Recurrent miscarriage is associated with increased numbers of CD5/20 positive lymphocytes and an increased incidence of thyroid antibodies

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.

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.

Maternal and cord blood BAFF and APRIL levels during pregnancy

PROBLEM

Dysregulation of factors vital to the survival B cells and/or plasma cells, such as BAFF and APRIL, could be detrimental to a pregnancy.

METHOD OF STUDY

Serially collected first-, second-, and third-trimester serum samples were measured for BAFF and APRIL by ELISA from 150 pregnant women (71 healthy + 79 with a chronic medical disease) at a single medical center. Postpartum serum samples were also collected from the majority of these women. Matched third-trimester and cord blood samples were collected from 168 women (86 healthy + 82 with a chronic medical disease). Data were analyzed by chi-square statistic, unpaired t-test, paired t-test, Mann-Whitney rank sum test, Wilcoxon signed rank test, Spearman rank order correlation, and receiver operator characteristic (ROC) curve analyses as appropriate.

RESULTS

Maternal serum BAFF levels declined as the pregnancies progressed and rebounded postpartum, whereas serum APRIL levels remained relatively flat throughout pregnancy and postpartum. Cord BAFF and APRIL levels correlated positively with gestation age and were considerably greater than the corresponding maternal third-trimester serum BAFF and APRIL levels, respectively. In women who developed preeclampsia, third-trimester BAFF levels were greater, rather than lower, than their corresponding second-trimester BAFF levels. ROC curve analysis suggested a potential role for third-trimester serum BAFF level as a biomarker of preeclampsia.

CONCLUSIONS

BAFF and APRIL are differentially regulated in the mother during and following pregnancy, whereas each is upregulated in the developing fetus. An increase in third-trimester serum BAFF level may portend development of preeclampsia.

Anti-thyroid antibodies and underlying generalized immunologic aberrations in patients with reproductive failures

The link between autoimmune thyroid diseases and reproductive failures, including implantation failure and pregnancy loss, has been attracted a great deal of attention in the last two decades. In this regard, a considerable progress has been achieved in understanding the etiopathogenesis of the adverse pregnancy consequences related to the presence of anti-thyroid antibodies, however, the exact action mechanisms of these antibodies are not fully comprehended. Thyroid peroxidase antibodies (TPOAbs), thyroglobulin antibodies (TgAbs) and TSH receptor antibodies (TRAbs) are the anti-thyroid antibodies which are present in autoimmune thyroid disorder (AITD) patients, such as Hashimoto's thyroiditis. In this condition, the thyroid hormones production, which are essential for normal implantation and pregnancy, are disrupted, and compromise the embryo or fetus development. In addition, a hypothesis suggests that there is underlying generalized immune abnormalities behind the presence of these antibodies. On the other hand, similar immunologic aberrations have been observed in thyroid autoimmunity and reproductive complications, which are postulated to be the proper answer for the scientists who seek for the pathophysiology behind the presence of these antibodies. Elevated inflammatory responses and decreased immunoregulatory actions, seem to be the main interfering pathologic factors in maternal tolerance toward fetus. In addition, cross reactivity of these antibodies with antigenic determinants of egg, embryo and placenta is another suggested mechanism, causing implantation and pregnancy complications. The ability of anti-thyroid antibodies in passing through the placental barrier and affecting the fetal thyroid gland, makes them more threatening for maintenance of a pregnancy.

A Predictive Role of Autoantibodies Against the Epitope aa168–183 of ENO1 in the Occurrence of Miscarriage Related to Thyroid Autoimmunity

Objective

The aim of the research is to study the association between the serum levels of autoantibodies against one important epitope (¹⁶⁸FMILPVGAANFREAMR¹⁸³, designated as P6) of α-enolase (ENO1-P6Abs) and miscarriage among euthyroid females with thyroid autoimmunity (TAI).

Methods

Anti-ENO1-P6 total IgG was investigated in 432 euthyroid women, and its four subclasses were analyzed in 184 euthyroid women. The serum FT4, TSH, TgAb, and TPOAb levels were determined using an electrochemiluminescence immunoassay. The serum ENO1-P6Ab and anti-protein disulfide isomerase A3 autoantibody (PDIA3Ab) levels were determined using an enzyme-linked immunosorbent assay.

Results

The serum levels of anti-ENO1-P6 total IgG, IgG2, IgG3, and IgG4 were significantly higher in euthyroid TAI females than in non-TAI controls. Additionally, anti-ENO1-P6 total IgG and its 4 subtypes were all markedly higher in euthyroid TAI females with pregnancy loss than those without miscarriage. Moreover, logistic regression analysis showed that highly expressed anti-ENO1-P6 total IgG, IgG1, IgG2, and IgG3 subtypes in the serum were all independent risk factors for euthyroid TAI-related miscarriage, and its IgG1 was also for non-TAI-related abortion. According to the trend test, the prevalence of miscarriage was increased in a titer-dependent manner with the raised levels of serum anti-ENO1-P6 total IgG and IgG1, IgG2, and IgG3 subtypes among euthyroid TAI females. The receiver operating characteristic curve analysis of anti-ENO1-P6 total IgG and IgG1, IgG2, and IgG3 subclass expressions in the serum for miscarriage prediction in euthyroid TAI females exhibited that the total areas under the curves were 0.773 ± 0.041, 0.761 ± 0.053, 0.827 ± 0.043, and 0.760 ± 0.050, respectively (all P <0.0001). Their corresponding optimal cut-off OD450 values were 0.68 (total IgG), 0.26 (IgG1), 0.97 (IgG2), and 0.48 (IgG3), with sensitivities of 70.8, 87.5, 83.3, and 85.4%, and specificities of 70.8, 59.1, 77.3, and 56.8%, respectively. There was an additive interaction between serum anti-ENO1-P6 and anti-PDIA3 total IgGs on the development of miscarriage (RERI = 23.6, AP = 0.79, SI = 5.37).

Conclusion

The highly expressed ENO1-P6Abs may be important risk factors for euthyroid TAI-related miscarriage. The serum levels of ENO1-P6Abs may become good predictive markers for pregnancy loss in euthyroid TAI females, especially its IgG2 subclass expression.

Levothyroxine in euthyroid thyroid peroxidase antibody positive women with recurrent pregnancy loss (T4LIFE trial): a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

Women positive for thyroid peroxidase antibodies (TPO-Ab) have a higher risk of recurrent pregnancy loss. Evidence on whether levothyroxine treatment improves pregnancy outcomes in women who are TPO-Ab positive women with recurrent pregnancy loss is scarce. The aim of this study was to determine if levothyroxine increases live birth rates in women who were TPO-Ab positive with recurrent pregnancy loss and normal thyroid function.

METHODS

The T4LIFE trial was an international, double-blind, placebo-controlled, phase 3 study done in 13 secondary and tertiary hospitals in the Netherlands, one tertiary hospital in Belgium, and one tertiary hospital in Denmark. Women (18-42 years) who were TPO-Ab positive, had two or more pregnancy losses, and had a thyroid stimulating hormone (TSH) concentration within the institutional reference range were eligible for inclusion. Women were excluded if they had antiphospholipid syndrome (lupus anticoagulant, anticardiolipin IgG or IgM antibodies, or β2-glycoprotein-I IgG or IgM antibodies), other autoimmune diseases, thyroid disease, previous enrolment in this trial, or contraindications for levothyroxine use. Before conception, women were randomly assigned (1:1) to receive either levothyroxine or placebo orally once daily. The daily dose of levothyroxine was based on preconception TSH concentration and ranged from 0·5-1·0 μg/kg bodyweight. Levothyroxine or placebo was continued until the end of pregnancy. The primary outcome was live birth, defined as the birth of a living child beyond 24 weeks of gestation measured in the intention-to-treat population. The trial was registered within the Netherlands Trial Register, NTR3364 and with EudraCT, 2011-001820-39.

RESULTS

Between Jan 1, 2013, and Sept 19, 2019, 187 women were included in the study: 94 (50%) were assigned to the levothyroxine group and 93 (50%) were assigned to the placebo group. The trial was prematurely stopped when 187 (78%) of the 240 predefined patients had been included because of slow recruitment. 47 (50%) women in the levothyroxine group and 45 (48%) women in the placebo group had live births (risk ratio 1·03 [95% CI 0·77 to 1·38]; absolute risk difference 1·6% [95% CI -12·7 to 15·9]). Seven (7%) women in the levothyroxine group and seven (8%) in the placebo group reported adverse events, none of them were directly related to the study procedure.

INTERPRETATION

Compared with placebo, levothyroxine treatment did not result in higher live birth rates in euthyroid women with recurrent pregnancy loss who were positive for TPO-Ab. On the basis of our findings, we do not advise routine use of levothyroxine in women who are TPO-Ab positive with recurrent pregnancy loss and normal thyroid function.

FUNDING

Dutch Organization for Health Research and Development, Fonds NutsOhra, Dutch Patient Organization of Thyroid Disorders, the Jan Dekkerstichting and Dr Ludgardine Bouwmanstichting, and a personal donation through the Dutch Patient Organization of Thyroid Disorders.

Immunohistochemical Evaluation of CD3, CD4, CD8, and CD20 in Decidual and Trophoblastic Tissue Specimens of Patients with Recurrent Pregnancy Loss

Recurrent miscarriages affect up to 5% of couples. CD3⁺ (T-lymphocytes), CD4⁺ (helper T-lymphocytes), CD8⁺ (cytotoxic T-lymphocytes), and CD20⁺ (B-lymphocytes) cells may participate in the pathophysiology of recurrent pregnancy loss (RPL). The aim of this study was to investigate the complicity of these molecules in RPL. The experimental specimens were obtained from 20 females who underwent miscarriages in the first gestational trimester, while the control group’s specimens consisted of 20 females who proceeded with voluntary pregnancy termination during the same period. Tissue samples were taken from the decidua basalis, decidua parietalis, and trophoblast (placental chorionic villi) and were studied using immunohistochemical methods. Monoclonal antibodies were used against CD3, CD4, CD8, and CD20 cells. The lymphocyte levels in the decidua parietalis displayed profound disparities among the two groups. The decidua basalis and trophoblast exhibited almost the same disparities regarding positive CD cells. The comparison of CD4⁺ and CD8⁺ cells in the endometrial tissue revealed a significant difference between the two groups of study. The analysis uncovered a strong relationship between RPL and the presence of CD3⁺, CD4⁺, CD8⁺, and CD20⁺ cells in the decidua parietalis tissue. The number of positive T cells was decreased in the decidual basalis and chorionic villi, proving that their absence significantly disrupts the balance of the immunological environment.

Patients with Autoimmune Thyroid Diseases Have Higher Prevalence of Positive Antiphospholipid Antibodies: A Systematic Review and Meta-Analysis

INTRODUCTION

Autoimmune thyroid diseases (AITDs) and antiphospholipid syndrome (APS) are commonly seen in childbearing-age women and can lead to recurrent miscarriages. Studies with a relatively small sample size were conducted and concluded inconsistent results on the relationship between AITDs and APS or the presence of antiphospholipid (aPL) antibodies. This meta-analysis aimed to provide evidence on the possible association between AITDs and APL using primary data from all relevant studies.

METHODS

Literature databases including PubMed, Embase, and Cochrane were searched from the time when the databases were established to March 2022. A total of 7 studies that met all inclusion criteria were selected in this meta-analysis, with 475 AITD patients and 764 healthy controls. After data extraction, the pooled odds ratio (OR) and the 95% confidence interval (95% CI) were calculated.

RESULTS

The risk of positive APL in AITD patients was approximately 3 folds higher in AITD patients compared with those in healthy controls (OR 3.41, 95% CI 2.29-5.08, p < 0.001). There was no significant association between the risk of Graves' disease (GD) and positive APL (OR 9.3, 95% CI 0.10-824.73, p=0.33). The risk of positive APL in patients with Hashimoto's thyroiditis (HT) increased over 2 folds compared with healthy controls (OR 3.35, 95% CI 1.55-7.23, p=0.002).

CONCLUSIONS

The result of this meta-analysis proved that the presence of APL was significantly increased in patients with AITD compared with healthy individuals, especially in patients with Hashimoto's thyroiditis.

The Role of Cell and Gene Therapies in the Treatment of Infertility in Patients with Thyroid Autoimmunity

There is a rising incidence of infertility worldwide, and many couples experience difficulties conceiving nowadays. Thyroid autoimmunity (TAI) is recognized as one of the major female infertility causes related to a diminished ovarian reserve and potentially impaired oocyte maturation and embryo development, causing adverse pregnancy outcomes. Growing evidence has highlighted its impact on spontaneously achieved pregnancy and pregnancy achieved by in vitro fertilization. Despite the influence of thyroid hormones on the male reproductive system, there is insufficient data on the association between TAI and male infertility. In past years, significant progress has been achieved in cell and gene therapies as emerging treatment options for infertility. Cell therapies utilize living cells to restore healthy tissue microenvironment and homeostasis and usually involve platelet-rich plasma and various stem cells. Using stem cells as therapeutic agents has many advantages, including simple sampling, abundant sources, poor immunogenicity, and elimination of ethical concerns. Mesenchymal Stem Cells (MSCs) represent a heterogeneous fraction of self-renewal, multipotent non-hematopoietic stem cells that display profound immunomodulatory and immunosuppressive features and promising therapeutic effects. Infertility has a genetic component in about half of all cases, although most of its genetic causes are still unknown. Hence, it is essential to identify genes involved in meiosis, DNA repair, ovarian development, steroidogenesis, and folliculogenesis, as well as those involved in spermatogenesis in order to develop potential gene therapies for infertility. Despite advances in therapy approaches such as biological agents, autoimmune disorders remain impossible to cure. Recent research demonstrates the remarkable therapeutic effectiveness of MSCs in a wide array of autoimmune diseases. TAI is one of many autoimmune disorders that can benefit from the use of MSCs, which can be derived from bone marrow and adipose tissue. Cell and gene therapies hold great potential for treating autoimmune conditions, although further research is still needed.

Thyroid Autoimmunity in Adverse Fertility and Pregnancy Outcomes: Timing of Assisted Reproductive Technology in AITD Women

Thyroid autoimmunity (TAI) is prevalent in women of live-birthing age and has independently been associated with complications of fertility and pregnancy, in the case of spontaneous conception or after assisted reproductive technology (ART) treatment. However, it remains challenging to identify causation between infertility and TAI, even interventional trials looking at the impact of levothyroxine (LT4) treatment on fertility and pregnancy outcomes due to differences among study results which related to small scales, impropriate study designs, enrollment criteria of infertility cause and titer/hormone concentration measurements. Furthermore, many questions remain unsettled in ART management in AITD infertile women attempt pregnancy. Therefore, further observational and interventional trials are needed more comprehensive multiple-center, double blinded, and randomized.

First-trimester serum BAFF:sFlt-1 ratio as a candidate early biomarker of spontaneous abortion

PROBLEM

Immunologic, angiogenic, and anti-angiogenic factors are associated with spontaneous abortion (SAB). B cell-activating factor (BAFF), a proliferation-inducing ligand (APRIL), placental growth factor (PlGF), and soluble fms-like tyrosine kinase-1 (sFlt-1) may play a role in SAB and may serve singly or in combination as an early biomarker of SAB.

METHOD OF STUDY

In this prospective observational study, serum sFlt-1, PIGF, BAFF, and APRIL levels were measured in the first trimester of pregnancy in a medically diverse group of women and in non-pregnant controls. Associations and discriminative values of first-trimester sFlt-1, PIGF, BAFF, and APRIL levels and the corresponding APRIL:BAFF, BAFF:sFlt-1, and sFlt-1:PlGF ratios with development of SAB were tested.

RESULTS

Median serum BAFF level was lower (p = .007) and median serum sFlt-1 level was higher (p < .001), in the first trimester of pregnancy than in non-pregnant controls. SAB developed in 27 of the pregnant women (11.3%), and first-trimester levels of BAFF (but not APRIL) and sFlt-1 (but not PIGF) were associated with SAB. Using optimal cutoffs determined through receiver operating characteristics curves, the best discriminator of SAB was the serum BAFF:sFlt-1 ratio, specifically among non-nulliparous women and women with prior SAB.

CONCLUSION

First-trimester serum BAFF:sFlt-1 ratio is a candidate indicator/predictor of SAB among non-nulliparous women and women with prior SAB. If validated through additional studies, then early identification of pregnant women at high risk for SAB through this simple blood test would assist in counseling and facilitate clinical trials of therapeutic interventions.

Does thyroid autoimmunity affect the reproductive outcome in women with thyroid autoimmunity undergoing assisted reproductive technology?

PROBLEM

Our study aims to investigate whether the anti-thyroperoxidase antibody (TPO-Ab) and TSH level in euthyroid women have any association with reproductive outcomes after the ART cycle.

METHODS OF STUDY

A total of 1107 patients who were enrolled in the study were divided into four groups based on serum TSH level and TPO-Ab status: group A, 0.3 ≤ TSH < 2.5 mIU/L and TPO-Ab^- ; group B, 0.3 ≤ TSH < 2.5 mIU/L and TPO-Ab⁺ ; group C, 2.5 ≤ TSH < 4.2 mIU/L, and TPO-Ab^- ; and group D, 2.5 ≤ TSH < 4.2 mIU/L, TPO-Ab⁺ . The differences in ART cycles and pregnancy outcomes were analyzed between study groups.

RESULTS

The fertilization rate in group D (73%) was significantly lower than that in groups A (83% P < .001), B (84% P = .001), and C (82% P = .002). The biochemical pregnancy rates of groups B (7%) and D (12%) were significantly higher than those of group A (2%) (P = .028 and P = .017, respectively). TPO-Ab was related to a higher biochemical pregnancy rate (P = .002, OR = 5.311, 95% CI 1.859-15.169) and TSH over 2.5 mIU/L was related to higher ICSI rate (P = .001, OR = 1.759, 95% CI 1.250-2.476) by logistic regression analysis. The receiver operating characteristic (ROC) also verified the results.

CONCLUSION

The impacts of TSH ≥ 2.5 mIU/L on the intracytoplasmic sperm injection (ICSI) rate, TSH ≥ 2.5 mIU/L and TPO-Ab⁺ on the fertilization rate, and TPO-Ab⁺ on the biochemical pregnancy rate, rather than the effect on abortion, clinical pregnancy, and live birth, were emphasized.

Impact of thyroid disease on fertility and assisted conception

Thyroid autoimmunity (TAI) and/or thyroid dysfunction are prevalent in women of reproductive age and have independently been associated with adverse fertility and pregnancy outcomes, in the case of spontaneous conception or after assisted reproductive technology (ART). Thus, it seems reasonable to screen for thyrotropin (TSH) and thyroid peroxidase autoantibodies (TPO-abs) in infertile women attempting pregnancy. However, even if the relationship between fertility and thyroid dysfunction and/or TAI persists when properly controlled for other variables, it remains challenging to claim causation. Several studies with different designs (cross sectional, case -control, prospective and retrospective cohort studies) have looked at the association between thyroid autoimmunity, thyroid function and fertility. Heterogeneity among study results are related to small numbers of included patients, poor study design, selection of causes of infertility and different assays used to measure TAI, thyroid hormones and TSH reference values. Indeed, there is no consensus regarding the upper limit of normal for TSH to define thyroid dysfunction and the cut-off levels for intervention. Furthermore, data from interventional trials looking at the impact of levothyroxine treatment on fertility outcome in randomised controlled studies are scarce. Despite the recent update of the guidelines by the American Thyroid Association (ATA) for the Diagnosis and Management of Thyroid Disease during Pregnancy and the postpartum, many questions remain unsettled in ART.

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.

Autoimmune thyroid disease during pregnancy

Understanding of changes in thyroid function and the consequences of thyroid disease during pregnancy has rapidly grown in the past two decades, and revised American Thyroid Association guidelines on this topic were published in 2017. This Review explores the association between thyroid autoimmunity and complications during and after pregnancy. Thyroid autoimmunity refers to the presence of antibodies to thyroperoxidase or thyroglobulin, or thyroid-stimulating hormone receptor antibodies (TRAbs), or a combination of these, and is present in up to 18% of pregnant women. Thyroid antibodies in pregnant women with normal functioning thyroids (ie, euthyroid) have been associated with several complications, including miscarriage and premature delivery. Treatments to improve pregnancy outcomes are being studied. Whether thyroid antibodies are associated with infertility and assisted reproductive technology outcomes is unclear; although, treatment with low doses of levothyroxine, which is usually used to treat hypothyroidism, can be considered in such situations. Additionally, thyroid antibodies have been associated with other neonatal and maternal complications. All these associations require confirmation in larger prospective studies, and their pathogenic mechanisms need to be better understood. Post-partum thyroiditis is substantially more frequent in women who have thyroid antibodies during pregnancy than in those who do not have thyroid antibodies; however, whether treatment can prevent post-partum thyroiditis in women who are or have been antibody positive is unknown. Finally, TRAbs cross the placenta from the mother to the fetus and can cause fetal or neonatal hyperthyroidism. Therefore, women who are positive for TRAbs during pregnancy should be monitored.

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.

Clinical aspects of hyperthyroidism, hypothyroidism, and thyroid screening in pregnancy

OBJECTIVE

To evaluate the peer-reviewed literature on hypothyroidism, hyperthyroidism, and thyroid autoimmunity in pregnancy.

METHODS

We review published studies on thyroid autoimmunity and dysfunction in pregnancy, the impact of thyroid disease on pregnancy, and discuss implications for screening.

RESULTS

Overt hyperthyroidism and hypothyroidism are responsible for adverse obstetric and neonatal events. Several studies of association suggest that either subclinical hypothyroidism or thyroid autoimmunity increase the risk of complications. One randomized controlled trial showed that pregnant women with subclinical hypothyroidism benefit from treatment in terms of obstetric and neonatal complications, whereas another study demonstrated no benefit in the intelligence quotient of babies born to women with subclinical hypothyroidism. Thyroid autoimmunity has been associated with increased rate of pregnancy loss, recurrent miscarriage, and preterm delivery.

CONCLUSION

Current guidelines agree that overt hyperthyroidism and hypothyroidism need to be promptly treated and that as potential benefits outweigh potential harm, subclinical hypothyroidism also requires substitutive treatment. The chance that women with thyroid autoimmunity may benefit from levothyroxine treatment to improve obstetric outcome is intriguing, but adequately powered randomized controlled trials are needed. The issue of universal thyroid screening at the beginning of pregnancy is still a matter of debate, and aggressive case-finding is supported.

Maternal vaccination: moving the science forward

BACKGROUND

Infections remain one of the leading causes of morbidity in pregnant women and newborns, with vaccine-preventable infections contributing significantly to the burden of disease. In the past decade, maternal vaccination has emerged as a promising public health strategy to prevent and combat maternal, fetal and neonatal infections. Despite a number of universally recommended maternal vaccines, the development and evaluation of safe and effective maternal vaccines and their wide acceptance are hampered by the lack of thorough understanding of the efficacy and safety in the pregnant women and the offspring.

METHODS

An outline was synthesized based on the current status and major gaps in the knowledge of maternal vaccination. A systematic literature search in PUBMED was undertaken using the key words in each section title of the outline to retrieve articles relevant to pregnancy. Articles cited were selected based on relevance and quality. On the basis of the reviewed information, a perspective on the future directions of maternal vaccination research was formulated.

RESULTS

Maternal vaccination can generate active immune protection in the mother and elicit systemic immunoglobulin G (IgG) and mucosal IgG, IgA and IgM responses to confer neonatal protection. The maternal immune system undergoes significant modulation during pregnancy, which influences responsiveness to vaccines. Significant gaps exist in our knowledge of the efficacy and safety of maternal vaccines, and no maternal vaccines against a large number of old and emerging pathogens are available. Public acceptance of maternal vaccination has been low.

CONCLUSIONS

To tackle the scientific challenges of maternal vaccination and to provide the public with informed vaccination choices, scientists and clinicians in different disciplines must work closely and have a mechanistic understanding of the systemic, reproductive and mammary mucosal immune responses to vaccines. The use of animal models should be coupled with human studies in an iterative manner for maternal vaccine experimentation, evaluation and optimization. Systems biology approaches should be adopted to improve the speed, accuracy and safety of maternal vaccine targeting.

Impaired outcome of controlled ovarian hyperstimulation in women with thyroid autoimmune disease

BACKGROUND

Controlled ovarian hyperstimulation (COH) is a crucial step of assisted reproductive technology (ART). Thyroid dysfunction and autoimmune thyroid disease (ATD) may negatively affect the outcome of ART, but the underlying mechanisms are still poorly understood. Our aim was to evaluate the respective role of ATD and thyroid function, as assessed by serum thyrotropin (TSH), on the early outcome of COH.

METHODS

In total, 262 (202 ATD-negative and 60 ATD-positive) euthyroid subfertile women underwent ART. Before COH, serum follicle-stimulating hormone (FSH), luteinizing hormone, and estradiol (E2) were measured at cycle day 3, and progesterone at cycle day 21. At oocyte pickup and at embryo transfer, we evaluated the performance of recombinant FSH (r-FSH), as assessed by serum E2 concentration/total administered r-FSH units (E2/r-FSH) ratio and by oocyte quality.

RESULTS

At both oocyte pickup and embryo transfer, the performance of r-FSH was significantly poorer in ATD-positive than in ATD-negative women. In the ATD-positive group, women with a TSH <2.5 mIU/L displayed a higher serum E2 concentration at oocyte pickup, a higher E2/r-FSH ratio, and a greater number of mature metaphase II oocytes than women with a TSH >2.5 mIU/L. When ATD-positive women were divided into quartiles according to their serum TSH level, both the ovarian response to r-FSH and the number of mature metaphase II oocytes significantly increased from the lowest to the highest quartiles of serum TSH concentration.

CONCLUSIONS

ATD has a negative effect on the early outcome of COH, but this negative influence may be avoided with adequate levothyroxine therapy aimed at keeping TSH <2.5 mU/L. Thyroid antibodies and serum TSH should be checked in any woman undergoing ART.

To B or not to B cells-mediate a healthy start to life

Maternal immune responses during pregnancy are critical in programming the future health of a newborn. The maternal immune system is required to accommodate fetal immune tolerance as well as to provide a protective defence against infections for the immunocompromised mother and her baby during gestation and lactation. Natural immunity and antibody production by maternal B cells play a significant role in providing such immunoprotection. However, aberrations in the B cell compartment as a consequence of maternal autoimmunity can pose serious risks to both the mother and her baby. Despite their potential implication in shaping pregnancy outcomes, the role of B cells in human pregnancy has been poorly studied. This review focuses on the role of B cells and the implications of B cell depletion therapy in pregnancy. It highlights the evidence of an association between aberrant B cell compartment and obstetric conditions. It also alludes to the potential mechanisms that amplify these B cell aberrances and thereby contribute to exacerbation of some maternal autoimmune conditions and poor neonatal outcomes. Clinical and experimental evidence suggests strongly that maternal autoantibodies contribute directly to the pathologies of obstetric and neonatal conditions that have significant implications for the lifelong health of a newborn. The evidence for clinical benefit and safety of B cell depletion therapies in pregnancy is reviewed, and an argument is mounted for further clinical evaluation of B cell-targeted therapies in high-risk pregnancy, with an emphasis on improving neonatal outcomes and prevention of neonatal conditions such as congenital heart block and fetal/neonatal alloimmune thrombocytopenia.

Thyroid antibodies and miscarriage: where are we at a generation later?

In 1990, an association between thyroid antibody positivity and spontaneous miscarriage was first reported. A generation has passed since the initial observation. Over that time a robust literature has developed which has confirmed the initial finding and expanded upon it. The present paper reviews the literature that has been generated over the last twenty years on the following topics: (1) thyroid antibodies and spontaneous miscarriage, (2) thyroid antibodies and recurrent abortion, (3) etiology of pregnancy loss in thyroid antibody positive women, and (4) discussion of future research directions.

Thyroid autoimmunity and miscarriage: a meta-analysis

OBJECTIVE

To investigate whether thyroid autoimmunity (TAI) is associated with increased risk of miscarriage in euthyroid women.

METHODS

An electronic search was conducted using the databases Medline, PubMed, EMBASE and the Cochrane library, from inception to October 2010. A systematic review of the studies on the association between TAI and miscarriage was performed. The odd ratios of case-control studies and relative risks of cohort studies were pooled respectively. The software Review Manager (version 4.3.1) was applied for meta-analysis.

RESULTS

The search strategy identified 53 potentially relevant publications, 22 of which were included in the meta-analysis. A clear association between thyroid autoimmunity and miscarriage was observed with a pooled odds ratio of 2·55 (95% CI 1·42-4·57, P=0·002) in eight case-control studies and a pooled relative risk of 2·31 (95% CI 1·90-2·82, P<0·000 01) in 14 cohort studies. Women with TAI were found to have slightly higher age [age difference, 1·29 years] (95% CI 0·43-2·16, P=0·003) and thyroid-stimulating hormone (TSH) levels [TSH difference, 0·61 mIU/l] (95% CI 0·51-0·71, P<0·000 01) compared with those without TAI.

CONCLUSION

Based on the currently available evidence, it appears that the presence of thyroid autoimmunity is associated with an increased risk of spontaneous miscarriage in euthyroid women.

Thyroid autoimmunity and its association with cellular and humoral immunity in women with reproductive failures

PROBLEM

thyroid autoimmunity (TAI), which is T helper (Th)1-cell-mediated autoimmunity to thyrocytes, is associated with increased risk of miscarriages and highly prevalent in women with infertility. We aim at investigating the prevalence of TAI in women with recurrent spontaneous abortions (RSA) or unexplained infertility (UI) and its relationship with cellular and humoral immune abnormalities.

METHOD OF STUDY

prevalence of antiphospholipid antibodies, anti-nuclear antibody, other non-organ-specific antibodies (NOSAs; anti-dsDNA, anti-ssDNA, anti-histone, anti-Scl70), peripheral blood natural killer (NK) cell levels (%) and cytotoxicity, and CD3(+) /CD4(+) Th1/Th2 cell ratios were compared in women with and without TAI. Thyroid functional tests (TFT) were analyzed in both groups before and after pregnancy.

RESULTS

tumor necrosis factor-α/IL-10 expressing CD3(+) /CD4(+) cell ratios (P < 0.05), CD56(+) NK cell levels (P < 0.05), the prevalence of anticardiolipin antibodies (P < 0.05) and other NOSAs (P < 0.005) were significantly higher in women with TAI when compared to women without TAI. Changes in thyroid-stimulating hormone levels between before and after pregnancy in women with TAI were significantly higher when compared to those of women without TAI (P < 0.05).

CONCLUSION

TAI is associated with impaired cellular and humoral immune responses in women with RSA or UI. In women with TAI, serial TFT is recommended when pregnancy is established.

The role of thyroid autoimmunity in fertility and pregnancy

The thyroid gland and gonadal axes interact continuously before and during pregnancy. Hypothyroidism influences ovarian function by decreasing levels of sex-hormone-binding globulin and increasing the secretion of prolactin. In women of reproductive age, hypothyroidism can be reversed by thyroxine therapy to improve fertility and avoid the need for use of assisted reproduction technologies. For infertile women, preparation for medically assisted pregnancy comprises controlled ovarian hyperstimulation that substantially increase circulating estrogen concentrations, which in turn can severely impair thyroid function. In women without thyroid autoimmunity these changes are transient, but in those with thyroid autoimmunity estrogen stimulation might lead to abnormal thyroid function throughout the remaining pregnancy period. Prevalence of thyroid autoimmunity is significantly higher among infertile women than among fertile women, especially among those whose infertility is caused by endometriosis or ovarian dysfunction. Presence of thyroid autoimmunity does not interfere with normal embryo implantation, but the risk of early miscarriage is substantially raised. Subclinical and overt forms of hypothyroidism are associated with increased risk of pregnancy-related morbidity, for which thyroxine therapy can be beneficial. Systematic screening for thyroid disorders in pregnant women remains controversial but might be advantageous in women at high risk, particularly infertile women.

Thyroid insufficiency during pregnancy: complications and implications for screening

In 2007, clinical practice guidelines concerning the management of thyroid dysfunction during pregnancy and postpartum were published in the Journal of Clinical Endocrinology and Metabolism. They were elaborated on by a panel of experts, representative of the Latin American Thyroid Society, the Asia and Oceania Thyroid Society, the American Thyroid Association, the European Thyroid Association, the American Association of Clinical Endocrinologists and the Endocrine Society. In women not known to have thyroid dysfunction, universal screening during pregnancy is not recommended, but thyroid function tests are advised in those with prior therapeutic head or neck irradiation, a history of preterm delivery, in cases of infertility and in the presence of risk factors for thyroid disease. Risks factors for thyroid dysfunction are considered as a personal or family history of thyroid diseases, presence of thyroid antibodies (when known), personal history of autoimmune diseases and the presence of signs or symptoms suggesting hypo- or hyperthyroidism. In this review, we summarize the modifications of the pituitary-thyroid axis during pregnancy, with particular attention on thyroid insufficiency. We consider the most important risk factors for thyroid dysfunction and focus our attention on the complications for the progeny, deriving from a condition of maternal thyroid impairment. We will discuss the matters in favor of or against a thyroid-screening program at the beginning of pregnancy.

Thyroid autoimmunity, infertility and miscarriage

Thyroid autoimmunity (TAI), infertility and miscarriage are currently issues of extreme interest that have attracted the attention of many investigators. Several papers have been published, focusing on women of childbearing age that include healthy women, women with recurrent miscarriage and those undergoing assisted conception. Most of these studies show a significant association between the presence of thyroid autoantibodies, infertility and a higher miscarriage rate. The underlying pathogenetic mechanisms, which might explain the association between TAI and infertility, remain speculative given the scarce information from animal models and from in vitro data addressing the potential effects of TAI on fertility. Adequate levels of circulating thyroid hormones are of primary importance for normal reproductive function and inadequate delivery of triiodothyronine to granulosa and stromal cells may disrupt normal female reproductive function. With regards to the association between TAI and miscarriage, a close relationship has been largely confirmed in recent studies. The aim of this review is to present the relevant information published so far in the literature regarding TAI and miscarriage in euthyroid female individuals.

Subclinical hypothyroidism

PURPOSE OF REVIEW

Mild or subclinical hypothyroidism is characterized by normal serum free thyroxine concentrations with elevated serum thyroid-stimulating hormone concentrations. Subclinical hypothyroidism is relatively prevalent in the general population, especially among women and the elderly. The main cause of subclinical hypothyroidism is autoimmune chronic thyroiditis. The present report reviews the most important and recent studies on subclinical hypothyroidism, and discusses the most controversial aspects of this topic.

RECENT FINDINGS

Several studies have demonstrated that subclinical hypothyroidism may affect both diastolic and systolic cardiac function. It may also worsen many risk factors for cardiovascular disease, including hypertension, abnormal endothelial function, and elevated low-density lipoprotein cholesterol concentrations. Furthermore, a growing body of evidence suggests that subclinical hypothyroidism may cause symptoms or progress to symptomatic overt hypothyroidism.

SUMMARY

Prompt treatment of subclinical hypothyroidism in pregnant women is mandatory to decrease risks for pregnancy complications and impaired cognitive development in offspring. Children with subclinical hypothyroidism should be treated to prevent growth retardation. Whether nonpregnant adult patients with subclinical hypothyroidism should be treated, and at what thyroid-stimulating hormone values, is debatable.

Thyroid disease and female reproduction

The menstrual pattern is influenced by thyroid hormones directly through impact on the ovaries and indirectly through impact on SHBG, PRL and GnRH secretion and coagulation factors. Treating thyroid dysfunction can reverse menstrual abnormalities and thus improve fertility. In infertile women, the prevalence of autoimmune thyroid disease (AITD) is significantly higher compared to parous age-matched women. This is especially the case in women with endometriosis and polycystic ovarian syndrome (PCOS). AITD does not interfere with normal foetal implantation and comparable pregnancy rates have been observed after assisted reproductive technology (ART) in women with and without AITD. During the first trimester, however, pregnant women with AITD carry a significantly increased risk for miscarriage compared to women without AITD, even when euthyroidism was present before pregnancy. It has also been demonstrated that controlled ovarian hyperstimulation (COH) in preparation for ART has a significant impact on thyroid function, particularly in women with AITD. It is therefore advisable to measure thyroid function and detect AITD in infertile women before ART, and to follow-up these parameters after COH and during pregnancy when AITD was initially present. Women with thyroid dysfunction at early gestation stages should be treated with l-thyroxine to avoid pregnancy complications. Whether thyroid hormones should be given prior to or during pregnancy in euthyroid women with AITD remains controversial. To date, there is a lack of well-designed randomized clinical trials to elucidate this controversy.

Thrombophilias and recurrent pregnancy loss: a critical appraisal of the literature

Thrombophilias are suggested to play a role in recurrent miscarriage. The aim of this study was to evaluate the literature of the past 10 years regarding the association between thrombophilias and recurrent miscarriage. We concluded that there is a large variety in applied study methodology. Therefore, we defined criteria for an adequate study on the relationship of thrombophilias on recurrent pregnancy loss: (i) no exclusion criteria for patients or at least the same criteria for patients and controls; (ii) a clear definition of the gestational age at previous losses; (iii) a well-described control group; (iv) clear description of the test methods and moment of testing; and (v) a clear description of the (non) significant differences or odds ratio between cases and controls. Eleven out of 69 studies fulfilled these criteria. Their results show significant higher serum homocysteine levels among women with a history of recurrent miscarriage. No relation was found between recurrent miscarriage and the methylenetetrahydrofolate reductase C667T mutation. No relation was observed for the levels of antithrombin, protein C and protein S. Seven studies on the association of factor V Leiden (FVL) and/or pathologic activated protein C ratio (pAPCR) showed that FVL may play a role in second trimester losses, as do antiphospholipid antibodies. Studies on the prothrombin gene mutation yielded conflicting results. Consequently, large prospective studies according to the aforementioned criteria are needed to establish if there is a relationship between thrombophilias and recurrent miscarriage at all. At present, there is only justification for testing for homocysteine levels, antiphospholipid antibodies and FVL in women with a history of recurrent miscarriage.

Thyroid autoimmunity and the risk of miscarriage

Approximately one-third of all pregnancies end in miscarriage. The etiology of recurrent abortion remains unknown in approximately 50% of all women. In the early 1990s it was discovered that unselected euthyroid women who present with thyroid antibodies (thyroid peroxidase and thyroglobulin) in the first trimester of pregnancy have a two-four-fold increase in their miscarriage rates. The majority of studies investigating women with recurrent abortion have also found a significant increase in thyroid antibody positivity compared with controls. Although the etiology of miscarriage in thyroid antibody women remains unknown, recent data have revealed a potential direct effect of thyroglobulin antibodies on pregnancy loss in a murine model. Uncontrolled studies assessing the effect of levothyroxine on decreasing the miscarriage rate in euthyroid antibody positive women, have demonstrated a decreased miscarriage rate.

Thyroid dysfunction and autoimmunity in infertile women

A prospective study was undertaken in 438 women (ages, 32 +/- 5 years) with various causes of infertility, and in 100 age-matched (33 +/- 5 years) healthy parous controls with the aim of assessing the prevalence of autoimmune thyroid disease (AITD) and hitherto undisclosed alterations of thyroid function. Female origin of the infertility was diagnosed in 45% of the couples, with specific causes including endometriosis (11%), tubal disease (30%), and ovarian dysfunction (59%). Male infertility represented 38% and idiopathic infertility 17% of the couples. Overall, median thyrotropin (TSH) was significantly higher in patients with infertility compared to controls: 1.3 (0.9) versus 1.1 (0.8) mIU/L. Serum TSH above normal (>4.2 mIU/L) or suppressed TSH (<0.27 mIU/L) levels were not more prevalent in the infertile women than in controls. The prevalence of positive thyroid peroxidase antibody (TPO-Ab) was higher in all investigated women of infertile couples, compared to controls (14% vs. 8%), but the difference was not significant. However, in infertility of female origin, a significant higher prevalence of positive TPO-Ab was present, compared to controls: 18% versus 8%. Furthermore, among the female causes, the highest prevalence of positive antibodies was observed in women with endometriosis (29%). When thyroid antibodies were positive, both hypothyroidism and hyperthyroidism were more frequent in all women of infertile couples and in the women with a female infertility cause, compared to women in the same groups but without positive TPO-Ab. The present study shows that in infertile women, thyroid autoimmunity features are significantly more frequent than in healthy fertile controls and this was especially the case for the endometriosis subgroup.

Autoimmune thyroid disease in pregnancy and the postpartum period: relationship to spontaneous abortion

The aim of this study was to determine the prevalence of autoimmune thyroid disease and the risk of miscarriage in autoimmune thyroid antibody (ATA)-positive women. Eight hundred seventy-six subjects completed the study, and 12.3% were thyroid antibody-positive (4.5% tested positive for both thyroid peroxidase antibody [TPO-Ab] and thyroglobulin autoantibody [Tg-Ab], 4.79% were TPO-Ab-positive only, and 3.1% were Tg-Ab-positive only). Fifty percent of the ATA-positive women and 14.1% of the ATA-negative group had a history of spontaneous abortion. Forty-eight of the ATA-positive women developed postpartum autoimmune thyroid dysfunction (PATD). Of these, 50% had hypothyroidism alone, 31.3% had transient hyperthyroidism followed by hypothyroidism, and 18.8% had transient thyrotoxicosis alone. Of the 48 PATD subjects, 12.5% developed persistent hypothyroidism. None of the ATA-negative women developed any form of thyroid dysfunction. The thyroid-stimulating hormone (TSH) levels in the ATA-positive group were significantly higher than those in the ATA-negative group, and only the ATA-positive women with a history of abortion had significantly higher TSH and lower free thyroxine (FT4) concentrations than the other subgroups. The results revealed a 5.5% prevalence rate for PATD in the study population. In addition to TPO-Ab, Tg-Ab is a useful marker for autoimmune thyroiditis.

Postpartum thyroiditis and autoimmune thyroiditis in women of childbearing age: recent insights and consequences for antenatal and postnatal care

Postpartum thyroiditis is a syndrome of transient or permanent thyroid dysfunction occurring in the first year after delivery and based on an autoimmune inflammation of the thyroid. The prevalence ranges from 5-7%. We discuss the role of antibodies (especially thyroid peroxidase antibodies), complement, activated T cells, and apoptosis in the outbreak of postpartum thyroiditis. Postpartum thyroiditis is conceptualized as an acute phase of autoimmune thyroid destruction in the context of an existing and ongoing process of thyroid autosensitization. From pregnancy an enhanced state of immune tolerance ensues. A rebound reaction to this pregnancy-associated immune suppression after delivery explains the aggravation of autoimmune syndromes in the puerperal period, e.g., the occurrence of clinically overt postpartum thyroiditis. Low thyroid reserve due to autoimmune thyroiditis is increasingly recognized as a serious health problem. 1) Thyroid autoimmunity increases the probability of spontaneous fetal loss. 2) Thyroid failure due to autoimmune thyroiditis-often mild and subclinical-can lead to permanent and significant impairment in neuropsychological performance of the offspring. 3) Evidence is emerging that as women age subclinical hypothyroidism-as a sequel of postpartum thyroiditis-predisposes them to cardiovascular disease. Hence, postpartum thyroiditis is no longer considered a mild and transient disorder. Screening is considered.

Thyroid autoimmunity in patients with recurrent spontaneous miscarriages

Recurrent spontaneous miscarriage (RSM) is a multifactorial problem. Auto- and alloimmune parameters have been implicated. Antithyroid antibodies (ATA) were tested in a group of women with RSM. The presence of antipaternal antibodies (APCA) was evaluated as an index of alloimmune contribution. Thirty euthyroid women with RSM (three or more consecutive miscarriages) aged 25-37 years were compared with 15 matched controls. Thyroid peroxidase (TPO) and thyroglobulin antibodies were tested with a chemiluminescence immunoassay and APCA were tested with a cross-match reaction. Results were compared using the chi-squared test. There was a higher frequency of ATA in women with RSM compared to controls (37% versus 13%, p < 0.05). Twenty of the women (67%) with RSM were tested negative for APCA, indicating an alloimmune contribution to their infertility. In this subgroup of women, the frequency of ATA continued to be higher than controls (40% versus 13%, p < 0.05). In conclusion, women with RSM, independent of APCA status, have a higher frequency of ATA. This may represent an additional marker for impaired regulation of the maternal immune system.

Antineutrophil cytoplasmic antibodies and other immunologic abnormalities in patients with habitual abortion

PROBLEM

The immunologic mechanisms of pregnancy loss in habitual aborters with antiphospholipid and antinuclear antibodies have not been fully clarified. The possible association of antineutrophil cytoplasmic antibodies (ANCAs) with recurrent miscarriage was examined.

METHOD OF STUDY

In a prospective, controlled trial of 59 women with recurrent abortion, the prevalence of pANCA (antimyeloperoxidase), cANCA (antiproteinase-3), and immunoserologic abnormalities of systemic lupus erythematosus (SLE) anti double-stranded DNA, anti-SSA, anti-SSB, anti-U1RNP, anti-Sm, anticardiolipin and antinuclear antibodies, LE-cell, lupus anticoagulant, and complement-3 were investigated.

RESULTS

pANCA occurred in 2, and cANCA in 6 of 59 case patients, but neither was observed in the controls (P = 0.09 for cANCA). cANCA levels were significantly higher in patients than in controls (P = 0.028). Six recurrent aborters were identified as having a group of immunoserologic abnormalities characteristic of SLE.

CONCLUSIONS

Immunologic mechanisms detectable in SLE may operate in a subgroup of habitual aborters with suspected immunologic cause. ANCAs occur more frequently in patients with recurrent miscarriage than in controls.

Thyroid antibody titer and avidity in patients with recurrent miscarriage

OBJECTIVE

To determine whether the titer and avidity of the thyroid peroxidase antibody differs between pregnant women in their first trimester who have a history of recurrent miscarriage and whose pregnancies continue to term and those whose pregnancies fail again later in the first trimester.

DESIGN

Controlled clinical study.

SETTING

Healthy volunteers in an academic research environment.

PATIENT(S)

Pregnant women in their first trimester who had a history of recurrent miscarriage (> or = 3 miscarriages) and who were known to be positive for the thyroid peroxidase antibody.

INTERVENTION(S)

None of the patients received any medication.

MAIN OUTCOME MEASURE(S)

Thyroid peroxidase antibody titer and avidity (i.e., the net binding strength between antibody and antigen).

RESULT(S)

At the time of presentation, thyroid peroxidase antibody titer and avidity was significantly higher in those women who later miscarried compared with those whose pregnancies continued. In those whose pregnancies continued to term, titer and avidity declined as the pregnancy progressed.

CONCLUSION(S)

Autoimmunity plays a role in recurrent miscarriage. Among a group of patients who had had recurrent miscarriages, there appeared to be differences in the humoral response to the pregnancy between those whose pregnancies continued to term and those whose pregnancies failed again.

Thyroid autoantibodies are not associated with recurrent pregnancy loss

OBJECTIVE

Approximately 1% of all women have recurrent pregnancy loss, defined as >/=3 spontaneous losses of pregnancy; however, a cause is determined in only 50% of cases. Recent studies have associated the presence of thyroid autoantibodies during the first trimester of pregnancy with spontaneous abortion in the current pregnancy among women without a history of recurrent abortion. The objective of this study was to determine whether circulating thyroid autoantibodies were associated with recurrent pregnancy loss.

STUDY DESIGN

Sera from 74 nonpregnant women with a history of recurrent pregnancy loss and from 75 healthy, fertile control subjects of similar gravidity were tested for thyroglobulin and thyroid peroxidase antibodies by means of radioimmunoassay kits. All women had a third-generation thyroid-stimulating hormone assay performed. Samples were obtained >/=6 months after a pregnancy.

RESULTS

Twenty-two of the women with a history of recurrent pregnancy loss (29.3%) and twenty-eight of the control subjects (37%) had positive results for either one or both of the thyroid autoantibodies (P >. 05). Mean thyroid-stimulating hormone levels and the proportion of women with abnormal thyroid-stimulating hormone values did not differ between the 2 groups.

CONCLUSION

Women with a history of recurrent pregnancy loss are no more likely than are fertile control subjects to have circulating thyroid autoantibodies. Testing for antithyroid antibodies is not clinically useful in the evaluation of patients with a history of recurrent pregnancy loss.

Altered interleukin 12 and nitric oxide levels in recurrent miscarriage

The causes of recurrent miscarriage are not fully understood. Recent studies have suggested that whilst a TH 2 type immune response may be associated with a healthy pregnancy, miscarriage may be associated with a TH 1 type response. Serum levels of nitric oxide (NO) and Interleukin 12 (IL 12) were measured in; healthy non-pregnant women; healthy pregnant women; women suffering spontaneous abortion; pregnant women with a history of recurrent miscarriage; non-pregnant women with a history of recurrent miscarriage. Normal pregnancy was associated with a significant decrease in serum levels of nitrite (13.0 vs. 22.0 P < 0.0001). In women admitted with spontaneous abortion there was a significant increase in the levels of nitrite (16.0 vs. 13.0 P < 0.05), but no change in IL 12 compared to normal pregnant women. In pregnant women with a history of recurrent miscarriage levels of nitrite (16.0 vs. 13.0 P < 0.05) and IL 12 (10.0 vs. 6.0 P < 0.0006) were significantly elevated compared to normal pregnancy. When these women were sampled prior to becoming pregnant the levels of NO were found to be significantly lower than those in the non-pregnant control group (13.1 vs. 22.0 P < 0.05) although levels of IL 12 were unchanged. No correlation was found between serum nitrite and IL 12 levels. This report further supports the idea that polarisation of the immune response during pregnancy may predispose to recurrent miscarriage.

[Treatment of keloids and hypertrophic cicatrices]

BACKGROUND

Infertile women positive for thyroid antibodies suffer from a poor pregnancy/delivery outcome, although conflicting data have been published. Our objective was to investigate if levothyroxine (LT4) exerts any effect on pregnancy and/or delivery rates in thyroid peroxidase antibody (TPOAb)-positive (+) women undergoing assisted reproductive technologies.

METHODS

Patients undergoing treatment were screened for TPOAb, thyroid-stimulating hormone (TSH) and free thyroxine (FT4). A total of 72 (15%) out of the 484 euthyroid women selected were TPOAb (+). These 72 patients were randomly divided into two groups: group A (n = 36) underwent LT4 treatment, group B (n = 36) placebo. Group C consisted of 412 women (85%) who were TPOAb negative (-). All patients received controlled ovarian stimulation. The endpoints of treatment were pregnancy rate, miscarriage rate and delivery rate.

RESULTS

No differences in pregnancy rate were observed between the three groups. Miscarriage rate was higher in TPOAb (+) in comparison to TPOAb (-) [relative risk: 2.01 (95% CI = 1.13-3.56), P = 0.028].

CONCLUSIONS

The pregnancy rate is not affected either by presence of TPOAb or treatment with LT4. However, TPOAb (+) women show a poorer delivery rate compared to TPOAb (-). LT4 treatment in TPOAb (+) does not affect the delivery rate.