no more than one live birth after, in whom all recognised non-immunologic causes of recurrent miscarriage had been ruled out and no simultaneous treatment was given. DATA COLLECTION AND ANALYSIS The review author and the two co-authors independently extracted data and assessed study quality for all studies considered for this review. MAIN RESULTS Twenty trials of high quality were included. The various forms of immunotherapy did not show significant differences between treatment and control groups in terms of subsequent live births: paternal cell immunization (12 trials, 641 women), Peto odds ratio (Peto OR) 1.23, 95% confidence interval (CI) 0.89 to 1.70; third party donor cell immunization (three trials, 156 women), Peto OR 1.39, 95% CI 0.68 to 2.82; trophoblast membrane infusion (one trial, 37 women), Peto OR 0.40, 95% CI 0.11 to 1.45; intravenous immune globulin, Peto OR 0.98, 95% CI 0.61 to 1.58. AUTHORS' CONCLUSIONS Paternal cell immunization, third party donor leukocytes, trophoblast membranes, and intravenous immune globulin provide no significant beneficial effect over placebo in improving the live birth rate.
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Affiliation(s)
- T F Porter
- LDS Hospital, Maternal-Fetal Medicine, 8th Avenue and C Street, Salt Lake City, Utah 84105, USA.
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Pandey MK, Rani R, Agrawal S. An update in recurrent spontaneous abortion. Arch Gynecol Obstet 2005; 272:95-108. [PMID: 15906053 DOI: 10.1007/s00404-004-0706-y] [Citation(s) in RCA: 148] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2003] [Accepted: 10/12/2004] [Indexed: 11/29/2022]
Abstract
Recurrent spontaneous abortion (RSA) is defined as three or more consecutive pregnancy losses prior to the 20th week of gestation. The etiology of recurrent spontaneous abortion is often unclear and may be multifactorial, with much controversy regarding diagnosis and treatment. Reasonably accepted etiologic causes include, genetics, anatomical, endocrine, placental anomalies, hormonal problems, infection, smoking and alcohol consumption, exposure to environmental factors, psychological trauma and stressful life event, certain coagulation and immunoregulatory protein defects. Detection of an abnormality in any of these areas may result into specific therapeutic measures, with varying degrees of success. However, the majority of cases of RSA remains unexplained and is found to be associated with certain autoimmune (APA, ANA, ACA, ATA, AECA) and alloimmune (APCA, Ab2, MLR-Bf) antibodies that may play major role in the immunologic failure of pregnancy and may lead to abortion. Alteration in the expression of HLA-G molecules, T-helper-1 (Th-1) pattern of cytokines and natural killer (NK) cells activity may also induce abortion. Various forms of treatment like antithrombotic therapies such as aspirin and heparin, intravenous immunoglobulin (IVIg) therapy, immunotherapy with paternal lymphocytes and vitamin D3 therapy are effective mode of treatment for unexplained cause of fetal loss in women with RSA.
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Affiliation(s)
- Manoj Kumar Pandey
- Division of Molecular Immunology, Cincinnati Children's Hospital Medical Center, MLC 7021 TCH RF 5503 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA.
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Pandey MK, Agrawal S. Induction of MLR-Bf and protection of fetal loss: a current double blind randomized trial of paternal lymphocyte immunization for women with recurrent spontaneous abortion. Int Immunopharmacol 2004; 4:289-98. [PMID: 14996420 DOI: 10.1016/j.intimp.2004.01.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2003] [Revised: 01/02/2004] [Accepted: 01/06/2004] [Indexed: 11/29/2022]
Abstract
The present study was conducted to evaluate the efficacy of paternal lymphocyte (PL) immunotherapy and its relation with the development of mixed lymphocyte reaction blocking antibodies (MLR-Bf) and the success of pregnancy outcome in women with recurrent spontaneous abortion (RSA). A total of 124 women with unknown causes of abortions was registered for immunotherapy under double blind randomized trial by using the list of computer-generated numbers. Each 5 x 10(6) autologous lymphocyte (AL), third party lymphocyte (TPL) and PL was dissolved separately in 1 ml of sterile normal saline (NS). Each 1 ml of cell suspension and neat NS was injected in women with RSA through intramuscular (250 microl), intradermal (250 microl), subcutaneous (250 microl) and intravenous (250 microl) routes. All women participants with RSA received six identical immunizations at the regular interval of 4 weeks, and were then screened for the development of MLR-Bf after the completion of immunization course, and also at the first, second and third trimesters (12th, 24th and 36th weeks) of pregnancy. However, nonimmunized MLR-Bf positive women with RSA did not receive any kind of therapy (NT) and were used as one of the control group in the present study. We have observed that PL-immunized women with RSA showed a significantly increased level of MLR-Bf (>30) and pregnancy success (84%) as compared to those women with RSA who received either AL (33%), TPL (31%), NS (25%) or those who did not receive any kind of treatment (NT, 44%; P<0.001). Our results indicated the importance of immunotherapy with PL in women with RSA and also showed that MLR-Bf can be considered as one of the important factors for pregnancy improvement.
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Affiliation(s)
- Manoj Kumar Pandey
- Molecular Medicine Program, Guggenheim -18, Mayo Clinic, 200, First Street, SW, Rochester, MN-55905, USA.
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17
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Clark DA. Shall We properly Re-examine the Status of Allogeneic Lymphocyte Therapy for Recurrent early Pregnancy Failure? Am J Reprod Immunol 2004; 51:7-15. [PMID: 14725561 DOI: 10.1046/j.8755-8920.2003.00133.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PROBLEM How to evaluate immunological therapy advocated for recurrent spontaneous abortion and implantation failure. I was invited to comment on the opinion article of Chaouat (AJRI December 2003). METHODS A critical examination of key beliefs and application of the principles of evidence and logic utilizing current data. RESULTS AND CONCLUSIONS Although rationale has no bearing on efficacy of proposed treatments and is not sufficient justification for routine practice, insufficient attention to data concerning patient selection, insufficient attention to treatment methodology, and lack of full disclosure in some clinical trials needs to be corrected. A more systematic collection of follow-up data is needed.
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Affiliation(s)
- David A Clark
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Abstract
BACKGROUND Immunologic aberrations might be the cause of recurrent early pregnancy loss in some women. OBJECTIVES The objective of this review was to assess the effects of leukocyte immunisation or other immunologic treatments such as intravenous immune globulin (IVIG) on the live birth rate in women with previous unexplained recurrent miscarriages. SEARCH STRATEGY The Cochrane Pregnancy and Childbirth Group trials register was searched (September 2002). Individual patient data were obtained from the American Society for Reproductive Immunology. SELECTION CRITERIA Randomised trials of immunotherapy in women with three or more prior miscarriages and no more than one live birth; all recognised non-immunologic causes ruled out and no simultaneous treatment intervention. DATA COLLECTION AND ANALYSIS Eligibility and trial quality were assessed by one reviewer. MAIN RESULTS Nineteen trials of high quality were included. The various forms of immunotherapy did not show significant differences between treatment and control groups in terms of subsequent live births: paternal cell immunisation (11 trials, 596 women), odds ratio (OR) 1.05, 95% confidence intervals (CI) 0.75 to 1.47; third party donor cell immunization (3 trials, 156 women), OR 1.39, 95% CI 0.68 to 2.82; trophoblast membrane infusion (1 trial, 37 women), OR 0.40, 95% CI 0.11 to 1.45; intravenous immune globulin (IVIG), OR 0.98, 95% CI 0.61 to 1.58. REVIEWER'S CONCLUSIONS Paternal cell immunization, third party donor leukocytes, trophoblast membranes, and intravenous immune globulin provide no significant beneficial effect over placebo in preventing further miscarriages.
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Affiliation(s)
- J R Scott
- Department of Obstetrics and Gynaecology, University of Utah Medical Centre, 420 Chipeta Way, Suite 100, Salt Lake City, Utah 84108, USA.
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Agrawal S, Pandey MK, Pandey A. Prevalence of MLR blocking antibodies before and after immunotherapy. JOURNAL OF HEMATOTHERAPY & STEM CELL RESEARCH 2000; 9:257-62. [PMID: 10813539 DOI: 10.1089/152581600319478] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Immunologically specific blocking factors (BF) are believed to play a protective role in the maintenance of pregnancy. We compared the levels of BF in normal pregnant women and in patients with recurrent spontaneous abortion (RSA) and observed that the two groups differ significantly from one another. MLC inhibitory activity was present throughout normal pregnancy and was found to be specific to the husband's HLA antigens. Immunotherapy was performed in 28 recurrent aborters using husband's lymphocytes, after which levels of blocking antibodies increased in 23 patients. The difference in the label of MLR BF in the preimmunotherapy and postimmunotherapy groups was statistically significant and was associated with successful pregnancy outcome in 82.15% of cases. The appearance of the MLR BF and its continuation in a successful pregnancy might represent an appropriate immune state that may be playing an important role in maintenance of pregnancy.
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Affiliation(s)
- S Agrawal
- Department of Medical Genetics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Ramsoondar JJ, Christopherson RJ. Treatment of gilts with leukocytes from the sire does not improve reproductive performance. Anim Reprod Sci 1998; 54:13-21. [PMID: 9877061 DOI: 10.1016/s0378-4320(98)00101-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The effectiveness of pretreatment of gilts with leukocyte antigens on reproductive performance was studied. Two experiments were carried out that involved the treatment of gilts with leukocytes prior to artificial or natural insemination. Gilts were randomly assigned to one of three treatment groups. Group A gilts received two doses of 2 x 10(8) sire's leukocytes; one injected intra-peritoneal at first estrus and the other infused into the uterus immediately prior to insemination at the second estrus cycle. Group B gilts were similarly treated with the 'gilt's own' (autologous) leukocytes and Group C animals received phosphate buffered saline as controls. The same boars were used as sires across all three treatment groups. Gilts were slaughtered during the fifth week of pregnancy and their reproductive performance assessed. When data from the three groups were compared there were significant differences in embryo survival and placental weights between the sire's leukocyte treatment and PBS control groups. Embryo survival rate (No viable embryos/No corpora lutea x 100) at the fifth week of gestation was lower (p < 0.05) and placental weights were higher in the sire's leukocyte treatment group (p < 0.05). However, the latter may likely be due to fewer developing embryos. Embryo survival and placental weights did not vary significantly between the sire's and autologous leukocytes treatment groups. The treatment of gilts with leukocytes from the boars used as sires showed no improvement on subsequent reproductive outcome over that observed for the autologous leukocytes or PBS control treatments. Consequently, in a healthy well managed herd leukocytes treatment offers no advantage to pig reproductive function.
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Affiliation(s)
- J J Ramsoondar
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Canada.
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21
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Gentile T, Llambias P, Dokmetjian J, Margni RA. Effect of pregnancy and placental factors on the quality of humoral immune response. Immunol Lett 1998; 62:151-7. [PMID: 9698113 DOI: 10.1016/s0165-2478(98)00041-8] [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: 02/08/2023]
Abstract
Asymmetrical IgG molecules are characterised by the presence of a mannose-rich oligosaccharide group in only one of the two Fab fragments, which impairs the corresponding paratope, causing such molecules to behave as univalent antibodies and therefore as antigen blockers [1-3]. During human and murine pregnancy, an increase has been detected in asymmetrical IgG molecules in serum and those bound to the placenta, which normally releases factors capable of modulating the immune response. It thus seemed of interest to investigate the effect of placental culture supernatants (PCS) on in vivo and in vitro synthesis of rat immunoglobulin IgG1, IgG2a, IgG2b and IgG2C, particularly the ratio of symmetrical and asymmetrical molecules in each isotype. The effect of PCS was determined in vivo by means of passive transfer to virgin females and in vitro by analysing the supernatants of spleen cells cultured in the presence of PCS. The results showed that neither pregnancy status nor PCS were capable of modifying serum levels of IgG2a, IgG2b or IgG2c, whereas the level of IgG1 was reduced. When PCS were added to the spleen cells cultures, an in vitro increase was observed in IgG2a, IgG2b and IgG2c production. The separation of symmetrical from asymmetrical IgG molecules was performed by affinity chromatography in Concanavalin A-Sepharose, as such lectin binds high mannose sugars present only in asymmetrical IgG molecules. It is shown that pregnancy and PCS induce an increase in IgG1 and IgG2 molecules asymmetrically glycosylated, capable of binding to ConA-Sepharose. Therefore, the placenta is capable of releasing factors which can regulate the relative proportion of asymmetrical IgG molecules and induce quantitative and qualitative modifications of the in vitro and in vivo produced antibodies.
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Affiliation(s)
- T Gentile
- Instituto de Estudios de la Immunidad Humoral (CONICET-UBA), Facultad de Farmacia y Bioquimica, Universidad de Buenos Aires, Argentina
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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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Malinowski A, Prochowska A, Banasik M, Wilczyński J, Szpakowski M, Zeman K, Oszukowski P, Lerch E. Clinical and immunological condition of newborns of mothers treated for recurrent spontaneous abortions with paternal lymphocytes immunization. Eur J Obstet Gynecol Reprod Biol 1997; 73:55-61. [PMID: 9175690 DOI: 10.1016/s0301-2115(96)02688-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the clinical condition at birth and some laboratory parameters in newborns of mothers treated for recurrent spontaneous abortion (RSA) of unknown etiology with paternal lymphocytes immunization. STUDY DESIGN The study comprised 104 newborns delivered by 102 women with RSA, who underwent alloimmunization and 90 randomly chosen control newborns. The following parameters were analysed in two groups of newborns: general condition at birth, physical development, course of adaptation period, values of hematological and immunological (percentage of CD3, CD4, CD8, CD19 and CD3/CD25 lymphocytes, chemiluminescence of neutrophils at rest and stimulated with opsonized zymosane) parameters in umbilical arterial blood. RESULTS No statistically significant differences were noted between the two groups of newborns as to the duration of pregnancy, birth weight, general condition at birth, occurrence of complications in the adaptation period and values of studied hematological and immunological parameters. CONCLUSION These results suggest that immunization with paternal lymphocytes in women with RSA of unknown etiology not only creates better prognosis for the outcome of the pregnancy, but is also safe for the fetus and the newborn.
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Affiliation(s)
- A Malinowski
- Department of Obstetrics and Gynecology, Military Medical Academy, Polish Mother's Memorial Hospital, Lodz
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24
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Affiliation(s)
- P C Arck
- McMaster University, Departments of Medicine, Pathology, Obstetrics and Gynecology, Hamilton, Canada
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Clark DA, Daya S, Coulam CB, Gunby J. Implication of abnormal human trophoblast karyotype for the evidence-based approach to the understanding, investigation, and treatment of recurrent spontaneous abortion. The Recurrent Miscarriage Immunotherapy Trialists Group. Am J Reprod Immunol 1996; 35:495-8. [PMID: 8738721 DOI: 10.1111/j.1600-0897.1996.tb00130.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Clark DA, Arck PC, Jalali R, Merali FS, Manuel J, Chaouat G, Underwood JL, Mowbray JF. Psycho-neuro-cytokine/endocrine pathways in immunoregulation during pregnancy. Am J Reprod Immunol 1996; 35:330-7. [PMID: 8739449 DOI: 10.1111/j.1600-0897.1996.tb00489.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PROBLEM Some mammalian pregnancy failure is thought to occur by immunological or immunologically modifiable mechanisms. The original model wherein spontaneous abortion was proposed to represent rejection of the conceptus as an allograft has been supplanted by a model of maternal paraimmunological natural effector cell toxicity to fetal trophoblast more closely related to tumor rejection. The problem is to integrate current information concerning the role of immunological, paraimmunological, endocrinological, and stress-triggered neural factors that determine whether or not abortion will occur. METHODS Review of existing data. RESULTS An integrated model is proposed. CONCLUSION Immunological factors play an important role in abortion processes and prevention of abortions. The existence of abortogenic mechanisms and their regulation appears to be based upon optimizing survival of the species. Two new conceptual models provide a useful framework for further investigation of human pregnancy failure and its treatment.
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Affiliation(s)
- D A Clark
- McMaster University, Department of Medicine, Hamilton, Ontario, Canada
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Kishore R, Agarwal S, Halder A, Das V, Shukla BR, Agarwal SS. HLA sharing, anti-paternal cytotoxic antibodies and MLR blocking factors in women with recurrent spontaneous abortion. J Obstet Gynaecol Res 1996; 22:177-83. [PMID: 8697349 DOI: 10.1111/j.1447-0756.1996.tb00962.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To study the prevalence of HLA sharing between spouses and its correlation with presence of antipaternal cytotoxic antibody (APCA) and mixed lymphocyte reaction (MLR) blocking factors in recurrent spontaneous aborters (RSA). DESIGN Study was carried out at Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGI), Lucknow, from 1988-1992. Hundred couples with 3 or more consecutive recurrent spontaneous abortions and equal number of age, parity and ethinically matched normal controls were selected for studying HLA, APCA and MLR blocking factors. Meta-analysis was performed using standard formula and significance was tested by Chi-square analysis. RESULTS Significant HLA sharing was observed in couples with RSA at A and DR loci compared to normal controls (p < 0.001). Twenty-seven point eight percent of couples with RSA were positive for APCA compared to 49% of controls (p < 0.01). MLR blocking factors were detected in 26% couples with RSA compared to 78% in controls (p < 0.001). An inverse correlation between HLA sharing and APCA and MLR positivity was demonstrated. CONCLUSION The study supports that greater HLA sharing between spouses, associated with lack of an appropriate immune response to them could be responsible for RSA.
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Affiliation(s)
- R Kishore
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Sagot P, Bignon J, Cesbron A, Cheneau ML, Boog G, Muller JY. Lack of evidence for a role of HLA-DP in unexplained recurrent spontaneous abortion. Transfus Clin Biol 1995; 2:145-50. [PMID: 7627354 DOI: 10.1016/s1246-7820(05)80041-2] [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]
Abstract
Using the "Polymerase Chain Reaction-Sequence Specific Oligoprobes" (PCR-SSOp) technique, we studied the HLA-DPB locus in both partners of 59 couples with a history of three spontaneous abortions, and of 38 control couples in order to determine the role of this centromeric region of the major histocompatibility complex (MHC) in the immune reaction needed for a favorable course of pregnancy. As no particular phenotypes were noted, and also neither excessive HLA-DP homozygosity in sterile women nor excessive HLA-DP allele sharing between sterile partners, this MHC class II sub-region would seem to play no role either directly or by linkage disequilibrium, in the development of normal pregnancy.
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Affiliation(s)
- P Sagot
- Fédération de Gynécologie-Obstétrique et Biologie de la Reproduction, Centre Hospitalier Régional Universitaire de Nantes
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Abstract
PROBLEM Safe, effective, and inexpensive alternatives to partner leukocyte immunotherapy are being sought. Psychotherapy may be effective but it is uncertain what constitutes effective treatment and the form of treatment tested in cohort controlled trials is expensive. IVIG also appears effective, but is expensive. METHOD A published double blind randomized controlled trial in which Intralipid (Kabi Vitrum, Toronto, Ontario) was used as a control versus trophoblast membrane vesicles was reviewed. A prediction made from this data was then tested using the DBA/2-mated CBA/J mouse model of recurrent spontaneous abortion. RESULTS It can be hypothesized from the human clinical trial data that Intralipid even in small doses could be an effective antiabortion treatment. The number of patients in the published study is too small for the required degree of precision. Intralipid was highly effective in preventing abortion in mice, and protection was prolonged. This may be explained by previous data in the literature showing that Intralipid affects the reticuloendothelial system of the recipient. CONCLUSIONS The evidence suggests that Intralipid might be an effective treatment for human recurrent miscarriages, and injection into women who may become pregnant has been found ethically acceptable at one university center. Comparison of Intralipid to partner leukocyte immunotherapy or IVIG would be worthwhile. For adequate statistical power, this would require a large, multicenter, prognostically stratified randomized controlled trial and could be accomplished via the Recurrent Miscarriage Immunotherapy Trialists Group network.
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Affiliation(s)
- D A Clark
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Daya S, Gunby J. The effectiveness of allogeneic leukocyte immunization in unexplained primary recurrent spontaneous abortion. Recurrent Miscarriage Immunotherapy Trialists Group. Am J Reprod Immunol 1994; 32:294-302. [PMID: 7718097 DOI: 10.1111/j.1600-0897.1994.tb01129.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
PROBLEM Unexplained primary recurrent spontaneous abortion (RSA) can be viewed as a partner-specific problem for which immunization with allogeneic leukocytes is being offered as therapy. Published data from randomized controlled trials have produced conflicting results regarding treatment effectiveness. The aim of this study was to perform a subgroup analysis of the data from a recent worldwide collaborative meta-analysis using the raw data for patients with primary RSA entered into randomized controlled trials of immunotherapy. METHODS Data from randomized controlled trials in eight centers were included in this analysis. Individual patients were included only if they had had three or more spontaneous abortions, no previous pregnancy beyond 20 weeks' gestation, no identifiable cause for the abortions, and no evidence of antipaternal antibodies. Meta-analysis by centre and logistic regression analysis were performed to determine the overall effect of treatment in achieving live birth and to identify variables that affect the prognosis for a successful outcome. RESULTS In the meta-analysis by center, immunotherapy significantly improved the live birth rate (common odds ratio = 1.94, 95% confidence interval (CI) = 1.20 to 3.12). In the analysis by patient, the likelihood of a successful outcome was also significantly better with treatment (relative risk = 1.46, 95% CI 1.19 to 1.69). The absolute treatment effect was 16.3% producing a number needed to treat of 6. The number of previous abortions had a significant negative correlation with live birth rate, such that for each additional pregnancy loss beyond three, the likelihood of live birth was reduced by 23%. CONCLUSION Allogeneic leukocyte immunization is an effective treatment for unexplained primary RSA when pretreatment antipaternal antibodies are absent. Better diagnostic tests are required to identify patients who may derive maximal benefit from this therapeutic approach.
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Affiliation(s)
- S Daya
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
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31
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Affiliation(s)
- N Gleicher
- Center for Human Reproduction, Chicago, Illinois
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Maruyama T, Makino T, Iwasaki K, Sugi T, Saito S, Umeuchi M, Ozawa N, Matsubayashi H, Nozawa S. The influence of intravenous immunoglobulin treatment on maternal immunity in women with unexplained recurrent miscarriage. Am J Reprod Immunol 1994; 31:7-18. [PMID: 8166949 DOI: 10.1111/j.1600-0897.1994.tb00841.x] [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: 01/29/2023] Open
Abstract
PROBLEM Recently the protective value of high-dose intravenous immunoglobulin (IVIG) in the treatment of unexplained recurrent miscarriage has been reported to be similar to that of conventional immunotherapy with paternal leukocytes. We examined the effect of IVIG treatment on the cellular and humoral level of maternal immunity to demonstrate the possible mechanism by which IVIG might act to prevent recurrence of pregnancy loss. METHOD Eight patients were treated with a 20- to 25-g dose of IVIG every 2 to 3 wk during their first-trimester pregnancies. The development of anti-idiotypic autoantibodies against maternal T-cell receptors, maternal anti-paternal lymphocyte antibodies detected by flow cytometric crossmatch, and changes of maternal lymphocyte subpopulations were monitored before pregnancy and then weekly during IVIG treatment. RESULTS Five of eight patients gave birth successfully after IVIG treatment given during the first trimester of pregnancy (success rate: 62.5%). Although we could not demonstrate a general immunological effect of IVIG on maternal immunity in vivo, a few significant changes of immunological parameters were found in some patients. CONCLUSION Our results suggest that the effect of IVIG on maternal immunity is not a passive increase of blocking antibody including anti-HLA antibody or modification of maternal T-cell subsets but, more likely, a passive increase of anti-idiotypic antibody against anti-HLA antibody or soluble HLA antigens. However, whether the immunomodulating effect of IVIG is related to its possible mechanism to prevent abortion remains unestablished.
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Affiliation(s)
- T Maruyama
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo, Japan
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Lubinski J, Vrdoljak VJ, Beaman KD, Kwak JY, Beer AE, Gilman-Sachs A. Characterization of antibodies induced by paternal lymphocyte immunization in couples with recurrent spontaneous abortion. J Reprod Immunol 1993; 24:81-96. [PMID: 8229995 DOI: 10.1016/0165-0378(93)90012-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This study was designed to identify and characterize the allo- and autoantibodies induced following successful paternal lymphocyte immunization to prevent recurrent spontaneous abortion. Firstly the titers of maternal anti-paternal antibodies in women with successful pregnancies as determined by the flow cytometry crossmatch (FCXM) were highly variable; however, in all cases, the initial pre-immunization titers were negative and the post-immunization titers were positive by the FCXM in successfully treated women. Secondly, the specificities of maternal alloantibodies to paternal HLA antigens (immunogen) were evaluated. No all predicted antibodies to mismatched paternal HLA antigens were found by microlymphocytotoxicity (MCX) assays and the specificities varied. Thirdly, antibodies in post- but not preimmunization sera reacted with two lymphoid cell lines, SupT1 and SB; in addition, the rise and fall of the titers of these sera with paternal cells seemed to be reflected with the cell lines by the FCXM. Fourthly, autoantibodies to activated lymphocytes were detected and seemed to correlate with successful immunization since women who had another abortion following immunotherapy lacked these autoantibodies. These findings suggest that the antibody response following successful immunotherapy is complex and needs to be studied further to understand the mechanism of this treatment.
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Affiliation(s)
- J Lubinski
- Department of Microbiology and Immunology, University of Health Sciences/Chicago Medical School, IL 60064
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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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Clark DA, Banwatt D, Chaouat G. Stress-triggered abortion in mice prevented by alloimmunization. Am J Reprod Immunol 1993; 29:141-7. [PMID: 8373522 DOI: 10.1111/j.1600-0897.1993.tb00579.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
PROBLEM To determine if immunotherapy can prevent abortion triggered by mechanisms that in humans may be treatable by psychotherapy. METHOD The effects of alloimmunization against paternal strain antigens were tested in pregnant mice subjected to stress. RESULTS Restraint stress boosted the resorption rate assessed on day 13.5 of pregnancy in DBA/2-mated C3H/HeJ mice with an optimal effect on day 4.5 of pregnancy, and premating alloimmunization greatly reduced the effect. By contrast, CBA/J and A/J mice proved resistant to abortion boosting by restraint stress. A/J mice mated to DBA/2 or C3H/HeJ males showed reduced fertility, perhaps due to failure of pregnancy immediately after the stress, but this was not corrected by alloimmunization with either DBA/2 [class I + class II major histocompatibility complex (MHC) immunogen] or C3H/HeJ (class I MHC immunogen) splenocytes. There was a reduction in the endogenous resorption rate, however, and implantation number was slightly increased by preimmunization using DBA/2 cells. The abortion rate could be boosted, however, by ultrasonic noise stress of high abortion rate CBA/J, and preimmunization using BALB/c (H-2d) splenocytes protected. A similar boosting of loss in low abortion rate BALB/k mice was ameliorated (albeit not completely) by preimmunization with allogenic paternal but not syngeneic splenocytes. CONCLUSIONS Immunotherapy may protect against a variety of potential triggers of spontaneous abortion, including those that may be amenable to psychological remedies, and possible mechanisms are discussed.
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Affiliation(s)
- D A Clark
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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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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Herrera-Gonzalez NE, Dresser DW. Fetal-maternal immune interaction: blocking antibody and survival of the fetus. DEVELOPMENTAL AND COMPARATIVE IMMUNOLOGY 1993; 17:1-18. [PMID: 8449247 DOI: 10.1016/0145-305x(93)90011-e] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
In the late 1940s it became clear that the homograft reaction was essentially the result of an immune response. Subsequently, Medawar commented on the apparent paradox of the survival of the mammalian fetus in the face of such a potential (cell-mediated) immune response. In an outbred population the fetal-placental unit will be antigenically different to the mother by virtue of its complement of paternal genes and additionally there may be developmental or stage-specific gene products that are immunogenic. Many mechanisms have been proposed to account for the survival of the fetus in the face of a potential immune attack and, while many of these have been investigated in considerable detail, there has been no clear-cut indication that any one plays a predominant role. Either control of immune rejection of the fetus is exercised by an as yet undiscovered mechanism or, more probably, by a combination of some or all of the mechanisms that have been proposed by many workers over the last three decades. Potential controlling processes, which will be reviewed briefly, include: systemic and local modification of maternal responsiveness; altered expression of MHC antigens on extra-embryonic tissues; the placenta as a barrier; and blocking antibody responses. We discuss some of our recent studies in which we have started to look for potential blocking antibodies in a mouse model system. Cells secreting immunoglobulins M and G, characterized in hemolytic plaque assays, have been mapped to areas close to the midgestation mouse embryo, using an immunocryohistological technique. A scaled-down version of hybridoma technology has been used as an analytical probe of the specificity and isotype of immunoglobulin secreted by cells originating either from close to the embryo/fetus or from the para-aortic lymph nodes (PALN). So far monoclonal (IgG1) antibodies with specificity for embryonic cells have been derived together with some monoclonal immunoglobulins with as yet uncharacterized antibody specificity.
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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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Hwang JL, Ho HN, Yang YS, Hsieh CY, Lee TY, Gill TJ. The role of blocking factors and antipaternal lymphocytotoxic antibodies in the success of pregnancy in patients with recurrent spontaneous abortion. Fertil Steril 1992; 58:691-6. [PMID: 1426311 DOI: 10.1016/s0015-0282(16)55313-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To elucidate the role of mixed lymphocyte reaction blocking factors (BF) and complement-dependent antipaternal lymphocytotoxic antibodies on the outcome of pregnancy in unexplained recurrent spontaneous aborters. DESIGN A controlled study of immunotherapy in which the treated group was immunized with the husband's or a third party donor's lymphocytes and the control group received autologous lymphocytes. SETTING Tertiary care institution. PATIENTS Forty-three patients in the control group and 48 patients in the treated group. INTERVENTION The before and after immunization levels of BF and antipaternal lymphocytotoxic antibodies were measured. MAIN OUTCOME MEASURES The existence or changing pattern of BF and antipaternal lymphocytotoxic antibodies levels before and after immunization had no influence on the pregnancy outcome in either group of patients. CONCLUSION Neither BF nor antipaternal lymphocytotoxic antibodies is essential for successful pregnancy. They probably reflect the immunological response of the mother to exposure to fetal antigens.
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Affiliation(s)
- J L Hwang
- Department of Obstetrics and Gynecology, Medical College and Hospital National Taiwan University, Taipei, Republic of China
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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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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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Abstract
Published reports of controlled studies of immunization treatment in recurrent abortion have not shown any ability of either third-party cells or the husband's cells to prevent further abortions, whereas preliminary results of ongoing studies speak in favor of a beneficial effect of third-party cells. However, the lack of significant differences so far does not prove that immunotherapy in habitual abortion is ineffective, because all of these studies include too few patients in each group to give any conclusive results. Only a mega-trial could evaluate the efficacy and side effects of leukocyte immunotherapy. Such controlled studies are needed to clarify the true benefits, risks, and limitations of immunization treatment in recurrent abortion. Factors such as appropriate inclusion criteria, the time relationship between immunization and the next pregnancy, the number of immunizations required, the cell source and cell doses need to be established. Until this additional information is available this treatment should not be considered routinely indicated. This approach should be restricted to a few centers in order to provide maximal possibilities for collection and evaluation of the data.
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Affiliation(s)
- A M Unander
- Department of Obstetrics and Gynecology, Sahlgren Hospital, University of Göteborg, Sweden
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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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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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Clark DA, Beard RW. Authors' reply. BJOG 1991. [DOI: 10.1111/j.1471-0528.1991.tb10386.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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