Angiogenic factors and the lectin pathway of complement in women with secondary recurrent pregnancy loss

The poor remodeling of placental spiral arteries seen in preeclampsia is also discussed to contribute to recurrent pregnancy loss (RPL) preceded by abnormal angiogenesis and excessive complement activation. Low levels of Mannose-binding-lectin (MBL), a pattern recognition molecule (PRM) of the lectin pathway, have been found in women with RPL. We propose that pregnancy loss is connected to defective angiogenesis with reperfusion damage in the placenta and decreased levels of PRM in the lectin pathway in women with RPL. In this cohort study, we investigate the angiogenic factors and the lectin complement pathway in early pregnancy and their time-dependent relationship with pregnancy outcomes in 76 women with secondary RPL (sRPL) who have at least four prior pregnancy losses and a live birth. We evaluated levels of Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), Vascular Endothelial Growth Factor (VEGF), soluble fms-like tyrosine kinase-1 (sFlt-1), and the PRMs, MBL, ficolin-1, -2, -3 and an additional soluble PRM, Pentraxin-3, during the 5th, 6th, and 7th gestational weeks. Our results showed that, compared to live births, pregnancies that ended in loss were associated with elevated VEGF levels and decreased levels of the Ang-2/Ang-1 ratio. Also, increasing levels of ficolin-2 were significantly associated with pregnancy loss, with MBL showing no association. Our research suggests that women with sRPL may have inadequate placentation with impaired angiogenesis in pregnancies ending in a loss.

NK and T Cell Subtypes in the Endometrium of Patients with Recurrent Pregnancy Loss and Recurrent Implantation Failure: Implications for Pregnancy Success

BACKGROUND

RPL and RIF are challenges in reproductive medicine. The immune system plays a pivotal role in endometrial receptivity, successful implantation, and pregnancy complications. Immunological changes have been associated with RPL and RIF. Understanding immune dysregulation especially in NK and T cell subtypes may lead to better diagnostic concepts and treatments. From July 2019 to August 2020 patients with RPL and RIF underwent a standardized diagnostic procedure including endometrial biopsies. Immune cell analysis was performed using flow cytometry. Patients were contacted in March 2023 and interviewed concerning their pregnancy outcomes following diagnostics.

RESULTS

Out of 68 patients undergoing endometrial biopsies, 49 patients were finally included. Live birth rates were high with 72% in RPL and 86% in RIF. Immune cell analysis revealed that patients with RPL had more cytotoxic CD56dimCD16high cells, while RIF patients had more CD56+ uNK cells. RPL patients with pregnancy complications showed increased NKT cell percentages.

CONCLUSION

Our findings suggest specific immune changes in RPL and RIF patients, offering potential therapeutic targets. Tailored immunotherapy based on endometrial immunophenotyping might be an option, but further research is needed.

Biopsy-free profiling of the uterine immune system in patients with recurrent pregnancy loss and unexplained infertility

RESEARCH QUESTION

What are the differences in menstrual blood lymphocytes between controls, patients with recurrent pregnancy loss (RPL) and patients with unexplained infertility (uINF)?

DESIGN

Prospective study including 46 healthy controls, 28 RPL and 11 uINF patients. A feasibility study compared lymphocyte compositions of endometrial biopsies and menstrual blood collected during the first 48 h of menstruation in seven controls. In all patients, peripheral and menstrual blood from the first and subsequent 24 h were analysed separately by flow cytometry, focusing on the main lymphocyte populations and natural killer (NK) cell subsets.

RESULTS

The first 24 h of menstrual blood resembles the uterine immune milieu as tested by endometrial biopsy. RPL patients showed significantly higher menstrual blood CD56+ NK cell numbers than controls (mean ± SD: 31.13 ± 7.52% versus 36.73 ± 5.4%, P = 0.002). Menstrual blood CD56dimCD16bright NK cells within the CD56+ NK cell population were decreased in RPL (16.34 ± 14.65%, P = 0.011) and uINF (15.7 ± 5.91%, P = 0.02) patients versus control (20.42 ± 11.53%). uINF patients had the lowest menstrual blood CD3+ T cell counts (38.81 ± 5.04%, control versus uINF: P = 0.01) and cytotoxicity receptors NKp46 and NKG2D on CD56brightCD16dim cells were higher in uINF (68.12 ± 11.84%, P = 0.006; 45.99 ± 13.83%, P = 0.01, respectively) and RPL (NKp46: 66.21 ± 15.36%, P = 0.009) patients versus controls. RPL and uINF patients had higher peripheral CD56+ NK cell counts versus controls (11.42 ± 4.05%, P = 0.021; 12.86 ± 4.29%, P = 0.009 versus 8.4 ± 3.5%).

CONCLUSIONS

Compared with controls, RPL and uINF patients had a different menstrual blood-NK-subtype profile, indicating an altered cytotoxicity. In future studies, this non-invasive analysis might enable identification and monitoring of patients receiving immunomodulatory medications.

Antibiotic-free vaginal microbiota transplant with donor engraftment, dysbiosis resolution and live birth after recurrent pregnancy loss: a proof of concept case study

Background

Vaginal dysbiosis covers imbalances in the vaginal microbiota, defined by altered composition of bacteria, viruses, and fungi and is associated with euploid pregnancy losses, premature birth, infertility, or bacterial vaginosis. A large proportion of women who have vaginal dysbiosis do not experience any symptoms. Antibiotics are the traditional treatment, recently combined with local probiotics in some cases. Vaginal Microbiota Transplantation (VMT) with eubiotic vaginal bacterial microbiota after antibiotic eradication of pathogens has successfully been performed in a case study with five patients, but no VMT has been performed without the use of antibiotics.

Methods

This is a proof of concept case study. The patient was found to have vaginal dysbiosis at the RPL clinic at Copenhagen University Hospital Hvidovre, Denmark on the 23rd of June 2021. She was offered and accepted to receive experimental treatment in the form of a VMT as a compassionate use case. VMT is the transfer of cervicovaginal secretions (CVS) from a healthy donor with a Lactobacillus-dominant vaginal microbiome to a recipient with a dysbiotic vaginal microbiome. CVS is a mixture of e.g., mucus, bacteria, metabolites present in the vaginal canal. Potential donors were thoroughly screened for the absence of STIs, and the most suitable donor sample for the specific patient in this study was determined via an in vitro microbiome competition assay.

Findings

A 30-year-old patient with one livebirth and a complicated pregnancy history of two stillbirths and 1 s trimester pregnancy loss in gestational weeks 27 (2019), 17 (2020) and 23 (2020) respectively with complaints of vaginal irritation and discharge that had aggravated in all her pregnancies. Her vaginal microbiome composition showed a 90% dominance of Gardnerella spp. After one VMT there was a complete shift in microbiome composition to 81.2% L. crispatus and 9% L. jensenii with a concurrent resolvement of vaginal symptoms. Single nucleotide polymorphism-analysis confirmed her microbiome to be of donor origin and it remain stable now 1.5 years after the VMT. Five months after the VMT she became pregnant and has successfully delivered a healthy baby at term.

Interpretation

Here we report a successful VMT with confirmed donor strain engraftment followed by a successful pregnancy and delivery after a series of late pregnancy losses/stillbirths. Findings suggest that VMT is a potential treatment for severe vaginal dysbiosis. Further, larger studies are required.

Funding

The study was partially funded (i.e., analysis costs) by Freya Biosciences Aps, Fruebjergvej, 2100 Copenhagen, Denmark.

Successful isolation of viable stem cells from cryopreserved microfragmented human adipose tissue from patients with knee osteoarthritis - a comparative study of isolation by tissue explant culture and enzymatic digestion

PURPOSE

To investigate if viable stem cells could be isolated and expanded from cryopreserved microfragmented adipose tissue (AT) harvested from patients with knee osteoarthritis.

METHODS

Microfragmented abdominal AT from knee osteoarthritis patients was cryopreserved at -80 °C in cryoprotectant-medium. The samples were thawed for stem cell isolation by tissue explant culture (TEC) and enzymatic digestion (ED), respectively. Viability, population doublings, and doubling time were assessed by trypan blue staining and flow cytometry. Cell type and senescence-associated β-galactosidase activity were analyzed by flow cytometry. Osteogenic and adipogenic differentiation was assessed quantitatively by Alizarin-Red-S and Oil-Red-O staining, respectively.

RESULTS

Microfragmented AT from 7 patients was cryopreserved for a period of 46-150 days (mean (SD) 115.9 days (44.3 days)). Viable stem cells were successfully recovered and expanded from all patients using both isolation methods with no significant difference in viable population doublings or doubling time from passage 1 to 3 (p > 0.05). Low levels of senescence-associated β-galactosidase activity was detected for both methods with no significant difference between TEC and ED (p = 0.17). Stemness was verified by stem cell surface markers and osteogenic and adipogenic differentiation performance. Adventitial stem cells (CD31^-CD34⁺CD45^-CD90⁺CD146^-), pericytes (CD31^-CD34^-CD45^-CD90⁺CD146⁺), transitional pericytes (CD31^-CD34⁺CD45^-CD90⁺CD146⁺), and CD271⁺ stem cells (CD31^-CD45^-CD90⁺CD271⁺) were identified using both methods. More pericytes were present when using TEC (25% (24%)) compared to ED (3% (2%)) at passage 4 (p = 0.04).

CONCLUSIONS

Viable stem cells can be isolated and expanded from cryopreserved microfragmented AT using both TEC and ED. TEC provides more clinically relevant pericytes than ED.

Recurrent Miscarriage: Diagnostic and Therapeutic Procedures. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/050, May 2022)

Purpose The aim of this guideline is to standardize the diagnosis and therapy of recurrent miscarriage (RM) using evidence from the recent literature. This is done by using consistent definitions, objective evaluations and standardized treatment protocols.

Methods When this guideline was compiled, special consideration was given to previous recommendations in prior versions of this guideline and the recommendations of the European Society of Human Reproduction and Embryology, the Royal College of Obstetricians and Gynecologists, the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine, and a detailed individual search of the literature about the different topics was carried out.

Recommendations Recommendations about the diagnostic and therapeutic procedures offered to couples with RM were developed based on the international literature. Special attention was paid to known risk factors such as chromosomal, anatomical, endocrinological, physiological coagulation, psychological, infectious and immune disorders. Recommendations were also developed for those cases where investigations are unable to find any abnormality (idiopathic RM).

Uterine microbiota plasticity during the menstrual cycle: Differences between healthy controls and patients with recurrent miscarriage or implantation failure

In contrast to the former notion of a sterile womb, sequencing techniques have proven a bacterial colonization of the uterus. However, timing of microbiota analysis regarding possible intra-cycle variations as well as specific alterations in patients with recurrent miscarriage (RM) or recurrent implantation failure (RIF) remain unknown. In total, n = 20 RM-, n = 20 RIF-patients and n = 10 healthy controls were included in this prospective study. In every subject, uterine flushing was performed during follicular, ovulatory and luteal phase. Bacterial DNA was isolated and 16S amplicon sequencing analysis of the V3-V4 region was carried out. Diversity measures were compared between samples from the disease groups and the control group separately for each timepoint of the menstrual cycle and over time. In the control group a significant decrease of species richness and evenness was shown around ovulation which remained at this lower level during the luteal phase (Shannon index), indicating a more uniform distribution of microbiota (p < 0.05). This loss of diversity during the menstrual cycle was not apparent in RIF and RM patients. A higher similarity was seen in taxonomic distribution between RM and RIF patients compared to the control group. Longitudinal dynamics included increases in Firmicutes (controls and RM only) and a concomitant loss of Proteobacteria in controls that was not present in RIF and RM. We demonstrate longitudinal intra-cycle-dependent changes in the endometrial microbiota of healthy controls. An increased diversity in both patient groups could be the cause or consequence of a micro-environment that is more prone to pregnancy failures.

Sexual function in male cancer survivors is not correlated to sperm quality

PURPOSE

Both infertility and erectile dysfunction (ED) are known long-term consequences of cancer treatment in young male cancer survivors. In the present study, we aimed to assess whether sperm quality and sexual function in male cancer survivors are associated.

METHODS

In this prospective study, n = 244 patients male cancer survivors who underwent sperm analysis and cryopreservation between 2008 and 2018 prior to the initiation of gonadotoxic treatment were invited. In total n = 50 had a follow-up sperm analysis and completed two questionnaires, the Aging Males' Symptom Scale (AMS) and the International Index of Erectile Function (IIEF-EF). Differences between the individual parameters were analyzed using the Wilcoxon or Mann Whitney test.

RESULTS

Azoospermia was present in n = 16/50 (32.0%) patients at time of follow-up. ED occurred in n = 9/43 (20.9%) patients and was observed more frequently in patients with oligo- or azoospermia than in those with normospermia, even though this association was not statistically significant. Sperm parameters (total sperm count, sperm concentration, progressive motility) did not differ between time of cryopreservation and time of follow-up. Mean total, somatic, psychological, and sexual AMS score was 23.6, 9.9, 6.6, and 6.8, respectively. Mean total IIEF-EF score was 27.3, indicating mainly mild ED.

CONCLUSIONS

More than one-third of cancer patients suffered from azoospermia, and ED was primarily present in this subgroup. We recommend implementing the screening of sexual dysfunction in the annual sperm testing that should be offered to all men after gonadotoxic treatment. Our study highlights the importance of counseling young cancer patients on both aspects-future infertility and sexual function-prior to treatment and at follow-up visits.

P–423 Lower cytotoxicity: Altered natural killer cell activation in recurrent implantation failure

Study question

Within this prospective study, we aim to differentiate immune cell subpopulations in recurrent implantation failure (RIF) patients and fertile controls.

Summary answer

A misbalanced immune profile of NK cell subpopulations is present in RIF patients and might be a potential risk factor that requires further detailed analysis.

What is known already

So far, there is no conclusive opinion on the prognostic value of testing immune cell populations in women with RIF. Increased numbers of cytotoxic (CD56dimCD16bright) peripheral natural killer (pNK)-cells and CD56brightCD16dim mainly in the uterus occurring NK cells (uNK) seemed to be more prevalent in RIF patients. NK cell cytotoxicity is regulated by a complex interaction of activating and inhibiting receptors, such as the NKGD2 and natural cytotoxicity receptors including NKp46, NKp30 and NKp44. Dysregulated pNK cells could affect the adhesion and implantation of the embryo thereby contributing to RIF.

Study design, size, duration

Within this prospective study between March 2018 and August 2020 immune diagnostics of pNK cells and subpopulations as well as regulatory T-cells in RIF patients (defined as ≥ 3 failed fresh or frozen embryo transfers of good quality embryos (Istanbul criteria) and non-pregnant controls (nulli- and multipara) were performed using flow cytometry analysis.

Participants/materials, setting, methods

In total, n = 42 RIF and n = 85 controls were included. Absolute numbers and percentages of total lymphocytes of CD56dimCD16bright, CD56brightCD16dim NK cells, CD45+CD25+FoxP3+-regulatory T-cells and activation markers (CD57+, CD62L+, NKGD2+, NKp46+) were measured in patients and controls (n = 60 nulligravida, n = 25 para) in the mid-luteal phase. Statistical analysis was performed using SPSS Version 26 considering p &lt; 0.05 statistically significant.

Main results and the role of chance

RIF patients showed significantly lower numbers and percentages of CD56dimCD16bright pNK cells (mean±SD per µl: 187,5±113,3 vs. 281,9±163,4 p = 0.001;%: 87,4±8,8 vs. 90,6±6,0 p = 0.017) and higher levels of CD56brightCD16dim pNK cells (mean±SD per%: 10,5±8,3 vs. 7,6±5,5 p = 0.021) compared to controls. Further, lower percentages of CD56dimCD16brightCD62L + (mean±SD per%: 23,5±11,1 vs. 32,0±14,0 p = 0.001), CD56dimCD16brightNKGD2 + (mean±SD per%: 94,0±6,8 vs. 96,4±4,2 p = 0.014) and CD56dimCD16brightNKp46 + (mean±SD per%: 65,8±19,5 vs. 76,1±14,0 p = 0.001) were observed in RIF patients (p &lt; 0.05). A different activation of pNK cells represented by high levels of CD62L+, NKGD2+, NKp46+ surface markers in controls and higher levels of CD56brightCD16dim pNK cells in RIF patients could contribute to RIF. No difference was present in levels of CD45+CD25+FoxP3+-regulatory T-cells within the study population.

Limitations, reasons for caution

As controls composed out of not only nulli- but also multipara, higher levels of pNK cells in controls, could be induced by fetal microchimerism in multiparas, however, results remained significant after removing multipara from statistical analysis.

Wider implications of the findings: These findings condense into the assumption of a non-linear association between NK cytotoxicity and successful pregnancy. A lower NK cytotoxicity in RIF patients could potentially lead to an altered immune environment impeding a successful implantation process.

Trial registration number

Drks00020803

O-128 Intra-cycle alterations of the uterine microbiota in patients with recurrent miscarriage or recurrent implantation failure and healthy controls

Study question

Uterine microbiota: are there differences within three major time points of the menstrual cycle in healthy controls, recurrent miscarriage (RM) and recurrent implantation failure (RIF) patients?

Summary answer

Compared to controls, RM and RIF patients showed an altered uterine microbiota throughout the menstrual cycle, with a lower dominance of lactobacilli.

What is known already

In contrast to the former notion of a sterile womb, bacterial colonization in the uterus and the placenta has been demonstrated. Studies showed that Lactobacillus-dominated endometrial microbiota correlate with reproductive success. Moreover, the presence of non-Lactobacillus-dominated microbiota, especially with detection of Gardnerella and Streptococcus in the endometrial fluid, seems to be associated with lower implantation-, ongoing pregnancy- and live birth-rates. However, intra-cycle variations in healthy women as well as possible alterations in patients with RM or RIF remain unknown.

Study design, size, duration

In total, n = 20 RM patients (≥ 3 consecutive miscarriages), n = 20 RIF patients (≥3 fresh or frozen embryo transfers with negative serum hCG, good quality embryos) and n = 10 healthy controls (no pregnancy) were included in this study. All patients had a 28 day menstrual cycle. During follicular, ovulatory and luteal-phase, after a thorough cleaning of the cervix, a flexible catheter was introduced into the uterine cavity and a uterine flushing with 1ml of NaCl was performed.

Participants/materials, setting, methods

Bacterial DNA was extracted using a QIAamp DNA kit (Qiagen) in combination with a PrecellysR24 homogenizer (Peqlab, Erlangen, Germany) according to the manufacturer’s instructions. The V3-V4 region of the bacterial 16S rRNA gene was amplified. Samples were pooled in equimolar ratios and progressed to pyrosequencing using an Illumina MiSeq se-quencer with MiSeq Kit V2 (250 bp paired-end). Analysis of 16S rRNA data, including alpha- and beta-diversity, were calculated using the phyloseq package in R.

Main results and the role of chance

For the Shannon index (species richness and evenness) a significant decrease during the ovulation period was shown in the control group, indicating a more uniform microbiota (p &lt; 0.05). This loss of diversity was not shown in RIF and RM patients. Overall, we could observe a higher similarity in taxonomic distribution in RM compared to the RIF patients. Longitudinal dynamics included increases in Firmicutes (CTRL and RM only) and a concomitant loss of Proteobacteria. Notably, significant amounts of bacteroides were only detected in the RIF patients. Actinobacteria were more frequent in both, RM and RIF as compared to controls.

Limitations, reasons for caution

To minimize the impact of a potential contamination, we performed pre-experiments with paired samples both from the vaginal fornix and the endometrial cavum and could show a significant difference in overall microbiome configuration. However, the route of sample can still be prone to contamination.

Wider implications of the findings

For the first time, we were able to show cycle-dependent alterations in the endometrial microbiome. These findings underline the role of an altered endometrial microbiome as a cause for RM and RIF and can contribute to the future establishment of therapeutic strategies in cases of a dysbalanced microbiome.

Trial registration number

Drks00020803

P–088 Sexual functioning is impaired in cancer survivors after cancer therapy

Study question

Is impaired sexual functioning correlated to sperm quality in cancer survivors?

Summary answer

Erectile dysfunction affects 25.0% of cancer survivors, independent of sperm quality. 22.9% of patients show symptoms consistent with a reduced testosterone level.

What is known already

Gonadotoxic treatment in male cancer patients can end up in reversible or permanent impaired spermatogenesis, testosterone insufficiency, and sexual dysfunction.

Study design, size, duration

In this prospective single-center study, sexual functioning was assessed in male cancer survivors, who underwent sperm cryopreservation at the Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Austria from 01/2010 to 12/2018. Sexual functioning was assessed between 03–12/2020 via two questionnaires: Aging Male Score (AMS) and International Index of Erectile Function (IEEF-EF).

Participants/materials, setting, methods

Thirty-five cancer survivors (testicular cancer: n = 16 [45.7%], hematological malignancies: n = 15 [42.9%], others: n = 4 [n = 11.4%]) filled in two questionnaires (AMS and IEEF-EF) during routine follow-up visit at the Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck and the Department of Urology, Medical University Innsbruck, Austria. Moreover, sperm quality was assessed and normozoospermia was defined in accordance with the 2010 WHO criteria (sperm concentration ≥15 million/mL, progressive motility ≥32%, and ≥4% normal morphology).

Main results and the role of chance

Mean age at sperm cryopreservation and follow-up visit was 25.1±4.2 and 31.9±6.3 years, respectively with a mean follow-up time of 81.4±12.5 months. Rate of erectile dysfunction was low (75.0% no dysfunction, 15.6% low dysfunction, 3.1% low-moderate dysfunction, 3.1% moderate, 3.1% severe dysfunction). Moreover, AMS score indicated no, low, moderate and severe symptoms consistent with a low testosterone level in 77.1%, 8.6%, 2.9%, and 2.9% of patients, respectively. Oligozoospermia was observed in up to 48% of the patients with TM and in only 23% patients with HM. Patients with TM showed significantly reduced sperm count (18.7 × 106/mL [5.3–43.0]) and total sperm count (42.4 × 106/ejaculate [13.3–108.5]) compared to HM (p = 0.03). There was no difference in sexual functioning between patients with HM or TM. Sexual functioning did no correlate with sperm count, progressive motility or morphology.

Limitations, reasons for caution

Although the study may be limited by its small sample size, it is the first to assess a correlation of sperm quality and sexual dysfunction in cancer survivors.

Wider implications of the findings: As every fourth male cancer patient suffers from impaired sexual functioning after gonadotoxic treatment, this important topic should be addressed in clinical and scientific future. Future studies should focus on both, somatic and psychosomatic reasons for sexual dysfunction.

Trial registration number

none

Definition, diagnostic and therapeutic options in recurrent implantation failure: an international survey of clinicians and embryologists

STUDY QUESTION

What is the global variability in recurrent implantation failure (RIF) definition, investigation and therapy, currently offered to patients undergoing IVF?

SUMAMRY ANSWER

Definitions, diagnostic investigations and treatments offered to RIF patients differ widely amongst assisted reproduction healthcare professionals and clinical guidelines on RIF are urgently needed.

WHAT IS KNOWN ALREADY

RIF affects around 10% of patients undergoing IVF worldwide. There is no consensus on the definition of RIF, its diagnostic investigations or the therapeutic options, which leads to inconsistencies in clinical practice.

STUDY DESIGN, SIZE, DURATION

A cross-sectional study of clinicians and embryologists was conducted between May and June 2020. The survey included 43 questions aimed at understanding participants' background and their current practice with regards to defining, investigating and managing RIF. The questions were designed by the European Society of Human Reproduction and Embryology (ESHRE) Special Interest Group (SIG) on implantation and early pregnancy following three consensus meetings.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 8579 ESHRE members from 6916 IVF centers were invited to participate using two global email calls based on their pre-specified interest in implantation and early pregnancy. SurveyMonkey and SPSS were used for data collection and analysis, respectively. Furthermore, differences were reported in the answers of European and non-European professionals, as well as between public and private settings and among clinicians clustered according to the average number of RIF patients treated per year.

MAIN RESULTS AND THE ROLE OF CHANCE

The final data set included 735 clinicians and 300 embryologist or IVF-biologists. The majority defines RIF based on the number of failed embryo transfers (ETs) with the most common threshold adopted being three ETs both fresh and frozen. More than two-thirds take lifestyle factors into account, mainly drugs, smoking and BMI. The highest consensus on which diagnostic investigations should be performed was reached for anatomical malformations and gynecological aspects focusing on hydrosalpinx, Asherman's syndrome, endometrial thickness and endometriosis. Concerning treatment of RIF patients, the highest consensus was reached for preconceptional therapies, including BMI adjustment, smoking and endometritis followed by therapies during IVF procedures.

LIMITATIONS, REASONS FOR CAUTION

The response rate was relatively low, but comparable to other surveys.

WIDER IMPLICATIONS OF THE FINDINGS

A consensus on definition, diagnosis and treatment of RIF would help to reduce costly, time-consuming and poorly validated approaches.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used. B.T. received support from Bayer for Clinical trials concerning endometriosis and Ferring for clinical trials concerning ovarian stimulation. She received reimbursement for travel expenses from Astropharm, Ferring. Dr Kade and is a shareholder of Reprognostics. She is a board member of the Austrian Society for Obstetrics and Gynecology (OEGGG), the associate head of the 'Reproduktionsmedizinische Zentren Baden-Württemberg' (RZBW), a member of guideline group of the German Society for Obstetrics and Gynecology (DGGG) and an editorial board member of the following journals: American Journal of Reproductive Immunology (AJRI), Archives of Gynecology and Obstetrics. All the other authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Recurrent Spontaneous Miscarriage: a Comparison of International Guidelines

While roughly 30% of all women experience a spontaneous miscarriage in their lifetime, the incidence of recurrent (habitual) spontaneous miscarriage is 1 – 3% depending on the employed definition. The established risk factors include endocrine, anatomical, infection-related, genetic, haemostasis-related and immunological factors. Diagnosis is made more difficult by the sometimes diverging recommendations of the respective international specialist societies. The present study is therefore intended to provide a comparison of existing international guidelines and recommendations. The guidelines of the ESHRE, ASRM, the DGGG/OEGGG/SGGG and the recommendations of the RCOG were analysed. It was shown that investigation is indicated after 2 clinical pregnancies and the diagnosis should be made using a standardised timetable that includes the most frequent causes of spontaneous miscarriage. The guidelines concur that anatomical malformations, antiphospholipid syndrome and thyroid dysfunction should be excluded. Moreover, the guidelines recommend carrying out pre-conception chromosomal analysis of both partners (or of the aborted material). Other risk factors have not been included in the recommendations by all specialist societies, on the one hand because of a lack of diagnostic criteria (luteal phase insufficiency) and on the other hand because of the different age of the guidelines (chronic endometritis). In addition, various economic and consensus aspects in producing the guidelines influence the individual recommendations. An understanding of the underlying decision-making process should lead in practice to the best individual diagnosis and resulting treatment being offered to each couple.

Sperm banking before gonadotoxic treatment: is it worth the effort?

We aimed to compare the sperm quality in different cancer types and benign diseases before gonadotoxic treatment, and assess the usage rate of cryopreserved sperm for assisted reproductive treatment (ART). This retrospective study was conducted at two university clinics between January 2008 and July 2018. A total of 545 patients suffering from cancer or benign diseases were included in the study. The pretreatment sperm analyses were based on the World Health Organization (WHO) guidelines. Patients with testicular malignancy (TM) showed a significantly lower sperm count (median [interquartile range]: 18.7 × 10⁶ [5.3 × 10⁶–43.0 × 10⁶] ml⁻¹; P = 0.03) as well as total sperm count (42.4 × 10⁶ [13.3 × 10⁶–108.5 × 10⁶] per ejaculate; P = 0.007) compared to other malignant and benign diseases. In addition, patients with nonseminomatous TM showed the lowest sperm count (14.3 × 10⁶ [6.0 × 10⁶–29.9 × 10⁶] ml⁻¹, vs seminomas: 16.5 × 10⁶ [4.6 × 10⁶–20.3 × 10⁶] ml⁻¹; P = 0.001). With reference to the WHO 2010 guidelines, approximately 48.0% of the patients with TM and 23.0% with hematological malignancies (HM) had oligozoospermia. During the observation period, only 29 patients (5.3%) used their frozen sperms for 48 ART cycles, resulting in 15 clinical pregnancies and 10 live births. The sperm quality varies with the type of underlying disease, with TM and HM patients showing the lowest sperm counts. Due to the observed low usage rate of cryopreserved sperm, further patient interviews and sperm analyses should be included in the routine oncologic protocols to avoid unnecessary storage expenses. However, sperm banking is worth the effort as it provides hope for men who cannot reproduce naturally after gonadotoxic treatment.

Bedeutung der Fertilitätschirurgie bei Kinderwunsch

Die Bedeutung der Fertilitätschirurgie bei Kinderwunsch kann vielfach aufgrund fehlender eigener Erfahrung während der Facharztweiterbildung nicht erfasst werden, da nur an wenigen Zentren eine spezifische operative Ausbildung erfolgt. Neben der Abklärung anatomischer Fehlbildungen mittels Hysteroskopie bzw. Laparoskopie gehört die operative Myom- und Endometriosebehandlung zu den Standardverfahren der Fertilitätschirurgie. Hier ist die Erfahrung der Reproduktionsmediziner gefragt, damit unter maximaler Schonung der Ovarreserve ein bestmöglichstes Ergebnis hinsichtlich Endometriosesanierung bzw. Myomenukleation erreicht wird. Die Abklärung der Tubendurchgängigkeit mit Chromopertubation ist nach wie vor Goldstandard, auch wenn im ambulanten Sektor vorwiegend nichtoperative Verfahren zum Einsatz kommen. Die diagnostische und gegebenenfalls operative Hysteroskopie dient der Beurteilung des Endometriums und erlaubt den Ausschluss von Entzündungsprozessen oder dem Vorliegen von Polypen.

Immunological Risk Factors in Recurrent Pregnancy Loss: Guidelines Versus Current State of the Art

Around 1-5% of all couples experience recurrent pregnancy loss (RPL). Established risk factors include anatomical, genetic, endocrine, and hemostatic alterations. With around 50% of idiopathic cases, immunological risk factors are getting into the scientific focus, however international guidelines hardly take them into account. Within this review, the current state of immunological risk factors in RPL in international guidelines of the European Society of Reproduction and Embryology (ESHRE), American Society of Reproductive Medicine (ASRM), German/Austrian/Swiss Society of Obstetrics and Gynecology (DGGG/OEGGG/SGGG) and the Royal College of Obstetricians and Gynecologists (RCOG) are evaluated. Special attention was drawn to recommendations in the guidelines regarding diagnostic factors such as autoantibodies, natural killer cells, regulatory T cells, dendritic cells, plasma cells, and human leukocyte antigen system (HLA)-sharing as well as treatment options such as corticosteroids, intralipids, intravenous immunoglobulins, aspirin and heparin in RPL. Finally, the current state of the art focusing on both diagnostic and therapeutic options was summarized.

Different Background: Natural Killer Cell Profiles in Secondary versus Primary Recurrent Pregnancy Loss

(1) Background: Prior studies suggested a significant impact of previous live births on peripheral natural killer cells (pNK) in patients with recurrent pregnancy loss (RPL). Patients with primary RPL (pRPL, no live birth) showed higher numbers of pNK than secondary RPL patients (sRPL, ≥ 1 live birth). (2) Methods: To further determine immunological differences between RPL patients and controls, we analysed pNK subpopulations and activation markers in pRPL (n = 47), sRPL (n = 24) and controls with previous live birth (sCtrl, n = 25) and nullipara (pCtrl, n = 60) within a prospective study. Percentages and numbers of CD56dimCD16bright cells, subpopulations and activation markers (CD57+, CD62L+, NKG2D+, NKp46+) were measured in non-pregnant RPL patients and n = 85 controls (n = 60 pCtrl, n = 25 sCtrl) in the mid-luteal phase by flow cytometry. (3) Results: Compared to sRPL patients, sCtrls showed higher CD56+ and CD56dimCD16bright numbers. Further, sRPL patients showed lower numbers of CD56dimCD16brightNKG2D+ and CD56dimCD16brightNKp46+ than sCtrls. (4) Conclusion: We suggest a chronic immune stimulation leading to a lower NK-cell count in sRPL patients with a lower NK cytotoxicity. This underlines the necessity to investigate pNK subpopulations as well as pRPL and sRPL separately to delineate the immune alterations in RPL.

Recurrent miscarriage is not associated with a higher prevalence of inherited and acquired thrombophilia

PROBLEM

Although not being recommended in guidelines, many physicians perform routine screening for thrombophilia in RM patients suspecting a higher prevalence in these patients. The aim of this study was to analyze the prevalence of inherited and acquired thrombophilia in a large cohort of RM patients.

METHOD OF STUDY

Within a multicenter case-control study, n = 820 RM patients and n = 141 controls were included. The prevalence of inherited and acquired thrombophilia including deficiency of protein C/S and antithrombin, elevation of factor VIII activity, APC resistance including mutation in the factor V Leiden gene, mutation in the prothrombin gene and antiphospholipid antibodies were assessed. Further, we performed a meta-analysis of the prevalence of thrombophilia in RM patients including studies between 01/2000 and 01/2020.

RESULTS

An antiphospholipid syndrome (APLS) was only present in RM patients. Increased factor VIII concentration was significantly more prevalent in controls (RM vs controls: 5.8% vs 11.0%). None of the other thrombophilia did differ significantly between RM patients and controls. The meta-analysis revealed no significant difference in the occurrence of these thrombophilia between RM patients and controls.

CONCLUSION

The prevalence of inherited thrombophilia does not differ between RM patients and controls. When analyzing rare events like thrombophilia, a high number of patients are needed to obtain reliable results, which might explain contradictory findings in previous studies analyzing small cohorts of RM patients. Despite being less prevalent than previously described, we still recommend screening for APLS as it is associated with severe pregnancy complications.

Diagnosis and Therapy Before Assisted Reproductive Treatments. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Register Number 015-085, February 2019) - Part 1, Basic Assessment of the Woman

Introduction Supporting and counselling couples with fertility issues prior to starting ART is a multidisciplinary diagnostic and therapeutic challenge. The first German/Austrian/Swiss interdisciplinary S2k guideline on "Diagnosis and Therapy Before Assisted Reproductive Treatments (ART)" was published in February 2019. This guideline was developed in the context of the guidelines program of the German Society of Gynecology and Obstetrics (DGGG) in cooperation with the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). Aims One third of the causes of involuntary childlessness are still unclear, even if the woman or man have numerous possible risk factors. Because the topic is still very much taboo, couples may be socially isolated and often only present quite late to a fertility center. At present, there is no standard treatment concept, as currently no standard multidisciplinary procedures exist for the diagnostic workup and treatment of infertility. The aim of this guideline is to provide physicians with evidence-based recommendations for counselling, diagnostic workup and treatment. Methods This S2k guideline was developed on behalf of the Guidelines Commission of the DGGG by representative members from different professional medical organizations and societies using a structured consensus process. Recommendations The first part of this guideline focuses on the basic assessment of affected women, including standard anatomical and endocrinological diagnostic procedures and examinations into any potential infections. Other areas addressed in this guideline are the immunological workup with an evaluation of the patient's vaccination status, an evaluation of psychological factors, and the collection of data relating to other relevant factors affecting infertility. The second part will focus on explanations of diagnostic procedures compiled in collaboration with specialists from other medical specialties such as andrologists, human geneticists and oncologists.

Diagnosis and Treatment Before Assisted Reproductive Treatments. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Register Number 015-085, February 2019) - Part 2, Hemostaseology, Andrology, Genetics and History of Malignant Disease

Introduction Supporting and counselling couples with fertility issues prior to starting ART is a multidisciplinary diagnostic and therapeutic challenge. The first German-language interdisciplinary S2k guideline on "Diagnosis and Therapy Before Assisted Reproductive Treatments (ART)" was published in February 2019. The guideline was developed in the context of the guidelines program of the German Society of Gynecology and Obstetrics (DGGG) in cooperation with the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). Aim In one third of cases, the cause of involuntary childlessness remains unclear, even if the woman or man have numerous possible risk factors. Because the topic is still very much taboo, couples may be socially isolated and often only present quite late to a fertility center. There is no standard treatment concept for these patients at present, as there are currently no standard multidisciplinary procedures for the diagnostic workup and treatment of infertility. The aim of this guideline is to provide physicians with evidence-based recommendations for counselling, diagnosis and treatment. Methods This S2k guideline was developed on behalf of the Guidelines Commission of the DGGG by representative members from different professional medical organizations and societies using a structured consensus process. Recommendations This second part of the guideline describes the hematological workup for women as well as additional diagnostic procedures which can be used to investigate couples and which are carried out in cooperation with physicians working in other medical fields such as andrologists, geneticists and oncologists.

The impact of previous live births on peripheral and uterine natural killer cells in patients with recurrent miscarriage

BACKGROUND

Peripheral and uterine natural killer cells (pNK and uNK cells) are key players in the establishment and maintenance of pregnancy and are disturbed in patients with recurrent miscarriage (RM). Different immunologic risk factors have been proposed between patients with primary RM (pRM, no previous live birth) and secondary RM (sRM, ≥ 1 previous live birth). However, so far, the study populations mainly consisted of small subgroups. Therefore, we aimed to analyse pNK and uNK cells in a large, well defined study population within a prospective study.

METHODS

In total, n = 575 RM patients (n = 393 pRM, n = 182 sRM) were screened according to a standard protocol for established risk factors as well as pNK and uNK cells. Peripheral blood levels of CD45⁺CD3^-CD56⁺CD16⁺ NK cells were determined by flow cytometry and uterine CD56⁺ NK cells by immunohistochemistry in mid-luteal non-pregnant RM patients. Exclusion of patients with ≥1 established risk factor revealed n = 248 idiopathic RM patients (iRM, n = 167 primary iRM (ipRM), n = 81 secondary iRM (isRM)).

RESULTS

Patients with pRM and ipRM showed significant higher absolute numbers and percentages of pNK cells compared to sRM and isRM patients (pRM/ipRM vs sRM/isRM, mean ± SD /μl: 239.1 ± 118.7/244.9 ± 112.9 vs 205.1 ± 107.9/206.0 ± 105.6, p = 0.004/ p = 0.009; mean ± SD %: 12.4 ± 5.5/12.8 ± 5.4 vs 11.1 ± 4.6/11.1 ± 4.3, p = 0.001; p = 0.002). Only patients with isRM showed significantly higher uNK levels compared to patients with ipRM (mean ± SD /mm² 288.4 ± 239.3 vs 218.2 ± 184.5, p = 0.044).

CONCLUSIONS

The demonstrated differences in pNK and uNK cells in RM patients depending on previous live birth might indicate differences in NK cell recruitment and potentially different underlying immune disorders between pRM and sRM. As there is an overlap in the distribution of the NK cell results, further studies with focus on NK cell function are needed in order to clearly identify RM patients with distinct immune abnormalities. The clinical relevance of our findings should be interpreted cautiously until specificity and sensitivity are further evaluated.

Higher prevalence of colonization with Gardnerella vaginalis and gram-negative anaerobes in patients with recurrent miscarriage and elevated peripheral natural killer cells

The role of vaginal infections in recurrent miscarriage (RM) is discussed controversially and screening is not recommended in international guidelines. Peripheral and uterine NK cells (pNK, uNK) play an important role in the establishment of a healthy pregnancy and are targets of immune diagnostics in RM patients. The aim of this study was to analyze the composition of the vaginal microbiota in RM patients and to correlate the findings to clinical characteristics as well as NK cell parameters. In total, n=243 RM patients with ≥3 consecutive miscarriages were recruited between 11/2011 and 03/2016. Vaginal swabs were analyzed by microbiological culture. Further, a cervical swab was taken in n=187 patients and the presence of Chlamydia trachomatis was evaluated by a molecular assay. Peripheral blood levels of CD45+CD3-CD56+CD16+ pNK (determined by four-color fluorescence flow cytometry) and CD56+ uNK (uterine biopsy, determined by immunohistochemistry) were analyzed. The prevalence of Gardnerella vaginalis colonization in RM patients was 19.0%, gram-negative anaerobes 20.5%, Candida species 7.9%, group B Streptococcus 11.0% and Enterobacteriaceae 14.8%. Commensal lactobacilli were absent in 14.5% of the women. Chlamydia trachomatis was detected in n=1 case (0.53%). The prevalence of Gardnerella vaginalis and gram-negative anaerobes in RM patients with elevated pNK (>280/μl, n=69) was significantly higher (p=0.012, p=0.04) compared to patients with normal pNK (n=174). In conclusion, RM patients with elevated pNK suffer more often from colonization by Gardnerella vaginalis and gram-negative anaerobes. This might indicate an association between the vaginal microbiota, local inflammation, changes in immune parameters and miscarriage.

Pre-Pregnancy Levels of Peripheral Natural Killer Cells as Markers for Immunomodulatory Treatment in Patients with Recurrent Miscarriage

Immunological risk factors in patients with recurrent miscarriage (RM) are discussed controversially. Abnormalities of natural killer cells (NK) have been described in RM patients. Lipid infusions are known to modulate lymphocyte subsets. The aim of this study was to identify immune parameters that predict success of treatment with lipid infusions in RM patients with elevated NK. In sum, n = 341 couples with RM were screened for established risk factors and peripheral lymphocyte subpopulations as well as uterine NK cells. We identified n = 136 patients with ≥ 2 consecutive RM and elevated NK. So far, n = 40 RM patients with NK disorders were treated with lipid infusions starting at positive pregnancy test, every 2 weeks until 12 + 0 weeks of gestation (GW) or miscarriage. The pre-pregnancy immune diagnostics in idiopathic RM (iRM) patients with ongoing pregnancy were compared to the group with miscarriages and healthy controls (n = 15). Pre-pregnancy immune diagnostics differed significantly between the groups, with significant higher levels of peripheral NK (% and /µL) in iRM patients who miscarried again compared to controls (p = 0.0035 and p = 0.0019). Furthermore, iRM patients show lower percentages of CD3⁺ lymphocytes than healthy controls (p = 0.0049). In n = 22/40 (55%) patients, pregnancy is ongoing >12 + 0 GW. RM patients with very high pre-pregnancy peripheral NK (pNK) lymphocytes might not benefit from lipid infusions. Pre-pregnancy immunomodulatory treatment in RM patients might be helpful to lower pNK levels and establish an immune environment which is supportive for fetal development.

The "killer cell story" in recurrent miscarriage: Association between activated peripheral lymphocytes and uterine natural killer cells

Peripheral and uterine NK cells (pNK, uNK) can be distinguished according to their receptor expression. Recent studies indicate an association of elevated pNK and uNK with recurrent miscarriage (RM). This study aimed to analyze pNK and uNK in patients with RM and healthy controls. Out of n=590 RM patients screened according to a standard diagnostic protocol, n=268 couples with ≥3 consecutive RM were identified. Subgroups consisted of n=151 primary RM (pRM), n=85 secondary RM (sRM), n=32 tertiary RM (tRM) and n=42 healthy controls. Finally, n=147 idiopathic RM (iRM) and n=121 non-iRM patients were identified. Peripheral blood levels of CD45+CD3-CD56+CD16+ NK cells were determined in non-pregnant patients and controls in the mid-luteal phase by FACS. In n=129 RM patients a uterine biopsy was taken to evaluate CD56+ NK cells by immunohistochemistry. PRM showed higher absolute pNK than sRM (median/μl (Q1;Q3): 234 (147;306) vs 176 (128;245), p=0.02). Further a trend towards higher pNK percentages in pRM was detected. UNK numbers did not differ between RM subgroups and did not correlate with pNK. However, the rate of highly elevated uNK was increased in iRM compared to non-iRM patients (p=0.04). Further, higher numbers of CD45+CD3-DR+ (p<0.01) and CD45+CD3+CD8+DR+ (p=0.04) peripheral lymphocytes were associated with higher uNK numbers. In conclusion, elevated pNK were present in pRM patients. Although pNK and uNK numbers did not correlate, the association between high CD45+CD3-DR+ and CD45+CD3+CD8+DR+ peripheral lymphocytes and uNK might indicate that activated NK, B and T cells provide cytokines for the differentiation of uNK.

Reduced cortical thickness and its association with social reactivity in children with autism spectrum disorder

Symptomatology and behavioral characteristics in autism spectrum disorders (ASD) have increasingly been linked to abnormalities in early brain growth patterns of affected children. Studies investigating specific components of gray matter structure, such as cortical thickness (CT), have produced conflicting results, and have rarely included additional measures of social impairment. In the present study, we applied a surface-based whole brain analysis to investigate CT in a sample of 36 pre-adolescent children [18 subjects with ASD (IQ mean: 111) and 18 healthy controls (IQ mean: 112.8), age range 6-12 years]. The CT analysis revealed widespread, but mostly left-hemispheric thinning in frontal, temporal, parietal and occipital brain areas related to the theory-of-mind network and the heteromodal association cortex. In an exploratory analysis, CT was observed to be differently associated with social impairment in children with ASD compared with typically developing children. The affected neuroanatomical regions are related to characteristic deficits in language, cognition and behavior that are often observed in the disorder. The relationship between social impairment and CT in children with ASD and controls seems to indicate aberrant developmental trajectories in ASD emerging early in life.

Volumetric alterations in the heteromodal association cortex in children with autism spectrum disorder

BACKGROUND

We investigated if alterations in higher-order association areas related to schizophrenia, namely the heteromodal association cortex (HASC), are also observable in subjects with autism spectrum disorder (ASD).

METHODS

A group of 18 children with ASD and 18 healthy controls (HC) underwent magnetic resonance imaging (MRI). The examination comprised an analysis of group differences in gray matter (GM) volume, surface area (SA) and hemispheric lateralization.

RESULTS

Differences in GM volumes in children with ASD and HC were detected in frontal and parietal areas related to the HASC. No HASC structure that showed changes in GM volume exhibited differences in SA. Alterations in hemispheric lateralization between ASD and HC are seen in a frontal area of the HASC.

CONCLUSIONS

Our results indicate that changes in HASC areas are not restricted to schizophrenia, but extend to other psychiatric disorders, namely ASD. The lacking group differences in SA indicate that changes in GM volume are possibly evoked by other variables than SA in children with ASD.

[Structural connectivity and diffusion tensor imaging in autism spectrum disorders]

Over the past years, diffusion tensor imaging (DTI) has become an important brain-imaging technique in neuropsychiatric research. DTI allows noninvasive visualization of white matter tracts. In addition, with DTI it is possible to quantify the structural integrity of the investigated fiber tracts. In child and adolescent psychiatry, DTI has become an increasingly important research tool, especially for conditions like autism spectrum disorders (ASD). Yet, correct interpretation of DTI findings can be challenging, especially for clinicians. Thus, the present review article explains the basic principles of this frequently used imaging technique as well as essential indices, like fractional anisotropy, radial, mean, and axial diffusivity and its two main applications, fibertracking and whole brain analysis. The strengths and weaknesses as well as future perspectives are discussed in light of DTI studies in children and adolescents with ASD.

Fronto-temporal disconnectivity and symptom severity in children with autism spectrum disorder

OBJECTIVES

There is increasing evidence that many of the core behavioural impairments in autism spectrum disorders (ASD) emerge from disconnectivity of networks that are important for social communication. The present study aimed at investigating which specific fibre tracts are impaired in ASD and if possible alterations of white matter are associated with clinical symptomatology.

METHODS

Eighteen children with ASD and 18 carefully matched typically developing controls aged 6-12 years were examined using diffusion tensor imaging (DTI) and voxel-based morphometry (VBM). Fractional anisotropy (FA) values were correlated with symptom severity as indexed by the children's scores on the Autisms Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview-Revised (ADI-R).

RESULTS

Decreased FA values were identified for the fornix (FO), the superior longitudinal fasciculus (SLF) the corpus callosum and the uncinate fasciculus (UF) in the ASD group compared to controls, with most prominent differences in the UF bilaterally and the right SLF. FA values of affected fibre tracts were negatively associated with clinical measures of autistic symptomatology. We did not observe significantly altered grey or white matter concentration after correction for multiple comparisons.

CONCLUSION

Our findings support the hypothesis of abnormal white matter microstructure of fronto-temporal cortical networks in ASD, which are associated with core symptoms of the disorder.