Rezidivierende Aborte und frustrane In-vitro-Fertilisation

Antikörper gegen das antikoagulatorisch wirkende Annexin V, das in der Plazenta vorkommt, wurden in aktuellen Arbeiten in Zusammenhang mit rezidivierenden Aborten oder wiederholten Fehlversuchen von In-vitro-Fertilisierungen (IVF) gebracht und zum Teil kontrovers diskutiert. Patientinnen, Material, Methoden: Wir untersuchten die Plasmen von 56 Frauen (mittleres Lebensalter 34,7 Jahre) mit wiederholten IVF-Fehlversuchen und/oder rezidivierenden Frühaborten auf APC-Resistenz, Lupusantikoagulanzien und Antikörper gegen Annexin V, Cardiolipin oder β2-Glykoprotein-1. Ergebnisse: Das Vorkommen von APC-Resistenz war mit 14% (8/56) am häufigsten, gefolgt von erhöhten Antikörperspiegel gegen Cardiolipin (IgG/ IgM) mit 12% (7/56), Antikörper gegen β2-Glykoprotein-1 (3/56, 5%) und Annexin-V (1/56, 2%). 42 (75%) dieser Patientinnen hatten einen weiteren IVF-Versuch und erhielten niedermolekulares Heparin und/oder Azetylsalizylsäure im Falle einer APC-Resistenz, eines Lupusantikoagulanz oder eines erhöhten Antikörperspiegels gegen Cardiolipin oder β2-Glykoprotein-1. Bei den neuerlichen IVF-Versuchen resultierten 19 (34%) Schwangerschaften, davon nur 4 Frühaborte (7%). Die einzige Patientin mit erhöhter Anti-Annexin-V-Konzentration, die davor 7 frustrane IVF-Versuche hatte, erhielt während des 8. IVF-Versuchs 40 mg Enoxaparin (Lovenox®) einmal täglich subkutan und wurde schwanger. Diskussion, Schlussfolgerung: Unsere Ergebnisse zeigen, dass bei Frauen mit häufigen IVF-Misserfolgen eine Anti-Annexin-V-Positivität weitaus seltener vorkommt als APC-Resistenz, Lupusantikoagulanzien oder erhöhte Antikörperspiegel gegen Cardiolipin oder β2-Glykoprotein. Das IVF-Ergebnis von Frauen mit APCResistenz, Lupusantikoagulanzien oder erhöhte Antikörperspiegel gegen Cardiolipin oder β2-Glykoprotein scheint durch niedermolekulares Heparin positiv beeinflusst zu werden.

[Recurrent miscarriage or failed in-vitro fertilization: antibodies against annexin V, cardiolipin, beta-2-glycoprotein-1 and APC-resistance]

Antibodies against annexin-V, a potent anticoagulant abundant in placental tissues, were recently controversially reported to be associated with recurrent miscarriages or failures of in-vitro-fertilization (IVF) attempts.

PATIENTS, MATERIAL, METHODS

We screened 56 women (34.7 +/- 4.3 years of age: mean +/- 1 SD) with recurrent IVF failures and/or early pregnancy losses for resistance against activated protein C, lupus anticoagulant and antibodies against annexin V, cardiolipin or beta(2)-glycoprotein-1. Among them the prevalence of APC-R (8/56, 14%) and elevated levels of IgG- or IgM-anti-cardiolipin antibodies (7/56, 12%) were more common than elevated levels of (IgG or IgM) antibodies against beta(2)-glycoprotein-1 (3/56, 5%) or annexin-V (1/56, 2%). 42 (75%) of the women had another IVF-attempt after this haemostaseological evaluation and received low molecular weight heparin and/ or acetylsalicylic acid in the case of positivity for APC-resistance, lupus anticoagulant or antibodies against annexin V, cardiolipin or beta(2)-glycoprotein-1.

RESULTS

The outcome of these IVF-attempts were 19 pregnancies (34%): 4 early miscarriages (7%) and 15 so far uncomplicated pregnancies (27%). The only woman with an elevated anti-annexin V (IgG) level had had 7 IVF before and received 40 mg Enoxaparin (Lovenox) subcutaneously once daily during the 8(th) IVF, which resulted in a healthy pregnancy.

DISCUSSION, CONCLUSION

Our findings suggest that among women with recurrent IVF failures anti-annexin V antibody positivity is less prevalent than APC-resistance, lupus anticoagulant (LA) or elevated levels of antibodies against cardiolipin, beta(2)-glycoprotein-1 and that the IVF-result of women with APC-R, LA or with elevated levels of antibodies against annexin V, cardiolipin or beta(2)-glycoprotein might be positively influenced by low molecular weight heparin.

Inflammatory genes are upregulated in expanded ataxin-3-expressing cell lines and spinocerebellar ataxia type 3 brains

Spinocerebellar ataxia type 3 (SCA3) is a polyglutamine disorder caused by a CAG repeat expansion in the coding region of a gene encoding ataxin-3. To study putative alterations of gene expression induced by expanded ataxin-3, we performed PCR-based cDNA subtractive hybridization in a cell culture model of SCA3. In rat mesencephalic CSM14.1 cells stably expressing expanded ataxin-3, we found a significant upregulation of mRNAs encoding the endopeptidase matrix metalloproteinase 2 (MMP-2), the transmembrane protein amyloid precursor protein, the interleukin-1 receptor-related Fos-inducible transcript, and the cytokine stromal cell-derived factor 1alpha (SDF1alpha). Immunohistochemical studies of the corresponding or associated proteins in human SCA3 brain tissue confirmed these findings, showing increased expression of MMP-2 and amyloid beta-protein (Abeta) in pontine neurons containing nuclear inclusions. In addition, extracellular Abeta-immunoreactive deposits were detected in human SCA3 pons. Furthermore, pontine neurons of SCA3 brains strongly expressed the antiinflammatory interleukin-1 receptor antagonist, the proinflammatory cytokine interleukin-1beta, and the proinflammatory chemokine SDF1. Finally, increased numbers of reactive astrocytes and activated microglial cells were found in SCA3 pons. These results suggest that inflammatory processes are involved in the pathogenesis of SCA3.

Modulation of ovarian function by an oral contraceptive containing 30 micrograms ethinyl estradiol in combination with 2.00 mg dienogest

Twenty-two healthy female volunteers with normal ovulatory cycles, aged between 20 and 34 years (27.3 +/- 4.1), were included in a single-center, noncomparative study to investigate the modulation of ovarian function by an oral contraceptive containing 30 micrograms ethinyl estradiol in combination with 2.00 mg dienogest. At baseline, during three treatment cycles and post-treatment, serum levels of luteinizing hormone, follicle-stimulating hormone, 17 beta-estradiol, and progesterone were assayed and ultrasonography was used to measure follicular size and the thickness of the endometrium. The primary efficacy variable was inhibition of ovulation as measured by ovarian activity grading. All volunteers ovulated during the pretreatment cycle. During treatment, none of the subjects had ovulatory cycles, although there was still some ovarian activity in several subjects. During the first treatment cycle, only 4% (1 subject) of cycles showed active follicle-like structures. The frequency of follicle-like structures increased to 33% and 35% during treatment cycles 2 and 3. The frequency of presumptive luteinized unruptured follicle-like structures was 5% (1 subject) and 15% (3 subjects) in treatment cycles 2 and 3. The serum hormone concentrations were effectively suppressed in comparison to baseline. The ovarian activity returned to baseline during the post-treatment period. One subject was excluded from further study because of a medical problem believed unrelated to use of the oral contraceptive. No serious adverse events were recorded during the course of the study. The results of the present investigation indicate that the modulatory effects on ovarian function of the monophasic oral-contraceptive containing 30 micrograms ethinyl estradiol combined with 2.00 mg dienogest lead to adequate suppression of ovarian activity and effective inhibition of ovulation.

Double-blind, randomized, placebo controlled study on the effects of the monophasic oral contraceptive containing 30 micrograms ethinyl estradiol and 2.00 mg dienogest on the hemostatic system

Forty healthy female volunteers aged between 19 and 35 years (27.3 +/- 4.1 years) with normal menstrual cycles were included in a double-blind, randomized, placebo-controlled study to investigate the influence on the hemostatic system of an oral contraceptive containing 30 micrograms ethinyl estradiol in combination with 2.00 mg dienogest, which is a 19-norprogestin without a 17 alpha-ethinyl group. At baseline and during one treatment cycle, 12 hemostatic parameters were measured on cycle days 7, 14, and 21. The hemostatic parameters were categorized as either procoagulatory, anticoagulatory and profibrinolytic, or antifibrinolytic and indicative of fibrin turnover. Differences between placebo and 30 micrograms ethinyl estradiol and 2.00 mg dienogest of plasma levels of hemostatic parameters on cycle days 21 of the precycle and treatment cycle were chosen as target variables. Prothrombin fragment 1 + 2 (F 1 + 2) was chosen as the main target variable. Equivalence of F 1 + 2 between placebo and active treatment was noted. Among the procoagulatory factors, only factor VII activity was found to be increased over placebo in the active treatment group, but decreased in the placebo group. Protein C activity increased during the treatment with 30 micrograms ethinyl estradiol and 2.00 mg dienogest, and was higher than that of the placebo group in which this parameter decreased during the treatment cycle. There was a corresponding increase in fibrinolytic activity being reflected by higher plasminogen levels in the active treatment group in comparison with placebo. An increase was noted for the fibrinolytic parameter D-dimer. Apart from isolated measurements, the parameters remained in their respective normal ranges. The data combine to suggest that 30 micrograms ethinyl estradiol and 2.00 mg dienogest has a balanced effect on the hemostatic system stimulating both procoagulatory and fibrinolytic activity.

Inhibition of ovulation by an oral contraceptive containing 100 micrograms levonorgestrel in combination with 20 micrograms ethinylestradiol

Twenty-four healthy female volunteers with normal ovulatory cycles, aged between 20 and 34 years (27.5 +/- 4.3), were included in a single-center, non-comparative study to investigate the effect on inhibition of ovulation of an oral contraceptive containing 20 micrograms ethinylestradiol in combination with 100 micrograms levonorgestrel. At baseline, during three treatment cycles and post-treatment, ultrasonography was used to examine the ovaries, to measure follicular size, and to measure the thickness of the endometrium. Serum levels of LH, FSH, estradiol, progesterone, total testosterone, free testosterone, SHBG, and CBG were also measured. Compared with treatment cycle 1, an increase in residual ovarian activity (follicle grades 4-5) was observed in cycles 2 and 3. Mean levels of LH, FSH, 17 beta-estradiol and progesterone remained suppressed during treatment. No escape ovulation was observed during the treatment phase of the study and there were no pregnancies. Ovulation was noted to return rapidly in the posttreatment cycle. Subjective and objective tolerance of the present regimen was noted to be good. Results indicate that the monophasic oral contraceptive containing 100 micrograms levonorgestrel combined with 20 micrograms ethinylestradiol effectively inhibits ovulation, providing adequate suppression of ovarian activity.

[Successful outcome of "intracytoplasmic sperm injection" (ICSI) within the scope of in vitro fertilization]

Poor function of spermatozoa accounts for half of all human infertility. "Intracytoplasmic sperm injection" (ICSI) is a new micromanipulatory method for the treatment of male infertility. "ICSI" was performed in cases of oligoasthenozoospermia in 12 IVF cycles, obtaining a fertilisation rate of 71.2% of all micromanipulated oocytes. So far four ongoing pregnancies occurred. Thus "Intracytoplasmic sperm Injection" represents a new encouraging technique to conceive, even in cases of severe male infertility.