Antinuclear antibodies positivity in women in reproductive age: From infertility to adverse obstetrical outcomes - A meta-analysis

ANA-positive versus ANA-negative Antiphospholipid Antibody-positive Patients: Results from the Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking (APS ACTION) Clinical Database and Repository ("Registry")

OBJECTIVES

This study focused on the prevalence and impact of ANA in aPL-positive patients without concomitant systemic autoimmune rheumatic diseases (SARDs).

METHODS

Data from aPL-positive patients with or without Revised Sapporo APS classification criteria were retrieved from the Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking (APS ACTION) Registry. Patients with concomitant SARDs were excluded.

RESULTS

A total of 430 aPL-positive patients were included in the analysis, 56% ANA-positive (ANA+) and 44% ANA-negative (ANA-). ANA positivity was significantly associated with history of haematologic manifestations (persistent autoimmune haemolytic anaemia, thrombocytopenia, leukopenia and/or lymphopenia) (16% of ANA+ vs 7% of ANA-, P = 0.006). Triple aPL-positivity was more frequent in the ANA+ subgroup (P = 0.02), along with low baseline C3 and C4 levels (P = 0.05 and P = 0.009, respectively), and higher frequency for ENA. Among aPL-positive patients with no APS classification, ANA+ patients showed a higher rate of arthritis (P = 0.006). Among female patients who have experienced at least one pregnancy, 113 were ANA+ and 96 were ANA-; ANA- patients had a higher number of pregnancies (P = 0.018), and number of live births (P = 0.014). A wider proportion of ANA+ patients were treated with HCQ (P < 0.001).

CONCLUSION

When we analysed aPL-positive patients with no other SARDs, ANA status was not associated with thrombosis or pregnancy morbidity. Interestingly, ANA+ patients showed higher rates of systemic autoimmune features, including haematologic manifestations, multiple aPL positivity, lower complement levels, ENA positivity, and joint involvement, and were more often treated with HCQ. Finally, aPL-positive subjects who were ANA- had a higher rate of pregnancies and live births.

Exploring the Immunological Aspects and Treatments of Recurrent Pregnancy Loss and Recurrent Implantation Failure

Recurrent pregnancy loss (RPL) is defined as the occurrence of two or more consecutive pregnancy losses before 24 weeks of gestation. It affects 3-5% of women who are attempting to conceive. RPL can stem from a variety of causes and is frequently associated with psychological distress and a diminished quality of life. By contrast, recurrent implantation failure (RIF) refers to the inability to achieve a successful pregnancy after three or more high-quality embryo transfers or at least two instances of egg donation. RIF shares several causative factors with RPL. The immunological underpinnings of these conditions involve alterations in uterine NK cells, reductions in M2 macrophages and myeloid-derived suppressor cells, an increased Th1/Th2 ratio, a decreased Treg/Th17 ratio, the presence of shared ≥3 HLA alleles between partners, and autoimmune disorders. Various therapeutic approaches have been employed to address these immunological concerns, achieving varying degrees of success, although some therapies remain contentious within the medical community. This review intends to explore the immunological factors implicated in RPL and RIF and to analyze the immunological treatments employed for these conditions, which may include steroids, intravenous immunoglobulins, calcineurin inhibitors, anti-TNF antibodies, intralipid infusions, granulocyte colony-stimulating factor, and lymphocyte immunotherapy.

Association between antinuclear antibodies and pregnancy prognosis in recurrent pregnancy loss patients

STUDY QUESTION

Can antinuclear antibodies (ANA) affect the subsequent live birth rate (LBR) in patients with unexplained recurrent pregnancy loss (RPL) in the absence of antiphospholipid antibodies (aPL)?

SUMMARY ANSWER

Women with unexplained RPL have a high probability of live birth following a positive pregnancy test (>70%), being similar between those with positive and negative ANA testing, regardless of the cut-off value.

WHAT IS KNOWN ALREADY

The RPL guidelines of the ESHRE state that 'ANA testing can be considered for explanatory purposes'. However, there have been a limited number of studies on this issue and sample sizes have been small, and the impact of ANA on the pregnancy prognosis is unclear.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study was conducted at Nagoya City University Hospital between 2006 and 2019. The study included 1021 women with RPL without known cause.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Hysterosalpingography or 3D-ultrasound, chromosome analysis for both partners, blood tests for aPL, ANA, hypothyroidism, and diabetes mellitus were performed before a subsequent pregnancy. ANAs were measured by indirect immunofluorescence on Hep-2 cell slides. The cutoff dilution used was 1:40. In addition, patients were classified according to the ANA pattern on immunofluorescence staining: homogeneous, speckled, nucleolar, centromeric, peripheral, cytoplasmic, and others. LBRs were compared between ANA-positive and ANA-negative patients after excluding patients with antiphospholipid antibody syndrome, an abnormal chromosome in either partner and a uterine anomaly.

MAIN RESULTS AND THE ROLE OF CHANCE

Considering the cut-off value = 1:40 dilution, the subsequent LBRs were 72.5% (256/353) for the ANA-positive group and 73.2% (489/668) for the ANA-negative group; odds ratio (OR) = 0.97, 95% CI = 0.72-1.29. After excluding the miscarriages occurring from embryonic aneuploidy, the biochemical pregnancy losses, and the ectopic pregnancies, LBRs were 92.8% (256/276) for the ANA-positive group and 93.0% (489/526) for the ANA-negative group: OR = 0.97 (95% CI = 0.55-1.70). Considering the cut-off value = 1:80 dilution, the subsequent LBRs were 75.0% (87/116) for the ANA-positive group and 72.7% (658/905) for the ANA-negative group; OR = 1.13 (95% CI = 0.72-1.76). After excluding the miscarriages occurring from embryonic aneuploidy, the biochemical pregnancy losses, and the ectopic pregnancies, LBRs were 89.7% (87/97) for the ANA-positive group and 93.3% (658/705) for the ANA-negative group: OR = 0.62 (95% CI = 0.30-1.27). Considering the cut-off value = 1:160 dilution, the subsequent LBRs were 82.4% (28/34) for the ANA-positive group and 72.6% (717/987) for the ANA-negative group; OR = 1.76 (95% CI = 0.72-4.29). After excluding the miscarriages occurring from embryonic aneuploidy, the biochemical pregnancy losses, and the ectopic pregnancies, LBR were 93.3% (28/30) for the ANA-positive group and 92.9% (717/772) for the ANA-negative group: OR = 1.07 (95% CI = 0.25-4.63). There was no difference in LBR between the 2 groups before or after adjustment for age and BMI, but ANA-positive patients were significantly older than ANA-negative patients when using the 1:40 dilution, and ANA-positive patients had significantly lower BMIs than ANA-negative patients when using the 1:80 dilution.

LIMITATIONS, REASONS FOR CAUTION

A healthy control group was not established, making it impossible to compare ANA positivity rates between healthy controls and RPL patients. There were significant differences in age (1:40 dilution) and BMI (1:160 dilution) between the ANA-positive and ANA-negative groups.

WIDER IMPLICATIONS OF THE FINDINGS

Our results suggest that ANA testing is not useful to predict future pregnancy loss in women with RPL without known cause.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by MEXT Promotion of Distinctive Joint Research Center Program, Grant Number JPMXP0621467963 and used for English proofreading costs. There are no competing interests for all authors.

TRIAL REGISTRATION NUMBER

N/A.

The correlation between ANAs and pregnancy loss and their impact on IVF/ICSI-ET pregnancy outcomes in patients with recurrent pregnancy loss

OBJECTIVE

To explore the correlation between antinuclear antibodies (ANAs) and pregnancy loss (PL), and to observe its impact on the pregnancy outcomes of in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) in recurrent PL (RPL) patients.

METHODS

In this retrospective study, patients first seen at the hospital between January 2016 and December 2022 and who underwent two ANA tests within 4-6 weeks were included. After exclusion of confounding factors, patients were allocated to the non-pregnancy loss (non-PL), single-PL, or RPL group according to previous number of PLs, and the correlation between PL and ANAs was analyzed. The first embryo transfer (ET) after in vitro IVF/ICSI without immunological treatment was placed in the RPL group, and patients were classified into the ANA-negative or ANA-positive subgroup according to ANA titer. The effect of ANAs on pregnancy outcomes in the RPL patients after IVF/ICSI-ET was further analyze.

RESULTS

The results of multivariate unordered logistic regression showed that when the non-PL group was used as the reference, ANA positivity was an independent risk factor for RPL (P = 0.023) but not for single PL (P = 0.654). When the single-PL group was used as the reference, ANA positivity was an independent risk factor for RPL (P = 0.022). Multivariate logistic regression analysis revealed that the early PL rate of the ANA-positive subgroup was significantly higher than that of the ANA-negative subgroup (P = 0.009), and the total PL rate of the ANA-positive subgroup was significantly higher than that of the ANA-negative subgroup (P = 0.049).

CONCLUSION

The results showed that ANA positivity may be related to RPL occurrence, but there was no significant correlation between ANA positivity and single PL. ANA positivity is associated with PL occurrence in RPL patients after transfer, and the correlation is reflected mainly in the first trimester.

Outcomes of first assisted reproductive technology treatment in infertile women with and without antinuclear antibodies: A prospective cohort study

BACKGROUND

It has been shown that antinuclear antibodies (ANAs) are associated with adverse reproductive events. The presence of ANAs may reduce the pregnancy rate in women undergoing assisted reproductive technology (ART) treatment.

METHODS

This study aimed to investigate the potential effect of ANAs on the outcomes of infertile women undergoing in-vitro fertilization and embryo transfer (IVF-ET) or intracytoplasmic sperm injection (ICSI) for the first time. In total, 907 women were enrolled, with 192 (21.14 %) cases in the ANA+ group and 715 (78.86 %) cases in the ANA- group. Baseline data were collected, and associations between ANAs and oocyte maturation rate, high-quality embryo rate, clinical pregnancy rate, live birth rate and miscarriage rate were analysed.

RESULTS

Compared with the ANA- group, the ANA+ group had a considerably lower oocyte maturation rate (0.69 ± 0.31 vs 0.77 ± 0.26; P = 0.003) and a lower high-quality embryo rate (0.53 ± 0.30 vs 0.78 ± 0.92; P < 0.01). ANAs had no effect on clinical pregnancy rate, live birth rate and miscarriage rate in infertile women receiving ART for the first time.

CONCLUSIONS

These findings suggest that ANAs reduce oocyte maturation rate and high-quality embryo rate in infertile women undergoing IVF-ET/ICSI for the first time, but do not have a significant effect on clinical pregnancy rate, live birth rate and miscarriage rate. When testing for ANAs is part of the planned treatment protocol, this should be undertaken in advance of starting IVF-ET/ICSI.

Impact of Systemic Lupus Erythematosus on Conception: Insights into Infertility, Fertility Preservation, Assisted Reproductive Technology, and Pregnancy Outcomes

Many individuals with systemic lupus erythematosus (SLE) face significant challenges manifesting their family planning goals due to numerous factors, including disease-related complications, treatment-induced effects, immunological factors, self-imposed limitations, and the socioeconomic impacts of having a chronic disease. Instances of unexplained infertility are also prevalent. Encouragingly, advancements in treatment modalities, risk factor management, specialized training within the medical community, and enhanced patient/provider education have contributed to an increase in successful pregnancies among SLE patients, fostering a safer, more promising reproductive landscape. However, despite advances, individuals with SLE continue to struggle with the complexities of family building. This review explores infertility and pregnancy outcomes in SLE, fertility preservation, the role of assisted reproductive technology, and considerations for tailoring these approaches to SLE patients.

Anticentromere antibodies are the most potent antinuclear antibodies in reducing live birth outcomes after ICSI

RESEARCH QUESTION

How, and to what extent, do anticentromere antibodies (ACA) reduce live birth outcomes after ICSI?

STUDY DESIGN

Retrospective cohort study of infertile women aged 30-43 years who underwent ICSI between September 2016 and March 2021. Women with a history or current diagnosis of symptomatic connective tissue disease were excluded. Immunofluorescence staining detected antinuclear antibodies (ANA). Staining pattern and titre (cut-off, 1:160) were used to divide infertile women into three groups: positive for ACA (ACA+) (n = 28); positive for ANA other than ACA (ANA+) (n = 77); and negative for both ACA and ANA (control) (n = 3723).

RESULTS

Cumulative live birth rate (CLB) was lowest in ACA+ (7%, 31% and 46% in ACA+, ANA+ and control, respectively) (ACA+ versus control, P < 0.0001; ACA+ versus ANA+, P = 0.011; ANA+ versus control, P = 0.012). A small impairment in meiosis I and a larger impairment in meiosis II, fertilization and embryo cleavage caused the decrease. Multiple pronuclei formation increased (RR versus control, 5.33; 95% CI 4.26 to 6.65) and good-quality blastocyst development decreased (RR 0.34; 95% CI 0.22 to 0.53). Multiple logistic regression analysis showed that ACA was associated with CLB outcome (OR 0.08, 95% CI 0.02 to 0.36); the other four ANA staining patterns were not.

CONCLUSIONS

The effect of ACA on live birth outcomes is strongest after ICSI among ANA, primarily through the impairment of meiosis II and subsequent stages. Repeated ICSI failure and eggs with multiple pronuclei may warrant specific testing for ACA.

Immunological parameters of maternal peripheral blood as predictors of future pregnancy outcomes in patients with unexplained recurrent pregnancy loss

INTRODUCTION

Unexplained recurrent pregnancy loss (URPL), affecting approximately 1%-5% of women, exhibits a strong association with various maternal factors, particularly immune disorders. However, accurately predicting pregnancy outcomes based on the complex interactions and synergistic effects of various immune parameters without an automated algorithm remains challenging.

MATERIAL AND METHODS

In this historical cohort study, we analyzed the medical records of URPL patients treated at Xiangya Hospital, Changsha, China, between January 2020 and October 2022. The primary outcomes included clinical pregnancy and miscarriage. Predictors included complement, autoantibodies, peripheral lymphocytes, immunoglobulins, thromboelastography findings, and serum lipids. Least absolute shrinkage and selection operator (LASSO) analysis and logistic regression analysis was performed for model development. The model's performance, discriminatory, and clinical applicability were assessed using area under the curve (AUC), calibration curve, and decision curve analysis, respectively. Additionally, models were visualized by constructing dynamic and static nomograms.

RESULTS

In total, 502 patients with URPL were enrolled, of whom 291 (58%) achieved clinical pregnancy and 211 (42%) experienced miscarriage. Notable differences in complement, peripheral lymphocytes, and serum lipids were observed between the two outcome groups. Moreover, URPL patients with elevated peripheral NK cells (absolute counts and proportion), decreased complement levels, and dyslipidemia demonstrated a significantly increased risk of miscarriage. Four models were developed in this study, of which Model 2 demonstrated superior performance with only seven predictors, achieving an AUC of 0.96 (95% CI: 0.93-0.99) and an accuracy of 0.92. A web-based platform was established to visually present model 2 and to facilitate its utilization by clinicians in outpatient settings (available from: https://yingrongli.shinyapps.io/liyingrong/).

CONCLUSIONS

Our findings suggest that the implementation of such prediction models could serve as valuable tools for providing comprehensive information and facilitating clinicians in their decision-making processes.

[Humoral Immunity Abnormalities in Advanced Maternal-Age Women With Recurrent Spontaneous Abortion: A Single Center Study]

Objective

To determine the humoral immunity in advanced maternal-age women with recurrent spontaneous abortion (RSA).

Methods

A retrospective study was performed between January 2022 and October 2023 in the Department of Reproductive Immunity of Shanghai First Maternity and Infant Hospital. Women with RSA were recruited and multiple autoantibodies were tested. Multivariate logistic regression was performed to compare the associations between different age groups (20 to 34 years old in the low maternal-age group and 35 to 45 years in the advanced maternal-age group) and multiple autoantibodies, while controlling for three confounding factors, including body mass index (BMI), previous history of live birth, and the number of spontaneous abortions. Then, we investigated the differences in the humoral immunity of advanced maternal-age RSA women and low maternal-age RSA women.

Result

A total of 4009 women with RSA were covered in the study. Among them, 1158 women were in the advanced maternal-age group and 2851 women were in the low maternal-age group. The prevalence of antiphospholipid syndrome, systemic lupus erythematosus, Sjogren's syndrome, rheumatoid arthritis, and undifferentiated connective tissue disease was 15.6% and 14.1%, 0.0% and 0.1%, 0.9% and 0.9%, 0.3% and 0.0%, and 23.7% and 22.6% in the advanced maternal-age group and low maternal-age group, respectively, showing no statistical difference between the two groups. The positive rates of antiphospholipid antibodies (aPLs), antinuclear antibody (ANA), extractable nuclear antigen (ENA) antibody, anti-double stranded DNA (dsDNA) antibody, anti single-stranded DNA (ssDAN) antibody, antibodies against alpha-fodrin (AAA), and thyroid autoimmunity (TAI) were 19.1% and 19.5%, 6.6% and 6.6%, 9.2% and 10.5%, 2.0% and 2.0%, 2.2% and 1.2%, 5.1% and 4.9%, and 17.8% and 16.8%, respectively. No differences were observed between the two groups. 1.6% of the women in the advanced maternal-age group tested positive for lupus anticoagulant (LA), while 2.7% of the women in the low maternal-age group were LA positive, with the differences being statistically significant (odds ratio=0.36, 95% confidence interval: 0.17-0.78). In the 4008 RSA patients, the cumulative cases tested positive for the three antibodies of the aPLs spectrum were 778, of which 520 cases were positive for anti-β2 glycoprotein Ⅰ antibodies (β2GPⅠ Ab)-IgG/IgM, 58 were positive for aCL-IgG/IgM, 73 were positive for LA, 105 were positive for both β2GPⅠ Ab-IgG/IgM and aCL-IgG/IgM, 17 were positive for both β2GPⅠ Ab-IgG/IgM and LA, 2 were positive for both aCL-IgG/IgM and LA, and 3 were positive for all three antibodies.

Conclusion

Our study did not find a difference in humoral immunity between RSA women of advanced maternal age and those of low maternal age.

Evaluation of Recurrent Pregnancy Loss

Recurrent pregnancy loss (RPL) affects approximately 5% of couples. Although RPL definitions vary across professional societies, an evaluation after a second clinically recognized first-trimester pregnancy loss is recommended. Good quality evidence links parental chromosomal rearrangements, uterine anomalies, and antiphospholipid syndrome (APS) to RPL. In contrast, the relationship between RPL and other endocrine, hematologic, and immunologic disorders or environmental exposures is less clear. Anticoagulant therapy and low-dose aspirin are recommended for patients with RPL who have also been diagnosed with APS. Vaginal progesterone supplementation may be considered in patients experiencing vaginal bleeding during the first trimester. Surgical correction may be considered for patients with RPL in whom a uterine anomaly is identified. Evaluation and management of additional comorbidities should be guided by the patient's history rather than solely based on the diagnosis of RPL, with the goal of improving overall health to reduce complications in the event of pregnancy. Most people with RPL, including those without identifiable risk factors, are expected to achieve a live birth within 5 years from the initial evaluation. Nevertheless, clinicians should be sensitive to the psychological needs of individuals with this condition and provide compassionate and supportive care across all stages.

Predicting risk of subsequent pregnancy loss among women with recurrent pregnancy loss: An immunological factor-based multivariable model

PROBLEM

Studies on subsequent pregnancy loss prediction models specific for recurrent pregnancy loss (RPL) patients are very limited. This study aims to develop a risk predictive model based on the immunological parameters for the subsequent pregnancy loss risk in northwest Chinese RPL patients.

METHOD OF STUDY

Totally of 357 RPL patients recruited from Lanzhou University Second Hospital were included in this retrospective study. Univariate analysis was performed on RPL patients with outcomes of live birth or pregnancy loss. Subsequently, the least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression were utilized to select variables among baseline and clinical characteristics and to develop a pregnancy loss risk prediction model with all 357 RPL patients. The area under the curve (AUC), calibration curve and decision curve analyses were used to evaluate the performance of the prediction model; moreover, 10-fold cross-validation was used for internal validation.

RESULTS

Ten factors of maternal age, age of menarche, previous pregnancy loss, IL-10, complement 4, IgA, antiprothrombin antibody IgG/IgM, rheumatoid factor IgA, and lupus anticoagulant (LA) 1/LA2 ratio were finally selected as variables for the prediction model of pregnancy loss risk. The AUC value and Hosmer-Lemeshow test p-value of the model were .707 and .599, respectively, indicating a satisfactory discrimination and calibration performance. Moreover, the clinical decision curve suggested this prediction model have a good positive net benefit.

CONCLUSIONS

This is the first prediction model for the risk of subsequent pregnancy loss in northwest Chinese women with RPL, providing a user-friendly tool to clinicians for the early prediction and timely management of RPL patients.

Expanding the role of chromosomal microarray analysis in the evaluation of recurrent pregnancy loss

Multiple factors contribute to recurrent pregnancy loss (RPL). This review highlights the latest international guidelines for RPL workup, including immunological testing, by the American Society for Reproductive Medicine (ASRM), the European Society of Human Reproduction and Embryology (ESHRE), and the Royal College of Obstetricians and Gynaecologists (RCOG). These three societies recommend testing for antiphospholipid syndrome. ESHRE and RCOG also recommend thyroid peroxidase antibody testing, whereas ASRM does not. All guidelines advise against testing of natural killer cells, cytokines, antinuclear antibodies, human leukocyte antigen (HLA) compatibility, anti-HLA antibodies, and anti-sperm antibodies. However, when following ASRM, ESHRE or RCOG diagnostic guidelines, over 50% of cases have no identifiable cause. Genetic testing of products of conception (POC) can improve our understanding of unexplained RPL as aneuploidy is a common cause of RPL. Based on studies reporting results from chromosomal microarray analysis (CMA) of POC, we propose a novel algorithm for RPL evaluation. The algorithm involves following evidence-based societal guidelines (published by ASRM, ESHRE, or RCOG), excluding parental karyotyping, in combination with CMA testing of miscarriage tissue. When utilizing this new evaluation algorithm, the number of unexplained cases of RPL decreases from over 50% to less than 10%. As a result, most patients are provided an explanation for their loss and healthcare costs are potentially reduced. Patients with an otherwise negative workup with euploid POC, are classified as "truly unexplained RPL". These patients are excellent candidates for enrollment in randomized, controlled trials examining novel immunological testing and treatment protocols.

Diagnostic factors for recurrent pregnancy loss: an expanded workup

PURPOSE

There is limited information on the risk factors for recurrent pregnancy loss (RPL).

METHODS

In this study, a patient-based approach was used to investigate the possible involvement and relative relevance of a large number of diagnostic factors in 843 women with RPL who underwent an extensive diagnostic workup including 44 diagnostic factors divided into 7 major categories.

RESULTS

The rates of abnormalities found were: (1) genital infections: 11.74%; (2) uterine anatomic defects: 23.72%; (3) endocrine disorders: 29.42%; (4) thrombophilias: 62%; (5) autoimmune abnormalities: 39.2%; (6) parental karyotype abnormalities 2.25%; (7) clinical factors: 87.78%. Six hundred and fifty-nine out of eight hundred and forty-three women (78.17%) had more than one abnormality. The mean number of pregnancy losses increased by increasing the number of the abnormalities found (r = 0.86949, P < 0.02). The factors associated with the highest mean number of pregnancy losses were cervical isthmic incompetence, anti-beta-2-glycoprotein-1 antibodies, unicornuate uterus, anti-prothrombin A antibodies, protein C deficiency, and lupus anticoagulant. The majority of the considered abnormalities had similar, non-significant prevalence between women with 2 versus ≥ 3 pregnancy losses with the exception of age ≥ 35 years and MTHFR A1298C heterozygote mutation. No difference was found between women with primary and secondary RPL stratified according to the number of abnormalities detected (Chi-square: 8.55, P = 0.07). In these women, the only factors found to be present with statistically different rates were age ≥ 35 years, cigarette smoking, and genital infection by Ureaplasma.

CONCLUSION

A patient-based diagnostic approach in women with RPL could be clinically useful and could represent a basis for future research.