Physician approval for pregnancy in patients with systemic lupus erythematosus showing only serological activity: A vignette survey study

OBJECTIVE

The European League Against Rheumatism recommends that the disease activity of systemic lupus erythematosus should be stable before pregnancy because complications and disease flares increase if pregnancy occurs while disease activity is high. However, some patients have ongoing serological activity even after treatment. Herein, we investigated how physicians decide on the acceptability of pregnancy in patients showing only serological activity.

METHODS

A questionnaire was administered from December 2020 to January 2021. It included the characteristics of physicians, facilities, and the allowance for pregnancies of patients using vignette scenarios.

RESULTS

The questionnaire was distributed to 4946 physicians, and 9.4% responded. The median age of respondents was 46 years, and 85% were rheumatologists. Pregnancy allowance was significantly affected by the duration of the stable period and status of serological activity [duration: proportion difference 11.8 percentage points (p.p.), P < .001; mild activity: proportion difference -25.8 p.p., P < .001; high activity: proportion difference -65.6 p.p., P < .001]. For patients with high-level serological activity, 20.5% of physicians allowed pregnancy if there were no clinical symptoms for 6 months.

CONCLUSIONS

Serological activity had a significant effect on the acceptability of pregnancy. However, some physicians allowed patients with serological activity alone to become pregnant. Further observational studies are required to clarify such prognoses.

POS0734 THE CLINICAL JUDGMENT FOR THE ACCEPTABILITY OF PREGNANCY IN PATIENTS WITH SEROLOGICALLY ACTIVE SLE IN JAPAN: A NATIONWIDE ONLINE SURVEY FROM THE VIGNETTE STUDY

Background

The risk of pregnancy complications, such as gestational hypertension is high in pregnancies with SLE. In addition, the risk of flare is elevated if pregnancy occurs during the high disease activity. The EULAR recommendation provides a checklist for preconception counseling, in which patients with SLE desiring pregnancy were required the condition that the disease activity prior to pregnancy should be stable for 6-12 months in terms of serological activity (1). However, it does not provide specific criteria for serological activity so that physicians should evaluate the risk of pregnancy in each case by their clinical intuitions.

Objectives

In order to uncover the present clinical situation for the acceptability of pregnancy in patients with SLE, we performed questionnaire survey to physicians regarding to the degree of serological activity.

Methods

This cross-sectional study was performed to physicians registered with the Japanese College of Rheumatology from December 2020 to January 2021 using the online survey. The questionnaire asked about the characteristics of physicians, facilities and the permission of pregnancies with SLE using vignette scenarios. In this study, data from vignettes of women visiting a regular outpatient clinic were used. The vignettes varied in age (28 or 35 years), duration of stable disease and serological activity. Analysis methods were descriptive statistics, chi-square test. generalized estimating equations (GEE) was performed to investigate the relationship between the determining permission for pregnancy and the scenario patient’s characteristics (age, period of stable disease, titer of anti ds-DNA antibody)

Results

The questionnaire was distributed to 4946 physicians, and 463 responded. Completion rate (ratio agreed to participate/finished survey) of survey was 91.1%. The median age of physicians was 46 (interquartile range (IQR) 2-10). The specialty was rheumatology (84.9%), other internal medicine (8%), and pediatrics (5.6%). There were no significant differences in patient’s age about the acceptability of pregnancy (coeffficianet -0.02, 95% CI -0.17 -0.01, p=0.42). Case who had been stable for 6 months were more tolerant of pregnancy than case who had been stable for 3 months (coeffficianet 0.12, 95% CI 0.09-0.15, P<0.001) Pregnancy was not allowed in case with mild or high serological activity (mild: coefficient -0.49, 95% CI -0.29- -0.22, p <0.001, high: -0.64, 95% CI -0.65 - -0.61, p <0.001). In contrast, as many as 92 (19.2%) physicians tolerated pregnancy even in the presence of residual high anti ds-DNA antibody titers. Female physicians are significantly more cautious about pregnancy than male when patients have a serologically high activity (12% vs 37.5%, p<0.001). There were no significant differences in specialty status or clinical experience.

Conclusion

We found that even mild serological activity alone had a significant negative effect on the physician’s decision to allow pregnancy. We conclude that current physicians make cautious decisions about pregnancies of patients with SLE following the recommendation. On the other hand, an additional investigation should be performed about the results of pregnancies in patients with serological abnormalities, since there are some physicians who thought that pregnancy may be acceptable for patients with only serological abnormalities if the clinical symptoms are stable.

References

[1]Ann Rheum Dis．2017 Mar;76(3):476-485

Acknowledgements

I would like to express my gratitude to the members of Japan College of Rheumatology who cooperated in filling out the questionnaire.

Disclosure of Interests

Sakiko Isojima: None declared, Nobuyuki Yajima: None declared, Ryo Yanai: None declared, Yoko Miura: None declared, Shingo Fukuma: None declared, Kayoko Kaneko: None declared, Keishi Fujio: None declared, Kenji Oku: None declared, Masakazu Matsushita: None declared, Takako Miyamae: None declared, Takashi Wada: None declared, Yuko Kaneko: None declared, Yoshiya Tanaka Speakers bureau: Y. Tanaka has received speaking fees and/or honoraria from Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Grant/research support from: Y. Tanaka has received research grants from Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, and consultant fee from Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie., Ayako Nakajima: None declared, ATSUKO MURASHIMA: None declared

Serum anti-Müllerian hormone levels in women with rheumatoid arthritis during tumor necrosis factor-α inhibitor treatment: Exploratory research

Background

We evaluated serum anti-Müllerian hormone in women with rheumatoid arthritis newly introduced to tumor necrosis factor-α inhibitor treatment for 54 weeks to investigate the treatment's effect on ovarian reserve.

Methods

A total of 12 premenopausal women with rheumatoid arthritis aged 20-50 years were recruited at our division, who had been newly treated with tumor necrosis factor-α inhibitor (infliximab or etanercept) from 1 April 2008 to 31 March 2014. Serial serum anti-Müllerian hormone levels and disease activity scores (DAS28-CRP) were examined at defined periods: start of treatment and 14, 30, and 54 weeks after start of treatment.

Results

DAS28-CRP scores in 12 women were significantly decreased from a mean of 4.6 (±SD: 0.4) to 2.3 (±0.4) after 54 weeks of treatment (p < 0.001). Serum anti-Müllerian hormone levels and its z scores did not change significantly.

Conclusion

Treatment with a tumor necrosis factor-α inhibitor did not affect serum anti-Müllerian hormone levels in 12 women with rheumatoid arthritis during 54-week treatment.

Clinical Characteristics of Rheumatoid Arthritis Patients Achieving Functional Remission with Six Months of Biological DMARDs Treatment

Objective Although previous studies have reported the prognostic factors for functional remission, no reports have cited the predictive factors. Our aim was to study the predictive factors for functional remission, which is a treatment goal in rheumatoid arthritis (RA), after receiving biological disease-modifying antirheumatic drugs (bDMARDs) treatment for six months. Methods The study consisted of 333 RA patients treated with bDMARDs for six months. The following patient characteristics were investigated: age, gender, disease duration, type of bDMARDs, baseline steroid and methotrexate dosage, and levels of serum rheumatoid factor, matrix metalloprotease, anti-cyclic citrullinated peptides antibody, tumor necrosis factor-α, and interleukin-6. In our evaluation, we used the Simplified Disease Activity Index (SDAI) for RA disease activity, health assessment questionnaire disability index (HAQ-DI) for activity of daily living, Short Form (SF)-36 for quality of life, and Hamilton Depression Rating Scale (HAM-D) or Self-rating Depression Scale (SDS) to determine the patients' depression status. The subjects were divided into two groups: patients with HAQ-DI≤0.5 and HAQ-DI>0.5 at 6 months. Results A univariate analysis comparing a group of RA patients without functional remission (n=68) showed that the patients with functional remission (n=164) had the following in common compared with those without remission: younger age, shorter disease duration, lower baseline steroid dosage, lower SDAI, lower HAQ-DI, higher SF-36, and lower HAM-D. Only lower HAQ-DI scores and "mental health" score on the SF-36 were detected using a logistic regression analysis. Conclusion These findings suggested that RA patients with lower HAQ-DI and lower depression scores at baseline were more likely to achieve functional remission using bDMARDs treatment than those without these variables.

Comparative Study of Infliximab Therapy and Methotrexate Monotherapy to Improve the Clinical Effect in Rheumatoid Arthritis Patients

Objective We examined whether infliximab (IFX) therapy was more effective than methotrexate (MTX) monotherapy to achieve an improvement in depressive states in Rheumatoid Arthritis (RA) patients. Methods We examined 152 RA patients (72 IFX patients and 80 MTX patients). We conducted an open-label cohort study to evaluate the disease activity of RA (Simplified Disease Activity Index; SDAI), depressive states (Hamilton Rating Scale for Depression; HAM-D), Activity of Daily Living (ADL) (modified Health Assessment Questionnaire; mHAQ) and Quality of Life (QOL) [Short Form (SF)-36] in patients before and 6 months after receiving therapy. The HAM-D, SDAI, mHAQ and SF-36 scores after 6 months of therapy were measured as the outcomes. Results We analyzed 60 IFX patients and 53 MTX patients. The HAM-D scores significantly improved in both groups (p<0.001), but there was no significant difference in the effectiveness between the IFX and MTX therapies (p=0.792). The SDAI scores significantly improved in both groups after therapy (p<0.001), and IFX therapy was more effective than MTX therapy (p=0.004). The mHAQ and HAM-D scores also improved significantly in both groups after therapy (p<0.001), but no significant difference in the effectiveness between the IFX and MTX therapies was observed (p=0.272, 0.792). The scores of all 8 items of the SF-36 improved in both groups after therapy, but IFX therapy was more effective than MTX therapy in only 4 of the 8 items (p<0.05). Conclusion Both IFX and MTX therapy improved the clinical efficacy, ADL, QOL and depressive states. However, no significant differences regarding an improvement in the depressive states and ADL were observed between IFX therapy and MTX monotherapy.

Serum anticyclic citrullinated protein antibody titers are correlated with the response to biological agents in patients with rheumatoid arthritis

Anticyclic citrullinated protein antibody (ACPA) is known as an important indicator for diagnosis of rheumatoid arthritis (RA). Our aim was to examine the relationship between the serum ACPA titer at baseline and responsiveness to biological agents (antagonists of either tumor necrosis factor or interleukin 6) in patients with RA. ACPA was measured using second-generation chemiluminescent enzyme immunoassay. Disease activity was assessed using disease activity scores 28. Fifty-seven RA patients with biological agents were enrolled, and the median ACPA titer at baseline was 110.0 U/mL. The median ACPA titer was 23.3 U/mL and 183.0 U/mL in the good and moderate response groups, respectively, which were significantly lower than in the no response group (404.0 U/mL). In addition, 69.2% and 26.9% of patients with low (<100 U/mL) and moderate (100–499 U/mL) basal ACPA titers showed a moderate to good response. Of the patients with higher (≥500 U/mL) basal ACPA titers, only 14.0% and 42.5% showed a good or moderate response, respectively. The remission rate was 77.8% in the ACPA-negative, which was significantly higher than the rate of 25% in the ACPA-positive patients. The results suggest that the ACPA titers are correlated with the efficacy of the biological agents used in patients with RA.

A case of Degos disease: demonstration of C5b-9-mediated vascular injury

A 68-year-old Japanese male presented with atrophic erythematous white lesions with peripheral dark reddish rims on his back. Multiple ulcers were detected from his stomach to his large intestine using endoscopy. Although the patient was given high doses of a steroid, aspirin, dipyridamole, and intravenous immunoglobulin therapy, he died of gastrointestinal hemorrhage, perforation and septic shock. An autopsy examination revealed pauci-inflammatory thrombotic microangiopathy with endothelial cell injury, fibrous occlusive arteriopathy, and vascular C5b-9 deposition in the wall of the gastrointestinal tract from the esophagus to the large intestine as well as in the dermis of the skin.

Effect of TNF antagonists on the productivity of daily work of patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is a significant cause of work disability and job loss. The resulting economic burden experienced by patients has received considerable research attention. This research assesses the effect of tumor necrosis factor (TNF) antagonists (infliximab, etanercept) on the ability of RA patients living in Japan to work and participate in society. A total of 42 patients with active RA were enrolled and given biological therapy for 12 months (mo). Of these patients, 14 were employed full-time, 6 were employed part-time, and 22 were not employed. Twenty-six patients were given infliximab, and sixteen were given etanercept. The amount of domestic labor performed before the biologics served as a baseline and was assigned a value of 0%. After treatment with biologics, the productivity was evaluated using the visual analog scale (VAS; −100 to +100 mm). The administration of TNF antagonists to RA patients who exhibited an insufficient response to medical treatment significantly improved the Disease Activity Score 28 (DAS 28) after both 6 mo and 12 mo (P < 0.0001). A significant correlation was found between the improvement in their DAS 28 and improvements in their work situation (Productivity VAS) (P < 0.05). Of particular interest is the significant correlation between the values of baseline mHAQ and the percent changes of Productivity VAS that was observed after 6 mo and 12 mo (P < 0.05). Our findings indicate that medical treatment of RA with TNF antagonists improves the patients' ability to perform their jobs and housekeeping. Because loss of productivity is an important contributor to the indirect costs of RA, our findings are relevant for the pharmacoeconomic assessment of treatments.

Local analysis of the edge dislocation core in BaTiO(3) thin film by STEM-EELS

The a <100> edge dislocation core formed in an epitaxial BaTiO(3) (BTO) thin film grown on a substrate was investigated by scanning transmission electron microscopy combined with electron energy-loss spectroscopy. Elemental analysis using core-loss spectrum indicates that the atomic ratios of O/Ti and Ba/Ti are decreased at the dislocation core. The near-edge fine structure of the oxygen K-edge recorded from the dislocation core differs slightly from that of relaxed BTO region, which suggests that Ba-O bonding is decreased at the dislocation core. The structure of the dislocation core is discussed using a high-angle annular dark-field image and the electron energy-loss spectroscopy results.

Possible presence of O-linked carbohydrate in the human male reproductive tract CD52

Male reproductive tract CD52 (mrtCD52) is an antigen recognized by a complement-dependent sperm-immobilizing monoclonal antibody (SI-Abs) derived in an infertile patient. The molecule has been shown to contain a unique N-linked carbohydrate that does not cross-react with other tissues. In this study, we have investigated whether O-linked carbohydrate as well as N-linked carbohydrate is present in mrtCD52 using specific lectins and anti-CD52 core peptide antiserum. The lectin PNA, which recognizes O-linked carbohydrate [Galbeta1-3GalNAc], reacted with mrtCD52 and showed a similar polymorphic reaction pattern to that of the anti-peptide antiserum in western blotting analysis on two-dimensional SDS-PAGE. The PNA-reactive spots disappeared after removal of O-linked carbohydrate, but not after removal of N-linked carbohydrate. These results suggest that O-linked carbohydrate is present in mrtCD52. The moiety may possibly contribute to a specific antigenic epitope of mrtCD52.

Screening for deletions in interval D16-22 of the Y chromosome in azoospermic and oligozoospermic Japanese men

The genetic basis of infertility remains unclear in a majority of infertile men. In this study, the Y chromosome long arm involving the DAZ (deleted in azoospermia) gene was screened in order to evaluate the occurrence of microdeletion in Japanese infertile men. One hundred and fifty-seven infertile Japanese men with azoospermia and oligozoospermia were analyzed for microdeletions in interval D16-22 of the Y chromosome, using polymerase chain reaction with sequence-tagged site markers. Sixteen sets of oligonucleotide primers were synthesized for the polymerase chain reaction, and Southern blot analysis was also performed. The men were divided into five categories on the basis of sperm concentration: functional azoospermia (A; n = 24), azoospermia caused by obstruction (AO; n = 20), oligozoospermia I (OI, sperm concentration less than I x 10(5)/ml; n = 33), oligozoospermia II (OII, sperm concentration less than 1 x 10(6)/ml; n = 30), and oligozoospermia III (OIII, sperm concentration less than 1 x 10(7)/ml; n = 50). Thirty fertile men with a sperm concentration of more than 2 x 10(7)/ml were also analyzed as controls. Microdeletions were identified, in 12 (7.6%) of the 157 infertile men, as follows: 1 man in category A, 1 in category AO, 5 in category OI, 4 in category OII, and 1 in category OIII. No deletion was identified in the fertile men. One common region around sY240 was identified in 11 of the infertile men with microdeletions. This locus may contain specific genes for spermatogenesis. The sperm concentration in the ten oligozoospermic men with microdeletions was below 1 x 10(6)/ml. There were no correlations between the severity of spermatogenic defects and the extent of the microdeletions. These results suggested that genes in the interval D16-22 of the Y chromosome might have important roles in spermatogenesis.

Assisted reproduction technology for patients with congenital bilateral absence of vas deferens

PURPOSE

We investigate the frequency of cystic fibrosis transmembrane conductance regulator gene mutations in Japanese patients with congenital bilateral absence of the vas deferens, and assess treatment outcomes of assisted reproduction interventions.

MATERIALS AND METHODS

In 10 Japanese patients with bilateral congenital absence of the vas deferens genetic analysis was performed for known frequent mutations of the cystic fibrosis transmembrane conductance regulator gene using polymerase chain reaction amplification followed by dot-blot hybridization with the allele-specific oligonucleotide probes and direct sequencing. Intracytoplasmic sperm injection using spermatozoa retrieved from the testes was performed in 7 of the couples.

RESULTS

No known mutations of the gene were detected in the patients. However, analysis of the polythymidine tract polymorphism in intron 8 revealed 30% allele frequency of 5T. Pregnancy was achieved in 7 cycles of intracytoplasmic sperm injection using spermatozoa retrieved from the testes.

CONCLUSION

The 5T variant in intron 8 polythymidine tract was identified with high allelic frequency in Japanese patients with congenital bilateral absence of the vas deferens, suggesting that the disease in Japan is also partially caused by this particular mutation of the cystic fibrosis transmembrane conductance regulator gene. Modern assisted reproduction technology offers an important option for patients with congenital bilateral absence of the vas deferens.

Assisted reproduction for infertile patients with 9 + 0 immotile spermatozoa associated with autosomal dominant polycystic kidney disease

We investigated the clinical feature of patients with totally immotile spermatozoa due to 9 + 0 ultrastructural flagellar defects and polycystic kidney disease. We also tried to establish the feasibility of applying modern assisted reproduction technology (ART) in these patients. During 6-year interval a total of 1956 Japanese men were referred to the male infertility clinic. Of them, 16 were diagnosed to have immotile spermatozoa and four of them exhibited axonemal 9 + 0 defects in the sperm flagella. These four also had autosomal dominant polycystic kidney disease (ADPKD). Intrauterine insemination (IUI) and conventional in-vitro fertilization and embryo transfer failed to achieve fertilization. Intracytoplasmic sperm injection (ICSI) with 100% immotile spermatozoa was performed in all four cases. Two-pronuclear fertilization was obtained in 27 of the 70 (38.6%) of the successfully injected oocytes, but no pregnancy resulted. In one case, a few motile spermatozoa were present at the second cycle of ICSI, a pregnancy was successfully achieved using these spermatozoa. While immotile spermatozoa from patients with the axonemal 9 + 0 defect achieved fertilization by ICSI, the embryos failed to develop. Our results indicate that the central microtubules may play a role in fetal development. Since the 4 patients with 9 + 0 defects also had ADPKD, the genetic linkage between these two conditions should be studied by molecular biological methods so as to aid our ability to counsel such patients.

The operation of a superconducting wiggler at TERAS

A superconducting wiggler has been successfully installed at the ETL 800 MeV electron storage ring facility (TERAS). The operation of the wiggler at magnetic field strengths of 5 T with electron beam energy of 750 MeV has been accomplished. The wiggler has been designed and constructed to produce synchrotron radiation with critical photon energy around 3 keV for scientific, industrial and medical applications. We report here experiments that demonstrate the possibility of stable operation of a superconducting wiggler in a small storage ring.

Characterization of fertilization-blocking monoclonal antibody 1G12 with human sperm-immobilizing activity

A mouse hybridoma (1G12) producing sperm-immobilizing MoAb to human sperm was established and characterized in order to study the antigens relevant to sperm immobilization by antibodies. MoAb 1G12 had strong sperm-immobilizing and agglutinating activities and also showed a fertilization-blocking activity on in vitro fertilization tests. The antibody absorption experiments showed that MoAb 1G12 reacted not only to ejaculated sperm but also human seminal plasma, suggesting that the corresponding antigen might be a sperm coating antigen. The MoAb also reacted with peripheral blood lymphocytes. In histochemical studies, the epithelia of corpus epididymis were most strongly stained. Ejaculated sperm were stained with a granular pattern for their entire surface by immunofluorescence. MoAb 1G12 recognized polymorphic glycoproteins of 15-25 kD in the ejaculated sperm extract in Western blot analysis. After deglycosilation of the sperm extract, only a single staining band of under 15 kD was detected by MoAb 1G12. This suggests that the antigen epitope recognized by MoAb 1G12 might be a peptide of the core portion of the glycoprotein. MoAb 1G12 might be a useful tool for studying the mechanism of egg-sperm interaction, and also be applied to identifying the corresponding antigen by using gene technology.

Diversity of the blocking effects of antisperm antibodies on fertilization in human and mouse

The blocking effects of complement-dependent sperm immobilizing antibodies in the sera of infertile women and monoclonal antisperm antibodies against humans and mice on fertilization were investigated. The hemizona assay (HZA) and sperm penetration assay (SPA) were used to study the inhibitory effects of sera from 22 infertile patients positive for sperm immobilizing antibodies. Use of these tests allowed us to differentiate whether the antibody blocked sperm-zona pellucida tight binding and/or sperm penetration into the ooplasm. The zona pellucida penetration assay (ZPA) was also used to study the effects of four monoclonal antibodies (mAbs) on human sperm penetration into the zona pellucida. Seven mAbs against murine spermatozoa were tested for their inhibitory effects on in-vitro fertilization (IVF) and HZA in mice. Of 22 patient sera with sperm immobilizing antibodies, 21 (95.5%) inhibited HZA attachment and penetration, whereas this did not occur in any of 13 patient sera without these antibodies. However, 19 of 22 (86.4%) patient sera with sperm immobilizing antibodies and eight of 13 (61.5%) patient sera without these antibodies inhibited the SPA. Two (2C6, 1G12) of four mAbs against human spermatozoa showed strong inhibitory effects in all the assays (HZA, ZPA and SPA). One mAb (3B10) did not inhibit HZA but blocked ZPA and SPA. Another mAb (H6-3C4) seemed to have no inhibitory effects on fertilization. Two (Vx 5 and Vx 8) of seven mAbs against murine spermatozoa inhibited IVF in mice but did not block mouse HZA. These findings suggest that antisperm antibodies block fertilization at specific stages. Some of them may inhibit sperm capacitation and thus prevent all processes of fertilization that follow. Some other antibodies may not affect capacitation and sperm binding to zona pellucida but inhibit the acrosome reaction, followed by the blocking of sperm penetration through zona pellucida and ooplasm.

Analysis of an epitope sequence recognized by a monoclonal antibody MAb-5H4 against a porcine zona pellucida glycoprotein (pZP4) that blocks fertilization

The zona pellucida glycoprotein that surrounds the mammalian oocyte has several target antigens that have potential use in the development of a contraceptive vaccine. In the present study, an epitope sequence recognized by a monoclonal antibody to the porcine zona pellucida glycoprotein ZP4 was determined. Three candidate peptides were synthesized, based on an epitope mapping by cDNA and an analysis of chain flexibility of porcine ZP4. Only one synthetic peptide, corresponding to amino acid positions 50-67, reacted with the monoclonal antibody; the other synthetic peptides, corresponding to positions 60-79 and 70-100, did not react. The reactive epitope was identified as CTYVLDPENL, corresponding to positions 50-59 of porcine ZP4. The peptide inhibited the reaction of the monoclonal antibody binding to native ZP4 in a dose-dependent manner. When the synthetic peptide 50-67 was used to immunize mice, the resultant antisera reacted not only with the synthetic peptide but also with native pig zona pellucida. In addition, anti-peptide 50-67 antibody inhibited porcine fertilization in vitro. It is thus concluded that the peptide identified as an epitope for the monoclonal antibody would be a promising candidate for the development of a contraceptive vaccine.

Direct production of the Fab fragment derived from the sperm immobilizing antibody using polymerase chain reaction and cDNA expression vectors

PROBLEM

Sperm immobilizing antibodies cause infertility mainly through complement dependent sperm immobilization. To analyze any effect of sperm immobilizing antibody on fertilization, we had already established cell lines that secrete IgM monoclonal antibody (MAb H6-3C4) and IgG monoclonal antibody (MAb EnBCMGS). The latter was a class-switched recombinant IgG antibody that shares the same variable region as MAb H6-3C4. The biological effects of the IgG antibody were also reported previously to eliminate sperm immobilizing or sperm agglutinating activities. However, the method of chemical digestion of IgG had some disadvantage to prepare the purified Fab fragment stably and in large quantities. This time we report a unique method to obtain the recombinant Fab fragments (Fab EnBCMGS) using polymerase chain reaction (PCR) and cDNA expression vectors.

METHOD

Two kinds of PCR primers were designed to make a truncated heavy chain (Fd) gene of MAb EnBCMGS. The amplified Fd gene and light chain gene were ligated into cDNA expression vectors and then transfected into mammalian cells.

RESULTS

Expression of the Fd gene and light chain gene were confirmed by Northern blotting. Secretion of the recombinant Fab fragment from mammalian cells was also confirmed by Western blotting. The Fab fragment showed biological activity as is expected by FACS analysis.

CONCLUSION

This method enables the stable production of genuine Fab fragments of IgG in mammalian cells without any chemical treatment that may be time consuming and affect the quality of the Fab fragments.

Progesterone treatment decreases sulfate carbohydrate antigen on endometrial carcinoma cells and inhibits the cell binding to laminin

To investigate the effects of progesterone on endometrial carcinoma, sulfated carbohydrate antigen was studied using a monoclonal antibody, termed E8, that reacts with sulfatide. The reactivity of monoclonal antibody (MAb) E8 with endometrial carcinoma tissues decreased when patients were treated with medroxyprogesterone acetate (MPA). A reduction of reactivity of MAb E8 with endometrial carcinoma cells was also observed in in vitro examinations using an endometrial carcinoma cell line, Ishikawa cells incubated in MPA-containing medium. Sulfated carbohydrate, such as sulfatide, is the site of binding with laminin. The binding of cell surface components with laminin is thought to be an initial step in the invasion and metastasis of carcinoma cells. The MPA-treated Ishikawa cells bound to laminin-coated dishes less [corrected] efficiently than nontreated cells. MPA treatment of endometrial carcinoma reduces the sulfatide carbohydrate on the carcinoma cell surface and may be clinically more effective in reducing cell binding to laminin.

The effects of patients' sera with sperm-immobilizing antibodies on sperm of the Japanese monkey

In order to study the interspecies cross-reactivity of sperm-immobilizing antibodies found in sera of women who were infertile for unknown reasons, we used the sperm-immobilization test to examine the effects of patients' sera with or without sperm-immobilizing antibodies on the sperm of the Japanese monkey (Macaca fuscata). Fourteen of 17 antibody-positive sera and 7 of 14 antibody-negative sera showed sperm-immobilizing activity with regard to monkey sperm. The sperm-immobilizing antibody that was active against both human and monkey sperm could be absorbed only by sperm from each corresponding species. The periodate treatment of human or monkey sperm markedly diminished their antibody-absorbing capabilities. Human and mouse monoclonal antibodies having sperm-immobilizing activity with regard to human sperm showed no sperm-immobilizing activity with regard to monkey sperm. These results indicate that the sperm-immobilizing activity of the sera of infertile women against human and monkey sperm might be due to antibodies with different specificities, which recognize a unique carbohydrate antigen epitope expressed in the sperm of each species.

Identification and characterization of a 27 kDa acrosome protein of human sperm defined by a monoclonal antibody with fertilization-blocking effect

A monoclonal antibody, MAb 1G1, possessing a strong fertilization-blocking activity was prepared by immunizing a BALB/c mouse with capacitated human sperm in order to study the molecular nature of sperm antigens relevant to fertilization. MAb 1G1 inhibited human sperm penetration into zona-free hamster eggs. It reacted to the apical portion of acrosome-reacted human sperm, but did not react to live sperm before the acrosome reaction as demonstrated by immunofluorescence staining. In paraffin-embedded testis sections, the round spermatids, spermatocytes and spermatozoa were stained with MAb 1G1, but the spermatogonia were not stained. Neither Sertoli cells, Leydig cells nor other somatic tissues were stained. The sperm of Japanese monkey, bull, boar, hamster and mouse were not stained. Therefore, the staining of sperm was species specific. The antigen corresponding to MAb 1G1 showed a band at 27 kDa by immunoblotting. The reactivity of the antigenic component was not destroyed by periodic acid treatment. From the results obtained, it was postulated that the antigenic molecule might be a polypeptide. These results indicated that this MAb might be a useful tool for studying the mechanism of human sperm-egg fertilization and the development of a contraceptive vaccine.

Amino acid sequence of a porcine zona pellucida glycoprotein ZP4 determined by peptide mapping and cDNA cloning

Mammalian zona pellucida is an attractive target for developing a contraceptive vaccine. In this study, the amino acid sequence of a core protein of porcine zona pellucida glycoprotein ZP4 was determined by peptide mapping and cDNA cloning. Two kinds of ZP4 peptides were identified: one consisted of 128 amino acid residues and the other of 133 amino acid residues with an additional five amino acid sequence at the carboxy-terminal end of the 128 amino acid peptide. Both peptides had two potential N-linked glycosylation sites. The 128 amino acid peptide showed 39.1% similarity to the amino-terminal region of mouse ZP2 polypeptide. The positions of five cysteine residues were the same for porcine ZP4 and mouse ZP2. The cloned cDNA possessed an additional 195 nucleotides at the 3' end of the sequence corresponding to the 133 amino acid peptide. This additional sequence was found to encode the amino-terminal 10 amino acid sequence of porcine ZP2 polypeptide. These results suggest that porcine ZP4 and ZP2 are derived from a common parent polypeptide by proteolytic cleavage at the position between 133 and 134 residues.

Effects of sperm-immobilizing antibodies on sperm-zona pellucida tight binding

OBJECTIVE

To evaluate the in vitro effects of sperm-immobilizing antibodies on sperm-zona pellucida (ZP) tight binding.

DESIGN

The hemizona assay (HZA) was used to study the inhibitory effects of infertile women's sera with and without sperm-immobilizing antibodies on sperm ZP tight binding. These results were compared with those of monoclonal sperm-immobilizing antibodies.

SETTING

The patients were collected from a university hospital infertility clinic.

PATIENTS

Sera from 40 infertile women (24 with and 16 without sperm-immobilizing antibodies) and 2 postpartum women as control were used.

RESULTS

Of 24 patients' sera with sperm-immobilizing antibodies, 23 (96%) showed significant inhibitory effect, whereas none of 16 patient's sera without sperm-immobilizing antibodies exhibited any inhibitory effect. However, there was no correlation between the antibody titers of sperm-immobilizing antibody and the hemizona index. Among four monoclonal sperm-immobilizing antibodies tested, only one showed a significant inhibitory effect on the sperm-zona tight binding. A human monoclonal antibody derived from an infertile woman with sperm-immobilizing antibodies, whose serum showed an inhibitory effect on HZA, did not inhibit the HZA.

CONCLUSIONS

There are at least two kinds of sperm-immobilizing antibodies, one with both activities of sperm immobilization and blocking of sperm-zona tight binding and another with the former activity alone. The vast majority of sperm-immobilizing antibodies reduce zona binding even without the presence of complement.

Determination of immunoglobulin classes and subclasses of sperm immobilizing antibodies in infertile women and the inhibitory effect of IgG4 subclass on the sperm immobilizing antibody activity

Immunoglobulin classes and subclasses of sperm immobilizing antibodies (SI-Abs) in the sera of sterile women were determined by the absorption of patients' sera with Staphylococcus aureus and immunoadsorbents bound with class or subclass-specific anti-human immunoglobulin antibodies. Among 18 patients' sera tested, 16 had the IgG-dominant SI-Abs and the remaining 2 sera contained IgM-dominant SI-Abs. From the former patients' sera, 9 were further studied to determine the IgG subclasses; 6 of them had IgG1-dominant SI-Abs, one IgG2-dominant, and in the other two IgG1 and IgG2 were equally dominant. Interestingly, SI-Ab activities in 6 of the 9 patients' sera increased after absorption of IgG4 subclass and the addition of IgG4 purified from an SI-positive patient to the same patient's serum diminished the SI-Ab activities.

Single nucleotide substitution of the androgen receptor gene in a case with receptor-positive androgen insensitivity syndrome (complete form)

Complete androgen insensitivity syndrome is caused by X chromosome linked disorder resulting in a target organ insensitivity to androgen. Two variants have been described in this syndrome. In the first, the binding of [3H]dihydrotestosterone (17 beta-hydroxy-5 alpha-androstan-3-one) to the androgen receptor is undetectable (receptor-negative), whereas in the second variant normal levels of androgen receptor are detectable but the binding of [3H] dihydrotestosterone to the androgen receptor is significantly thermolabile under certain conditions (receptor-positive). In receptor-negative cases, genetic disorders of the androgen receptor gene have been demonstrated. On the other hand, the genetic disorder of androgen receptor in receptor-positive cases is little known. In this study, the gene structure of androgen receptor in a receptor-positive case using a polymerase chain reaction technique is studied in the fibroblasts cultured from genital skin. The results demonstrate that the substitution of nucleotide (guanine-->cytosine) in exon G of the androgen receptor causes the replacement of an amino acid in position 820 (glycine-->alanine) which occurs in the hormone-binding domain of the androgen receptor. The substitution of nucleotide may explain the thermolability of the androgen receptor in a case with receptor-positive androgen insensitivity syndrome.

Stable production of recombinant human sperm immobilizing antibody using cDNA expression vectors

PROBLEM

Sperm immobilizing antibodies present in sterile women may be one of the principal causes of immunological infertility. We already established cell lines that secrete recombinant human IgG sperm immobilizing antibody using class-switched (from IgM to IgG) genomic immunoglobulin genes. However, these transfectants produced a small quantity of antibody and required continuous use of a medium with selective reagents. We have now constructed cell lines that stably secrete the antibody in large quantities using immunoglobulin cDNAs and cDNA expression vectors.

METHOD

The immunoglobulin heavy chain cDNA was cloned from transfectants that secrete the class-switched human IgG sperm immobilizing antibody. The light chain cDNA, which had already been cloned, and the heavy chain cDNA were inserted into the modified bovine papilloma virus-based cDNA expression vectors BCMGSNeo and BCMGSHyg, respectively. These constructs were sequentially transfected into a mouse myeloma cell line by electroporation.

RESULTS

The established transfectants produced recombinant antibody that retained human sperm immobilizing activity in nonselective medium for at least 30 days. Moreover, the production of the antibody was increased three times over that of the previous cell lines.

CONCLUSION

We have established an unique method that improves the production of sperm immobilizing antibody stably and in large quantities.

Sperm immobilizing antibodies react to the 3-O-sulfated galactose residue of seminolipid on human sperm

It is well known that very few women who possess sperm immobilizing antibodies in their sera can conceive naturally even though there are no abnormalities in their reproductive organs on routine medical examination. A monoclonal antibody (MAb), designated 2H12, was produced by immunizing a BALB/c mouse with the human choriocarcinoma cell line JEG-3. MAb 2H12 showed strong sperm immobilizing activities and reacted to sulfatide and seminolipids. The sperm immobilizing activities of 2H12 were clearly absorbed with sulfatide or seminolipid whilst several other sperm immobilizing MAbs that were made by immunization with human sperm or seminal plasma could not be absorbed with the same sulfoglycolipids. The sperm immobilizing antibodies in the sera of infertile women with unknown cause were also clearly absorbed with sulfatide or seminolipid. MAb 2H12-conjugated immunobeads (MAb 2H12-IMBs) bound to motile sperm. This binding of 2H12-IMBs to sperm was competitively inhibited either by 2H12 or women's sera containing sperm immobilizing antibodies, but not by normal women's sera or several other sperm immobilizing MAbs to human sperm. These results suggest that the sperm immobilizing antibody in women's sera is directed against the 3-O-sulfogalactose residue of seminolipid on the sperm membrane.

Antifertility effect of active immunization with ZP4 glycoprotein family of porcine zona pellucida in hamsters

Female golden hamsters were immunized with solubilized porcine zona pellucida (s-PZP) or ZP4 glycoprotein family isolated from s-PZP by preparative SDS-PAGE. Both antigen preparations induced production of antibodies which reacted not only with porcine zona pellucida but also with the hamster zona pellucida. The hamsters immunized with solubilized porcine zona pellucida mainly produced antibodies reactive to ZP3, while the hamsters immunized with ZP4 mainly produced antibodies reactive to ZP4. The former animals became permanently infertile but the infertility in the latter animals was temporary and they became pregnant later. Histological studies revealed that the ovarian follicles in hamsters immunized with s-PZP were completely destroyed leaving only atrophic follicle-like cell clusters, while in the ovaries of hamsters immunized with ZP4 a number of small follicles with oocytes remained intact. These observations are encouraging for the further characterization of the ZP4 antigens as candidates for the development of a contraceptive vaccine.

Comparative studies of the antigens recognized by sperm-immobilizing monoclonal antibodies

Characteristic properties of the antigens recognized by sperm-immobilizing monoclonal antibodies (SI-mAbs) from different sources were compared by ELISA competitive inhibition assay, Western blot analysis, chromatographic analysis, and enzymatic digestion studies. Among 9 SI-mAbs, human mAb H6-3C4 and three mouse mAbs--2C6, 2B6, and 2E5--also possessed strong sperm-agglutinating activity. Binding of human mAb H6-3C4 to sperm was strongly inhibited by the three mouse mAbs (2C6, 2B6, and 2E5), but not by the rat or the other four mouse mAbs. SDS-PAGE revealed that mAb H6-3C4 and three mouse mAbs recognized the same antigen molecules of 15-25 kDa present in both sperm extracts and seminal plasma. Chemical treatments with trifluoromethanesulfonic acid and sodium metaperiodate destroyed the antigen determinants recognized by the above four mAbs, as detected by both ELISA and antibody absorption tests. Western blot analysis revealed that the antigens were susceptible to treatments with papain, proteinase K, and N-glycanase, but resistant to trypsin, V8 protease, and thermolysin. These results indicate that one of the major antigens recognized by mAbs with sperm-immobilizing action may be a sperm membrane-associated glycoprotein of 15-25 kDa and the epitope may involve N-linked oligosaccharides.

Recognition of carbohydrate antigen epitopes by sperm-immobilizing antibodies in sera of infertile women

STUDY OBJECTIVE

To study carbohydrate natures in the antigen epitopes corresponding to sperm-immobilizing antibodies in infertile women.

DESIGN

Antibody absorption with human sperm and seminal plasma before and after treatments with trifluoromethanesulfonic acid or sodium metaperiodate.

PATIENTS

Thirty-three patients who showed a positive sperm immobilization test provided their sera for the experiment.

RESULTS

In 25 patients' sera whose sperm-immobilizing antibodies were absorbed with human seminal plasma, the antibody absorbing capabilities were completely abolished by deglycosylation treatment with trifluoromethanesulfonic acid. The sperm-immobilizing antibodies in 4 patients' sera were absorbed out with sperm membrane fraction before the treatment but not after the treatment with trifluoromethanesulfonic acid. In some patients' sera, the antibody-absorbing capabilities of ejaculated sperm were markedly reduced by sodium metaperiodate treatment.

CONCLUSION

The majority of sperm-immobilizing antibodies in infertile patients might be generated to carbohydrate structures of the sperm-coating antigens or sperm membrane antigens.

Blocking of human sperm-zona interaction by monoclonal antibodies to a glycoprotein family (ZP4) of porcine zona pellucida

To study zona pellucida antigens involved in human fertilization, five monoclonal antibodies (MAbs)--2A1, 2G3, 4A2, 4E12, and 5H4--were produced to a glycoprotein family (ZP4) isolated from heat-solubilized porcine zonae pellucidae. Each MAb reacted not only with solubilized porcine zona glycoproteins but also with the glycoproteins deglycosylated by trifluoromethanesulfonic acid treatment. They also reacted with intact zonae pellucidae of porcine and human oocytes. Three (4A2, 4E12, and 5H4) of the five MAbs showed a significant blocking effect on human sperm binding and penetration of human zonae pellucidae. The 5H4 MAb showed a strong reaction with ZP4 and ZP1 glycoprotein families of porcine zonae pellucidae, and four other MAbs reacted more strongly with ZP3 than with ZP4. The reactivity of 5H4 with porcine zona glycoproteins was destroyed by chymotrypsin digestion, but the antigen epitope was resistant to proteolysis by trypsin and endoproteinase Lys-C. A peptide fragment reactive to 5H4 was isolated by reverse-phase HPLC from endoproteinase Lys-C-treated ZP4 glycoproteins, and its molecular mass was determined to be 7 kDa by SDS-PAGE. These results suggested that the antigen epitope corresponding to 5H4 is a good candidate for development of a contraceptive vaccine.

Sperm immobilizing and fertilization-blocking monoclonal antibody 2C6 to human seminal plasma antigen and characterization of the antigen epitope corresponding to the monoclonal antibody

A monoclonal antibody (Mab 2C6) with strong sperm immobilizing and agglutinating activities was generated by cell fusion between spleen cells from a mouse immunized with human seminal plasma (HSP) and mouse myeloma cells. It also showed a strong inhibitory effect on human sperm-egg interaction. The corresponding antigen was present on the whole surface of ejaculated spermatozoa. In male genital organs, immunostaining with Mab 2C6 was observed in epididymis and seminal vesicle but not in testis. By Western blotting, immunostaining with Mab 2C6 was detected around the 15-25 kDa region under both reducing and non-reducing conditions. The antigen corresponding to Mab 2C6 was susceptible to treatment with periodate or trifluoromethanesulfonic acid. The antigenic activities were slightly increased by treatment with neuraminidase but reduced by further treatment with glycosidases. Enzymatic digestions with pronase and papain also reduced the antigenic activities. The antigen molecules exhibited a strong binding affinity to RCA lectin. These results indicated that Mab 2C6 recognized one of the components which might be secreted from epididymis or seminal vesicle and bind to ejaculated spermatozoa as a sperm coating antigen. The corresponding antigen seems to be a glycoprotein and its carbohydrate moiety has an important role in the conformation of the antigen epitope.

Further characterization of the porcine zona pellucida antigen corresponding to monoclonal antibody 3A4-2G1 exclusively cross-reactive with porcine and human zonae pellucidae

Biochemical and molecular analyses were performed for the porcine zona pellucida (ZP) antigen corresponding to the monoclonal antibody (Mab) 3A4-2G1 exclusively cross-reactive with porcine and human zonae pellucidae (ZPe). By SDS-PAGE and Western blot analysis, Mab 3A4-2G1 reacted with a 92-kDa component of solubilized porcine ZP (s-PZP) under non-reducing conditions, while reacting with a 23-kDa component under reducing conditions. Diagonal SDS-PAGE revealed that the 92-kDa component was composed of 69 kDa and 23 kDa molecules. In two-dimensional O'Farrell's electrophoresis, the antigen molecules reactive to Mab 3A4-2G1 were distributed over a wide range of PI as a family of proteins around 92 kDa and 23 kDa regions under non-reducing and reducing conditions, respectively. A murine antiserum raised to the isolated 23-kDa component reacted not only with the 23-kDa but also with the 92-kDa glycoprotein family. The anti-23 kDa serum showed a strong inhibitory effect on human sperm-egg interaction by in vitro fertilization. The reactivity of s-PZP to Mab 3A4-2G1 was markedly reduced by treatments with proteolytic enzymes but not significantly with glycosidic enzymes. However, chemical deglycosylation of the antigen markedly reduced the antigen's activity. These results suggested that Mab 3A4-2G1 recognized a conformational antigen epitope structure of ZP.

Correlation between quantitative antibody titers of sperm immobilizing antibodies and pregnancy rates by treatments

Immunological infertility in women who possessed sperm immobilizing (SI) antibodies made it very difficult to conceive using the usual treatments. We examined SI antibodies by the quantitative Sperm Immobilization Test and found the antibody titers (50% sperm immobilization unit: SI50 unit) associated with pregnancy rates. Patients with high SI50 titers (greater than 10 units) did not conceive by ordinary or repeated artificial inseminations with husband's semen (AIH) except when treated with in vitro fertilization (IVF) and embryo replacement. Patients with relatively low SI50 titers (less than 10 units) could conceive either by repeated or ordinary AIH, though the success rates were lower than by IVF-embryo replacement. It is important to assess the SI50 titers by the quantitative method to select treatments for infertile women with SI antibodies. In follow-up studies of the patients who conceived successfully, it was found that SI50 titers tended to decline as pregnancy proceeded.

Efficacy of the high molecular weight fraction of plasma for the maintenance of pregnancy associated with thrombotic thrombocytopenic purpura

We have investigated the methods for the maintenance of a pregnancy in a patient with thrombotic thrombocytopenic purpura (TTP), said condition, since 1984, having been controlled by a plasma infusion every 3 to 4 weeks. In a preliminary trial it was confirmed that an infusion of the high molecular weight fraction (HMW-F) of plasma, separated by an Evaflux 2A fractionator, improved the patient's thrombocytopenia as the plasma infusion, and maintained its beneficial effect for about 2 weeks during early pregnancy. Though an occurrence of a toxemia-like syndrome responded to repeated plasma infusion, the dose of plasma required to improve the thrombocytopenia gradually increased and reached 5,040 ml by the 20th week of pregnancy. Thus, instead of periodic infusions of whole plasma, periodic infusions of the HMW-F of plasma were used. Under this regimen the platelet count remained above 10.0 x 10(4)/microliters during late pregnancy, and the total dose (2,600 ml) of HMW-F of plasma that was administered until delivery at full term was less than the dosage of whole plasma that was used during early pregnancy. In this manner we were able to obtain a healthy baby by controlling the patient's TTP during pregnancy. This method of preventing thrombocytopenia appears to be safer with respect to volume loading during pregnancy in the TTP patient.