Impacts of Cyclosporin A on clinical pregnancy outcomes of patients with a history of unexplained transfer failure: a retrospective cohort study

Alloimmune Causes of Recurrent Pregnancy Loss: Cellular Mechanisms and Overview of Therapeutic Approaches

Recurrent pregnancy loss (RPL) is a complex early pregnancy complication affecting 1-2% of couples and is often linked to immune dysfunction. Aberrations in T and B cell subpopulations, as well as natural killer (NK) cell activity, are particularly influential, with studies showing that abnormal NK cell activation and imbalances in T and B cell subtypes contribute to immune-mediated miscarriage risk. Successful pregnancy requires a tightly regulated balance between pro-inflammatory and anti-inflammatory immune responses. In the early stages, inflammation supports processes such as trophoblast invasion and spiral artery remodeling, but this must be tempered to prevent immune rejection of the fetus. In this review, we explore the underlying immune mechanisms of RPL, focusing on how dysregulated T, B, and NK cell function disrupts maternal tolerance. Specifically, we discuss the essential role of uterine NK cells in the early stages of vascular remodeling in the decidua and regulate the depth of invasion by extravillous trophoblasts. Furthermore, we focus on the delicate Treg dynamics that enable the maintenance of optimal immune homeostasis, where the balance, and not only the quantity of Tregs, is crucial for fostering maternal-fetal tolerance. Other T cell subpopulations, such as Th1, Th2, and Th17 cells, also contribute to immune imbalance, with Th1 and Th17 cells promoting inflammation and potentially harming fetal tolerance, while Th2 cells support immune tolerance. Finally, we show how changes in B cell subpopulations and their functions have been associated with adverse pregnancy outcomes. We further discuss current therapeutic strategies aimed at correcting these immune imbalances, including intravenous immunoglobulin (IVIg), glucocorticoids, and TNF-α inhibitors, examining their efficacy, challenges, and potential side effects. By highlighting both the therapeutic benefits and limitations of these interventions, we aim to offer a balanced perspective on clinical applications for women facing immune-related causes of RPL.

Non-Infectious Uveitis and Pregnancy, is There an Optimal Treatment? Uveitis Course and Safety of Uveitis Treatment in Pregnancy

In pregnancy, a plethora of factors causes changes in maternal immunity. Uveitis flare-ups are more frequent in the first trimester and in undertreated patients. Management of non-infectious uveitis during pregnancy remains understudied. A bibliographic review to consolidate existing evidence was performed by a multidisciplinary group of Ophthalmologists, Gynaecologists and Rheumatologists. Our group recommends initial management with minimum-required doses of corticosteroids, preferably locally, to treat intraocular inflammation whilst ensuring good neonatal outcomes. If ineffective, clinicians should consider addition of Cyclosporine, Azathioprine or Certolizumab pegol, which are seemingly safe in pregnancy. Other therapies (such as Methotrexate, Mycophenolate Mofetil and alkylating agents) are teratogenic or have a detrimental effect on the foetus. Furthermore, careful multidisciplinary preconception discussions and close follow-up are recommended, monitoring for flare-ups and actively tapering medication doses, with a primary endpoint focused on protecting ocular tissues from inflammation, whilst giving minimal risk of poor pregnancy and foetal outcomes.

Effects of high-normal fasting blood glucose on ART outcomes of frozen-thawed single blastocyst transfer in women with normal BMI

PURPOSE

This retrospective cohort study aims to investigate whether high-normal fasting blood glucose (FBG) affects assisted reproductive technology (ART) outcomes undergoing single blastocyst frozen-thawed embryo transfer (FET) cycles in women with normal body mass index (BMI).

METHODS

944 women with normal BMI and FBG levels undergoing single blastocyst FET cycles were enrolled. Based on the median of FBG (4.97 mmol/L, 1 mmol/L = 18 mg/dL), the subjects were categorized into the low-normal group (3.90 ≤ FBG ≤ 4.97 mmol/L, n = 472) and the high-normal group (4.97 < FBG < 6.10 mmol/L, n = 472). Multivariable logistic regression and receiver operating characteristic (ROC) were used to analyze the relationship between high-normal FBG and ART outcomes.

PRIMARY OUTCOME

live birth rate (LBR).

RESULTS

LBR was significantly lower in the high-normal group than in the low-normal group (36.8% vs. 45.1%, p = 0.010), and the miscarriage rate was considerably higher than that in the low-normal group (23.9% vs. 16.5%, p = 0.041). High-normal FBG of female was an independent predictor of live birth (adjusted OR:0.747, 95% CI: 0.541-0.963, p = 0.027) and miscarriage (adjusted OR:1.610, 95% CI: 1.018-2.547, p = 0.042). ROC analyses showed that the cut-off values of FBG (endpoints: live birth and miscarriage) were 5.07 mmol/L, and 5.01 mmol/L, respectively.

CONCLUSIONS

In women with normal BMI, high-normal FBG is an independent risk factor for lower LBR and higher miscarriage rate in single blastocyst FET cycles. Attention to preconception FBG monitoring in this particular population may allow early intervention to improve ART outcomes.

Prehypertension in male affects both semen quality and pregnancy outcomes in their first single blastocyst frozen-thawed embryo transfer cycles

OBJECTIVE

To investigate whether prehypertension (pre-HTN) in male affects semen quality and assisted reproductive technology (ART) outcomes.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated reproductive medicine center.

PATIENT(S)

Clinical data were collected from 1,043 couples undergoing their first single blastocyst frozen-thawed embryo transfer cycles.

INTERVENTION(S)

According to the blood pressure (1 mm Hg = 0.133 kPa) in male, including systolic blood pressure (SBP) and diastolic blood pressure (DBP), the subjects were divided into the control group (90 ≤ SBP < 120 mm Hg and 60 ≤ DBP < 80 mm Hg, n = 611) and the pre-HTN group (120 ≤ SBP < 140 mm Hg and/or 80 ≤ DBP < 90 mm Hg, n = 432). The association between pre-HTN and semen quality, and ART outcomes was then evaluated.

MAIN OUTCOME MEASURE(S)

Primary outcome: live birth rate.

SECONDARY OUTCOMES

semen quality, laboratory embryo outcomes, clinical pregnancy rate, biochemical pregnancy rate, miscarriage rate, and other pregnancy outcomes.

RESULT(S)

Compared with the control group, the pre-HTN group showed lower total sperm motility, total sperm count, sperm progressive motility, progressive sperm count , and higher prevalence of oligozoospermia (17.6% vs. 13.1%), and asthenozoospermia (37.7% vs. 19.8%). Meanwhile, compared with the control group, the pre-HTN group had a lower clinical pregnancy rate (42.8% vs. 57.6%) and a lower live birth rate (32.9% vs. 47.3%). There were no differences in the remaining parameters of semen quality, laboratory embryo outcomes (except for the proportion of intracytoplasmic sperm injection), and pregnancy outcomes between the two groups. Additionally, regression analysis showed that pre-HTN in male was an independent risk factor for clinical pregnancy (adjusted odds ratio, 0.57; 95% confidence interval, 0.44-0.74) and live birth (adjusted odds ratio, 0.58; 95% confidence interval, 0.44-0.75).

CONCLUSION(S)

Prehypertension in male not only results in lower semen quality, but also has negative consequences on the success of ART. It is an independent risk factor for clinical pregnancy and live birth in the first single blastocyst frozen-thawed embryo transfer cycles.

Immunosuppressants in women with repeated implantation failure in assisted reproductive techniques: a systematic review and meta-analysis

Objective

To compare outcomes in patients with repeated implantation failure undergoing Intracytoplasmic Sperm Injection/In vitro fertilization (IVF/ICSI) plus immunosuppressants such as prednisolone, prednisone, or cyclosporine A versus the use of IVF/ICSI alone.

Data source

Databases were systematically searched in PubMed, Cochrane, and Embase databases in September 2023.

Study Selection

Randomized clinical trials and observational studies with the outcomes of interest were included.

Data collect

We computed odds ratios (ORs) for binary endpoints, with 95% confidence intervals (CIs). Heterogeneity was assessed using I2 statistics. Data were analyzed using Review Manager 5.4.The main outcomes were live birth, miscarriage, implantation rate, clinical pregnancy, and biochemical pregnancy.

Data synthesis

Seven studies with 2,829 patients were included. Immunosuppressive treatments were used in 1,312 (46.37%). Cyclosporine A improved implantation rate (OR 1.48; 95% CI 1.01-2.18) and clinical pregnancy (1.89, 95% CI 1.14-3.14). Compared to non-immunosuppressive treatment, prednisolone and prednisone did not improve live birth (OR 1.13, 95% CI 0.88-1.46) and miscarriage (OR 1.49, 95% CI 1.07-2.09). Prednisolone showed no significant effect in patients undergoing IVF/ICSI, clinical pregnancy (OR 1.34; 95% CI 0.76-2.36), or implantation rate (OR 1.36; 95% CI 0.76-2.42).

Conclusion

Cyclosporine A may promote implantation and clinical pregnancy rates. However, given the limited sample size, it is important to approach these findings with caution. Our results indicate that prednisolone and prednisone do not have any beneficial effects on clinical outcomes of IVF/ICSI patients with repeated implantation failure.

PROSPERO

CRD42023449655.

Acupuncture improves the live birth of patients with repeated implantation failure: a retrospective cohort study

OBJECTIVE

To explore the therapeutic efficacy of acupuncture treatment on repeated implantation failure (RIF) patients with cryo-thawed embryo transfer (CET).

METHODS

In a retrospective cohort study, all eligible women undergoing RIF were recruited in our center from January 1, 2018 to December 31, 2021. The patients were grouped by whether an acceptance of acupuncture treatment before CET, including the acupuncture group (Acu-group, 55 cycles) and control group (Con-group, 244 cycles). Data were analyzed by using binary logistic regression to explore the relationship of acupuncture treatment with pregnancy outcomes.

RESULTS

The Acu-group had higher live-birth rate (LBR) [54.5% vs41.0%, respectively; odds ratio (OR) = 1.105, 95% confidence interval (CI) (1.029, 1.187), P =0.006] and ongoing pregnancy rate (OPR) [56.4% vs43.0%, respectively; OR= 1.100, 95% CI(1.025, 1.181), P =0.008] than the Con-group. There were no significant between-group differences in the rates of implantation [OR= 1.070, 95% CI(0.996, 1.149), P =0.064], clinical pregnancy [OR= 1.065, 95% CI(0.997, 1.138), P =0.061], biochemical pregnancy [OR= 1.002, 95% CI(0.903, 1.112), P =0.967], or miscarriage [OR= 0.778, 95% CI(0.551, 1.099), P =0.155]. Perinatal outcomes did not differ significantly between the two groups.

CONCLUSIONS

Acupuncture treatment could improve the LBR and OPR in RIF patients with CET cycles, suggesting a potential adjuvant therapy of acupuncture to improve the pregnancy outcomes in RIF patients.

Successful pregnancy after 10 consecutive failures in a liver transplant patient with advanced kidney failure

We report a successful, albeit complicated pregnancy with a live-born healthy baby at 28 weeks' gestation, after 10 pregnancy failures, in a 39-year-old patient with a history of liver transplantation and chronic kidney disease with hypertension and proteinuria. Multidisciplinary management (obstetrician, nephrologist and hepatology transplant specialist) allowed close monitoring, adaptation of immunosuppressive treatments and strict control of fetal growth. The onset of preeclampsia at 28 weeks' gestation led to a cesarean section, resulting in the birth of a healthy 830 g boy, with subsequent normal development. Following pregnancy, the patient experienced liver transplant rejection, which resolved after adapting immunosuppressive drugs. No deterioration in kidney function was observed in the year following delivery.

Effects of fasting hyperglycemia in men on pregnancy outcomes of singleton pregnant women with cryo-thawed embryo transfer

BACKGROUND

The relationship of metabolic issues to pregnancy outcomes during assisted reproductive technology (ART) is gaining much attention. Fasting Plasma Glucose (FPG) is one of the most common metabolic indicators. Abnormal FPG not only affects the quality of life of human body, but also has a bearing on reproductive health. However, most attentions are paid on women's physical health and reproductive assessment, the health status of the male partner on pregnancy outcomes during ART treatment is often neglected. This study investigated whether male fasting hyperglycemia (FH, FPG > 6.1 mmol/L) can affect live birth rates (LBR) in singleton intrauterine clinical pregnancy women with cryo-thawed embryo transfer (CET) cycles.

MATERIAL AND METHODS

A retrospective cohort study (370 CET cycles with first singleton clinical intrauterine pregnancy and grouped by male FPG) was conducted to analyze the relationship between male FH and clinical pregnancy outcomes using binary logistic regression; the odds ratios (ORs) and 95% confidence intervals (CIs) were calculated as a measure of relevancy. Live birth rate was the main outcome measure.

RESULTS

The live birth rate (LBR) was significantly lower [58.6% vs. 81.8%, P = 0.007, adjusted OR 0.635, 95% CI 0.456-0.884] and miscarriage rate (MR) was significantly higher [41.4% vs. 18.2%, P = 0.007, adjusted OR 1.575, 95% CI 1.131-2.195] in the FH group when compared with the Con group. There was no difference in healthy baby rate [88.2% vs. 89.6%, P = 0.058, adjusted OR 2.143, 95% CI 0.974-4.716] or abnormal birth weight rate (23.5% vs. 11.8%, P = 0.238, adjusted OR 2.859, 95% CI 0.777-10.460] between the FH and control group. No birth defects were observed in the present study.

CONCLUSION

Male FH is an independent risk factor for lower LBR and higher MR in singleton intrauterine pregnancy women with CET cycles.

Calcineurin inhibitors in the management of recurrent miscarriage and recurrent implantation failure: Systematic review and meta-analysis

Recurrent miscarriage (RM) affects up to 2.5% of couples of reproductive age. Up to 10% of couples using assisted reproductive technology experience recurrent implantation failure (RIF). Immunosuppressive drugs, such as calcineurin inhibitors (CNIs), has been proposed for RM and RIF management. This systematic review and meta-analysis (SRMA) aimed to evaluate the efficacy and safety of CNIs in RM and RIF treatment. We searched in the three databases. Review Manager 5.4.1 was used for statistical analysis. This review included 8 studies involving 1042 women (485 women in the CNIs group and 557 women in the control group). CNI treatment (cyclosporine [CsA] and tacrolimus [TAC]) increases live birth rate (LBR, odds ratio [OR]: 2.52; 95% confidence interval [CI]: 1.93-3.28, p < 0.00001) and clinical pregnancy rate (OR: 2.25; 95% CI: 1.54-4.40, p < 0.0001) and decreases miscarriage rate (OR: 0.45 95% CI: 0.32-0.63, p < 0.00001) when compared to the control. Side effects and obstetric and neonatal complications was similar in both groups. In conclusion, CNIs increased LBR in women with RM and RIF but there is a moderate risk of bias. Subgroup analysis revealed that CNIs improved LBR in women with RM with a low risk of bias. However, in women with RIF, with moderate to high risk of bias. The use of CsA and TAC, in low doses and for a short period, for managing reproductive failures in women seems to be safe, not causing serious side effects nor increasing the risk of obstetric and neonatal complications.

Demystifying the impact of prenatal tobacco exposure on the placental immune microenvironment: Avoiding the tragedy of mending the fold after death

Prenatal tobacco exposure (PTE) correlates significantly with a surge in adverse pregnancy outcomes, yet its pathological mechanisms remain partially unexplored. This study aims to meticulously examine the repercussions of PTE on placental immune landscapes, employing a coordinated research methodology encompassing bioinformatics, machine learning and animal studies. Concurrently, it aims to screen biomarkers and potential compounds that could sensitively indicate and mitigate placental immune disorders. In the course of this research, two gene expression omnibus (GEO) microarrays, namely GSE27272 and GSE7434, were included. Gene set enrichment analysis (GSEA) and immune enrichment investigations on differentially expressed genes (DEGs) indicated that PTE might perturb numerous innate or adaptive immune-related biological processes. A cohort of 52 immune-associated DEGs was acquired by cross-referencing the DEGs with gene sets derived from the ImmPort database. A protein-protein interaction (PPI) network was subsequently established, from which 10 hub genes were extracted using the maximal clique centrality (MCC) algorithm (JUN, NPY, SST, FLT4, FGF13, HBEGF, NR0B2, AREG, NR1I2, SEMA5B). Moreover, we substantiated the elevated affinity of tobacco reproductive toxicants, specifically nicotine and nitrosamine, with hub genes through molecular docking (JUN, FGF13 and NR1I2). This suggested that these genes could potentially serve as crucial loci for tobacco's influence on the placental immune microenvironment. To further elucidate the immune microenvironment landscape, consistent clustering analysis was conducted, yielding three subtypes, where the abundance of follicular helper T cells (p < 0.05) in subtype A, M2 macrophages (p < 0.01), neutrophils (p < 0.05) in subtype B and CD8+ T cells (p < 0.05), resting NK cells (p < 0.05), M2 macrophages (p < 0.05) in subtype C were significantly different from the control group. Additionally, three pivotal modules, designated as red, blue and green, were identified, each bearing a close association with differentially infiltrated immunocytes, as discerned by the weighted gene co-expression network analysis (WGCNA). Functional enrichment analysis was subsequently conducted on these modules. To further probe into the mechanisms by which immune-associated DEGs are implicated in intercellular communication, 20 genes serving as ligands or receptors and connected to differentially infiltrating immunocytes were isolated. Employing a variety of machine learning techniques, including one-way logistic regression, LASSO regression, random forest and artificial neural networks, we screened 11 signature genes from the intersection of immune-associated DEGs and secretory protein-encoding genes derived from the Human Protein Atlas. Notably, CCL18 and IFNA4 emerged as prospective peripheral blood markers capable of identifying PTE-induced immune disorders. These markers demonstrated impressive predictive power, as indicated by the area under the curve (AUC) of 0.713 (0.548-0.857) and 0.780 (0.618-0.914), respectively. Furthermore, we predicted 34 potential compounds, including cyclosporine, oestrogen and so on, which may engage with hub genes and attenuate immune disorders instigated by PTE. The diagnostic performance of these biomarkers, alongside the interventional effect of cyclosporine, was further corroborated in animal studies via ELISA, Western blot and immunofluorescence assays. In summary, this study identifies a disturbance in the placental immune landscape, a secondary effect of PTE, which may underlie multiple pregnancy complications. Importantly, our research contributes to the noninvasive and timely detection of PTE-induced placental immune disorders, while also offering innovative therapeutic strategies for their treatment.

The impact of the use of immunosuppressive treatment after an embryo transfer in increasing the rate of live birth

The tolerance of the immune system for the semi-allogeneic embryo is promoted by several factors and the cells involved in the immune system and factors in the mother during pregnancy. The dysregulation of the immune responses between the mother and fetus is a risk factor that raises the likelihood of rejection of the embryo and reproductive failure. To safeguard embryos and prevent immunological attacks, it is critical to suppress immunological rejection and encourage immunological tolerance. Based on current medical literature, it seems that immune cell management through immunosuppressive therapies can address reproductive failures. Immunosuppressive treatment has demonstrated encouraging results in terms of enhancing outcomes related to pregnancy and rates of live birth by regulating the immune responses of mothers and positively impacting the reproductive processes of humans. Currently, there is scarcity of high-quality data regarding the safety and efficacy of immunosuppressive therapies for children and mothers. Therefore, it is important to exercise caution while selecting use of any immunosuppressive therapy in pregnancy. This mini review provides a comprehensive overview of the existing literature regarding the impact of Calcineurin Inhibitors and anti-TNF treatment on improving the live birth rate following embryo transfer.

Recurrent implantation failure: A comprehensive summary from etiology to treatment

Implantation is the first step in human reproduction. Successful implantation depends on the crosstalk between embryo and endometrium. Recurrent implantation failure (RIF) is a clinical phenomenon characterized by a lack of implantation after the transfer of several embryos and disturbs approximately 10% couples undergoing in vitro fertilization and embryo transfer. Despite increasing literature on RIF, there is still no widely accepted definition or standard protocol for the diagnosis and treatment of RIF. Progress in predicting and preventing RIF has been hampered by a lack of widely accepted definitions. Most couples with RIF can become pregnant after clinical intervention. The prognosis for couples with RIF is related to maternal age. RIF can be caused by immunology, thrombophilias, endometrial receptivity, microbiome, anatomical abnormalities, male factors, and embryo aneuploidy. It is important to determine the most possible etiologies, and individualized treatment aimed at the primary cause seems to be an effective method for increasing the implantation rate. Couples with RIF require psychological support and appropriate clinical intervention. Further studies are required to evaluate diagnostic method and he effectiveness of each therapy, and guide clinical treatment.

Improved pregnancy outcomes of cyclosporine A on patients with unexplained repeated implantation failure in IVF/ICSI cycles: A retrospective cohort study

PROBLEM

Repeated implantation failure (RIF) is a daunting obstacle restricting the further improvement of embryo implantation rate (IR) and live birth rate (LBR). The beneficial effect of cyclosporine A (CsA) on reproductive outcomes of unexplained RIF(URIF) was explored after de novo embryo transfer (ET).

METHOD OF STUDY

A retrospective cohort study was conducted, comparing pregnancy outcomes of 146 cycles (CsA group, n = 62; control group, n = 84) at the IVF center of Suzhou Municipal Hospital from April 2016 to March 2020.

RESULTS

Baseline and transfer cycle characteristics of participants were comparable between groups. Overall, CsA exerted obvious improvement on IR (51.16% vs 31.97%, P = .006), clinical pregnancy rate (CPR) (58.06% vs 38.10%, P = .017), and LBR (48.39% vs 32.14%, P = .047). Especially, CsA showed remarkably enhancement on IR (41.38% vs 14.63%, P = .012), CPR (47.62% vs 17.24%, P = .021) of non-high quality embryos. No difference in obstetric and pediatric complications was observed, and no birth defects were reported under CsA application. CsA was found to be a predictor of clinical pregnancy [fine adjusted OR 2.360, 95 % CI 1.165-4.781; P = .017] and live birth [fine adjusted OR 2.339, 95% CI 1.124-4.867; P = .023] for multivariate logistic regression. Not surprisingly, the number of high quality embryos should also be considered as an independent predictor for clinical pregnancy [fine adjusted OR 1.637,95%CI 1.027-2.609; P = .038] and live birth [fine adjusted OR 1.890, 95% CI 1.165-3.068; P = .010].

CONCLUSION

CsA application in patients with URIF promotes the pregnancy outcomes and does not increase the risk of obstetric and pediatric complications.

miRNAs in decidual NK cells: regulators worthy of attention during pregnancy

The critical immune effectors, including T, B, and natural killer (NK) cells, dendritic cells, and macrophages participate in regulating immune responses during pregnancy. Among these immune cells, decidual NK (dNK) cells are involved in key placental development processes at the maternal-fetal interface, such as uterine spiral artery remodeling, trophoblast invasion, and decidualization. Mechanistically, dNK cells significantly influence pregnancy outcome by secreting cytokines, chemokines, and angiogenic mediators and by their interactions with trophoblasts and other decidual cells. MicroRNAs (miRNAs) are small non-coding RNA molecules that participate in the initiation and progression of human diseases. Although the functions of circulating miRNAs in pathological mechanism has been extensively studied, the regulatory roles of miRNAs in NK cells, especially in dNK cells, have been rarely reported. In this review, we analyze the effects of miRNA regulations of dNK cell functions on the immune system during gestation. We discuss aberrant expressions of certain miRNAs in dNK cells that may lead to pathological consequences, such as recurrent pregnancy loss (RPL). Interestingly, miRNA expression patterns are also different between dNK cells and peripheral NK (pNK) cells, and pNK cells in the first- and third-trimester of gestation. The dysregulation of miRNA plays a pivotal regulatory role in driving immune functions of dNK and pNK cells. Further understanding of the molecular mechanisms of miRNAs in dNK cells may provide new insights into the development of therapeutics to prevent pregnancy failure.