Thyroid autoimmunity and recurrent miscarriage

Primary versus secondary recurrent pregnancy losses: Clinical findings and live birth rate after comprehensive work-up and personalized management

INTRODUCTION

Recurrent pregnancy loss (RPL), defined as two or more consecutive pregnancy losses before 24 weeks of gestation, affects up to 1%-2% of couples. Aim of this retrospective cohort study was to report the main causes and pregnancy outcomes of a cohort of women with RPL and the efficacy of a personalized work-up and treatment in terms of live birth rate.

MATERIAL AND METHODS

Women with primary (pRPL) and secondary (sRPL) RPL underwent a complete work-up and personalized therapeutic management. Data related to clinical findings and subsequent pregnancy outcomes were collected. A retrospective comparison between clinical findings and pregnancy outcomes of pRPL vs sRPL was performed by Mann-Whitney U or Chi-square test.

RESULTS

Main findings after diagnostic work-up in pRPL (n = 157) vs sRPL (n = 138) couples were hormonal and metabolic factors (75% vs. 90%, p < 0.01), autoimmunity (52% vs. 59%, p = 0.2), acquired uterine/endometrial factors (43% vs. 34%, p = 0.2), vaginal and/or cervical infections (19% vs. 49%; p < 0.0001), congenital Mullerian anomalies (15% vs. 9%; p = 0.1), inherited thrombophilias (13% vs. 21%; p = 0.1), female karyotype abnormalities (2% vs. 2%; p = 0.9), sperm infections (27% vs. 22%; p = 0.1), abnormal semen analysis (17% vs. 14%; p = 0.1), male karyotype abnormalities (2% vs. 0%; p = 0.1). Higher pregnancy and fetal loss rate was observed in pRPL compared with sRPL (85% vs. 56%, p < 0.0001and 9% vs. 0%, p < 0.01, respectively). Higher live birth rate was found in pRLP vs sRPL women (76% vs. 56%, p < 0.001). Increased live birth rate was observed among pRPL women aged <40 years (OR 2.76; CI 1.36-5.64, p < 0.01) and/or with an AMH >1 ng/mL (OR 3.96; CI 1.34-12.52, p < 0.05). Among sRPL women, the age < 40 years was significantly associated to higher live birth rate (OR 3.23; 1.55-6.94, p < 0.01).

CONCLUSIONS

RPL is a heterogeneous multifactorial syndrome. A customized management can lead to a good pregnancy outcome in more than a half of cases. Age <40 and AMH >1 ng/mL are the major positive predictors of live birth rate in RPL women.

Prevalence of thyroid autoantibody positivity in women with infertility: a systematic review and meta-analysis

BACKGROUND

Thyroid autoimmunity (TAI) is associated with infertility and complications during pregnancy. However, the prevalence of thyroid autoantibodies in women with infertility remains unclear due to variability in study designs, sample sizes, and populations. In this meta-analysis, we aimed to assess the prevalence of thyroid autoantibodies in women with infertility compared with that in healthy controls.

METHODS

Systematic searches were conducted across PubMed, Embase, Web of Science, and the Cochrane Library from inception to February 5, 2024. The inclusion criteria were women with infertility and those with autoimmune thyroid antibodies. Studies in which relevant data could not be extracted, randomized control trial reports, studies with non-original or duplicate data, and non-English articles were excluded. The main outcome was prevalence rate.

RESULTS

The worldwide pooled prevalence of thyroid autoantibody positivity was 20%. In contrast, a significantly higher TAI prevalence was noted in the population with infertility than in healthy controls (risk ratio [RR] = 1.51). Subgroup analyses indicated that TAI prevalence was higher in patients receiving both assisted reproductive technology (ART) and non-ART treatments than in healthy controls (RR = 1.37 and 3.06, respectively). TAI prevalence was also higher in the recurrent abortion and non-recurrent abortion groups of infertility than in healthy controls (RR = 1.80 and 1.39, respectively). Additionally, a higher TAI prevalence was found in the euthyroid and non-simple euthyroid groups than in the control group (RR = 2.77 and 1.43, respectively). The prevalence was significantly higher in cases of unexplained infertility, endometriosis, ovulation disorders, and fallopian tube factors among women with infertility than among the control group (RR = 1.53, 1.83, 1.42, and 2.00, respectively).

CONCLUSIONS

Thyroid autoantibodies are more prevalent in patients with infertility than in healthy controls. Given the presence of thyroid autoantibodies, screening patients with infertility is clinically important.

Immunologic insights in recurrent spontaneous abortion: Molecular mechanisms and therapeutic interventions

Recurrent spontaneous abortion refers to the occurrence of two or more spontaneous abortions before or during the early stages of pregnancy. The immune system plays a crucial role in the maintenance of pregnancy and embryo implantation. Various immune cells, cytokines, and immune regulatory pathways are involved in the complex immune balance required for a stable pregnancy. Studies suggest that immune abnormalities may be associated with some recurrent spontaneous abortion cases, particularly those involving the dysregulation of immune cell function, autoimmune responses, and placental immunity. In terms of treatment, interventions targeting immune mechanisms are crucial. Various therapeutic approaches, including immunomodulatory drugs, immunoadsorption therapies, and immunocellular therapies, are continually being researched and developed. These approaches aim to restore the immune balance, enhance the success rate of pregnancies, and provide more effective treatment options for patients with recurrent spontaneous abortion.

Effect of anti-thyroid antibodies on recurrent miscarriage: A meta-analysis

SETTING

Previous studies addressed the association between anti-thyroid antibodies and recurrent miscarriage (RM), however, the role of anti-thyroid antibodies in RM patients is debatable.

OBJECTIVES

Therefore, we conducted this meta-analysis and the aim of this current study was to assess whether anti-thyroid peroxidase (anti-TPO) and/or anti-thyroglobulin (anti-TG) antibody positivity was associated with RM.

DESIGN

A meta-analysis was conducted.

PARTICIPANTS

Recurrent miscarriage patients.

METHODS

STATA 12.0 software were applied to compute odds ratios (ORs)/relative risks (RRs) and 95% CIs regarding association between anti-TPO and anti-TG antibodies and the prevalence of RM.

RESULTS

N = 28 studies (8875 participants) explored effect of anti-thyroid antibodies on RM. Analysis of the 28 studies revealed significant association between anti-TPO, anti-TG antibodies and the prevalence of RM with a random effects model (OR/RR = 2.02; 95% CI: 1.63-2.51, p < 0.001; I2 = 44.3%, p value for Q test = 0.004). Analysis of the 20 studies revealed significant association between anti-TPO antibodies and the prevalence of RM with a random effects model (OR/RR = 1.59; 95% CI: 1.25-2.03, p < 0.001; I2 = 43.1%, p value for Q test = 0.022). Analysis of the 14 studies revealed significant association between anti-TG antibodies and the prevalence of RM with a random effects model (OR/RR = 2.25; 95% CI: 1.56-3.23, p < 0.001; I2 = 49.2%, p value for Q test = 0.019).

CONCLUSIONS

Based on the currently available analysis, our findings suggest that women with anti-TPO and/or anti-TG antibodies have a higher risk of RM than that in negative antibody women. Further investigation is needed to better clarify the exact role of the anti-thyroid antibodies in RM and whether treatment is of benefit.

LIMITATIONS

First, differences from various detection methods and reagents used in different studies may affect the diagnostic interpretation of anti-thyroid antibodies, which might influence the accuracy of this meta-analysis. Second, positive anti-thyroid antibodies seem likely to be part of a more general disorder of maternal immune system, due to restrictions of funding and condition, a complete autoantibody screening investigation is hardly to conduct in all participants, and this could be a possible limitation of all included studies. Third, there is no mention of thyroxine therapy on RM, making the meta-analysis even more limited.

Impact of thyroid autoimmunity on the cumulative live birth rates after IVF/ICSI treatment cycles

BACKGROUND

Cumulative live birth rate (CLBR) is considered as the most important endpoint for assessing the probability of having a baby in a complete in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment cycle. Many previous studies have focused on the association between thyroid autoimmunity (TAI) and live birth rate after first embryo transfer cycle, however, evidence on whether the presence of TAI affects the CLBR is lacking. The purpose of this study is to investigate the impact of TAI on the CLBR in a complete IVF/ICSI cycle.

METHODS

This retrospective study included 12,796 women who underwent their first IVF/ICSI treatment between January 2019 and February 2021. Based on the levels of thyroid antibodies, 2,603 women were assigned to the TAI group, and 10,193 women were assigned to the control group. Subgroup analysis was performed according to the different causes of infertility (including male factor only, ovulation disorder, tubal factor, endometriosis and unexplained infertility) and different types and titres of thyroid antibodies. The primary outcome in this study was CLBR, which included live births from the fresh embryo transfer cycle and all subsequent frozen-thawed embryo transfer cycles performed before December 2021.

RESULTS

There was no significant difference in the CLBR between the TAI and control groups, even after adjusting for relevant confounders including age, body mass index, cause of infertility, thyroid function, protocols of controlled ovarian stimulation, type of transfer (fresh vs. frozen), type of transferred embryo (cleavage-stage embryo vs. blastocyst), and fertilization method (IVF vs. ICSI) (cumulative live birth: 50.6% vs. 52.1%, OR 0.94, 95% CI 0.86-1.02, adjusted OR 0.97, 95%CI 0.89-1.06). Subgroup analysis showed that no significant difference was observed in CLBR between the TAI and control groups for all causes of infertility, except for infertility attributed to endometriosis. Among women with endometriosis, the CLBR was significantly lower in the TAI group than that in the control group; however, this difference was not significant after adjusting for potential confounders including age, body mass index, thyroid function, protocols of controlled ovarian stimulation, type of transfer (fresh vs. frozen), type of transferred embryo (cleavage-stage embryo vs. blastocyst), and fertilization method (IVF vs. ICSI) (cumulative live births: 43.1% vs. 51.0%, OR 0.73, 95% CI 0.53-0.99, adjusted OR 0.74, 95% CI 0.53-1.02). Another subgroup analysis demonstrated that the type and titre of thyroid antibody did not affect CLBR in women with TAI.

CONCLUSIONS

In our study, there was no significant difference in the CLBR between women with TAI and those without TAI, which suggests that TAI did not affect the chances of having a baby in a complete IVF/ICSI treatment cycle.

Thyroglobulin Antibodies in Women with Recurrent Pregnancy Loss: A Systematic Review and Meta-Analysis

Background: Thyroid autoimmunity is the most prevalent autoimmune disorder among women of reproductive age and has been suggested as a risk factor in recurrent pregnancy loss (RPL)-a condition in which couples suffer several consecutive pregnancy losses, but where a cause can be identified in less than half of the cases. Most studies have focused on thyroid peroxidase antibodies (TPOAbs), not considering the presence of thyroglobulin antibodies (TgAbs). The aim of this study was to systematically assess the prevalence of TgAb positivity in women with RPL, and whether TgAb positivity was associated with the outcome of the next pregnancy. Methods: A systematic literature search of PubMed and Embase (from inception to April 29, 2023) was performed for studies reporting on TgAbs in women with RPL. The primary outcome was TgAb positivity in women with RPL compared with women without RPL, with a secondary outcome of association between TgAb positivity and the outcome of the next pregnancy. Pooled effect estimates were expressed as odds ratios (ORs) with confidence intervals [CI] using a random-effects model. The study was registered with PROSPERO (No. CRD42022310232) and adhered to the PRISMA guidelines. Results: A total of 770 studies were screened, 28 of which could be included reporting data from a total of 6868 women. The prevalence of TgAb positivity in women with RPL ranged from 3.6% to 28% compared with 2.4% to 29% in women without RPL. The OR for TgAb positivity was 1.93 ([CI 1.27-2.92]; I2 = 63%) compared with women without RPL, and for TgAbs and/or TPOAbs 2.66 ([CI 1.75-4.05]; I2 = 69%). Four studies reported on the outcome of the next pregnancy after antibody measurement with highly heterogeneous results (OR for pregnancy loss ranging from 0.99 in one study to 10.0 in the other study, and two studies reported no data eligible for meta-analysis). Consequently, a meta-analysis could not be performed. Conclusions: Women with RPL were significantly more often TgAb-positive than women without RPL. Although there was a lack of studies reporting prospective outcomes, the findings of this study support the significance of awareness about the strong association between RPL and thyroid autoimmunity.

Preconceptual thyroid peroxidase antibody positivity in women with recurrent pregnancy losses may contribute to an increased risk for another miscarriage

OBJECTIVE

To investigate preconceptual thyroid peroxidase antibody (TPO-ab) positivity and/or thyroid stimulating hormone (TSH) levels in the upper range of normal as risk factors for recurrent unexplained first-trimester miscarriage.

DESIGN

A post-hoc study of a randomized trial, in which acetylsalicylic acid did not affect the risk of a new miscarriage.

PATIENTS

Women (n = 483) with at least three unexplained recurrent first-trimester miscarriages investigated at a Swedish secondary referral center.

MEASUREMENTS

The levels of TPO-ab and TSH were determined before pregnancy. The occurrence of a new first-trimester miscarriage was analyzed by logistic regression with adjustments when applicable, for age, number of previous miscarriages, obesity and the investigated covariates levels of TPO-ab and TSH.

RESULTS

Including all first trimester miscarriages, odds ratio (OR) according to presence of TPO-ab was 1.60 (95% confidence interval [CI]; 0.99-2.57), after adjustment 1.54 (95% CI; 0.94-2.53). Very early (biochemical) pregnancy losses occurred more often in women with than without preconceptual TPO-ab (6.8% vs. 2.0%), OR 3.51 (95% CI; 1.15-10.71), after adjustment 2.91 (95% CI; 0.91-9.29). There was no association between TSH in the upper range of normal and a new miscarriage, adjusted OR 0.76 (95% CI; 0.32-1.83). A prediction model for a new miscarriage included number of previous miscarriages, woman's age and presence of TPO-ab.

CONCLUSION

In women with at least three recurrent unexplained pregnancy losses, the presence of TPO-ab may contribute to an increased risk of a first-trimester miscarriage, possibly more pronounced in very early pregnancy. TSH levels 2.5-4.0 mU/L do not seem to increase the miscarriage risk.

TSH and FT4 Reference Intervals in Pregnancy: A Systematic Review and Individual Participant Data Meta-Analysis

CONTEXT

Interpretation of thyroid function tests during pregnancy is limited by the generalizability of reference intervals between cohorts due to inconsistent methodology.

OBJECTIVE

(1) To provide an overview of published reference intervals for thyrotropin (TSH) and free thyroxine (FT4) in pregnancy, (2) to assess the consequences of common methodological between-study differences by combining raw data from different cohorts.

METHODS

(1) Ovid MEDLINE, EMBASE, and Web of Science were searched until December 12, 2021. Studies were assessed in duplicate. (2) The individual participant data (IPD) meta-analysis was performed in participating cohorts in the Consortium on Thyroid and Pregnancy.

RESULTS

(1) Large between-study methodological differences were identified, 11 of 102 included studies were in accordance with current guidelines; (2) 22 cohorts involving 63 198 participants were included in the meta-analysis. Not excluding thyroid peroxidase antibody-positive participants led to a rise in the upper limits of TSH in all cohorts, especially in the first (mean +17.4%; range +1.6 to +30.3%) and second trimester (mean +9.8%; range +0.6 to +32.3%). The use of the 95th percentile led to considerable changes in upper limits, varying from -10.8% to -21.8% for TSH and -1.2% to -13.2% for FT4. All other additional exclusion criteria changed reference interval cut-offs by a maximum of 3.5%. Applying these findings to the 102 studies included in the systematic review, 48 studies could be used in a clinical setting.

CONCLUSION

We provide an overview of clinically relevant reference intervals for TSH and FT4 in pregnancy. The results of the meta-analysis indicate that future studies can adopt a simplified study setup without additional exclusion criteria.

Glucose/insulin metabolism and vitamin D in women with recurrent pregnancy loss

OBJECTIVE

Glucose/insulin metabolism has been related to recurrent pregnancy loss (RPL) through mechanisms not really clarified. Also, vitamin D deficiency seems to be associated to RPL. The purpose of our study was to evaluate the correlation between glucose/insulin metabolism parameters and vitamin D levels in women with history of RPL.

STUDY DESIGN

Observational retrospective study on RPL women. The correlation among vitamin D levels and fasting glucose (FG), fasting insulin (FI), Homeostatic model assessment of insulin resistance (HOMA-IR) index, area under glucose curve (AUC-Glyc) and area under insulin curve (AUC-Ins), was evaluated.

RESULTS

One-hundred and twenty-seven RPL women were classified into three subgroups (0-1-2) according to the levels of FI. We found a statistically significant linear Pearson correlation between FI and HOMA-IR (r = .840; P = .001). An, inverse, but non-significant correlation both between vitamin D and FI (R = -.202, ns) and vitamin D levels and AUC-Ins (R = -.288, ns) was observed. The variables vitamin D, HOMA-IR and AUC-Ins were statistically significant in the considered subgroups (Vitamin D: ANOVA + Bonferroni test: 0 vs. 1; P = .001; 0 vs. 2; P = .010; 1 vs. 2; P = .657; HOMA-IR: ANOVA + Bonferroni test: 0 vs. 1; P = .014; 0 vs. 2; P = .001; 1 vs. 2; P = .001; AUC-Ins: ANOVA + Bonferroni test: 0 vs. 1; P = .010; 0 vs. 2; P = .206; 1 vs. 2; P = .980).

CONCLUSIONS

Vitamin D might play additional roles in the pathogenesis of RPL, beyond its well known immunomodulatory role.

Positive Impact of Levothyroxine Treatment on Pregnancy Outcome in Euthyroid Women with Thyroid Autoimmunity Affected by Recurrent Miscarriage

Impaired thyroid hormone availability during early pregnancy is associated with recurrent miscarriage (RM) and adverse pregnancy outcomes. The main cause of thyroid dysfunction is thyroid-related autoimmunity (TAI), characterized by a significantly higher serum level of thyroid-stimulating hormone (TSH) compared to that of women without thyroid autoimmunity. TAI is associated with a significantly increased risk of miscarriage, and the incidence of TAI in women experiencing RM is higher compared to normal fertile women. In the present study, we have performed a retrospective analysis comparing the ability to conceive, the number of miscarriages and full-term pregnancies between 227 euthyroid women with autoimmune thyroid disease affected by RM and treated with levothyroxine (LT4) as adjuvant therapy, and a control group of 230 untreated women. We have observed a significant improvement of full-term pregnancies in treated women (59%) compared to untreated women (13%, p < 0.0001). Compared to the control group, treated women had a lower percentage of miscarriages (12% vs. 30%) and improved capacity to conceive (57% vs. 29%). Using age as a variable, the outcome in women younger than 35 years was not influenced by the LT4 therapy. Whereas, in women over 35 years, supplementation with LT4 significantly reduced the miscarriage rate (p < 0.05). We can conclude that a transient impairment of TH availability, not easily detectable before pregnancy, could be an important cause of RM in a subset of euthyroid women with autoimmune thyroid disease. This transient impairment may be reverted using adjuvant treatment with low doses of LT4.

The Association Among Maternal Index of Nutritional Quality, Dietary Antioxidant Index, and Odds of Miscarriage Incidence: Case-Control Study

OBJECTIVE

Miscarriage is a pregnancy condition in which the fetus or embryo naturally dies before being able to survive independently. According to studies, diet and dietary factors are associated with the risk of miscarriage (pregnancies <20 weeks). A 168-item semi-quantitative feed frequency questionnaire was used to estimate the Dietary Antioxidant Index (DAI) and the Index of Nutritional Quality (INQ). We aimed to assess the relationship between INQ and DAI with odds of miscarriage.

METHOD

In summary, 135 Iranian women with a history of three or more miscarriages were included. We calculated the INQ using the following formula: INQ = consumed amount of a nutrient per 1,000 kcal/Recommended Dietary Allowance of that nutrient per 1,000 kcal. We standardized each dietary vitamins/minerals by subtracting the global mean and dividing the result by the universal standard deviation to compute DAI. We computed the DAI by summing up the standardized intakes of these vitamins and minerals and equal weight.

RESULTS

Regression models were used to extract the odds ratios (ORs) and 95% confidence intervals (CIs) in crude and multivariate adjustments. Controls significantly had higher INQ of vitamin B12, niacin, vitamin D, vitamin E, vitamin C, and zinc. Modeling INQs of vitamin D (OR: 0.004, 95% CI, 0.00-0.025) and B12 (OR: 0.04, 95% CI, 0.005-0.41) as a continuous variable showed a significant and protective effect in multivariate adjustment. Modeling DAI as a categorical variable showed a significant protective effect (OR_{DAI<0.054vs.DAI ≥0.054} = 0.43, 95% CI, 0.20-0.91).

CONCLUSIONS

Recommending a diet rich in antioxidants such as vitamin E, C, zinc, and selenium and a quality diet containing vitamins B12 and D can be considered an effective strategy to reduce the odds of miscarriage in women with a history of recurrent miscarriage.

Prevalence of Thyroid Autoimmunity in Women with Recurrent Pregnancy Loss

Background and objectives: Thyroid autoimmunity (TAI) has been associated with a significantly increased risk of miscarriage in women with recurrent pregnancy loss (RPL). The aim of this study was to determine the prevalence of TAI in women with RPL and compare the clinical characteristics of positive and negative TAI women. Materials and Methods: This is a retrospective cross-sectional study; 203 women with RPL were included. Thyroid profile, anti-thyroid peroxidase (TPO-Ab), and anti-thyroglobulin (TG-Ab) antibodies were measured in all participants. Clinical characteristics and causes of RPL were compared between positive and negative TAI. Results: Prevalence of TAI was 14.8%; prevalence of positive TPO-Ab and TG-Ab was 12.3% and 4.9%, respectively. Women with TAI had significantly higher concentrations of thyrotropin (TSH) compared to women without TAI (4.8 ± 3.8 versus 3.1 ± 1.1, p = 0.001). There was no significant difference in age, the number of gestations, miscarriages, state of antiphospholipid antibodies (aPL), or causes of RPL between women that were TAI-positive versus TAI-negative. Prevalence of positive TAI by cause of RPL was: endocrine 7/25 (28%), genetic 1/5 (20%), autoimmune 1/5 (20%), anatomic 8/55 (14.5%), and unexplained cause 13/112 (11.6%). Conclusions: The prevalence of TAI in women with RPL is 14.8%. Women with an endocrine cause have the highest prevalence of TAI.

Machine Learning (ML) based-method applied in recurrent pregnancy loss (RPL) patients diagnostic work-up: a potential innovation in common clinical practice

RPL is a very debated condition, in which many issues concerning definition, etiological factors to investigate or therapies to apply are still controversial. ML could help clinicians to reach an objectiveness in RPL classification and access to care. Our aim was to stratify RPL patients in different risk classes by applying an ML algorithm, through a diagnostic work-up to validate it for the appropriate prognosis and potential therapeutic approach. 734 patients were enrolled and divided into 4 risk classes, according to the numbers of miscarriages. ML method, called Support Vector Machine (SVM), was used to analyze data. Using the whole set of 43 features and the set of the most informative 18 features we obtained comparable results: respectively 81.86 ± 0.35% and 81.71 ± 0.37% Unbalanced Accuracy. Applying the same method, introducing the only features recommended by ESHRE, a correct classification was obtained only in 58.52 ± 0.58%. ML approach could provide a Support Decision System tool to stratify RPL patients and address them objectively to the proper clinical management.

Effect of antithyroid antibodies on women with recurrent miscarriage: A meta-analysis

Problem

The effect of thyroid autoimmunity (TAI) on the prevalence of recurrent miscarriage (RM) is highly debatable. No meta‐analysis has been published in the past decade to investigate the impact of TAI on women with RM.

Method of Study

Systemic literature search was conducted on PubMed, Embase, Cochrane, and Web of Science databases. English language literatures published between 1993 and 2019 were selected. We assessed the relationship between the prevalence of RM and thyroid peroxidase antibodies (TPO‐Ab) or antithyroid antibodies (ATA) and evaluated the thyroid‐stimulating hormone (TSH) level in TPO‐Ab‐positive women with RM. We also observed the treatment effect with levothyroxine (LT4) for RM. Review Manager 5.3 software was used to obtain the pooled odds ratios (OR).

Results

Analysis of 22 eligible studies revealed significant association between TPO‐Ab and the prevalence of RM (OR = 1.85; 95% CI, 1.38 to 2.49; P < .001)(n ≥ 3), (OR = 1.82; 95% CI, 1.13 to 2.92; P = .01) (n ≥ 3). Women with ATA + had higher risk of RM (OR = 2.36; 95% CI, 1.71 to 3.25; P < .00001)(n ≥ 3), (OR = 2.34; 95% CI, 1.70 to 3.22; P < .00001)(n ≥ 2). RM women with TPO‐Ab had higher TSH level when compared with those negative for TPO‐Ab (random‐effect SMD = 0.60; 95% CI, 0.31 to 0.90; P < .0001). We also found beneficial effects of LT4 supplementation on the outcome of live birth rate (LBR) among pregnant women with TPO‐Ab (OR = 3.04; 95% CI, 0.69 to 13.36; P = .14).

Conclusion

The presence of serum antithyroid antibodies does harms to women and can even lead to recurrent miscarriage; LT4 treatment may have beneficial to RM women.

The correlation of thyroid autoimmunity and peripheral and uterine immune status in women with recurrent miscarriage

PROBLEM

Thyroid autoimmunity (TAI), which is the most prevalent cause of thyroid dysfunction in women of reproductive age, is associated with increased risk of miscarriages and adverse pregnancy outcomes. However, the exact pathophysiology of TAI is still unknown. We aim at investigating the relationship between TAI and the peripheral and uterine immune markers in women with recurrent miscarriage (RM).

METHOD OF STUDY

Peripheral blood and endometrial tissue samples were collected during mid-luteal phase of 242 RM women to evaluate the prevalence of TAI, the thyroid function, the percentages of peripheral blood and endometrial lymphocytes, the levels of peripheral blood T helper 1 (Th1) cytokine and natural killer (NK) cell cytotoxicity.

RESULTS

There was no relationship between TAI and peripheral immune parameters. However, the percentage of endometrial Regulatory T (Treg) cells was significantly higher in RM women who were thyroid antibody positive than in those who were antibody negative (p ＜ 0.05).

CONCLUSION

Thyroid antibody positivity seems to be part of a more generalized immune dysfunction. The increased endometrial Treg cells in RM patients with TAI may ameliorate coincidental TAI during pregnancy by linked suppression and prevent the over-reactive status of the immune system.

The pathogenic role of autoantibodies in recurrent pregnancy loss

In the present manuscript, we review the recent research investigating the pathogenic association between most studied autoantibodies and recurrent pregnancy loss. Pregnancy loss represents a common obstetric complication occurring in about 15%-25% of all clinically recognized pregnancies. The recurrence of pregnancy loss identifies a distinct clinical entity, that is recurrent pregnancy loss (RPL), affecting about 2%-4% of couples. Several factors, including age, chromosomal abnormalities, uterine anomalies, thrombophilic disorders, endocrinopathies, hormonal and metabolic disorders, infections, sperm quality, and lifestyle issues, are involved in RPL. The role of autoantibodies in RPL is only partially determined. In some cases (antiphospholipid antibodies [aPL]), their involvement is well established. In other cases (anti-thyroid autoantibodies, antinuclear, anti-transglutaminase, and anti-endomysial antibodies), it is still debated, despite multiple, although not fully conclusive, evidences strongly suggest a possible involvement in RPL. Further extensive research is needed to definitively confirm or exclude their actual role.

Amniotic fluid antiphospholipid antibodies: potential role in antiphospholipid syndrome-independent aberrant implantation process

BACKGROUND

The direct role of antiphospholipid antibodies (aPL) at maternal-fetal interface has not been fully investigated, especially whether they are involved in physiological and pathological implantation conditions, in an antiphospholipid syndrome (APS)-independent manner. In fact, trophoblast cells and placental endothelial cells at the implantation site express potential aPL targeted-phospholipid antigens (PL Ags); thus, the local production and presence of their specific antibodies, not related to APS (characterized by aPL presence in the peripheral blood), could be a potential marker of aberrant invasion, implantation and fetal-maternal immune tolerance processes.

METHODS

Anti-Beta₂glycoprotein I (anti-β₂GPI) and anticardiolipin (aCL Ab) antibodies (the most clinically relevant aPL) were detected by immunoenzymatic assay (ELISA), in the amniotic fluid (AF) of 167 women with physiological and complicated common pregnancy conditions, sharing an aberrant implantation process, such as recurrent pregnancy loss (RPL), autoimmune hypothyroidism (ahT) and smoking. All women included in the study were negative to peripheral blood aPL.

RESULTS

aCL and anti-β₂GPI antibodies were detectable in all the AF samples. RPL, ahT and smoking patients had higher level of anti-β₂GPI Abs (IgM) compared to women with physiological pregnancies (p < 0.0001). Since IgM cannot cross the placenta, their local production in response to maternal-fetal interface stimuli, could be hypothesized.

CONCLUSIONS

The presence of aPL in the AF (not related to APS) could reveal a potential clinical significance at maternal-fetal interface in selected pregnancy complications, in which an aberrant implantation process, and in turn an impaired fetal-maternal immune tolerance cross-talk, could occur.

Thyroid Peroxidase Antibodies and Prospective Live Birth Rate: A Cohort Study of Women with Recurrent Pregnancy Loss

Background: Thyroid autoimmunity has been associated with pregnancy loss. Suggested mechanisms include thyroid function aberrations or an underlying breach of immunotolerance. We hypothesized that thyroid autoimmunity is a marker of the latter in women with recurrent pregnancy loss. This study investigated thyroid peroxidase antibody (TPOAb) status as a predictor of live birth in women with unexplained recurrent pregnancy loss. Methods: Cohort study of 825 consecutive women with recurrent pregnancy loss followed at the tertiary referral center for Recurrent Pregnancy Loss, Copenhagen University Hospital (Rigshospitalet), from 2011 to 2017. Recurrent pregnancy loss was defined as ≥3 consecutive losses, and as unexplained by absence of antiphospholipid syndrome, parental chromosome abnormality, or uterus malformation. Upon first visit, all women were screened for thyrotropin (TSH) and TPOAbs (TPOAb positivity: ≥60 kIU/L). Adjusted logistic regression analyses included as covariates the following: maternal age, TSH, previous number of losses, body mass index, smoking, pregnancy achieved by assisted reproductive technology, and thyroxine replacement (T4) treatment. Results: We included 825 women with a total of 3246 previous losses, of whom 139 (16.8%) were TPOAb positive. TPOAb positivity was not associated with the previous number of losses (p = 0.41). Women with unexplained recurrent pregnancy loss had a live birth rate in the first pregnancy after referral of 62.8% (285 of 454). TPOAb positivity was found in 78 of 454 (17.2%) women and was associated with a reduced live birth rate (51.3% vs. 65.2%, p = 0.02, adjusted odds ratio [aOR] 0.2 [0.1-0.6] p = 0.001). Treatment with T4 increased live birth rate significantly (aOR 3.7 [1.4-9.8], p = 0.007), and TPOAb-positive women receiving T4 had a live birth rate similar to that of TPOAb-negative women not receiving T4 (p = 0.70). Only 30% of TPOAb-positive women and 39% of women treated with T4 during pregnancy had known thyroid disease at referral. Conclusion: In a large cohort of women with unexplained recurrent pregnancy loss, TPOAb positivity was predictive of a reduced live birth rate. However, T4 treatment improved odds of live birth. The study supports screening for TPOAbs as a risk factor in women with unexplained recurrent pregnancy loss. The beneficial effect of T4 treatment in this high-risk group needs confirmation by randomized controlled trials. Close collaboration between fertility experts and endocrinologists is paramount.

Effect of alpha-lipoic acid and myoinositol on endometrial inflammasome from recurrent pregnancy loss women

PROBLEM

A significant increased expression/activation of one of the most well-characterized inflammasomes, the NAcht leucine-rich-repeat protein-3 (NALP-3), in the endometrium from idiopathic recurrent pregnancy loss women (RPL) has been previously found by our research group. We therefore, suggested this event as being one of the molecular mechanisms altering endometrial inflammatory status during early pregnancy. In the present research, we attempt to investigate whether molecules with anti-inflammatory activity, alpha-lipoic acid (ALA), and/or myoinositol affect the endometrial NALP-3 expression and activation.

METHOD OF STUDY

Women with a history of idiopathic RPL (n = 30) were included in the study and compared to a control group (n = 15). Endometrial tissues were collected by hysteroscopy during the mid-luteal phase. RPL women underwent a three-month prescription of tablets containing ALA plus myoinositol (Sinopol^® ). After treatment, hysteroscopic biopsies were repeated in RPL patients. Inflammasome expression was evaluated by immunohistochemical and Western blot analysis. NALP-3 activation was studied by quantifying the secretion of both caspase-1 and interleukin (IL)-1ß and IL-18 through ELISA. In ex vivo experiments, the effects of each molecule on endometrial inflammasome were studied.

RESULTS

Sinopol^® significantly reduced the RPL endometrial inflammasome expression and activation. ALA, but not myoinositol, significantly reduced the endometrial inflammasome expression and activity.

CONCLUSION

Our data suggest a role for ALA on RPL inflammasome. Understanding the mechanisms involved in RPL and the observation that specific molecules are able to interfere with such complex at the endometrium might provide new rational design approaches to a personalized evaluation of endometrial status and, ultimately, a targeted medicine.

Endocrine causes of recurrent pregnancy loss

OBJECTIVE

To review the available data on endocrine disorders and recurrent pregnancy loss.

FINDINGS

Our group found that most endocrine disorders do not seem to be correlated with a diagnosis of recurrent pregnancy loss (RPL). The exception to this is testing for thyroid stimulating hormone and thyroid antibodies, which is recommended due to a strong correlation with recurrent pregnancy loss and positive anti-thyroid peroxidase antibodies.

CONCLUSION

The available literature supports testing thyroid function and antibodies in women with RPL. Testing for other endocrine disorders is only warranted if otherwise clinically indicated, independent from a history of recurrent pregnancy loss.

Human leukocyte antigen DQ2/DQ8 positivity in women with history of stillbirth

PROBLEM

The aim of this study was to investigate the prevalence of human leukocyte antigens (HLA) DQ2 and DQ8 haplotypes, two common polymorphisms associate with celiac disease (CD), in women with previous stillbirth, but not affected by CD.

METHOD OF STUDY

Women with history of unexplained term stillbirth referred to our Center for High-Risk Pregnancies for a preconception counseling, and women with previous uncomplicated pregnancies, were enrolled as cases and controls. Celiac women were excluded from the study. Genetic tests for HLA DQ2/DQ8 were performed, and patients' data were compared.

RESULTS

The population included 56 women with a previous term stillbirth and 379 women with history of uncomplicated pregnancies. The prevalence of HLA-DQ2 or DQ8 positivity was significantly higher in cases than in controls (50% vs 29.5%) (P = 0.0031). Women with HLA DQ8 genotype have a significantly higher risk of stillbirth (OR: 2.84 CI: 1.1840-6.817) and in case of DQ2 genotype the OR for stillbirth was even higher (OR: 4.46 CI: 2.408-8.270). In the stillbirth group, SGA neonates were significantly more frequent in those with HLA-DQ2/DQ8 haplotypes than in those resulted negative to genetic testing (85.7% vs 42 .8%, P = 0.004).

CONCLUSION

In women with history of term stillbirth, a significantly higher prevalence of HLA DQ2/DQ8 haplotypes has been found compared to women with previous uneventful pregnancies. In addition, HLA DQ2/DQ8 positivity was significantly associated with suboptimal fetal growth in intrauterine fetal death cases, as shown by an increased prevalence of SGA babies.

Secondary and tertiary preventions of thyroid disease

INTRODUCTION

Secondary and tertiary preventions are concerned with the recognition of the disease process in a very early stage and delay in progression to complete disease and minimization of complications and the impact of illness.

METHODS

All articles related to secondary and tertiary prevention of thyroid diseases were reviewed. Using related key words, articles published between 2001 and 2015 were evaluated, categorized, and analyzed.

RESULTS

In secondary prevention, congenital hypothyroidism and subclinical hypo and hyperthyroidism are equally important. Routine screening of patients with multinodular goiter by either ultrasonography or calcitonin is a controversial issue, while calcitonin assessments in medullary cancer and RET in family members are recommended. Screening of thyroid disease in pregnancy is limited to those with risk factors. Views regarding the importance of thyroid autoimmunity in secondary prevention are also presented. In tertiary prevention, prescribing excessive doses of levothyroxine, in the elderly in particular and appropriate care of all patients to avoid progression and complications are the key issues.

CONCLUSION

Optimization of management of thyroid diseases requires timely screening, prevention of progression to more sever disease, optimal medical care, and avoidance of iatrogenic conditions.

Ectopic pregnancy in women with recurrent miscarriage

AIM

The aim of this study was to investigate the possible association between recurrent miscarriage (RM) and ectopic pregnancy (EP).

METHODS

In this case-control retrospective study, the clinical cards of women followed as outpatients in the RM and low-risk pregnancy offices of the Obstetrics and Gynecology Unit at the Policlinico Tor Vergata University Hospital were carefully reviewed for the occurrence of EP.

RESULTS

Overall, 598 women with RM and 2043 normal women without RM (controls) were included in the study. Among these women, 4974 pregnancies were analyzed, in which 2028 miscarriages occurred. The EP rate (3.51%) was significantly higher in RM than in control women (1.51%) [odds ratio = 2.31 (95% confidence interval: 2.3-2.4)]; it was particularly high in women with primary RM (5.11%). However, when EP rates were calculated not by women but by overall pregnancies, no differences could be found between RM and control women. In control women, the absence of a miscarriage in the reproductive history was associated with a lower rate of EP.

CONCLUSIONS

Women with RM, particularly primary RM, are at increased risk of EP. This increased risk seems to be dependent on the high number of pregnancies occurring in women with RM rather than to specific characteristics of these women.

RBPJ mediates uterine repair in the mouse and is reduced in women with recurrent pregnancy loss

Unexplained recurrent pregnancy loss (uRPL) is associated with repeated embryo loss and endometrial repair with elevated endometrial expression of inflammatory cytokines, including IFN-γ. Notch signaling through its transcription factor recombination signal binding protein Jκ (RBPJ) regulates mechanisms including the immune response and repair after tissue injury. Initially, null mutation of RBPJ in the mouse uterus ( Pgr^cre/+Rbpj^f/f; Rbpj c-KO) results in subfertility, but we have found that these mice become infertile after pregnancy as a result of dysfunctional postpartum uterine repair, including delayed endometrial epithelial and myometrial regeneration. RNA sequencing of postpartum uterine repair sites revealed global up-regulation of inflammatory pathways, including IFN signaling. Consistent with elevated IFN-γ, macrophages were recruited and polarized toward an M1-cytotoxic phenotype, which is associated with preventing repair and promoting further tissue injury. Through embryo transfer experiments, we show that dysfunctional postpartum repair directly impairs future embryo implantation in Rbpj c-KO mice. Last, we clinically correlated our findings from the Rbpj c-KO mouse in women diagnosed with uRPL. Reduced RBPJ in women with uRPL was associated with increased levels of IFN-γ. The data, taken together, indicate that RBPJ regulates inflammation during endometrial repair, which is essential for future pregnancy potential, and its dysregulation may serve as an unidentified contributor to uRPL in women.-Strug, M. R., Su, R.-W., Kim, T. H., Mauriello, A., Ticconi, C., Lessey, B. A., Young, S. L., Lim, J. M., Jeong, J.-W., Fazleabas, A. T. RBPJ mediates uterine repair in the mouse and is reduced in women with recurrent pregnancy loss.

Reproductive Endocrinology in Recurrent Pregnancy Loss

Endocrine disruptions may be important in patients experiencing recurrent pregnancy loss (RPL). This review focuses on data available on RPL and the endocrine system to investigate relevant, and perhaps modifiable, endocrine factors of importance for the disorder. Evidence indicates that some hormones may be important as immune modulators and a better understanding of this interplay has potential for improving pregnancy outcome in RPL. To date there is a lack of consensus on the effect of endocrine treatment options in RPL and there is a strong need for large randomized-controlled trials.

OLR1 and Loxin Expression in PBMCs of Women with a History of Unexplained Recurrent Miscarriage: A Pilot Study

AIMS

The aim of this study was to evaluate the expression of OLR1 and its alternative splicing isoform Loxin in unexplained recurrent miscarriage (uRM).

METHODS

Sixty-three women of reproductive age were recruited and were divided into four groups: 18 pregnant and 23 non-pregnant women with uRM, and 12 pregnant and 10 non-pregnant women with physiological pregnancies. Complementary DNA derived from peripheral blood mononuclear cells (PBMCs) was analyzed by quantitative real-time PCR to evaluate the expression of OLR1 and Loxin. Oxidized low-density lipoproteins (ox-LDLs) were assayed from serum by a commercially available kit.

RESULTS

Pregnant uRM women presented with a higher, though not significant, OLR1/Loxin ratio and a higher ox-LDLs serum level (p ≤ 0.05) compared with pregnant control women. OLR1 and Loxin levels were significantly decreased in non-pregnant uRM women compared with the control (OLR1: 0.00018 vs. 0.00043, p ≤ 0.005; Loxin: 0.00018 vs. 0.00060, p ≤ 0.005, respectively). Loxin expression decreased by about two-thirds (p ≤ 0.005) in pregnant women compared with non-pregnant control women. A higher expression of OLR1 in pregnant women compared with non-pregnant women with uRM (p ≤ 0.05) was observed, but no variation in Loxin expression was observed.

CONCLUSIONS

The results of this study show an association of peripheral OLR1 and Loxin expression levels in uRM women, and they suggest the possible existence of an uncontrolled oxidative stress in these women in the first trimester of pregnancy.

Relationship between Intrauterine Bacterial Infection and Early Embryonic Developmental Arrest

Background:

Early embryonic developmental arrest is the most commonly understudied adverse outcome of pregnancy. The relevance of intrauterine infection to spontaneous embryonic death is rarely studied and remains unclear. This study aimed to investigate the relationship between intrauterine bacterial infection and early embryonic developmental arrest.

Methods:

Embryonic chorion tissue and uterine swabs for bacterial detection were obtained from 33 patients who underwent artificial abortion (control group) and from 45 patients who displayed early embryonic developmental arrest (trial group).

Results:

Intrauterine bacterial infection was discovered in both groups. The infection rate was 24.44% (11/45) in the early embryonic developmental arrest group and 9.09% (3/33) in the artificial abortion group. Classification analysis revealed that the highest detection rate for Micrococcus luteus in the early embryonic developmental arrest group was 13.33% (6/45), and none was detected in the artificial abortion group. M. luteus infection was significantly different between the groups (P < 0.05 as shown by Fisher's exact test). In addition, no correlation was found between intrauterine bacterial infection and history of early embryonic developmental arrest.

Conclusions:

M. luteus infection is related to early embryonic developmental arrest and might be one of its causative factors.

The Establishment of an HE4-CLIA Method and the Combined Analysis of HE4 and CA125 in Ovarian Cancer

BACKGROUND

The human epididymal secretory protein 4 (HE4) is a novel, verified biomarker for the early diagnosis of ovarian cancer.

METHODS

Magnetic beads were coated with capture antibodies and were used with acridinium ester labeled detection antibodies in a sandwich-type immunoassay. The patient's HE4 serum levels were measured simultaneously with the chemiluminescence immunoassay (CLIA) kit we developed and electrochemiluminescence immunoassay (ECLIA) kit from Roche (Mannheim, Germany). CA125 was also detected by time-resolved fluoroimmunoassay. The diagnostic value was analyzed.

RESULTS

The assay demonstrated a linear range from 2.5 to 2,000 pmol/l, with an analytical sensitivity of 2.5 pmol/l. The reproducibility, recovery, and specificity of the immunoassay were demonstrated to be acceptable. Compared with the ECLIA kit from Roche in 124 serum samples (40 patients with ovarian cancer, 35 patients with benign gynecological diseases, and 49 health controls), there is a satisfied correlation coefficient of 0.875. The area under the receiver-operating curve (ROC-AUC) was 0.903 (95% CI was 0.839-0.966, P < 0.001) for HE4, 0.787 (95% CI was 0.694-0.879, P < 0.001) for CA125, and 0.914 (95% CI was 0.866-0.962, P < 0.001) for combined analysis of HE4 and CA125.

CONCLUSIONS

A quantitative method (HE4-CLIA) for detecting HE4 in serum was successfully established. Preliminary clinical sample analysis showed HE4-CLIA has a certain clinical value in the screening and diagnosis of ovarian cancer. Moreover, in distinguishing benign from malignant ovarian lesions, HE4 has higher demonstrated accuracy than CA125.

Uterine blood flow indices, antinuclear autoantibodies and unexplained recurrent miscarriage

OBJECTIVE

To study the correlation between 2D and 3D uterine flow indexes and the presence or the absence of antinuclear antibodies (ANA) in women with unexplained recurrent miscarriage (uRM).

METHODS

Fifty-two subjects (26 uRM and 26 control women) underwent 2D Doppler measurement of pulsatility index and resistance index of the uterine arteries in both the follicular and midluteal phase of the cycle. Additionally, 3D ultrasonography determination of vascularisation index, flow index, and vascularisation flow index was carried out with the aid of the VOCAL technique. Serum assay for the presence of ANA was performed in all women.

RESULTS

Pulsatility index of ANA+ uRM women was higher than that of ANA- uRM women and control ANA+ and ANAwomen, both in the follicular and in the midluteal phase of the cycle. Vascularisation index in ANA- uRM women was significantly higher than that in ANA+ control women. Flow index in uRM ANA+ women was significantly lower than that of each of the other groups.

CONCLUSION

ANA might be involved in uRM by determining an impairment in uterine blood flow hemodynamic, particularly in uterine blood flow intensity and uterine artery impedance.

Human IgG Antinuclear Antibodies Induce Pregnancy Loss in Mice by Increasing Immune Complex Deposition in Placental Tissue: In Vivo Study

PROBLEM

A threefold higher prevalence of antinuclear antibodies (ANA) has been reported in patients with recurrent pregnancy loss (RPL). Nevertheless, the role of ANA in reproductive failure is still unclear. The aim of this study was to investigate the role of ANA during early pregnancy in vivo.

METHOD OF STUDY

We used pregnant mice treated with immunoglobulin G (IgG) obtained from normal healthy subjects (NHS); ANA(+) sera of patients with RPL; and ANA(+) sera from women with uncomplicated pregnancies (HW). Placental immunohistochemical/immunofluorescence staining was performed to detect complement and immune complex deposition. ELISA was performed to evaluate complement levels.

RESULTS

ANA(+) IgG from RPL women significantly increased embryo resorption rate, reduced C3, and increased C3a serum levels compared to NHS IgG or ANA(+) -HW IgG. Increased C3 deposition and increased immune complex staining in placental tissues from mice treated with ANA(+) -RPL IgG fraction compared to NHS- and ANA(+) -HW-IgG-treated mice were found.

CONCLUSION

ANA(+) IgG injection in mice is able to induce fetal resorption and complement activation. The presence on placental tissues of immune complexes and complement fragments suggests the complement activation as a possible mechanism of placental damage.

Does the presence of autoantibodies without autoimmune diseases and hereditary thrombophilia have an effect on recurrent pregnancy loss?

OBJECTIVE

To assess whether the presence of autoantibodies has any effect on recurrent pregnancy loss (RPL) and obstetric complications in women who do not have autoimmune diseases and hereditary thrombophilia.

METHODS

Retrospectively, 515 patients who underwent antibody investigation with anti-nuclear antibody, extractable nuclear antigen, anti-double stranded DNA, anti-parietal cell, anti-smooth muscle, anti-mitochondrial (AMA), anti-thyroid peroxidase, anti-thyroglobulin (anti-TG) and anti-phospholipid (aPL) at Hacettepe University were included. Of those patients, 212 had one or more autoantibodies whereas the remaining 303 were negative for all autoantibodies. RPL was the primary outcome and was defined as ≥2 pregnancy losses (n = 119).

RESULTS

The frequency of RPL was significantly higher in the autoantibody positive group than controls (28.3% versus 14.5%, p<0.001). Anti-TG (21.2% versus 7.8%, p < 0.001), aPL (18.3% versus 5.6%, p < 0.001) and AMA (4.8% versus 0.5%, p = 0.001) antibodies were more common in patients with RPL. For the view of obstetric complications, oligohydramniosis (3.8% versus 0.7%, p = 0.03) and stillbirth (17.0% versus 10.6%, p = 0.002) were significantly higher in the autoantibody-positive group.

CONCLUSIONS

Even in women without autoimmune disease or hereditary thrombophilia, autoantibodies per se might directly increase the risk of RPL and obstetric complications. The screening anti-TG and aPL autoantibodies in the first step might be considered in patients with RPL.

Statistical Correlations of the Spontaneous Abortion with Trombophilia and Other Associated Pathologies

15-20% of all known pregnancies progress with a miscarriage or an ectopic pregnancy. The recurrent miscarriage is a delicate clinical situation because with all the advances in genetic and immunologic research the incriminating factors haven't been discovered yet. The treatment is also subject to controversies, being perceived as either ineffective or aggressive. A number of 376 pregnant women with a gestational age smaller than 12 weeks have been selected, 226 of them with spontaneous abortion. In the study group of patients with previous spontaneous abortions we have found a series of associated pathology. From the cases with secondary non idiopathic recurrent miscarriage we have identified 4 cases of thrombophilia with antiphospholipid syndrome, 2 cases of thrombocytosis, one case of autoimmune thyroiditis, one case of uterine tumor, one case of MTHFR C homozygous thrombophilia and one case of FVL heterozygous thrombophilia. Knowing the correlations between the recurrent miscarriage and the hereditary thrombophilia as well as the options of treatment for increasing the chances of having a pregnancy with a normal evolution direct the doctors in testing the patients with recurrent miscarriage for hereditary thrombophilia.

Evidence-based management of recurrent miscarriages

Recurrent miscarriages are postimplantation failures in natural conception; they are also termed as habitual abortions or recurrent pregnancy losses. Recurrent pregnancy loss is disheartening to the couple and to the treating clinician. There has been a wide range of research from aetiology to management of recurrent pregnancy loss. It is one of the most debated topic among clinicians and academics. The ideal management is unanswered. This review is aimed to produce an evidence-based guidance on clinical management of recurrent miscarriage. The review is structured to be clinically relevant. We have searched electronic databases (PubMed and Embase) using different key words. We have combined the searches and arranged them with the hierarchy of evidences. We have critically appraised the evidence to produce a concise answer for clinical practice. We have graded the evidence from level I to V on which these recommendations are based.

Recurrent miscarriage and cervical human papillomavirus infection

PROBLEM

To investigate the possible relationship between human papillomavirus (HPV) infection and recurrent miscarriage (RM).

METHODS

In this retrospective case-control study, 49 women with unexplained RM (Group 1 - cases) and 475 women without any miscarriage and with at least one pregnancy at term (Group 2 - controls) were checked for cervical HPV infection through Hybrid Capture(®) II (HC 2) or polymerase chain reaction (PCR).

RESULTS

HPV+ DNA tests were detected in 13 (26.53%) RM women and in 294 (61.89%) control women (P < 0.001). The prevalence rate in HPV+DNA tests was significantly different in the 30-39 years age range. No differences between groups were detected in HPV types, nor in the cytological and histological findings.

CONCLUSION

Women with RM have a lower prevalence of HPV+DNA tests than controls. This suggests that immune reactivity potentially leading to RM could be in some way protective against genital HPV infection.

Thyrotropin receptor autoantibodies and early miscarriages in patients with Hashimoto thyroiditis: a case-control study

We have previously hypothesized that early miscarriage in women with Hashimoto thyroiditis might be the result of a cross-reactivity process, in which blocking autoantibodies against thyrotropin receptor (TSHr-Ab) antagonize hCG action on its receptor on the corpus luteum. To test this hypothesis from the clinical perspective, we investigated the presence of TSHr-Ab in Hashimoto thyroiditis patients with apparently unexplained, first-trimester recurrent miscarriages compared to that in Hashimoto thyroiditis patients with documented normal fertility. A total of 86 subjects (43 cases and 43 age-matched controls) were finally included in a case-control study. No difference in the prevalence of TSHr-Ab positivity was detected between cases and controls (Fisher's exact test, p value = 1.00). In patients with recurrent miscarriages, TSHr-Ab concentrations did not predict the number of miscarriages (univariate linear regression, p value = 0.08). These results were robust in sensitivity analyses, including only cases with full investigation or those with three or more miscarriages. We conclude that no role could be advocated for TSHr-Ab in the aetiology of recurrent miscarriages in women with Hashimoto thyroiditis.

Thyroglobulin autoantibodies: is there any added value in the detection of thyroid autoimmunity in women consulting for fertility treatment?

BACKGROUND

Thyroid autoimmunity (TAI) is frequent in infertile women, but to what extent thyroglobulin autoantibodies (Tg-Abs) contribute to TAI is unclear in the literature. The aims of the present study were to determine the prevalence of TAI in women consulting for fertility problems and to investigate the impact of isolated Tg-Abs, isolated thyroid peroxidase autoantibodies (TPO-Abs), and the presence of both autoantibody types on thyroid function. Furthermore, thyroid function was compared between women with and without TAI and between infertile and fertile women.

METHODS

A cross-sectional data analysis nested within an ongoing prospective cohort study was performed in order to determine the prevalence of TAI in unselected women consulting our tertiary referral center for reproductive medicine (CRM). The women underwent a determination of serum thyrotropin (TSH), free thyroxine (FT4), TPO-Abs, and Tg-Abs. The cause of infertility, age, body-mass index (BMI), and smoking habits were recorded.

RESULTS

The prevalence of TAI was 16% (163/992). In 8% of cases, both types of autoantibodies were present, in 5% isolated positive Tg-Abs were found, and 4% had isolated positive TPO-Abs (p=0.025 and p=0.003 respectively). The prevalence of TAI was significantly higher in infertile women as compared to that in fertile controls (19% vs. 13%; p=0.047). The median serum TSH level was significantly higher in the women with TAI and with isolated positive Tg-Abs compared to that in women without TAI (1.83 [1.44] and 1.90 [0.85] vs. 1.47 [0.94] mIU/L; p<0.001 respectively). The median FT4, age, BMI, and smoking habits were comparable between the study groups.

CONCLUSIONS

The prevalence of TAI was higher in infertile women as compared to fertile women consulting our CRM. Five percent of the women had isolated positive Tg-Abs and a significantly higher serum TSH compared to that in women without TAI.

Multiple pregnancy failures: an immunological paradigm

Recurrent spontaneous abortion (RSA), three or more pregnancy losses prior to 20 weeks, occurs in about 1% of all pregnancies, 50% of RSA cases remain unexplained and unresolved. Recently, immune pathways have been implicated in the pathophysiology of RSA. Immune tolerance of the fetal-placental unit and placental angiogenesis are mandatory for a successful pregnancy outcome. Unscheduled dysregulation of the placental vasculature is thought to be the pathophysiologic mechanisms underlying an array of pregnancy complications like infertility, miscarriage, pre-eclampsia, and fetal growth restriction and death. Investigations on mechanisms and management of RSA are mired by substandard design and lack of optimal randomized clinical trials and have resulted in disagreement on guidelines for evaluation and treatments for patients with multiple pregnancy losses of unknown etiology. The present review focuses on evidence-based research discussion with immunologic causes, and immune-regulatory therapies recommended for helping patients with a history of RSA. We highlight data that might support revalidation of low molecular weight heparin as a protective therapy in RSA. Newly launched growth factors, GM-CSF, and potentially novel agents to suppress inflammatory rejection, including regulatory T cells, human chorionic gonadotropin, and M-CSF/IL-10, may work in concert with tender-loving-care therapy and give hope to couples with multiple pregnancy losses.