The selective use of heparin/aspirin therapy, alone or in combination with intravenous immunoglobulin G, in the management of antiphospholipid antibody-positive women undergoing in vitro fertilization

Antiphospholipid antibodies and infertility

Antiphospholipid antibodies (aPL) are an established cause of recurrent pregnancy loss. As defective embryonic implantation is a common link between unexplained infertility and recurrent miscarriage, interest has focused on the potential relationship between aPL and implantation failure after in vitro fertilization and embryo transfer (IVF-ET). This review critically examines the published data to determine whether women undergoing IVF-ET should be routinely screened for aPL. Although most studies have reported an increased prevalence of aPL among women undergoing IVF-ET, prospective studies examining the effect of aPL on the outcome of IVF-ET demonstrate that these antibodies do not significantly affect either the implantation or ongoing pregnancy rates. The increased prevalence of aPL among women with infertility is therefore likely to be part of a generalized autoimmune disturbance associated with infertility. Hence routine screening for aPL among women undergoing IVF-ET is not warranted and therapeutic interventions should be used only in well designed randomized controlled trials.

Evaluation of the couple with infertility in a managed care environment

The classic infertility evaluation is a costly experience for many couples. In the new era of managed care, it may be possible to perform a targeted evaluation that, while significantly lowering the total cost, will not impair our ability to correctly diagnose the cause of a couple's infertility. When combined with algorithms for streamlined treatment, it may be possible to significantly reduce the cost for the diagnosis and treatment of infertility.

Treatment of repeated unexplained in vitro fertilization failure with intravenous immunoglobulin: a randomized, placebo-controlled Canadian trial

OBJECTIVE

To evaluate the effect of intravenous immunoglobulin (IVIG) on pregnancy outcome in couples with repeated unexplained in vitro fertilization (IVF) failure.

DESIGN

Prospective, randomized, double blind, placebo-controlled clinical trial.

SETTING

A university-based and a free-standing IVF program.

PATIENT(S)

Fifty-one couples with a history of repeated unexplained IVF failure who were preparing for another fresh IVF cycle or replacement of cryopreserved embryos.

INTERVENTION(S)

Eligible women underwent a standard IVF stimulation using a long luteal phase GnRH analog protocol. Cryopreserved embryos were replaced after endometrial preparation with oral micronized estradiol and subsequent vaginal progesterone. The women were randomly selected to receive IVIG (500 mg/kg) or an equivalent volume of normal saline. The first infusion was given on the day of embryo transfer or during the preceding 72 hours. The second infusion was given 4 weeks later if a clinical pregnancy was confirmed by ultrasound.

MAIN OUTCOME MEASURE(S)

Live-birth rates.

RESULT(S)

Overall, the live-birth rates were 4/26 (15%) for the IVIG group and 3/25 (12%) for the placebo group (P=0. 52). There were 39 fresh IVF cycles, which yielded a clinical pregnancy rate of 28%, with live-birth rates of 4/21 (19%) for the IVIG group and 3/18 (17%) for the placebo group (P=0.59).

CONCLUSION(S)

In this randomized clinical trial, IVIG did not improve the live-birth rate in couples with repeated unexplained IVF failure, stringently defined by known determinants of IVF outcome.

Antibodies to phosphatidylethanolamine and phosphatidylserine are associated with increased natural killer cell activity in non-male factor infertility patients

Antiphospholipid antibodies (APA) have been identified in patients with recurrent pregnancy loss and IVF failure. Of these, antiphosphatidylethanolamine (aPE) and antiphosphatidylserine (aPS) may have special significance. A link between increased natural killer cell activity (NKa+) and trophoblast cell apoptosis has also been reported. This study was undertaken to determine how the APA profile was associated with peripheral NK cell activity. We evaluated 197 female IVF candidates for APA and NKa. Eighty-nine patients (45%) were APA+ and of these, 51 (57%) were aPE/aPS+. Fifty-four patients (27%) had increased NK cell activity. Some 51% of APA+ and 78% of aPE/aPS+ patients had increased NK cell activity compared with 8% and 13% when APA and aPE/aPS tested negative respectively (P: < 0.0001). Non-male factor infertility patients were APA+ and NKa+ in 57% and 34% of cases respectively, compared with 19% and 13% if a pure male factor was present. Some 88% of aPE/aPS+, non-male factor patients had increased NK cell activity, compared with 12% who tested aPE/aPS negative (P: < 0.0001) and 25% of aPE/aPS+, isolated male factor patients (P: < 0.0001). These findings establish a direct relationship between APA (specifically aPE/aPS) and increased peripheral NK cell activity among non-male factor infertility patients. It is possible that APA do not directly cause reproductive failure but rather function as markers or intermediaries for an underlying, abnormal activation of cellular immunity.

Treatment of the antiphospholipid antibody syndrome: progress in the last five years?

The gold standard for treatment of the antiphospholipid antibody syndrome (APS) after thrombosis remains high-intensity warfarin, and, in pregnancy, heparin and aspirin. Exciting developments include the potential role of hydroxychloroquine as a prophylactic drug, stem cell transplantation, and B-cell tolerance. Animal models appear to be a fruitful "proving ground" of new therapies. The introduction of revised classification criteria for APS should aid in appropriate characterization of, and selection of, patients for clinical trials.

Pregnancy in lupus

Patients with systemic lupus erythematosus with established disease have poorer pregnancy outcomes than do women with later onset disease. Active renal disease and maternal hypertension are important predictors of fetal loss and premature birth, respectively. Placental pathology in SLE patients is characterized by decidual vasculopathy and infarction, and in APLS patients, infarction can be extensive. Maternal anti-52 kD SSA/Ro by immunoblot continues to be an important risk factor for having a child with heart block. The risk of having a subsequent child with congenital heart block ranges between 12-16%. Childhood morbidity with heart block is high, with 63% eventually requiring pacemakers. In APLS, antiB2GP-I antibodies can have a significant role in the diagnosis, especially when the traditional assays for aCL antibodies and LAC are negative. Some obstetricians have found that IVIG improves the birthrate in aPL positive women who have recurrent spontaneous abortions after IVF.

A rational basis for the use of combined heparin/aspirin and IVIG immunotherapy in the treatment of recurrent IVF failure associated with antiphospholipid antibodies

PROBLEMS

1) Does the administration of heparin and aspirin (H/A) in combination with intravenous immunoglobulin G (IVIG) improve in vitro fertilization (IVF) implantation and birth rates in patients with recurrent IVF failure? 2) Is the effect of such treatment related to the antiphospholipid antibody (APA) status of the patients concerned?

METHOD OF STUDY

Subjects consisted of 89 women younger than 36 years of age whose infertility was a result of causes other than male infertility and who had experienced four or more failed IVF/embryo transfer procedures. Fifty-two women were APA+ (group A), and 37 were APA- (group B). All patients, regardless of their APA status, received H/A (5000 U sq bid), aspirin (81 mg po qd) from the inception of menotropin therapy along with IVIG (20 g) through a single infusion 3 to 10 days before egg retrieval.

RESULTS

Twenty-two (42%) of group A and 7 (19%) of group B patients achieved live births (P = 0.020).

CONCLUSIONS

IVF outcome is significantly improved when H/A and IVIG are administered to APA+ women with repeat IVF failures. APA- women do not seem to benefit from such treatment.