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Eliwa J, Papas RS, Kutteh WH. Expanding the role of chromosomal microarray analysis in the evaluation of recurrent pregnancy loss. J Reprod Immunol 2024; 161:104188. [PMID: 38171035 DOI: 10.1016/j.jri.2023.104188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/18/2023] [Accepted: 12/22/2023] [Indexed: 01/05/2024]
Abstract
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.
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Affiliation(s)
- Jasmine Eliwa
- Division of Obstetrics and Gynecology, University of Tennessee Health Sciences Center-Memphis, Memphis, TN, USA
| | - Ralph S Papas
- Infertility Division, Obstetrics & Gynecology Department, St George Hospital - University Medical Center - University of Balamand, Beirut, Lebanon
| | - William H Kutteh
- Division of Obstetrics and Gynecology, University of Tennessee Health Sciences Center-Memphis, Memphis, TN, USA; Recurrent Pregnancy Loss Center, Fertility Associates of Memphis, Memphis, TN, USA.
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Mao J, Feng Y, Zhu X, Ma F. The Molecular Mechanisms of HLA-G Regulatory Function on Immune Cells during Early Pregnancy. Biomolecules 2023; 13:1213. [PMID: 37627278 PMCID: PMC10452754 DOI: 10.3390/biom13081213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/27/2023] Open
Abstract
Human leukocyte antigen-G (HLA-G) is a non-classical human major histocompatibility complex (MHC-I) molecule with the membrane-bound and soluble types. HLA-G is primarily expressed by extravillous cytotrophoblast cells located at the maternal-fetal interface during pregnancy and is essential in establishing immune tolerance. This review provides a comprehensive understanding of the multiple molecular mechanisms by which HLA-G regulates the immune function of NK cells. It highlights that HLA-G binds to microRNA to suppress NK cell cytotoxicity and stimulate the secretion of growth factors to support fetal growth. The interactions between HLA-G and NK cells also activate senescence signaling, promoting spiral artery remodeling and maintaining the balance of maternal-fetal immune responses. In addition, HLA-G can inhibit the function of decidual T cells, dendritic cells, and macrophages. Overall, the interaction between trophoblast cells and immune cells mediated by HLA-G plays a crucial role in understanding immune regulation at the maternal-fetal interface and offers insights into potential treatments for pregnancy-related diseases.
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Affiliation(s)
- Jia Mao
- Center for Translational Medicine, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, State Key Laboratory of Biotherapy and Cancer Center, College of Life Sciences, Sichuan University, Chengdu 610064, China
| | - Ying Feng
- Department of Histology, Embryology and Neurobiology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu 610041, China;
| | - Xiaofeng Zhu
- Key Laboratory of Bio-Resource and Eco-Environment of Ministry of Education, State Key Laboratory of Biotherapy and Cancer Center, College of Life Sciences, Sichuan University, Chengdu 610064, China
| | - Fang Ma
- Center for Translational Medicine, Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu 610041, China
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3
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Vomstein K, Egerup P, Kolte AM, Behrendt-Møller I, Boje AD, Bertelsen ML, Eiken CS, Reiersen MR, Toth B, la Cour Freiesleben N, Nielsen HS. Biopsy-free profiling of the uterine immune system in patients with recurrent pregnancy loss and unexplained infertility. Reprod Biomed Online 2023; 47:103207. [PMID: 37211442 DOI: 10.1016/j.rbmo.2023.03.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/10/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023]
Abstract
RESEARCH QUESTION What are the differences in menstrual blood lymphocytes between controls, patients with recurrent pregnancy loss (RPL) and patients with unexplained infertility (uINF)? DESIGN Prospective study including 46 healthy controls, 28 RPL and 11 uINF patients. A feasibility study compared lymphocyte compositions of endometrial biopsies and menstrual blood collected during the first 48 h of menstruation in seven controls. In all patients, peripheral and menstrual blood from the first and subsequent 24 h were analysed separately by flow cytometry, focusing on the main lymphocyte populations and natural killer (NK) cell subsets. RESULTS The first 24 h of menstrual blood resembles the uterine immune milieu as tested by endometrial biopsy. RPL patients showed significantly higher menstrual blood CD56+ NK cell numbers than controls (mean ± SD: 31.13 ± 7.52% versus 36.73 ± 5.4%, P = 0.002). Menstrual blood CD56dimCD16bright NK cells within the CD56+ NK cell population were decreased in RPL (16.34 ± 14.65%, P = 0.011) and uINF (15.7 ± 5.91%, P = 0.02) patients versus control (20.42 ± 11.53%). uINF patients had the lowest menstrual blood CD3+ T cell counts (38.81 ± 5.04%, control versus uINF: P = 0.01) and cytotoxicity receptors NKp46 and NKG2D on CD56brightCD16dim cells were higher in uINF (68.12 ± 11.84%, P = 0.006; 45.99 ± 13.83%, P = 0.01, respectively) and RPL (NKp46: 66.21 ± 15.36%, P = 0.009) patients versus controls. RPL and uINF patients had higher peripheral CD56+ NK cell counts versus controls (11.42 ± 4.05%, P = 0.021; 12.86 ± 4.29%, P = 0.009 versus 8.4 ± 3.5%). CONCLUSIONS Compared with controls, RPL and uINF patients had a different menstrual blood-NK-subtype profile, indicating an altered cytotoxicity. In future studies, this non-invasive analysis might enable identification and monitoring of patients receiving immunomodulatory medications.
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Affiliation(s)
- Kilian Vomstein
- Recurrent Pregnancy Loss Unit, The Capital Region, Copenhagen University Hospitals, Hvidovre Hospital, DK-2650, Hvidovre, Denmark and Rigshospitalet, Copenhagen, Denmark; Department of Obstetrics and Gynecology, The Fertility Clinic, Copenhagen University Hospital Hvidovre, DK-2650, Denmark.
| | - Pia Egerup
- Recurrent Pregnancy Loss Unit, The Capital Region, Copenhagen University Hospitals, Hvidovre Hospital, DK-2650, Hvidovre, Denmark and Rigshospitalet, Copenhagen, Denmark
| | - Astrid Marie Kolte
- Recurrent Pregnancy Loss Unit, The Capital Region, Copenhagen University Hospitals, Hvidovre Hospital, DK-2650, Hvidovre, Denmark and Rigshospitalet, Copenhagen, Denmark
| | - Ida Behrendt-Møller
- Recurrent Pregnancy Loss Unit, The Capital Region, Copenhagen University Hospitals, Hvidovre Hospital, DK-2650, Hvidovre, Denmark and Rigshospitalet, Copenhagen, Denmark; Department of Obstetrics and Gynecology, The Fertility Clinic, Copenhagen University Hospital Hvidovre, DK-2650, Denmark
| | - Amalie Dyhrberg Boje
- Recurrent Pregnancy Loss Unit, The Capital Region, Copenhagen University Hospitals, Hvidovre Hospital, DK-2650, Hvidovre, Denmark and Rigshospitalet, Copenhagen, Denmark
| | - Marie-Louise Bertelsen
- Recurrent Pregnancy Loss Unit, The Capital Region, Copenhagen University Hospitals, Hvidovre Hospital, DK-2650, Hvidovre, Denmark and Rigshospitalet, Copenhagen, Denmark
| | - Cecilie Sofie Eiken
- Recurrent Pregnancy Loss Unit, The Capital Region, Copenhagen University Hospitals, Hvidovre Hospital, DK-2650, Hvidovre, Denmark and Rigshospitalet, Copenhagen, Denmark
| | - Michelle Raupelyté Reiersen
- Recurrent Pregnancy Loss Unit, The Capital Region, Copenhagen University Hospitals, Hvidovre Hospital, DK-2650, Hvidovre, Denmark and Rigshospitalet, Copenhagen, Denmark
| | - Bettina Toth
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Nina la Cour Freiesleben
- Department of Obstetrics and Gynecology, The Fertility Clinic, Copenhagen University Hospital Hvidovre, DK-2650, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Henriette Svarre Nielsen
- Recurrent Pregnancy Loss Unit, The Capital Region, Copenhagen University Hospitals, Hvidovre Hospital, DK-2650, Hvidovre, Denmark and Rigshospitalet, Copenhagen, Denmark; Department of Obstetrics and Gynecology, The Fertility Clinic, Copenhagen University Hospital Hvidovre, DK-2650, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
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Cavalcante MB, da Silva PHA, Carvalho TR, Sampaio OGM, Câmara FEA, Cavalcante CTDMB, Barini R, Kwak-Kim J. Peripheral blood natural killer cell cytotoxicity in recurrent miscarriage: a systematic review and meta-analysis. J Reprod Immunol 2023; 158:103956. [PMID: 37236061 DOI: 10.1016/j.jri.2023.103956] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023]
Abstract
Dysregulated natural killer (NK) cells have been associated with recurrent miscarriages (RM). Studies have suggested that high peripheral blood NK cell cytotoxicities (pNKCs) are associated with an increased risk of RM. The aim of this systematic review (SR) and meta-analysis (MAs) is to investigate the difference in pNKC between nonpregnant and pregnant women with RM and controls and determine whether pNKC is reduced by immunotherapy. We searched the PubMed/Medline, Embase, and Web of Science databases. The MAs were conducted to compare pNKCs between women with and without RM before and during pregnancy as well as pre- and post-immunotherapy. Risk of bias in nonrandomized studies was assessed by the Newcastle-Ottawa Scale. Statistical analysis was performed using the Review Manager software. A total of 19 studies were included in the SR and 14 studies in the MAs. The MAs revealed higher pNKCs among nonpregnant women with RM compared to controls (MD, 7.99 95 %CI 6.40-9.58; p < 0.00001). pNKCs were also higher in pregnant women with RM than in pregnant controls (MD, 8.21 95 %CI 6.08-10.34; p < 0.00001). Women with RM showed significantly decreased pNKCs after the immunotherapy compared to before (MD, -8.20 95 %CI -10.20 - -6.19; p < 0, 00001). Additionally, there is an association between high pNKCs and the risk of pregnancy loss in women with RM. However, included studies showed substantial heterogeneities regarding the inclusion criteria of patients, techniques measuring pNKC, and types of immunotherapies. More studies are needed to evaluate the clinical efficiency of pNKCs in managing RM.
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Affiliation(s)
- Marcelo Borges Cavalcante
- Post graduate Program in Medical Sciences, Universidade de Fortaleza (UNIFOR), Fortaleza, CE 60.811-905, Brazil; CONCEPTUS - Reproductive Medicine, Fortaleza, CE 60.170-240, Brazil.
| | | | | | - Olga Goiana Martins Sampaio
- Post graduate Program in Medical Sciences, Universidade de Fortaleza (UNIFOR), Fortaleza, CE 60.811-905, Brazil
| | | | | | - Ricardo Barini
- Department of Obstetrics and Gynecology, Campinas University (UNICAMP), Campinas, SP 13.083-887, Brazil
| | - Joanne Kwak-Kim
- Reproductive Medicine and Immunology, Obstetrics and Gynecology, Clinical Sciences Department, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Vernon Hills, IL 60061, USA
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Stope MB, Mustea A, Sänger N, Einenkel R. Immune Cell Functionality during Decidualization and Potential Clinical Application. Life (Basel) 2023; 13:life13051097. [PMID: 37240742 DOI: 10.3390/life13051097] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/20/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Due to a vast influx in the secretory phase of the menstrual cycle, leukocytes represent 40-50% of the decidua at the time of implantation. Their importance for the implantation, maintenance of pregnancy, and parturition are known yet not fully understood. Thus, in idiopathic infertility, decidual immune-related factors are speculated to be the cause. In this review, the immune cell functions in the decidua were summarized, and clinical diagnostics, as well as interventions, were discussed. There is a rising number of commercially available diagnostic tools. However, the intervention options are still limited and/or poorly studied. In order for us to make big steps towards the proper use of reproductive immunology findings, we need to understand the mechanisms and especially support translational research.
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Affiliation(s)
- Matthias B Stope
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | - Alexander Mustea
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | - Nicole Sänger
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital Bonn, 53127 Bonn, Germany
| | - Rebekka Einenkel
- Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital Bonn, 53127 Bonn, Germany
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Von Woon E, Greer O, Shah N, Nikolaou D, Johnson M, Male V. Number and function of uterine natural killer cells in recurrent miscarriage and implantation failure: a systematic review and meta-analysis. Hum Reprod Update 2022; 28:548-582. [PMID: 35265977 PMCID: PMC9247428 DOI: 10.1093/humupd/dmac006] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/13/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Uterine natural killer cells (uNK) are the most abundant lymphocytes found in the decidua during implantation and in first trimester pregnancy. They are important for early placental development, especially trophoblast invasion and transformation of the spiral arteries. However, inappropriate uNK function has been implicated in reproductive failure, such as recurrent miscarriage (RM) or recurrent implantation failure (RIF). Previous studies have mainly focussed on peripheral NK cells (pNK), despite the well-documented differences in pNK and uNK phenotype and function. In recent years, there has been an explosion of studies conducted on uNK, providing a more suitable representation of the immune environment at the maternal-foetal interface. Here, we summarize the evidence from studies published on uNK in women with RM/RIF compared with controls. OBJECTIVE AND RATIONALE The objectives of this systematic review and meta-analysis are to evaluate: differences in uNK level in women with RM/RIF compared with controls; pregnancy outcome in women with RM/RIF stratified by high and normal uNK levels; correlation between uNK and pNK in women with RM/RIF; and differences in uNK activity in women with RM/RIF compared with controls. SEARCH METHODS MEDLINE, EMBASE, Web of Science and Cochrane Trials Registry were searched from inception up to December 2020 and studies were selected in accordance with PRISMA guidelines. Meta-analyses were performed for uNK level, pregnancy outcome and uNK/pNK correlation. Narrative synthesis was conducted for uNK activity. Risk of bias was assessed by ROBINS-I and publication bias by Egger's test. OUTCOMES Our initial search yielded 4636 articles, of which 60 articles were included in our systematic review. Meta-analysis of CD56+ uNK level in women with RM compared with controls showed significantly higher levels in women with RM in subgroup analysis of endometrial samples (standardized mean difference (SMD) 0.49, CI 0.08, 0.90; P = 0.02; I2 88%; 1100 women). Meta-analysis of CD56+ uNK level in endometrium of women with RIF compared with controls showed significantly higher levels in women with RIF (SMD 0.49, CI 0.01, 0.98; P = 0.046; I2 84%; 604 women). There was no difference in pregnancy outcome in women with RM/RIF stratified by uNK level, and no significant correlation between pNK and uNK levels in women with RM/RIF. There was wide variation in studies conducted on uNK activity, which can be broadly divided into regulation and receptors, uNK cytotoxicity, cytokine secretion and effect of uNK on angiogenesis. These studies were largely equivocal in their results on cytokine secretion, but most studies found lower expression of inhibitory receptors and increased expression of angiogenic factors in women with RM. WIDER IMPLICATIONS The observation of significantly increased uNK level in endometrium of women with RM and RIF may point to an underlying disturbance of the immune milieu culminating in implantation and/or placentation failure. Further research is warranted to elucidate the underlying pathophysiology. The evidence for measuring pNK as an indicator of uNK behaviour is sparse, and of limited clinical use. Measurement of uNK level/activity may be more useful as a diagnostic tool, however, a standardized reference range must be established before this can be of clinical use.
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Affiliation(s)
- Ee Von Woon
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive and Developmental Biology, Imperial College London, London, UK
- The Fertility Centre, Chelsea and Westminster Hospital, London, UK
| | - Orene Greer
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive and Developmental Biology, Imperial College London, London, UK
| | - Nishel Shah
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive and Developmental Biology, Imperial College London, London, UK
| | | | - Mark Johnson
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive and Developmental Biology, Imperial College London, London, UK
| | - Victoria Male
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive and Developmental Biology, Imperial College London, London, UK
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Reiser E, Bazzano MV, Solano ME, Haybaeck J, Schatz C, Mangesius J, Ganswindt U, Toth B. Unlaid Eggs: Ovarian Damage after Low-Dose Radiation. Cells 2022; 11:1219. [PMID: 35406783 DOI: 10.3390/cells11071219] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/24/2022] [Accepted: 04/02/2022] [Indexed: 11/17/2022] Open
Abstract
The total body irradiation of lymphomas and co-irradiation in the treatment of adjacent solid tumors can lead to a reduced ovarian function, premature ovarian insufficiency, and menopause. A small number of studies has assessed the radiation-induced damage of primordial follicles in animal models and humans. Studies are emerging that evaluate radiation-induced damage to the surrounding ovarian tissue including stromal and immune cells. We reviewed basic laboratory work to assess the current state of knowledge and to establish an experimental setting for further studies in animals and humans. The experimental approaches were mostly performed using mouse models. Most studies relied on single doses as high as 1 Gy, which is considered to cause severe damage to the ovary. Changes in the ovarian reserve were related to the primordial follicle count, providing reproducible evidence that radiation with 1 Gy leads to a significant depletion. Radiation with 0.1 Gy mostly did not show an effect on the primordial follicles. Fewer data exist on the effects of radiation on the ovarian microenvironment including theca-interstitial, immune, endothelial, and smooth muscle cells. We concluded that a mouse model would provide the most reliable model to study the effects of low-dose radiation. Furthermore, both immunohistochemistry and fluorescence-activated cell sorting (FACS) analyses were valuable to analyze not only the germ cells but also the ovarian microenvironment.
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Wu H, You Q, Jiang Y, Mu F. Tumor necrosis factor inhibitors as therapeutic agents for recurrent spontaneous abortion (Review). Mol Med Rep 2021; 24:847. [PMID: 34643255 DOI: 10.3892/mmr.2021.12487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 08/31/2021] [Indexed: 11/05/2022] Open
Abstract
Recurrent spontaneous abortion (RSA) is a troublesome pregnancy disorder that manifests as sequential early pregnancy losses; its causes are diverse and complex. Among the known possible causes of RSA, the development of an immune disorder in response to the embryo appears to be the most pronounced. The imbalance between immune rejection and immune tolerance contributes to pregnancy loss in females with RSA, wherein the abnormal ratio of T helper (Th)1 cell‑related cytokines [predominantly tumor necrosis factor (TNF)‑α] and Th2 cell‑related cytokines is a strong risk factor for RSA. TNF‑α is a pro‑inflammatory cytokine and TNF inhibitors have been effective in the treatment of various autoimmune diseases, such as ankylosing spondylitis, and inflammatory diseases, such as ulcerative colitis. Based on their immunomodulatory properties, TNF inhibitors have been used in the treatment of RSA to reduce the immune rejection rate and improvement in pregnancy outcomes has been observed in females suffering from RSA who were treated with TNF inhibitors. The aim of the present review was to interpret the involvement of TNF‑α in the immunological disorder underlying RSA and summarize the clinical outcomes of TNF inhibitor treatment in patients with RSA.
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Affiliation(s)
- Hong Wu
- Department of Integrated TCM and Western Medicine, Southwest Hospital, Army Medical University, Chongqing 400038, P.R. China
| | - Qingxia You
- Department of Integrated TCM and Western Medicine, Southwest Hospital, Army Medical University, Chongqing 400038, P.R. China
| | - Yi Jiang
- Department of Integrated TCM and Western Medicine, Southwest Hospital, Army Medical University, Chongqing 400038, P.R. China
| | - Fangxiang Mu
- Department of Reproductive Medicine, Lanzhou University Second Hospital, Lanzhou, Gansu 730030, P.R. China
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Vomstein K, Aulitzky A, Strobel L, Bohlmann M, Feil K, Rudnik-Schöneborn S, Zschocke J, Toth B. Recurrent Spontaneous Miscarriage: a Comparison of International Guidelines. Geburtshilfe Frauenheilkd 2021; 81:769-779. [PMID: 34276063 PMCID: PMC8277441 DOI: 10.1055/a-1380-3657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/01/2021] [Indexed: 01/11/2023] Open
Abstract
While roughly 30% of all women experience a spontaneous miscarriage in their lifetime, the incidence of recurrent (habitual) spontaneous miscarriage is 1 – 3% depending on the employed definition. The established risk factors include endocrine, anatomical, infection-related, genetic, haemostasis-related and immunological factors. Diagnosis is made more difficult by the sometimes diverging recommendations of the respective international specialist societies. The present study is therefore intended to provide a comparison of existing international guidelines and recommendations. The guidelines of the ESHRE, ASRM, the DGGG/OEGGG/SGGG and the recommendations of the RCOG were analysed. It was shown that investigation is indicated after 2 clinical pregnancies and the diagnosis should be made using a standardised timetable that includes the most frequent causes of spontaneous miscarriage. The guidelines concur that anatomical malformations, antiphospholipid syndrome and thyroid
dysfunction should be excluded. Moreover, the guidelines recommend carrying out pre-conception chromosomal analysis of both partners (or of the aborted material). Other risk factors have not been included in the recommendations by all specialist societies, on the one hand because of a lack of diagnostic criteria (luteal phase insufficiency) and on the other hand because of the different age of the guidelines (chronic endometritis). In addition, various economic and consensus aspects in producing the guidelines influence the individual recommendations. An understanding of the underlying decision-making process should lead in practice to the best individual diagnosis and resulting treatment being offered to each couple.
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Affiliation(s)
- Kilian Vomstein
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| | - Anna Aulitzky
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| | - Laura Strobel
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| | - Michael Bohlmann
- Zentrum für Gynäkologie und Geburtshilfe, St Elisabethen-Krankenhaus Lörrach gGmbH, Lörrach, Germany
| | - Katharina Feil
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| | | | - Johannes Zschocke
- Zentrum für medizinische Genetik, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Bettina Toth
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
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Strobel L, Vomstein K, Kyvelidou C, Hofer-Tollinger S, Feil K, Kuon RJ, Ebner S, Troppmair J, Toth B. Different Background: Natural Killer Cell Profiles in Secondary versus Primary Recurrent Pregnancy Loss. J Clin Med 2021; 10:E194. [PMID: 33430491 PMCID: PMC7826987 DOI: 10.3390/jcm10020194] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/21/2020] [Accepted: 01/04/2021] [Indexed: 02/06/2023] Open
Abstract
(1) Background: Prior studies suggested a significant impact of previous live births on peripheral natural killer cells (pNK) in patients with recurrent pregnancy loss (RPL). Patients with primary RPL (pRPL, no live birth) showed higher numbers of pNK than secondary RPL patients (sRPL, ≥ 1 live birth). (2) Methods: To further determine immunological differences between RPL patients and controls, we analysed pNK subpopulations and activation markers in pRPL (n = 47), sRPL (n = 24) and controls with previous live birth (sCtrl, n = 25) and nullipara (pCtrl, n = 60) within a prospective study. Percentages and numbers of CD56dimCD16bright cells, subpopulations and activation markers (CD57+, CD62L+, NKG2D+, NKp46+) were measured in non-pregnant RPL patients and n = 85 controls (n = 60 pCtrl, n = 25 sCtrl) in the mid-luteal phase by flow cytometry. (3) Results: Compared to sRPL patients, sCtrls showed higher CD56+ and CD56dimCD16bright numbers. Further, sRPL patients showed lower numbers of CD56dimCD16brightNKG2D+ and CD56dimCD16brightNKp46+ than sCtrls. (4) Conclusion: We suggest a chronic immune stimulation leading to a lower NK-cell count in sRPL patients with a lower NK cytotoxicity. This underlines the necessity to investigate pNK subpopulations as well as pRPL and sRPL separately to delineate the immune alterations in RPL.
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Affiliation(s)
- Laura Strobel
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (L.S.); (C.K.); (S.H.-T.); (K.F.); (B.T.)
| | - Kilian Vomstein
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (L.S.); (C.K.); (S.H.-T.); (K.F.); (B.T.)
| | - Christiana Kyvelidou
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (L.S.); (C.K.); (S.H.-T.); (K.F.); (B.T.)
| | - Susanne Hofer-Tollinger
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (L.S.); (C.K.); (S.H.-T.); (K.F.); (B.T.)
| | - Katharina Feil
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (L.S.); (C.K.); (S.H.-T.); (K.F.); (B.T.)
| | - Ruben-Jeremias Kuon
- Department of Gynecological Endocrinology and Fertility Disorders, Ruprecht-Karls University Heidelberg, Im Neuenheimer Feld 440, 69120 Heidelberg, Germany;
| | - Susanne Ebner
- Department of Visceral, Transplant and Thoracic Surgery (VTT), Daniel Swarovski Research Laboratory (DSL), Medical University of Innsbruck (MUI), Innrain 66, 6020 Innsbruck, Austria; (S.E.); (J.T.)
| | - Jakob Troppmair
- Department of Visceral, Transplant and Thoracic Surgery (VTT), Daniel Swarovski Research Laboratory (DSL), Medical University of Innsbruck (MUI), Innrain 66, 6020 Innsbruck, Austria; (S.E.); (J.T.)
| | - Bettina Toth
- Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; (L.S.); (C.K.); (S.H.-T.); (K.F.); (B.T.)
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Woon EV, Day A, Bracewell-Milnes T, Male V, Johnson M. Immunotherapy to improve pregnancy outcome in women with abnormal natural killer cell levels/activity and recurrent miscarriage or implantation failure: A systematic review and meta-analysis. J Reprod Immunol 2020; 142:103189. [PMID: 32889304 DOI: 10.1016/j.jri.2020.103189] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/12/2020] [Indexed: 12/14/2022]
Abstract
There is a trend towards offering immunotherapy to women with unexplained reproductive failure based on abnormal Natural Killer (NK) cell levels. Previous systematic reviews evaluating immunotherapy usage have not focused on women with abnormal level of NK cells. To address the gap in literature, this systematic review aims to evaluate the efficacy of immunotherapy to improve pregnancy outcome in women with recurrent miscarriage (RM) or implantation failure (RIF) specifically selected based on abnormal levels and/or activity of NK cells. Six databases were searched for peer-reviewed studies following PRISMA guidelines. Risk of bias assessment was conducted using RoB2 for randomized controlled trials (RCT) and ROBINS-I for non-RCT. Of 1025 studies identified, seven studies on intravenous immunoglobulin (IVIG) (four), prednisolone (one), etanercept (one) and intralipid (one) were included. Meta-analysis of the non-RCT IVIG studies (557 participants; 312 intervention, 245 controls) showed livebirth in favour of intervention (RR 2.57; 95 % CI = 1.79-3.69; p < 0.05), however there were significant heterogeneity (I2 = 62 %) and moderate to severe risk of bias in these studies. Individual RCTs reported improved livebirth outcome in etanercept, intralipid and prednisolone and this was significant in the former two (p < 0.05). In conclusion, there may be some benefit of immunotherapy, but paucity of high quality evidence means that it is not possible to support the use of immunotherapy even when selected based on abnormal NK cell level/activity. Further research with application of scientifically validated immunological biomarkers in well-planned large scale RCTs will determine whether immunotherapy is beneficial in this subpopulation of women.
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Affiliation(s)
- Ee Von Woon
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive & Developmental Biology, Imperial College London, Chelsea and Westminster Hospital Campus, 369 Fulham Roadd, London, UK.
| | - Andrea Day
- Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital NHS Foundation Trust, West Middlesex University Hospital, Twickenham Road, Isleworth, London UK
| | - Timothy Bracewell-Milnes
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive & Developmental Biology, Imperial College London, Chelsea and Westminster Hospital Campus, 369 Fulham Roadd, London, UK
| | - Victoria Male
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive & Developmental Biology, Imperial College London, Chelsea and Westminster Hospital Campus, 369 Fulham Roadd, London, UK
| | - Mark Johnson
- Department of Metabolism, Digestion and Reproduction, Institute of Developmental Reproductive & Developmental Biology, Imperial College London, Chelsea and Westminster Hospital Campus, 369 Fulham Roadd, London, UK
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Vomstein K, Voss P, Molnar K, Ainsworth A, Daniel V, Strowitzki T, Toth B, Kuon RJ. Two of a kind? Immunological and clinical risk factors differ between recurrent implantation failure and recurrent miscarriage. J Reprod Immunol 2020; 141:103166. [PMID: 32623188 DOI: 10.1016/j.jri.2020.103166] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/18/2020] [Accepted: 06/10/2020] [Indexed: 11/23/2022]
Abstract
Recurrent miscarriage (RM) and recurrent implantation failure (RIF) are unsolved challenges in reproductive medicine. Whether RIF patients share the same risk factors as RM patients is a matter of debate. Besides clinical factors, immune alterations are discussed in both conditions. The scope of this study was to compare the prevalence of clinical and immunological risk factors in a large cohort of RM and RIF patients. Between 11/2011 and 02/2019, 613 RM and 185 RIF patients were included. A screening for anatomical malformations, endocrine, autoimmune, prothrombotic and parental chromosomal disorders was performed. The immune status was assessed using flow cytometry analysis of peripheral lymphocyte subpopulations and uterine natural killer cells (uNK cells) using immunohistochemistry. RM patients showed a higher rate of intrauterine adhesions and elevated antinuclear antibodies ≥ 1:160 (p < 0.05). A higher prevalence of submucous fibroids and increased factor VIII levels were observed in RIF patients (p < 0.05). The prevalence of an antiphospholipid syndrome (APLS) was low and did not differ between the two groups. RIF patients had higher numbers of peripheral regulatory T-cells (p < 0.05). Significant more RIF patients were diagnosed with elevated uNK cells (p < 0.05). Differences in clinical and immunological risk factors of RM and RIF patients reflect different entities. Lower Tregs in RM and higher uNK cells in RIF patients might be related to the previous exposure of the immune system to fetal cells. The low prevalence of an APLS indicates a potential overestimation of this factor in the pathophysiology of RM and RIF.
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