Redirection of cytokine production by lymphocytes from women with pre-term delivery by dydrogesterone

Association between interleukin-6 and preterm birth: a meta-analysis

BACKGROUND

Interleukin (IL)-6 is a pro-inflammatory cytokine that plays an important role in preterm birth (PTB), Several meta-analyses investigated the association between IL-6 and PTB, but definitive conclusion has not yet been achieved. This updated meta-analysis aimed to ascertain the association between IL-6 and PTB by examining IL-6 levels in both normal birth and PTB groups.

MATERIAL AND METHODS

Prospective cohort studies were retrieved in PubMed, Embase, and the Cochrane library from their inception until 18 February 2020. The primary outcome was the association between IL-6 and PTB, and secondary outcomes were the association between IL-6 and spontaneous PTB.

RESULTS

Nine studies involving 1904 patients were included. Overall, IL-6 from different sample types (maternal blood, amniotic fluid and cervicovaginal fluid) was associated with PTB (standard mean difference [SMD]: 0.86, 95% confidence interval [CI]: 0.32 to 1.39, p < 0.001). Furthermore, the association was significant for IL-6 only in amniotic fluid (SMD: 1.87, 95%CI: 0.82 to 2.93, p < 0.001) and cervicovaginal fluid (SMD: 0.46, 95%CI: 0.09 to 0.84, p = 0.022), but not significant in maternal blood (SMD: -0.11, 95%CI: -0.57 to 0.34, p = 0.623). In addition, IL-6 was also associated with spontaneous PTB (SMD: 1.57, 95% CI: 0.18 to 2.95, p < 0.001).

CONCLUSIONS

Based on the available evidence, IL-6 in amniotic fluid and cervicovaginal fluid might be useful for predicting preterm birth.

The Effect of Progestins on Cytokine Production in the Peripheral Blood Mononuclear Cells of Menopausal Women and Their Luminol-Dependent Chemiluminescence

Steroid hormones are the key regulators of inflammatory and autoimmune processes. The role of steroid hormones is mostly inhibitory in these processes. The expression of IL-6, TNFα, and IL-1β, as markers of inflammation, and TGFβ, as a marker of fibrosis, could be useful tools to predict the response of an individual's immune system to the different progestins suitable for the treatment of menopausal inflammatory disorders, including endometriosis. In this study, the progestins P4 and MPA, as well as the novel progestin gestobutanoyl (GB), which possess potent anti-inflammatory properties towards endometriosis, were studied at a fixed concentration of 10 µM. Their influence on the production of the above cytokines in PHA-stimulated peripheral blood mononuclear cells (PBMCs) during 24 h incubation was evaluated by ELISA. It was found that synthetic progestins stimulated the production of IL-1β, IL-6, and TNFα and inhibited TGFβ production, while P4 inhibited IL-6 (33% inhibition) and did not influence TGFβ production. In the MTT-viability test, P4 also decreased PHA-stimulated PBMC viability by 28% during 24 h incubation, but MPA and GB did not have any inhibitory or stimulatory effects. The luminol-dependent chemiluminescence (LDC) assay revealed the anti-inflammatory and antioxidant properties of all the tested progestins, as well as some other steroid hormones and their antagonists: cortisol, dexamethasone, testosterone, estradiol, cyproterone, and tamoxifen. Of these, tamoxifen showed the most pronounced effect on the oxidation capacity of PBMC but not on that of dexamethasone, as was expected. Collectively, these data demonstrate that PBMCs from menopausal women respond differently to P4 and synthetic progestins, most likely due to distinct actions via various steroid receptors. It is not only the progestin affinity to nuclear progesterone receptors (PR), androgen receptors, glucocorticoid receptors, or estrogen receptors that is important for the immune response, but also the membrane PR or other nongenomic structures in immune cells.

Comparison of oral Dydrogesterone and 17-α hydroxyprogesterone caprate in the prevention of preterm birth

Background

Preterm birth (PTB) remains a significant problem in obstetric care. Progesterone supplements are believed to reduce the rate of preterm labor, but formulation, type of administration, and dosage varies in different studies. This study was performed to compare oral Dydrogesterone with intramuscular 17α-hydroxyprogesterone caproate (17α-OHPC) administration in prevention of PTB.

Methods

In this randomized clinical trial, we studied 150 women with singleton pregnancy in 28^Th-34^Th Gestational week, who had received tocolytic treatment for preterm labor. Participants were divided to receive 30 mg oral Dydrogesterone daily, 250 mg intramuscular 17α-OHPC weekly, or no intervention (control group). All treatments were continued until 37^Th Week or delivery, whichever occurred earlier. Obstetric outcomes, including latency period, gestational age at delivery, birth weight, neonatal intensive care unit (NICU) admission, and neonatal mortality were recorded. All patients were monitored biweekly until delivery.

Results

Baseline gestational age was not significantly different between groups. Latency period was significantly longer in the progesterone group compared with Dydrogesterone and control groups (41.06 ± 17.29 vs. 29.44 ± 15.6 and 22.20 ± 4.51 days, respectively; P < 0.001). The progesterone group showed significantly better results compared with the other two groups, in terms of gestational age at delivery, birth weight, and Apgar score (P < 0.001). None of the participants showed severe complications, stillbirth, or gestational diabetes.

Conclusion

Progesterone caproate can strongly prolong the latency period and improve neonatal outcomes and therefore, is superior to oral Dydrogesterone in the prevention of PTB.

Dydrogesterone Affects the Transcription of Genes in Innate Immune and Coagulation Cascade in Zebrafish Embryos

Dydrogesterone (DDG) acts on the reproduction but also affects the functioning of non-reproductive system. So far, the knowledge about other effects of DDG remains limited. Here we investigated the effects of DDG on the transcription of genes in innate immune and coagulation cascade in zebrafish embryos. The zebrafish embryos were exposed to DDG at 49.0, 527 and 5890 ng L^- 1 for 144 hour post fertilization (hpf). The results showed that DDG significantly decreased the transcription of marker genes (e.g. tnfa, il8 and cc-chem) involved in the innate immune response at environmental concentrations. Moreover, DDG also down-regulated the transcription of genes in coagulation cascade (e.g. fga, fgb, fgg and f2). These results indicated that DDG had potential effects on the innate immune and coagulation cascade functions in the early life zebrafish, thus further affecting fish growth and health.

Using the Immune System to Manage Immunologically-Mediated Pregnancy Loss

Pregnancy is not nearly as successful as laypersons might assume, challenged as it is by several complications such as threatened abortion, spontaneous miscarriage, preeclampsia, and preterm delivery, among others. The maternal immune system has been shown to contribute to the etiopathogenesis of some of these pregnancy complications. Pro-inflammatory and anti-inflammatory cytokines have been studied for their effects on pregnancy because of their powerful and versatile effects on cells and tissues. This review addresses the relationship between pro-inflammatory cytokines and recurrent miscarriage, which is an important complication of pregnancy. References for this review were identified by using PRISMA-IPD (Preferred Reporting Items for a Systematic Review and Meta-analysis of Individual Participant Data) Guidelines by conducting searches for published articles from January 1, 1990 until March 1, 2020 in the following databases: PubMed, Google Scholar, and MEDLINE via OVID by the use of the search terms “recurrent spontaneous miscarriage,” “cytokines,” “progesterone,” “progestogen,” “dydrogesterone,” and “immunomodulation.” This review also presents the proposed mechanisms of action of pro-inflammatory cytokines in pregnancy loss, and then goes on to discuss the modulation of cytokine profiles to a state that is favorable to the success of pregnancy. In addition to its indispensable endocrinologic role of progesterone in pregnancy, it also has some intriguing immunomodulatory capabilities. We then summarize studies that show that progesterone and dydrogesterone, an orally-administered progestogen, suppress the production of pro-inflammatory cytokines and enhance the production of anti-inflammatory cytokines before mentioning clinical studies on progestogen supplementation. These studies support the contention that progestogens should be explored for the immunotherapeutic management of pregnancy complications.

IL-10 producing B cells rescue mouse fetuses from inflammation-driven fetal death and are able to modulate T cell immune responses

Understanding the mechanisms leading to fetal death following maternal subclinical infections is crucial to develop new therapeutic strategies. Here we addressed the relevance of IL-10 secreting B cells (B10) in the maintenance of the immune balance during gestation. µMT females lacking mature B cells presented normal pregnancies, although their fetuses were smaller and their Treg pool did not expand as in B cell sufficient controls. Pregnant µMT females were more susceptible to LPS despite having less Treg; their fetuses died at doses compatible with pregnancy in WT animals. Adoptive transfer of IL-10 negative B effector cells or B cells from IL-10 deficient mice did not modify this outcome. The transfer of B10 cells or application of recombinant murine IL-10 reduced the fetal loss, associated with a normalization of Treg numbers and cytokine modulation at the feto-maternal interface. B cell-derived IL-10 suppressed the production of IL-17A and IL-6 by T cells and promoted the conversion of naïve cells into Treg. B10 cells are required to restore the immune balance at the feto-maternal interface when perturbed by inflammatory signals. Our data position B cells in a central role in the maintenance of the balance between immunity and tolerance during pregnancy.

Effects of Single-Nucleotide Polymorphisms in Cytokine, Toll-Like Receptor, and Progesterone Receptor Genes on Risk of Miscarriage

Spontaneous abortion is a complex, multifactorial pathology, where various genetic, neural, endocrine, and immunological factors are involved. Cytokines, Toll-like receptors, and progesterone receptors play critical roles in embryonic implantation and development. A delicate, stage-specific equilibrium of these proteins is required for successful pregnancy outcome. However, genetic variation from one individual to another results in variation in levels of Th1/Th2 cytokines, strength of identification of infectious agents by Toll-like receptors, and quality of progesterone recognition. Thus, a complex study encompassing effects of major SNPs of cytokine, TLR, and PGR genes on the risk of miscarriage is needed. In this study, we investigated SNPs of 9 genes (TLR2 G753A, TLR4 C399T, TLR9 G2848A, TGF-β1 C509T, PGR PROGINS, IL-6 G174C, IL-8 C781T, IL-10 C592A, and TNFα G308A) in 106 women, whose pregnancy ended in miscarriage, and 74 women, who delivered in term without any pregnancy complication. All participants are from Ukrainian population. As a result, TLR9 and IL-10 SNPs have been found to play critical roles in the development of spontaneous abortion. TLR2, TLR4, IL-6, IL-8, and PGR SNPs were identified as secondary factors that can also affect the risk of miscarriage. There was no association found between TGF-β1 and TNFα polymorphisms and miscarriage.

A randomized double-blind controlled trial of the use of dydrogesterone in women with threatened miscarriage in the first trimester: study protocol for a randomized controlled trial

Background

Miscarriage is a common complication of pregnancy occurring in 15–20 % of all clinically recognized pregnancies. Currently, there is still no good scientific evidence to support the routine use of progestogens for the treatment of threatened miscarriage because the existing studies were not large enough to show a significant difference and some of them were not randomized or double-blind.

Methods

This is a double-blind, randomized controlled trial. A total of 400 patients presenting with first-trimester threatened miscarriage will be enrolled. They will be randomized to take dydrogesterone 40 mg per os, followed by 10 mg per os three times a day or placebo until twelve completed weeks of gestation or 1 week after the bleeding has stopped, whichever is longer. The primary outcome is the percentage of miscarriage before 20 weeks of gestation.

Discussion

We postulate that the dydrogesterone therapy will significantly reduce the risk of miscarriage in women with threatened miscarriage.

Trial registration

This study is registered at ClinicalTrials.gov, NCT02128685. Registered on 29 April 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1509-8) contains supplementary material, which is available to authorized users.

RETRACTED: Oral dydrogesterone treatment during early pregnancy to prevent recurrent pregnancy loss and its role in modulation of cytokine production: a double-blind, randomized, parallel, placebo-controlled trial

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the ASRM Publications Committee. The Committee reviewed concerns related to the accuracy of data reported in Table 2 and the authors acknowledged significant errors that could not be corrected because they were unable to provide the original data. As the Committee cannot vouch for the accuracy of the data, we have issued a retraction of this article.

The role of progesterone and the progesterone receptor in human reproduction and cancer

Insufficient progesterone, effect possibly more on immune factors rather than adequate endometrial development, can be an easy remedial cause of infertility by simply supplementing the luteal phase with either vaginal or intramuscular or oral (dydrogesterone) progesterone. Progesterone will also help to reduce miscarriage rates when follicle maturing drugs are used for those with regular menses but follicular maturation defects, or women with recurrent miscarriages. One mechanism of action seems to be related to production of an immunomodulatory protein, the progesterone-induced blocking factor either in the cytoplasm or in the circulation. PIBF inhibits cytotoxicity of natural killer cells. Cancer cells may 'borrow' the same mechanism to escape NK cell immunosurveillance.

Cytokines as key players in the pathophysiology of preeclampsia

Preeclampsia (PE) is an important, common, and dangerous complication of pregnancy; it causes maternal and perinatal illness and is responsible for a high proportion of maternal and infant deaths. PE is associated with increased blood pressure and proteinuria, with a whole host of other potentially serious complications in the mother and fetus. The maternal syndrome in PE is primarily that of generalized dysfunction of the maternal endothelium, and this generalized endothelial dysfunction appears to be part of an exaggerated systemic inflammatory response that involves maternal leukocytes and proinflammatory cytokines. This review examines evidence that points to a significant role for the maternal immune system; inadequate trophoblast invasion of spiral arteries initiates ischemia and hypoxia in the placenta, resulting in an increased release of proinflammatory cytokines in the placenta. Placental ischemia and hypoxia also cause the enhanced release of trophoblast microparticles into the maternal circulation which stimulates increased induction of proinflammatory cytokines and the activation of maternal endothelial cells. This activation results in a systemic, diffuse endothelial cell dysfunction which is the fundamental pathophysiological feature of this syndrome. Recent evidence also supports important roles for proinflammatory cytokines in hypertension, proteinuria, and edema which are characteristic features of PE.

Inflammatory and procoagulant cytokine levels during pregnancy as predictors of adverse obstetrical complications

INTRODUCTION

Disturbances in cytokine networks are believed to be associated with increased risk of adverse pregnancy complications.

METHODS

Plasma samples collected from pregnant women with preterm deliveries, high-risk pregnancy complications including postpartum hemorrhage, hypertensive disorders, and multiple gestations, and normal pregnancies were analyzed at different periods throughout gestation and postpartum. Interleukin (IL) 1β , IL-6, IL-8, IL-10, tumor necrosis factor α, and antiprotein Z antibody levels were measured by enzyme-linked immunosorbent assay.

RESULTS

The IL-6 levels in preterm delivery patients were elevated during pregnancy with statistically significant differences observed at 21 to 32 weeks (P < .01) and 33+ weeks (P < .001). The IL-10 levels were increased in normal pregnancy at all time points compared to the other patient groups (P < .05). The TNF-α levels were elevated in the high-risk pregnancy group versus normal controls (P < .001 at <21 weeks and P < .05 at 21-32 weeks).

CONCLUSION

Analysis of the maternal plasma for elevated IL-6 and reduced IL-10 levels may be of value in the early prediction of pregnancy complications.

Increased maternal cytokine production and congenital heart defects

Congenital heart defects (CHDs) are a major cause of infant mortality. Most CHDs are thought to result from genetic, lifestyle, and environmental factors that include maternal obesity, diabetes, toxicant exposure, and alterations in anti-oxidant capacity. Since these well-documented risk factors are also associated with immune dysregulation, we sought to compare the maternal immune response in mothers carrying a fetus with a CHD with those mothers whose pregnancies were not affected by any birth defect. We conducted a case-control study to examine the maternal cytokine profile using multiplex technology in pregnant mothers (subject mean=26 weeks' gestation). This investigation revealed that whole blood cultures derived from case mothers produced higher levels of certain cytokines and chemokines compared with cultures from control subjects when activated with mitogen. Cultures from case subjects produced higher levels of IL-10, IL-13, IL-4, IL-5, IL-17, and IL-6, when stimulated with mitogen compared with control subjects. Plasma levels of chemokine MIP-1α were higher in cases compared with controls. In contrast, C-reactive protein levels were not statistically different. These results demonstrate the need to further examine the maternal cytokine signature in CHD-affected pregnancies. This information could pave the way toward maternal immunotherapeutic intervention to prevent CHDs, and novel biomarker discovery to improve pre-natal diagnosis.

The Th1:th2 dichotomy of pregnancy and preterm labour

Pregnancy is a unique immunological state in which a balance of immune tolerance and suppression is needed to protect the fetus without compromising the mother. It has long been established that a bias from the T helper 1 cytokine profile towards the T helper 2 profile contributes towards successful pregnancy maintenance. The majority of publications that report on aberrant Th1:Th2 balance focus on early pregnancy loss and preeclampsia. Over the last few decades, there has been an increased awareness of the role of infection and inflammation in preterm labour, and the search for new biomarkers to predict preterm labour continues. In this paper, we explore the evidence for an aberrant Th1:Th2 profile associated with preterm labour. We also consider the potential for its use in screening women at high risk of preterm labour and for prophylactic therapeutic measures for the prevention of preterm labour and associated neonatal adverse outcomes.

Successful pregnancy in a patient suffering from recurrent mid-trimester miscarriage with C9 deficiency after receiving cervical cerclage followed by clindamycin and progesterone: a case report

Complement component 9 (C9) deficiency is relatively common, especially in Japan. Here we present the case of a 27-year-old Japanese woman whose obstetric history involved three mid-trimester miscarriages (at 22 weeks', 18 weeks' and 21 weeks' gestation) and one early spontaneous miscarriage. Her fifth pregnancy was successfully managed by cervical cerclage at 13 weeks' gestation, followed by clindamycin administration (600 mg/day for 7 days) and progesterone injections (250 mg/week). She gave birth to a healthy 3326-g male infant at 40 weeks and 1 day gestation after natural onset of labor. After delivery, the serum complement components were analyzed. C9 protein and activity were undetectable in the patient's serum. We suggest that an immunologic disorder such as C9 deficiency should be considered as a potential complication of undiagnosed recurrent miscarriages.

Progesterone-mediated immunomodulation in pregnancy: its relevance to leukocyte immunotherapy of recurrent miscarriage

Progesterone is crucial for the establishment and maintenance of pregnancy. Progesterone-regulated genes in the pregnant uterus control the development of endometrial receptivity as well as recruitment and differentiation of decidual NK cells, which in turn act on angiogenesis and trophoblast invasion. The link between progesterone and the immune system is established by lymphocyte progesterone receptors expressed in peripheral blood gammadelta T cells of pregnant women and in peripheral NK cells. Regulation of lymphocyte progesterone receptors is activation related, thus efficient recognition of fetal antigens is a requirement for the initiation of progesterone-dependent immunoregulatory mechanisms. Several immunological effects of progesterone are mediated by progesterone-induced blocking factor--the product of a progesterone-induced gene in lymphocytes. One part of unexplained recurrent miscarriages might have an immunological etiology. Immunization of the mothers with paternal or third-party leukocytes aims to correct the misregulated antifetal immune response. There are, however, serious concerns about this treatment, including the lack of information about the mode of action and possible adverse effects of the treatment, the failure to detect a significant effect of immunotherapy and the lack of a reliable generally accepted marker for patient selection. These concerns will be discussed in this review.

Inflammatory cytokines and spontaneous preterm birth in asymptomatic women: a systematic review

OBJECTIVE

To estimate the association between inflammatory cytokines and the risk of spontaneous preterm birth in asymptomatic women.

DATA SOURCES

We searched electronic databases of the human literature in PubMed, EMBASE, and the Cochrane Library up to February 2010 using the following key words: "preterm/pre-term + (birth/delivery)" and "cytokine" or "inflammation/inflammatory + marker/biomarker."

METHODS OF STUDY SELECTION

We included observational studies that reported the association between common inflammatory cytokines and spontaneous preterm birth as an outcome in asymptomatic women. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using fixed and random effects models.

TABULATION, INTEGRATION, AND RESULTS

Seventeen primary studies comprising 6,270 participants met the inclusion criteria. Spontaneous preterm birth was strongly associated with increased levels of interleukin-6 (IL-6) in midtrimester cervicovaginal fluid (OR 3.05, 95% CI 2.00-4.67) (number needed to treat=7 for identifying an additional preterm delivery) and amniotic fluid (OR 4.52, 95% CI 2.67-7.65) (number needed to treat=7), but there was no association in plasma specimen (OR 1.5, 95% CI 0.7-3.0). Spontaneous preterm birth was strongly associated with increased C-reactive protein (CRP) levels in midtrimester amniotic fluid (OR 7.85, 95% CI 3.88-15.87) (number needed to treat=3), but the association was weak in plasma specimen (OR 1.53, 95% CI 1.22-1.90). There were insufficient data (fewer than three studies) for meta-analysis in other inflammatory cytokines.

CONCLUSION

Inflammatory cytokine IL-6 in cervicovaginal fluid and IL-6 and CRP in amniotic fluid but not in plasma are strongly associated with spontaneous preterm birth in asymptomatic women, suggesting that inflammation at the maternal-fetal interface, rather than systemic inflammation, may play a major role in the etiology of such spontaneous preterm births.

Dydrogesterone in threatened miscarriage: a Malaysian experience

INTRODUCTION

Threatened miscarriage is a common problem during pregnancy.

METHODS

The aim of this prospective, open, randomised study was to determine whether dydrogesterone was more effective than conservative management alone in preventing miscarriage in women with vaginal bleeding up to week 16 of pregnancy. Women were excluded if they had a history of recurrent miscarriage. A total of 191 women were randomised to dydrogesterone (40 mg stat followed by 10mg twice daily) or conservative management (control group). The treatment was considered successful if the pregnancy continued beyond 20 weeks of gestation.

RESULTS

The success rate in the dydrogesterone group was statistically significantly higher than that in the control group (87.5% vs. 71.6%; p<0.05). Miscarriage occurred in 12.5% of women in the dydrogesterone group compared with 28.4% in the control group (p<0.05). There were no differences between the groups with regard to the incidence of Caesarean section, placenta praevia, antepartum haemorrhage, preterm labour (weeks 28-36), pregnancy-induced hypertension or low birth weight (<2500 g) babies. There were no intrauterine deaths or congenital abnormalities in either group.

CONCLUSION

Compared with conservative management, dydrogesterone had beneficial effects on maintaining pregnancy in women with threatened miscarriage.

Dydrogesterone support in threatened miscarriage

INTRODUCTION

The aim of this study was to determine whether dydrogesterone helps to preserve pregnancy in women with threatened miscarriage.

METHODS

146 women who presented with mild or moderate vaginal bleeding during the first trimester of pregnancy were randomised to receive oral dydrogesterone (10mg b.i.d.) (n=86) or no treatment (n=60). Dydrogesterone was continued until 1 week after the bleeding had stopped. All women received standard supportive care.

RESULTS

The incidence of miscarriage was significantly lower in the dydrogesterone group than in the untreated group (17.5% vs. 25%; p<0.05). There were no statistically significant differences between the groups with respect to pregnancy complications or congenital abnormalities.

CONCLUSION

Dydrogesterone appears to have beneficial effects in women with threatened miscarriage.

Progesterone-induced blocking factor and cytokine profile in women with threatened pre-term delivery

PROBLEM

The objective of this study was to compare serum concentrations of progesterone-induced blocking factor (PIBF), anti-inflammatory (IL-10),and pro-inflammatory (IL-6, TNFa, and IFNc) cytokines of women with threatened pre-term delivery, with those of women with normal pregnancy and to evaluate the impact of PIBF on the outcome of pregnancy.

METHOD OF STUDY

A prospective study was conducted on a sample of 30 women with threatened pre-term delivery (study group) and 20 healthy pregnant women (control group) between the 24th and 37th gestational weeks. Serum PIBF, anti-inflammatory (IL-10), and pro-inflammatory (IL-6, TNFa, and IFNc) cytokine concentrations were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Thirteen of 30 patients (43.3%) with symptoms of threatened pre-term delivery, and one of 20 patients (5%) in the control group delivered before the 37th week of gestation. Mean PIBF concentrations in serum samples of patients with threatened pre-term delivery were significantly lower than in those of healthy pregnant women (171.12 +/-162.06 ng/mL versus 272.85 +/- 114.87 ng/mL; P < 0.05).Women with symptoms of threatened pre-term delivery had significantly lower serum levels of IL-10, and higher levels of IL-6 as well as IFNc compared with healthy controls.

CONCLUSION

Our results indicate that measuring PIBF and cytokine concentrations in serum during pregnancy is feasible and may be important for understanding immunological causes of pre-term delivery.