Autoimmune antiovarian antibodies and their impact on the success of an IVF/ET program

Innate and adaptive immune dysregulation in women with recurrent implantation failure

Recurrent implantation failure (RIF) is a condition where a woman fails to obtain pregnancy after multiple embryo transfer cycles, even with superior-quality blastocysts. There are various factors that can contribute to RIF, including immunologic disturbances. The immune system is extremely important during pregnancy. Immune cells such as T cells, B cells, natural killer (NK) cells, and macrophages (MQ) are present in the female reproductive tract and are accountable for regulating the immune response to invading pathogens and maintaining tissue homeostasis. Dysregulation of these immune cells can lead to inflammation, which can impair fertility. One of the most common immunological disturbances observed in RIF is an altered Th1/Th2 ratio, along with changes in NK cell and macrophage numbers. In addition, the presence of some antibodies, such as anti-ovarian antibodies, can also contribute to RIF. Interleukins have been implicated in the development of an inflammatory response that can interfere with successful embryo implantation. As a result, a comprehensive understanding of immunological compartments in RIF women could assist us in determining the immunological origins of this disease. We will discuss immunological factors that might contribute to RIF etiology, including cellular and molecular components.

The status of anti-ovarian antibody immunoassays: Valid or invalid, in or out?

There has been a paradign shift in the status of immunoassays. There used to be a time where immunoassays had a very narrow role in clinical medicine, but that is not the case in today's world. Immunoassays have taken a central role in helping us better understand and treat human diseases. The literature around anti-ovarian antibodies (AOA) immunoassay testings have been conflicting. Researchers challenged the specificity of the reported assays, but a systematic study was never elucidated on what/who the trouble maker was in rendering these tests so nonspecific. Attempts were made by our group in Mumbai, India, to throw light on the culprit behind the nonspecificity casative factor in the immunoassays and a method to overcome this was reported and published. This review highlights the stories back five and a half decades to date, to demonstrate where the status of AOA testing was, is and will be.

Insights into the autoimmune aspect of premature ovarian insufficiency

Premature ovarian insufficiency (POI) refers to a continuum of decreasing ovarian function in women before the age of 40. To date, the cause of POI in the majority of cases remain unresolved. Many cases has been linked to genetic, toxic, infections, enzymatic and iatrogenic causes. A key function of the immune system is to identify and differentiate "self" and "non self" i.e. tolerance. Loss of self-tolerance results in an immune response against self-tissues and thus autoimmunity. Various investigations have highlighted the role of autoimmunity and its pertinence to POI. Several potential immune antigenic targets in the ovary have been reported to be involved in autoantibody induced autoimmune attack. The presence of lymphocytic oöphorits in ovarian samples of patients with POI provides histopathological evidence of autoimmune ovarian involvement. Finally, POI is strongly associated with other autoimmune conditions including for instance Addison disease, autoimmune polyglandular syndrome (APS) -1, APS-4, hypothyroidism, and diabetes mellitus among other autoimmune diseases. Taken together, these lines of evidence provide strong basis that support the role of autoimmunity as a potential cause of disease etiopathogenesis. Continuing research is increasingly providing more insight into the complex disease process. The aim of this review is to summarize the current literature related to the autoimmune nature of POI.

Premature ovarian insufficiency and autoimmune diseases

Premature ovarian insufficiency (POI) is a clinical syndrome defined by loss of ovarian activity before the age of 40 years and has a potentially devastating effect upon women's health, both physically and psychologically. An underlying autoimmune disease has been identified in approximately 20% of patients with POI, the most common of which are disorders of the thyroid and adrenal glands. Nevertheless, in the majority of cases, the etiology is unknown. The damage mechanism to the ovary is usually caused by antibodies, and autoimmune POI is usually characterized by cellular infiltration of the theca cells of growing follicles by various inflammatory cells. Yet, other various factors and proteins of unknown clinical significance are present. The major diagnostic tool for otherwise idiopathic POI is the presence of autoantibodies against various ovarian components that strongly support the option of autoimmune etiology of POI. Treatment of the underlying cause of POI is the main strategy, although immunosuppressive therapy should be considered in a selected population of well-defined autoimmune POI and, as in idiopathic POI, in whom the resumption of ovarian activity is possible.

The Human Egg's Zona Pellucida

Human zona pellucida (ZP) matrix, a delicate network of thin interconnected filaments, is primarily composed of four glycoproteins, namely, ZP1, ZP2, ZP3, and ZP4. All four zona proteins share common structural elements such as signal peptide, "ZP domain," consensus furin cleavage site, transmembrane-like domain, and short cytoplasmic tail. In addition, ZP1 and ZP4 also have "Trefoil domain." Recombinant/native human zona proteins have been used to investigate their binding characteristics to the capacitated and/or acrosome-reacted spermatozoa. These investigations revealed that ZP1, ZP3, and ZP4 primarily bind to the head region of the capacitated human spermatozoa, whereas ZP2 binds to the acrosome-reacted sperm. However, using transgenic mice, N-terminal region of human ZP2 has also been shown to play an important role in binding of sperm to the egg. ZP1, ZP3, and ZP4 lead to dose-dependent increase in acrosome reaction, suggesting that in humans more than one ZP glycoprotein is responsible for induction of acrosome reaction. Glycosylation of these proteins, in particular, N-linked glycosylation as well as sialyl-Lewis^x, is essential for inducing acrosome reaction. Studies delineating downstream signaling events associated with induction of acrosome reaction reveal subtle differences between ZP3 and ZP1/ZP4 with respect to activation of Gi protein-coupled receptor and protein kinase A. The role of mutations in the zona proteins and ZP autoantibodies leading to infertility in women is suggestive and needs more rigorous experimentations for confirming their role in female infertility. The above-mentioned aspects of the human ZP glycoproteins have been discussed in this review.

The association of different auto-antibodies against ovarian tissues and gonadotropins and poor ovarian response in intracytoplasmic sperm injection cycles

This study aimed to assess the possible association between ovarian auto-antibodies and poor ovarian response to controlled ovarian hyperstimulation (COH) in patients undergoing intracytoplasmic sperm injection (ICSI) cycles. In total, 42 poor responders and 43 male factor subjects were enrolled in the study and underwent either a standard long gonadotropin-releasing hormone (GnRH) agonist or antagonist protocol. Anti-ovarian, anti-oocyte, anti-zona pellucida (anti-ZP) and anti-gonadotropin antibodies in their sera and follicular fluid (FF) were measured by an enzyme-linked immunosorbent assay technique (ELISA). The mean follicular fluid anti-oocyte antibody [ratio of optical density (OD) _sample/OD _Control] was significantly higher in poor responders compared to the normal group (2.40 ± 1.55 versus 1.72 ± 0.71, p = 0.012). The linear regression analysis showed an inverse correlation between FF anti-oocyte antibody concentrations and the number of: (i) retrieved oocytes (B = -1.212, r = -0.235, p = 0.030); (ii) mature oocytes (B = -1.042, r = -0.234, p = 0.031); (iii) embryos available (B = -0.713, r = -0.228, p = 0.036); and (iv) good quality embryos (B = -0.369, r = -0.229, p = 0.035). However, there were no significant differences between two groups in terms of FF and serum anti-ovarian, anti-gonadotropins and anti-ZP antibodies. The Pearson correlation analysis on 85 infertile patients showed a positive correlation between age and the levels of FF anti-oocyte antibody (r = 0.276, p = 0.010). This study demonstrated that FF anti-oocyte antibody could be associated with poor response to COH in ICSI cycles.

Ovulation Induction is a More Effective Stimulant on Antiovarian Antibody Production than In Vitro Fertilization

INTRODUCTION

Our aim in this study is to evaluate the effects of in vitro fertilization (IVF), including controlled ovarian hyperstimulation (COH) and the number of oocyte pick-up (OPU) procedures on the development of anti-ovarian antibodies (AOA).

METHODS

To evaluate the effects of IVF procedures, namely, COH and OPU, serum samples for measuring AOA concentration levels by enzyme-linked immunosorbent assay were collected on the third day of the menstrual cycle, at the end of the COH, and after OPU.

RESULTS

The AOA levels in IVF patients were significantly higher than the fertile control groups'. In the IVF group, neither COH nor OPU caused any increase in AOA levels when compared to the basal results. AOA levels were higher in patients with a history of 5-8 cycles of ovulation induction, before IVF treatment. There was no relationship between the basal AOA concentrations and the type of infertility, the etiology of infertility or the pregnancy outcomes, whereas there was a relationship between the AOA and the duration of infertility.

CONCLUSION

AOA levels of IVF patients were found to be higher than the fertile control groups'. AOA was found to be related to infertility in patients who had a longer duration of infertility and repeated ovulation induction procedures without IVF. COH and OPU during an IVF cycle did not cause an increase in AOA levels.

Role of zona pellucida glycoproteins during fertilization in humans

In the last decade, scientific investigations pertaining to the role of zona pellucida (ZP) glycoproteins during fertilization in humans have led to new insights. This has been achieved using purified native/recombinant human zona proteins and transgenic mice expressing human ZP glycoproteins. The proposed model in mice of ZP glycoprotein-3 (ZP3) acting as primary sperm receptor and ZP glycoprotein-2 (ZP2) as secondary sperm receptor has been modified for sperm-egg binding in humans. ZP glycoprotein-1 (ZP1), ZP3, and ZP glycoprotein-4 (ZP4) have been shown to bind to the capacitated human sperm. ZP2 binds to the acrosome-reacted human spermatozoa. Further, the eggs obtained from transgenic mice expressing human ZP2 alone or in conjunction with other human instead of mouse zona proteins showed binding of human sperm, suggesting that ZP2 might also play a role in sperm-egg binding. This function has been mapped to a domain corresponding to amino acid residues 51-144 of ZP2. In contrast to mice, where ZP3 is the primary agonist for inducing the acrosome reaction, in humans, the acrosome reaction can be mediated by ZP1, ZP3, and ZP4. The effect of mutations in the genes encoding zona proteins on the ZP morphology and infertility has not been established. Further, the role of autoantibodies against ZP in women with 'unexplained infertility' leading to poor outcome of in vitro fertilization is currently controversial and needs further investigations. Understanding the role of ZP glycoproteins during human fertilization facilitates the development of new contraceptives and strategies to overcome the problem of infertility.

Is there a role of autoimmunity in implantation failure after in-vitro fertilization?

PURPOSE OF REVIEW

The process of implantation involves the interaction of the human blastocyst and the uterine epithelium. Several autoimmune factors have been implicated to have an influence on implantation failure.

RECENT FINDINGS

Recent studies have investigated the role of autoimmune factors in implantation in women undergoing in-vitro fertilization. Antiphospholipid antibodies are identified more frequently in women undergoing in-vitro fertilization, but their presence does not appear to influence the outcome of pregnancy, miscarriage, or live birth rates. Antithyroid antibodies are commonly found in women of reproductive age, but implantation rates and miscarriage rates are not altered when women have normal thyroid function. Antinuclear antibodies may be a marker for underlying autoimmune disease when coupled with certain signs and symptoms, but low-titer antibodies do not influence in-vitro fertilization outcome. Antisperm antibodies are more often associated with fertilization failure when found in high titers in seminal plasma, in sperm, or in the mucosal immune system of women. Antisperm antibodies are uncommon but most often associated with ovarian hypofunction.

SUMMARY

Implantation is characterized by the interaction of two immunologically and genetically distinct tissues. During implantation, local and systemic immune factors, cytokines, and growth factors may interact with adhesion molecules and other matrix-associated proteins, glycoproteins, and peptides.

Corticosteroids in patients with antiovarian antibodies undergoing in vitro fertilization: a prospective pilot study

OBJECTIVE

Antiovarian autoantibodies (AOA) have been associated with reproductive failure, especially in in vitro fertilization (IVF) patients. Thus, the success rate of IVF might be improved by the use of corticosteroids. However, therapeutic trials with these drugs have yielded conflicting results, particularly because of heterogeneous inclusion criteria. Among women with previous IVF failure, we selected those who presented with a positive serum AOA assay, and analysed the efficacy of corticosteroids in improving the IVF outcome in these patients.

METHODS

One hundred patients with serum AOA detected by ELISA and at least two previously failed IVF attempts were selected. These patients underwent a further IVF cycle with 0.5 mg/kg prednisolone, started on the first day of the treatment cycle. In patients who became pregnant, corticosteroids were administered until the end of the first trimester of pregnancy and then progressively discontinued. AOA were assessed before and after oocyte retrieval. Clinical data of the corticosteroid-treated cycle were compared with data from the preceding IVF cycle for each patient.

RESULTS

No adverse effects resulting from corticosteroids were observed. Post oocyte retrieval antiovarian IgG were significantly lower in corticosteroid-treated attempts when compared with the preceding cycles. Twenty-six pregnancies resulted in the birth of 30 healthy children. The pregnancy rate, implantation rate, and live birth rate were 38.8%, 17.8%, and 26.5% respectively in prednisolone-treated cycles.

CONCLUSION

This study confirms the usefulness of corticosteroids in improving the success rate in a subset of patients with previous IVF failure and significant serum AOA levels.

[Ovarian autoimmunity and ovarian pathologies: antigenic targets and diagnostic significance]

The involvement of serum anti-ovarian autoantibodies (AOA) in ovarian pathology still remains controversial. In some cases of clinically patent ovarian failure, there seems to be a causal relationship between AOA and the ovarian disease. In patients with various organ-specific or systemic autoimmune diseases, or with unexplained, repeated reproductive failure, but otherwise normal ovarian function, it is even more difficult to determine the significance of AOA for several reasons: i) AOA recognize many different antigenic targets in the ovary ii) the antiovarian response may be transient or variable with time iii) the presence of AOA does not imply their aetiopathogenic role in the disease. The present paper reviews the clinical significance of AOA based on their ovarian targets as far as they have been identified until now.

Antibodies against granulosa luteinized cells and their targets in women attending IVF program

PROBLEM

The study was conducted to investigate the presence and the possible role of anti-granulosa luteinized cells (GLCs) antibodies in infertile patients, attending in vitro fertilization (IVF) cycles, as well as to attempt the identification of putative target antigens.

METHOD OF STUDY

A total of 101 sera from infertile women (patient group) and 33 sera from fertile women (control group) were investigated. The patients were divided in subgroups according to: ovarian response to controlled ovarian hyperstimulation (COHS)--poor responders and good responders; fertilization rate--low fertilization rate and high fertilization rate. The relation between embryo transfer (ET) outcome and prevalence of anti-GLC antibodies was investigated too. NONIDET P-40 (NP-40) and whole-GLC lysates, as antigenic materials, were used in enzyme-linked immunosorbent assay (ELISA) and immunoblotting, respectively.

RESULTS

Based on the cut-off value of 2 S.D. above the control mean value, the prevalence of patients positive for anti-GLC antibodies was found to be 28.7% (29/101) compared with 9.1% (3/33) in control fertile women (P < 0.05). Anti-GLC antibodies were detected in 54.8% (17/31) of women with low fertilization rate compared with 15.7% (11/70) of women with high fertilization rate (P = 0.003) and it was established that women positive for anti-GLC antibodies had lower fertilization rate, than those negative for anti-GLC antibodies. Immunoblotting has demonstrated a number of GLC proteins with molecular masses (MM) of 110, 70-80, 47 and 37 kDa, frequently reacting with anti-GLC antibodies in patient's sera, as possible targets.

CONCLUSION

The presented results on the prevalence and role of anti-GLC antibodies, as well as the data on the target antigens confirmed our hypothesis about the potential involvement of GLC antigens in some cases of immunological infertility in IVF patients.

Gonadal antibodies interfering with female reproduction

While the involvement of anti-ovarian antibodies (AOAs) is highly likely, yet still controversial, in patients with patent premature ovarian failure (POF), it is even more difficult--for several reasons--to ascertain the clinical significance of these antibodies in patients without obvious ovarian failure. First, AOAs form a heterogeneous group of antibodies recognizing several different antigenic targets such as granulosa and thecal cells, zona pellucida, oocyte cytoplasm, corpus luteum, as well as gonadotrophins and their receptors. Second, the detection of AOAs in various clinical situations does not readily imply a causal relationship between these antibodies and impaired ovarian function. Third, diagnostic tools for detecting AOAs and their molecular targets have to be improved to yield more reliable data and allow a better comprehension of the pathophysiology of AOAs. Preliminary results with immunosuppressive therapy in selected AOA patients have been encouraging, but randomized trials have to be performed.

[What are the antigenic targets in the ovary?]

The ovary can be the target of an autoimmune disease involving many different autoantigens. The clinical feature of this disease often results in premature ovarian failure or infertility and may be either isolated or associated with other autoimmune pathologies, especially with adrenal autoimmunity. The diagnosis of an autoimmune mechanism relies on the presence of anti-ovarian antibodies, whose prevalence is quite variable according to the different methods used to detect them, and to the different stages of the disease. In addition, their clinical significance is not always clear, as to their pathologic or epiphenomenal nature. However, the study of these autoantibodies has led to the identification of some of their antigenic targets which have to be known for a better understanding of the pathologic mechanisms involved. This paper reviews anti-steroid producing cells, anti-gonadotrophin receptor, anti-gonadotrophin, anti-corpus luteum, anti-zona pellucida and anti-oocyte antibodies.

Anticorps anti-ovaires et fécondation in vitro : cause ou conséquence ?

OBJECTIVES

To assess anti-ovarian antibodies (AOA) in serum samples at various times of in vitro fertilization (IVF) attempts to determine whether ovarian stimulation could result in the production of such autoantibodies in women.

PATIENTS AND METHODS

Prospective study on 134 patients and 138 IVF cycles using a classical long protocol. For each attempt, four serum samples were obtained, respectively, at the onset of downrelation (S1), end of downregulation (S13), after 7 days of follicular stimulation (S21) and the day of follicular puncture (SP). Five hundred and fifty two samples were tested with an enzyme-linked immunosorbent assay for three isotypes (IgG, IgA, IgM) of AOA.

RESULTS

In the whole group, mean concentrations of AOA for each isotype were compared group by group: S1-S13, S1-S21, S1-SP, S13-S21, S13-SP, S21-SP. Not any significant difference was observed whatever the isotype considered.

DISCUSSION AND CONCLUSION

This study shows the absence of influence of endogenous or exogenous ovarian stimulation by gonadotropins on anti-ovarian autoimmunity.

Premature ovarian failure associated with autoimmune polyglandular syndrome: pathophysiological mechanisms and future fertility

BACKGROUND

Autoimmune polyglandular syndromes (APS) are a series of disorders characterized by autoimmunity against two or more endocrine organs. Premature ovarian failure (POF) may also have an autoimmune origin and, when accompanied by other autoimmune endocrinopathies, may be part of the APSs. Onset of autoimmune ovarian failure usually occurs in childhood, adolescence, or adulthood, and as a result, fertility may be severely compromised.

CASE REPORT

A 26-year-old women with secondary amenorrhea, Addison's disease, and autoimmune hypothyroidism requested infertility evaluation. Examination, transvaginal ultrasonography, endocrine evaluation, and ovarian biopsy were performed. 21-Hydroxylase and antithyroid antibodies were demonstrated, but ovarian steroid cell antibodies (StCA) were absent at the time of her infertility evaluation. Transvaginal sonography demonstrated only a few ovarian follicles. An ovarian biopsy revealed lymphocytic infiltration of the ovary. This presentation is consistent with APS type II accompanied by autoimmune POF.

DISCUSSION

Unlike APS types I and III, autoimmune POF is more commonly encountered with APS types I and III than with APS type II. An autoimmune response to steroidogenic enzymes and ovarian steroid cells appears to mediate destruction of ovarian function. Although immunotherapy with corticosteroids (with or without in vitro fertilization [IVF]) may be successful in limited cases where several follicles are present, oocyte donation with IVF may be the best option for the patient seeking fertility, particularly in the absence of ovarian follicles.

CONCLUSIONS

Advances in molecular genetics may be valuable in predicting and counseling women at risk for APS and POF, and cryopreservation of ovarian tissue may offer hope to affected unmarried young women. It is reasonable to suggest that children and reproductive aged women with one autoimmune disorder should be periodically screened for other autoimmune disorders.

Ovarian autoimmune disease and ovarian autoantibodies

Detection of specific autoantibodies remains the most practical clinical and research marker of autoimmune disease. The lack of consensus on ovary specific antibodies as a marker for ovarian autoimmunity has clinical and research consequences. The objective of this review is to summarize the evidence for ovarian autoimmunity and the detection of ovary specific autoantibodies in humans. Evidence favors the presence of an autoimmune disease of the ovary. Ovarian autoantibodies are associated primarily with premature ovarian failure (POF) and unexplained infertility. Variations in detection of ovarian autoantibodies are likely to be due to study design elements such as antibody test format, antigen preparation, and criteria for study and comparison groups. In addition, multiple targets appear to be involved in ovarian autoimmunity including ovarian cellular elements and oocyte related antigens. Many studies only assess one target antigen, leaving individuals with ovarian autoimmunity unidentified. The next most significant advance in characterizing ovarian autoimmunity will be definitive identification of the specific antigens and development of standardized tests based on use of specific antigens.

Autoimmune factors in reproductive failure

The present review highlights recent studies that investigated the possible influences of autoimmune factors in reproductive success or failure. These factors include antiphospholipid antibodies, antithyroid antibodies, antinuclear antibodies, antisperm antibodies, and antiovarian antibodies. The majority of recent work has focused on these potential autoimmune factors; however, controversy still exists over indicated testing and treatment options. An association of antiphospholipid antibodies and recurrent pregnancy loss has been established, and treatment with subcutaneous heparin appears most efficacious. Other autoimmune factors are under investigation as markers of in-vitro fertilization failure. Limited data from treatment trials are presented.