Intravenous Immunoglobulin for Repeated IVF Failure and Unexplained Infertility

The use of immunomodulation therapy in women with recurrent implantation failure undergoing assisted conception: A multicentre cohort study

PROBLEM

Recurrent implantation failure (RIF) after multiple embryo transfers remains a vexing problem and immunomodulators have been used with conflicting results. This study aims to assess the effect of immunomodulation therapy on live birth rate (LBR) in women with RIF undergoing assisted reproduction treatment (ART).

METHOD OF STUDY DESIGN

This is a retrospective cohort study in multicentre network of private assisted conception units in the UK. The study included women who had at least two failed attempts of embryo transfers at CARE fertility network in the period from 1997 to 2018. Women in the treatment group had immunomodulator drugs in the form of corticosteroids, low molecular weight heparin (LMWH), and intravenous intralipid (IVIL) infusions, either separately or in combination, after immunological testing, in addition to standard ART whilst women in the control group had only ART without immunomodulators. The primary outcome was LBR per cycle. Secondary outcomes included the rates of clinical pregnancy (CPR), cumulative live birth (CLBR), and miscarriage.

RESULTS

A total of 27 163 ART cycles fulfilled the inclusion criteria, of which 5083 had immunomodulation treatment in addition to standard ART treatment, and 22 080 had standard ART treatment alone. Women in the treatment group were significantly older (mean age 38.5 vs. 37.1 years, p < .001), and had a higher number of previous failed ART cycles (mean 4.3 vs. 3.8, p < .01). There was a higher LBR in women who received immunomodulation therapy when compared with the control group (20.9% vs. 15.8%, odds ratio [OR] 1.4, 95% confidence interval [CI] 1.29-1.53, p < .001). Multivariate regression analysis showed that immunomodulation treatment was a significant independent predictor of live birth after adjusting for other confounders (adjusted OR [aOR] 1.33, 95% CI 1.15-1.54, p < .001). Survival analysis showed a higher CLBR in the treatment group (adjusted hazard ratio [aHR] 1.78, 95% CI 1.62-1.94, p < .001).

CONCLUSION(S)

This study provides evidence of a potential beneficial effect of immunomodulation therapy in women with RIF after immunological testing. There remains a need for high quality, adequately powered multicentre RCTs to robustly address the role of immunomodulation in women with RIF. There is also an urgent need for standardised screening tests for immune disorders that could preclude implantation.

Pregnancy by Oocyte Donation: Reviewing Fetal-Maternal Risks and Complications

Oocyte donation (OD) has greatly improved over the last three decades, becoming a preferred practice of assisted reproductive technology (ART) for infertile women wishing for motherhood. Through OD, indeed, it has become possible to overcome the physiological limitation due to the ovarian reserve (OR) exhaustion as well as the poor gamete reliability which parallels the increasing age of women. However, despite the great scientific contribution related to the success of OD in the field of infertility, this practice seems to be associated with a higher rate of major risky events during pregnancy as recurrent miscarriage, infections and placental diseases including gestational hypertension, pre-eclampsia and post-partum hemorrhage, as well as several maternal-fetal complications due to gametes manipulation and immune system interaction. Here, we will revisit this questioned topic since a number of studies in the medical literature focus on the successful aspects of the OD procedure in terms of pregnancy rate without, however, neglecting the risks and complications potentially linked to external manipulation or heterologous implantation.

Contradictory Effect of Lymphocyte Therapy and Prednisolone Therapy on CD3+CD8+CD56+ Natural Killer T Population in Women with Recurrent Spontaneous Abortion

Background

Natural killer T (NKT) cells are influential immune cells in pregnancy failures, including recurrent spontaneous abortion (RSA). Different approaches are used for these disorders due to their effects on maternal immunomodulation.

Aims

In the present study, we compared the effects of two typical immunotherapies (lymphocyte immunotherapy [LIT] and low-dose prednisolone) on CD3+CD56+CD16+ and CD3+CD56+CD8+ cells as two distinct subsets of NKT cells in Women with RSA.

Settings and Design

This study was a comparative cohort study conducted from 2021 to 2022. One hundred and five women with RSA were distributed into three treatment groups randomly.

Materials and Methods

Fifty women in the group of low-dose prednisolone therapy, fifty women in the LIT group and five women without any treatment as the control group were included in the study. NK and NKT cell subsets were assessed using flow cytometry. Furthermore, the concentration of interferon-gamma (IFN-γ), transforming growth factor-beta (TGF-β) and interleukin-10 (IL-10) was measured quantitatively using the enzyme-linked immunosorbent assay technique.

Statistical Analysis Used

Normality and comparisons between study groups were performed by non-parametric unpaired Mann-Whitney, Kruskal-Wallis rank sum test, and one-way ANOVA.

Results

The percentage of CD56dim NK cells was increased after prednisolone therapy, while this population significantly decreased in the LIT group. In contrast to the LIT group, the administration of prednisolone increased CD3+CD8+CD56+ NKT cells (P < 0.0001), which is helpful for pregnancy. The effect of the investigated treatment approaches on the population of peripheral CD3+CD56+CD16+ NKT cells of women with RSA was not adequately significant. The same situation was also observed regarding the serum level of IFN-γ. However, a significant decrease in serum levels of IL-10 and TGF-β was observed after prednisolone therapy.

Conclusion

The lower capability of LIT in changing the population of NKT cells compared to prednisolone therapy may be due to its mechanism of action, which is related to the production of blocking antibodies. These treatment approaches had different effects on NKT cells, indicating that NKT cell population and function can be affected using LIT and prednisolone therapy distinctly. In addition, prednisolone therapy and LIT in women with normal serum levels of IFN-γ have no harmful effects in changing the production of this critical cytokine.

Immunomodulation for unexplained recurrent implantation failure: where are we now?

In brief

Immune dysfunction may contribute to or cause recurrent implantation failure. This article summarizes normal and pathologic immune responses at implantation and critically appraises currently used immunomodulatory therapies.

Abstract

Recurrent implantation failure (RIF) may be defined as the absence of pregnancy despite the transfer of ≥3 good-quality blastocysts and is unexplained in up to 50% of cases. There are currently no effective treatments for patients with unexplained RIF. Since the maternal immune system is intricately involved in mediating endometrial receptivity and embryo implantation, both insufficient and excessive endometrial inflammatory responses during the window of implantation are proposed to lead to implantation failure. Recent strategies to improve conception rates in RIF patients have focused on modulating maternal immune responses at implantation, through either promoting or suppressing inflammation. Unfortunately, there are no validated, readily available diagnostic tests to confirm immune-mediated RIF. As such, immune therapies are often started empirically without robust evidence as to their efficacy. Like other chronic diseases, patient selection for immunomodulatory therapy is crucial, and personalized medicine for RIF patients is emerging. As the literature on the subject is heterogenous and rapidly evolving, we aim to summarize the potential efficacy, mechanisms of actions and side effects of select therapies for the practicing clinician.

Live Birth Rate in Women with Recurrent Pregnancy Loss after In Vitro Fertilization with Concomitant Intravenous Immunoglobulin and Prednisone

Pregnancy loss after in vitro fertilization (IVF) is at least as common as after spontaneous conception. Recurrent pregnancy loss (RPL) may often have an immunological background, and it is therefore relevant to test immune-based interventions in these patients. The objective was to investigate the effect of immunotherapy with intravenous immunoglobulin (IvIg) and prednisone (PRS) as concomitant therapy to IVF in women with RPL after earlier IVF treatments. In a cohort study conducted at The Danish RPL Clinic, 41 women with three or more consecutive pregnancy losses after IVF underwent at least one further IVF cycle with concomitant immunotherapy from 2012 to 2017. The immunotherapy with IvIg and PRS was given before embryo transfer and repeatedly in the first trimester when pregnancy was achieved. Fourteen women (34.2%) achieved a live birth after the first embryo transfer with immunotherapy, and a total of 32/41 (78%) achieved a live birth after up to 4 embryo transfers. Baseline characteristics and the presence of autoantibodies were not significantly different among women achieving live birth or not. The observed 34% birth rate in women with RPL after IVF receiving immunotherapy appears higher than the expected 16-19% birth rate without immunotherapy and is similar to findings in a previous cohort from our clinic. Concomitant immunotherapy as described may be a promising intervention for women with RPL after IVF; however, the effect must be tested in a randomized controlled trial.

Comparisons of benefits and risks of single embryo transfer versus double embryo transfer: a systematic review and meta-analysis

BACKGROUND

Evidence referring to the trade-offs between the benefits and risks of single embryo transfer (SET) versus double embryo transfer (DET) following assisted reproduction technology are insufficient, especially for those women with a defined embryo quality or advanced age.

METHODS

A systematic review and meta-analysis was conducted according to PRISMA guidelines. PubMed, EMBASE, Cochrane Library and ClinicalTrials.gov were searched based on established search strategy from inception through February 2021. Pre-specified primary outcomes were live birth rate (LBR) and multiple pregnancy rate (MPR). Odds ratio (OR) with 95% confidence interval (CI) were pooled by a random-effects model using R version 4.1.0.

RESULTS

Eighty-five studies (14 randomized controlled trials and 71 observational studies) were eligible. Compared with DET, SET decreased the probability of a live birth (OR = 0.78, 95% CI: 0.71-0.85, P < 0.001, n = 62), and lowered the rate of multiple pregnancy (0.05, 0.04-0.06, P < 0.001, n = 45). In the sub-analyses of age stratification, both the differences of LBR (0.87, 0.54-1.40, P = 0.565, n = 4) and MPR (0.34, 0.06-2.03, P = 0.236, n = 3) between SET and DET groups became insignificant in patients aged ≥40 years. No significant difference in LBR for single GQE versus two embryos of mixed quality [GQE + PQE (non-good quality embryo)] (0.99, 0.77-1.27, P = 0.915, n = 8), nor any difference of MPR in single PQE versus two PQEs (0.23, 0.04-1.49, P = 0.123, n = 6). Moreover, women who conceived through SET were associated with lower risks of poor outcomes, including cesarean section (0.64, 0.43-0.94), antepartum haemorrhage (0.35, 0.15-0.82), preterm birth (0.25, 0.21-0.30), low birth weight (0.20, 0.16-0.25), Apgar1 < 7 rate (0.12, 0.02-0.93) or neonatal intensive care unit admission (0.30, 0.14-0.66) than those following DET.

CONCLUSIONS

In women aged < 40 years or if any GQE is available, SET should be incorporated into clinical practice. While in the absence of GQEs, DET may be preferable. However, for elderly women aged ≥40 years, current evidence is not enough to recommend an appropriate number of embryo transfer. The findings need to be further confirmed.

Reproductive outcomes of women with recurrent pregnancy losses and repeated implantation failures are significantly improved with immunomodulatory treatment

This study investigated if immunomodulatory treatment improves the in-vitro fertilization (IVF) success rates of women with two or more recurrent pregnancy losses (RPL) and repeated implantation failures (RIF) with cellular immune abnormalities and thrombophilia. We performed a retrospective cohort study of 197 RPL patients who received immunomodulatory and anticoagulation treatment undergoing IVF cycles (fresh or frozen embryo transfer). Patients were divided into four groups; Group 1: women with RPL but without RIF, Group 2: women with RPL and RIF (≥3), Group 3: women with RPL after IVF cycles (>2) and without RIF, and Group 4: women with RPL after IVF cycles and RIF. Patients received immunomodulatory treatment with prednisone-only or prednisone and intravenous immunoglobulin G (IVIG) and anticoagulation treatment with low molecular weight heparin and low dose aspirin. IVF success rates of study groups were compared to those of the historical controls. The pregnancy rate of IVF cycles with immunomodulatory treatment was significantly increased in all patients (48.2 % vs. 33.0 %, P < 0.001), Group 1 (54.2 % vs. 30.5 %, P < 0.005) and Group 2 (33.3 % vs. 11.0 %, P < 0.005) as compared to historical controls. The live birth rates per ET cycle were significantly improved for all patients (1.8 % vs. 39.6 %, P < 0.001), and study groups compared to their historical controls (Group 1, 43.1 % vs. 0 %; Group 2, 33.3 % vs. 2.5 %; Group 3, 45.5 % vs. 2.3 %; and Group 4, 16.7 % vs. 1.2 %, P < 0.001, respectively). Immunomodulatory and anticoagulation treatment significantly improved the reproductive outcomes of IVF cycles in women with a history of RPL and/or RIF of immune etiologies.

The number of previous failed embryo transfer cycles is an independent factor affecting implantation rate in women undergoing IVF/ICSI treatment: A retrospective cohort study

The implantation rate (IR) in assisted reproductive technologies such as in vitro fertilization (IVF) and intracytoplasmic sperm injection is affected by many different factors such as age, quality of embryo, and stage of embryo development. This study aimed to investigate to what extent the number of previous failed embryo transfer cycles is an independent factor affecting IR.This was a single-center, retrospective cohort study of a consecutive series of 6376 day-3 embryo transfer (ET) cycles following IVF between January 2012 and August 2018. None of the subjects underwent endometrial scratch/injury prior to the treatment cycle, or received intravenous immunoglobulin, steroid, dehydroepiandrosterone, intralipid or heparin during the treatment with the aim of improving implantation rates.Multiple regression analysis showed that the 3 most important independent factors affecting the IR, in decreasing of importance: age, frozen or fresh embryo transfer and the number of previous ET cycles. Having controlled for 2 of the more important confounding variables including maternal age and the type of embryo, the IR in women who had 0, 1, 2, and 3 or more previous failed ET cycles were 45.8%, 35.9%, 31.2%, 21.0%, respectively (P < .001).Repeated implantation failure is a significant independent factor affecting the IR. The number of previous failed ET cycles should be considered in counselling women regarding the prognosis of a further IVF-ET treatment cycle.

Is there a Role of Intravenous Immunoglobulin in Immunologic Recurrent Pregnancy Loss?

Recurrent pregnancy loss (RPL) commonly refers to three or more miscarriages that occur before 20 weeks of pregnancy. The immunological cause of RPL could be either an auto- or alloimmune-related event or both. Because of the discovery of immunological abnormalities in RPL patients in clinical practice, several immunomodulatory therapies were introduced to maintain the immune balance at the maternal-fetal interface. Intravenous immunoglobulin (IVIg) is one of the immunomodulators. In recent years, several studies have analyzed the therapeutic effect of IVIg on RPL patients with antiphospholipid syndrome (APS) or unexplained RPL. However, their results are controversial. IVIg can be used in RPL patients with APS who have previously failed in other treatments. It is recommended that IVIg infusion could be considered used before conception in RPL patients who have cellular immune abnormalities such as increased natural killer (NK) cell counts, NK cell cytotoxicity, or increased T helper (Th)1/Th2 ratio, depending on the cut-off values of each hospital. The aim of this review was to summarize the mechanisms, efficacy, pharmacokinetics, and side effects associated with passive immunization using IVIg in immunologic RPL, according to the literature published in recent years. We hope that more obstetricians will be able to understand the timing and indication of IVIg properly in immunologic RPL patients and effectively enhance pregnancy outcomes for mothers and neonates.

The Role of Natural Killer Cells and Mast Cells in Female Infertility and Associated Treatment Outcomes

Introduction:

One of the identified causes of infertility has been related to the inability to regulate immunological tolerance of the maternal immune system against the developing fetus, thereby inhibiting the process of implantation. Various immune cells have been identified to contribute to the concept of un-regulated immunological tolerance, such as mast cells (MCs) and natural killer cells (NK). There are available evidences that MC play a role in the pathogenesis of infertility diseases like endometriosis and NK in specific infertility disease.

Objective:

Presently, there are studies to formulate and develop immunosuppressive drugs in order to suppress or inhibit the process of immune rejection caused by maternal immune cells. In addition, there have been reports regarding the use of steroids for the treatment of miscarriage that can inhibit the activity of most immune cells.

Conclusion:

This review is to give a comprehensive mini-review on the role of immune cells, especially mast cells and NK cells in developing novel infertility treatment.

Recurrent pregnancy loss and vitamin D: A review of the literature

Recurrent pregnancy loss (RPL) affects approximately 1%-2% of reproductive women. Auto- and cellular immune responses seem to be associated with RPL. Vitamin D (VD) has been shown to play a role in the modulation of the immune system. Effects of VD deficiency (VDD) in pregnancy have been associated with preeclampsia, gestational diabetes, fetal growth restriction, preterm labor, and sporadic spontaneous abortion (SA). We systematically reviewed articles that studied women with 2 or more SA and its association with VD. Eleven studies were included. Studies reported a high prevalence of VD insufficiency (VDI) or VDD in women with RPL and suggested that this could be associated with immunological dysregulation and consequently with RPL. Immunological benefits were reported in the peripheral blood of women with RPL after VD exposure. Thus, it is possible to speculate a beneficial role for VD supplementation in RPL. It seems that there are not differences in the vitamin D receptor (VDR) and CYP27B1 expression in endometrium of women with RPL but, in villous and decidual tissues, RPL women seem to have a decreased expression of VDR and, perhaps, a decreased expression of CYP27B1. Further randomized controlled studies are required to investigate the association between VDD or VDI and RPL.

The HLA-G 14-bp polymorphism and recurrent implantation failure: a meta-analysis

PURPOSE

The human leucocyte antigen-G (HLA-G) 14-bp insertion/deletion polymorphism was implicated in recurrent implantation failure (RIF), but individual published studies showed inconclusive results. Thus, a meta-analysis was performed to clarify the effect of HLA-G 14-bp polymorphism on RIF risk.

METHODS

A comprehensive search for relevant articles was conducted. The odds ratios (ORs) and 95% confidence intervals (CIs) for HLA-G 14-bp polymorphism and RIF were calculated.

RESULTS

A total of five studies were included. In studies conducted in RIF patients and controls who had at least one spontaneous pregnancy, meta-analysis revealed no statistically significant association between the HLA-G 14-bp polymorphism and RIF in allele contrast and all genetic models in the overall population, but significant association was found in the population of Caucasian origin under allele contrast (OR = 1.73, 95% CI, 1.20, 2.50) and genetic models of +14 bp/+14 bp vs. -14 bp/-14 bp (OR = 3.09, 95% CI, 1.43, 6.65). In studies conducted in RIF patients and controls who had successful pregnancy following IVF-ET, the meta-analysis showed that there was statistically significant association between the HLA-G 14 bp polymorphism and RIF in allele contrast (OR = 1.74, 95% CI, 1.13, 2.67) and genetic models of +14 bp/+14 bp vs. -14 bp/-14 bp (OR = 10.20, 95% CI, 2.47, 42.14) and dominant model (OR = 4.34, 95% CI, 1.72, 10.92). No publication bias was found in the present studies.

CONCLUSIONS

This meta-analysis suggested that the HLA-G 14-bp insertion allele may increase the risk of RIF in Caucasians. Further studies with large sample size of different ethnic populations are necessary.

Effect of Intravenous immunoglobulin on Th1 and Th2 lymphocytes and improvement of pregnancy outcome in recurrent pregnancy loss (RPL)

BACKGROUND

Women with elevated natural killer (NK) cell frequency and function during pregnancy, suffer from recurrent pregnancy loss (RPL). In the present study, the possible effect of intravenous immunoglobulin (IVIG) administration on Th1 and Th2 cell frequency, cytokine secretion, and expression of transcription factors is compared between RPL patients and control group.

MATERIALS AND METHODS

Totally, 44 women with a history of RPL (32 women as treated group and 12 as control group) were enrolled in the study. The frequency of Th1 and Th2 lymphocytes, the expression of transcription factors related to these cells and the serum levels of associated cytokines were assessed by flowcytometry, real-time PCR and ELISA, respectively. All, assessments were performed both before and after treatment with IVIG.

RESULTS

A significant reduction in Th1 lymphocyte frequency, transcription factor expression and cytokine levels were observed in IVIG-treated group, while all the above parameters indicated a significant increase for Th2 lymphocytes. Th1/Th2 ratio decreased significantly (p value<0.0001) at the end of treatment and 28 out of 32 (87.5%) women in IVIG-treated group had live birth in comparison with 5 out of 12 (41.6%) in untreated group.

CONCLUSION

IVIG administration proves to be an efficient therapeutic strategy which is able to enhance the success rate of pregnancy through a shift in Th2 responses. Furthermore, IVIG presents efficacy for the treatment of reproduction failures especially in subjects with immune cell abnormalities and increased NK cell level and function.

Immunosuppressive treatment using tacrolimus promotes pregnancy outcome in infertile women with repeated implantation failures

PROBLEM

We aim to investigate whether the peripheral blood T helper (Th) 1 cell level could predict pregnancy outcome in patients who have experienced repeated implantation failure (RIF, three or more) after ART cycles.

METHOD OF STUDY

This is a prospective cohort study of total 124 women with RIF who showed elevated Th1/Th2 (CD4⁺ IFN-γ⁺ /CD4⁺ IL-4⁺ ) cell ratios (≥10.3) and received tacrolimus at Sugiyama Clinic between November 2011 and July 2016. Patients were divided into three groups as per Th1 cell levels: Th1 level of <22.8 as Low; 22.8 to <28.8 as Middle, and 28.8 or greater as High group. The study patients received daily dose of tacrolimus 1-3 mg based on initial Th1/Th2 cell ratio.

RESULTS

The clinical pregnancy rates of Low, Middle, and High groups were 48.8%, 43.9%, and 33.3%, respectively (P=NS), with tacrolimus treatment. The ongoing pregnancy/delivery rate of Low group (46.3%) was significantly higher than that of High group (21.4%, P<.05). Middle group (34.3%) had higher success rate than High group, albeit without statistical significant.

CONCLUSION

We confirm our previous report that Th1/Th2 ratio can predict ART outcomes in patients with RIF and immunosuppressant treatment with tacrolimus, and peripheral blood Th1 cell levels were negatively correlated with pregnancy outcome.

Intravenous immunoglobulin G in women with reproductive failure: The Korean Society for Reproductive Immunology practice guidelines

The task force of the Korean Society for Reproductive Immunology recommends intravenous immunoglobulin G treatment in women with reproductive failure, including recurrent pregnancy loss and/or repeated implantation failure, who show cellular immune factors such as abnormal natural killer cell levels, natural killer cell cytotoxicity, and/or type 1 T helper immunity.

Role of Paternal Antigen-Specific Treg Cells in Successful Implantation

Maternal lymphocytes recognize fetal antigens, so tolerance is necessary to prevent rejection. Seminal plasma is important for induction of paternal antigen-specific Treg cells in the uterine draining lymph nodes and the pregnant uterus. Elimination of Treg cells during implantation or early pregnancy induces implantation failure or fetal resorption in mice. Immunosuppressive therapy with an anti-TNF antibody or the immunosuppressive agent tacrolimus improves the pregnancy rate in women with repeated implantation failure and recurrent pregnancy loss of unknown etiology, suggesting that Treg cells play an essential role in successful implantation and pregnancy in humans.

Immunomodulatory treatment with intravenous immunoglobulin and prednisone in patients with recurrent miscarriage and implantation failure after in vitro fertilization/intracytoplasmic sperm injection

OBJECTIVE

To assess outcome in terms of live-birth rate after fresh or frozen IVF/intracytoplasmic sperm injection assisted reproductive technology (ART) cycles where immunomodulation was given to patients with recurrent pregnancy loss after prior ART treatments.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care university hospital.

PATIENT(S)

Fifty-two patients with a history of at least three consecutive pregnancy losses after ART who underwent at least one further ART cycle with concurrent immunomodulation in 2003-2012.

INTERVENTION(S)

Immunomodulation with IV immunoglobulin and prednisone starting from before ET and continuing in the first trimester if pregnancy was established.

MAIN OUTCOME MEASURE(S)

Live-birth rate per ET and cumulative live-birth rate after up to five ETs.

RESULT(S)

Nineteen patients (36.5%) achieved a live birth after the first ET with immunomodulation, and a total of 32 patients achieved a live birth in the study period, resulting in a cumulative live-birth rate of 61.5%. There was no significant difference in baseline and immunological parameters between the patients achieving a live birth or not. The live-birth rate after the first immunomodulated ART cycle in our patients is higher than that reported in a previous study.

CONCLUSION(S)

Immunomodulation with a combination of IV immunoglobulin and prednisone is a promising treatment for recurrent pregnancy loss after ART, but randomized placebo-controlled trials are needed.