What do we really know about autoantibody abnormalities and reproductive failure: a critical review

A neuro-immune, neuro-oxidative and neuro-nitrosative model of prenatal and postpartum depression

A large body of evidence indicates that major affective disorders are accompanied by activated neuro-immune, neuro-oxidative and neuro-nitrosative stress (IO&NS) pathways. Postpartum depression is predicted by end of term prenatal depressive symptoms whilst a lifetime history of mood disorders appears to increase the risk for both prenatal and postpartum depression. This review provides a critical appraisal of available evidence linking IO&NS pathways to prenatal and postpartum depression. The electronic databases Google Scholar, PubMed and Scopus were sources for this narrative review focusing on keywords, including perinatal depression, (auto)immune, inflammation, oxidative, nitric oxide, nitrosative, tryptophan catabolites (TRYCATs), kynurenine, leaky gut and microbiome. Prenatal depressive symptoms are associated with exaggerated pregnancy-specific changes in IO&NS pathways, including increased C-reactive protein, advanced oxidation protein products and nitric oxide metabolites, lowered antioxidant levels, such as zinc, as well as lowered regulatory IgM-mediated autoimmune responses. The latter pathways coupled with lowered levels of endogenous anti-inflammatory compounds, including ω3 polyunsaturated fatty acids, may also underpin the pathophysiology of postpartum depression. Although increased bacterial translocation, lipid peroxidation and TRYCAT pathway activation play a role in mood disorders, similar changes do not appear to be relevant in perinatal depression. Some IO&NS biomarker characteristics of mood disorders are found in prenatal depression indicating that these pathways partly contribute to the association of a lifetime history of mood disorders and perinatal depression. However, available evidence suggests that some IO&NS pathways differ significantly between perinatal depression and mood disorders in general. This review provides a new IO&NS model of prenatal and postpartum depression.

The correlation of autoantibodies and uNK cells in women with reproductive failure

There is conflicting evidence on the role of autoimmune disorders in reproductive failure, including recurrent miscarriage (RM) and recurrent implantation failure (RIF), after in vitro fertilisation (IVF). Several commonly studied autoimmune markers in women with reproductive failure include antiphospholipid antibodies (APAs), thyroid peroxidase antibodies (TPA) and uterine natural killer (uNK) cells. However, there have not been any studies that have examined the correlation of these markers in women with reproductive failure. To determine if women who tested positive for autoantibodies (APA and thyroid peroxidase antibodies) have significantly higher uNK cell numbers than women who tested negative for these antibodies, the percentage of stromal cells that stained positive for CD56 was identified by immunocytochemistry in endometrial biopsies from 42 women with unexplained RM (29 women tested negative for autoantibodies and 13 women tested positive for autoantibodies) and 40 women with unexplained RIF (30 women tested negative for autoantibodies and 10 women tested positive for autoantibodies). Biopsies were obtained on days LH+7 to LH+9. There was no significant difference in uNK cell numbers between women with unexplained RM who tested negative and those who tested positive for autoantibodies. Similarly, there was no significant difference in uNK cell numbers between women with unexplained RIF who tested negative and those who tested positive for autoantibodies. In women with reproductive failure the presence of autoantibodies does not appear to affect the numbers of uNK cells in the endometrium around the time of implantation.

Cutting edge assessment of the impact of autoimmunity on female reproductive success

There, likely, is no more controversial issue in reproductive medicine than the effects of autoimmunity on female reproductive success. Published studies are, therefore, often biased. We performed PubMed, Google Scholar and Medline searches for the years 2000-2010 under various key words and phrases, referring to effects of autoimmunity/autoimmune diseases on pregnancy/pregnancy outcomes/pregnancy rates/reproduction/reproductive outcomes/fertility/infertility/fertility treatments/infertility treatments, and a number of similar terms. Reference lists of selected manuscripts were evaluated for additional, potential references. All selected manuscripts were reviewed by at least one author (N.G.). Opinions were reached based on preferential review of only selected studies, which offered data, primarily developed in pursuit of unrelated scientific questions. Data from various medical fields point, surprisingly effectively, toward significant impacts of autoimmunity on female reproductive success. Autoimmunity not only increases miscarriage risks but also reduces female fecundity and infertility treatment success. A, likely, reason why differences of opinion have persisted is that effects are primarily observed in genetically predisposed women, with specific fragile X mental retardation 1 (FMR1) genotypes. This discovery coincides with recently increasing appreciation of the importance of the long arm of the X chromosome (Xq) in control of functional ovarian reserve (reflective of female fertility) and autoimmunity, with FMR1at Xq27.3, located at cross roads of both. Autoimmune effects on female reproductive success deserve recognition. Further investigations must not ignore patient stratification, based on ovarian FMR1 genotypes. Genetic definition of high-risk patients should lead to development of successful therapeutic interventions.

Gestational dermatosis shortly after implantation associated with parental class II HLA compatibility and maternal immune activation: preliminary report of a prospective case series

BACKGROUND

Pregnancy represents a semi-allograft, subject to similar immune responses as allogeneic organ transplants. Tolerance of pregnancy appears best with maximal class II HLA heterogeneity between mother and father, while compatibilities are associated with increased pregnancy loss and maternal autoimmunity. Tolerance abnormalities often involve skin reactions. Abnormalities in tolerance of the fetal graft may do the same.

OBJECTIVE

To define the characteristics of a newly described dermatosis in very early pregnancy.

METHODS

Prospective case series of 7 couples/12 clinical episodes.

RESULTS

The dermatosis was observed in 7 out of 285 women undergoing in vitro fertilization (IVF; 2.5%; 95% CI 0.66-4.26%) and in 12 out of 277 total IVF cycles reaching embryo transfer (4.3%; 95% CI 1.93-6.73%). Prior to IVF all women reported autoimmune clinically significant allergies. All but 1 couple demonstrated class II HLA compatibility. Two of 4 pregnancies miscarried. All rashes erupted within days from embryo implantation.

CONCLUSIONS

The 'implantation rash' reported here is uncommon but not rare. It may be the consequence of abnormal maternal immune responses to embryo implantation in women with prior immune activation, associated with class II HLA compatibility between parents. Further prospective studies are required to better define this condition.

FMR1 genotype with autoimmunity-associated polycystic ovary-like phenotype and decreased pregnancy chance

The FMR1 gene partially appears to control ovarian reserve, with a specific ovarian sub-genotype statistically associated with a polycystic ovary (PCO)- like phenotype. Some forms of PCO have been associated with autoimmunity. We, therefore, investigated in multiple regression analyses associations of ovary-specific FMR1 genotypes with autoimmunity and pregnancy chances (with in vitro fertilization, IVF) in 339 consecutive infertile women (455 IVF cycles), 75 with PCO-like phenotype, adjusted for age, race/ethnicity, medication dosage and number of oocytes retrieved. Patients included 183 (54.0%) with normal (norm) and 156 (46%) with heterozygous (het) FMR1 genotypes; 133 (39.2%) demonstrated laboratory evidence of autoimmunity: 51.1% of het-norm/low, 38.3% of norm and 24.2% het-norm/high genotype and sub-genotypes demonstrated autoimmunity (p = 0.003). Prevalence of autoimmunity increased further in PCO-like phenotype patients with het-norm/low genotype (83.3%), remained unchanged with norm (34.0%) and decreased in het-norm/high women (10.0%; P<0.0001). Pregnancy rates were significantly higher with norm (38.6%) than het-norm/low (22.2%, p = 0.001). FMR1 sub-genotype het-norm/low is strongly associated with autoimmunity and decreased pregnancy chances in IVF, reaffirming the importance of the distal long arm of the X chromosome (FMR1 maps at Xq27.3) for autoimmunity, ovarian function and, likely, pregnancy chance with IVF.

Environmental influences on human growth and development: historical review and case study of contemporary influences

Over the past 100 years, the study of environmental influences on human physical growth and development has focused on the influences of social and economic factors; family and household characteristics; urbanization/modernization; nutrition; and features of the physical environment such as altitude, temperature and climate. Continuing in this tradition are current investigations into the roles of pollutants and other aspects of the human-made environment in affecting patterns of human growth and development, specifically the timing of sexual maturation and the development of obesity. Some of the methodological problems in conducting such studies are presented, as are results from an ongoing investigation among one Native American community that show relationships of pollutants to sexual maturation, overweight/obesity and thyroid system function which can impact growth and maturation.

Leukocytes: essential cells in ovarian function and ovulation

The disciplines of reproduction and immunology, once quite discrete, are now closely associated, with compelling evidence to suggest that immune mechanisms play important roles in the cervix, uterus, fallopian tubes and ovary. Cells and mediators classically described as part of the immune system are found throughout the reproductive tract. Disorders of reproduction, including pre-eclampsia, unexplained infertility, endometriosis, recurrent miscarriage and disturbed fetal growth almost certainly have some of their origins in the dysfunction of immune regulation. There appears to be some evidence that immune disorders, such as rheumatoid arthritis and scleroderma, can manifest as infertility, before clinical disease becomes apparent.

Persistent organic pollutants and anti-thyroid peroxidase levels in Akwesasne Mohawk young adults

Persistent organic pollutants, such as polychlorinated biphenyls (PCBs), hexachlorobenzene (HCB), and p,p'-dichlorophenyldichloroethylene (DDE), have been found to elicit a broad spectrum of biologic, metabolic, and immunologic responses. The potential of these pollutants to impair immune responses and trigger autoimmune disease is of growing concern, given their structural similarity to thyroid hormones and their potential to modulate the mechanisms and interfere with the binding of these hormones. We examine the relationship of different groupings of PCBs, according to chlorination and structure, and of p,p'-DDE and HCB to anti-thyroid peroxidase antibody, a useful tool in the evaluation of thyroid dysfunction, among 115 young adults of the Akwesasne Mohawk Nation. Overall, 18 participants (15.4%) had anti-thyroid peroxidase antibodies (TPOAb) levels above the normal laboratory reference range (23% of females, 9% of males). Among participants who were breast fed (n=47), those with an elevated TPOAb level had significantly higher levels of all PCB groupings, with the exception of levels of non-persistent PCBs which did not differ significantly. Levels of p,p'-DDE were also significantly elevated, while HCB and mirex were not higher among those with elevated TPOAb. Also, after stratifying by breast-feeding status, participants who were breast fed showed significant, positive relationships between TPOAb levels and all PCB groupings, except groups comprised of non-persistent PCBs, and with p,p'-DDE, HCB, and mirex. No effects were evident among non-breast-fed young adults. Further studies are necessary to elucidate the site and mechanism of action of these persistent organic pollutants (POPs) and to establish thresholds for these effects, especially among populations with background levels of toxicant exposure.

Gender as risk factor for autoimmune diseases

Most autoimmune diseases occur significantly more frequently in women than men. This female preponderance for abnormal autoimmune function has largely gone unexplained. Many investigations have concentrated on the effects of female and male sex hormones on immune function, by suggesting that estrogens favor the antibody production-enhancing Th2 response and, by doing so, possibly, increase the risk towards abnormal autoimmune function. Others have suggested that women are genetically predisposed towards abnormal autoimmune function, possibly because the X chromosome may confer susceptibility towards tolerance breakdown. Recent developments have, however, opened new research avenues. The possible association between persistent fetal-maternal microchimerism and the development of autoimmune diseases has attracted special interest. Since, in analogy to allogeneic organ transplantation, fetal-maternal (and maternal-fetal) microchimerism may play an important role in the immunologic tolerance of the fetal semi-allograft, female preponderance for autoimmune diseases may be understood as a consequence of increased allogeneic cell traffic in females (in comparison to males), increased risk for long-term microchimerism and, therefore, as a consequence of the former two, the development of abnormal autoimmunity. Under an evolutionary view point the occurrence of autoimmune diseases, in general, can be seen as the price to be paid for successful reproduction. In view of increased exposure to cell traffic, women, of course, would be expected to pay a higher price, reflected in more autoimmunity.

Why much of the pathophysiology of preeclampsia-eclampsia must be of an autoimmune nature

Preeclampsia-eclampsia (PE-E) is a poorly understood condition of human pregnancy, which can affect multiple organs and is a leading cause of maternal deaths worldwide. The etiology and pathophysiology remain enigmas, however, which hampers progress in prevention, diagnosis, and treatment of this condition. PE-E is characterized by many features typically seen in autoimmune diseases, or in association with autoimmune reactions. Although this does not mean that PE-E should be considered an autoimmune condition, it does suggest that abnormal autoimmune processes play an important part in the clinical presentation of PE-E. In that regard, PE-E mimics autoimmune responses also observed in situations of allograft rejection and graft-versus-host disease (GVHD). Indeed, PE-E shares many other clinical and laboratory characteristics with allograft rejection and GVHD. Recognizing PE-E as a clinical condition that is characterized by autoimmune abnormalities may facilitate earlier and more specific diagnosis, along with preventive and more specific therapies for women at risk.

Is Endometriosis Associated with Systemic Subclinical Inflammation?

Endometriosis is a pelvic inflammatory process with altered function of immune-related cells and increased number of activated macrophages in the peritoneal environment that secrete various local products, such as growth factors and cytokines. The elevation of cytokines and other factors in the peritoneal fluid is accompanied by the elevation of similar factors, such as CRP, SAA, TNF-alpha, MCP-1, IL-6, IL-8 and CCR1, in the peripheral blood of patients with endometriosis. CD44+ and CD14+ monocytes are significantly increased, while CD3+ T lymphocytes and CD20+ B lymphocytes show modest, but significant decrease in peripheral blood of women with endometriosis. This indicates that endometriosis could be viewed as a local disease with systemic subclinical manifestations. This review provides an overview of data on the changes of various factors in peripheral blood and their potential use as diagnostic tools in patients with endometriosis.

Autoantibodies in Argentine women with recurrent pregnancy loss

PROBLEM

To determine the presence or absence of subclinical autoimmunity in Caucasian Argentine healthy women with first trimester recurrent pregnancy loss (RPL), the sera of 118 healthy women with a history of three or more consecutive abortions and 125 fertile control women without abortions and two children were analyzed for the presence of autoantibodies: immunoglobulin (Ig)G and IgM anticardiolipin, antinuclear (ANA), antismooth muscle (ASMA), antimitocondrial (AMA), antiliver-kidney-microsomal fraction (LKM), antigastric parietal cells (GPC), antineutrophil cytoplasmatic (ANCA) and antibodies antigliadin type IgA and IgG and IgA antitransglutaminase related with celiac disease (CD).

METHOD OF STUDY

ANA, ASMA, AMA, anti-LKM, antibodies to GPC and ANCA were determined by indirect immunofluorescence (IFI) and anticardiolipin, antigliadina and antitransglutaminase antibodies were measured by enzyme-linked immunosorbent assays (ELISA).

RESULTS

There was no significant difference between controls and patients with ANA, ASMA, AMA, LKM, ANCA and GPC. The prevalence of anticardiolipin antibodies in RPL was significantly higher than controls (P < 0,01) and the prevalence of positive antibodies for antigliadina type IgA and IgG and IgA antitransglutaminase in RPL was significantly higher than controls (P < 0.04).

CONCLUSION

We show that Caucasian Argentine women with RPL showed significantly higher incidence of anticardiolipin antibodies than normal controls and finally we recommended the screening of IgA and IgG antigliadina and IgA antitransglutaminase antibodies in pregnancy, because of the high prevalence of subclinical CD in RPL and the chance of reversibility through consumption of a gluten free diet.

Preconception Peripheral Natural Killer Cell Activity as a Predictor of Pregnancy Outcome in Patients with Unexplained Infertility

PROBLEM

Preconception high peripheral natural killer (NK) cell activity in women with recurrent spontaneous abortion can predict subsequent miscarriages. We have examined prospectively, for the first time, the pregnancy rate in patients with unexplained infertility by measuring the peripheral NK activity.

METHOD OF STUDY

We tested the peripheral NK activity of 94 infertile women who despite treatment were unable to conceive for 6 or more months (mean; 2.4 years). Peripheral NK activity was measured by a chromium-51 release cytotoxicity assay. Women were followed for 2 years and assessed.

RESULTS

In 77 patients who were followed for 2 years, 28 had conceived but 49 did not. The peripheral NK activity of the group that became pregnant (mean +/- S.D.; 34.5 +/- 13.8%) was significantly lower than that of non-conception group (42.3 +/- 13.3%, P = 0.017).

CONCLUSIONS

Our finding suggests that elevated peripheral NK activity in patients with unexplained infertility is a risk factor for attaining pregnancy success.

Reflections on the management of reproductive failure in the antiphospholipid syndrome--the clinician's perspective

It is well known that women with systemic lupus erythematosus (SLE) who have antiphospholipid antibodies (aPL) are at increased risk for pregnancy loss. Additionally, other reproductive processes, such as unexplained infertility and implantation failure after in vitro fertilization and embryo transfer may be affected by aPL. Thus, clinical manifestations of the so-called 'gynaeco-obstetrical antiphospholipid syndrome' have been expanded into the concept of the 'reproductive autoimmune failure syndrome'. However, this is still a matter of debate with no general agreement with respect to both pathophysiological significance of the presence of aPL and patient management. This article analyses a number of controversies in the management of reproductive failure potentially associated with aPL in order to help clinicians dealing with such condition in daily clinical practice.

Low molecular weight heparin in immunological recurrent abortion--the incredible cure

The most compelling association between pregnancy loss and autoimmune phenomena has been with the presence of antiphospholipid antibodies (APA)--lupus anticoagulant and anticardiolipin antibody. The 'antiphospholipid antibody syndrome' has been described in women with a history of recurrent pregnancy loss or thrombosis with positive APA or lupus anticoagulant on two occasions. Although several treatments have been advocated, heparin and aspirin treatment is emerging as the treatment of choice for the APA syndrome associated with recurrent pregnancy loss. The rationale for prescribing aspirin in cases of recurrent reproductive failure associated with APA seropositivity is that aspirin may counter APA-mediated hypercoagulability in the choriodecidual space, a situation which if left unaddressed would traumatize the trophoblast and compromise feto-maternal exchange. Heparin on the other hand, through preventing APA from interfering with syncytialization of the early cytotrophoblast and by countering APA interference with phospholipid-decidual reactions that are vital to early implantation, might potentially promote both early implantation and subsequent placentation.

Low serum level of mannan-binding lectin is a determinant for pregnancy outcome in women with recurrent spontaneous abortion

OBJECTIVE

The purpose of this study was to investigate the genetic background for the previously reported finding of an increased frequency of low levels of mannan-binding lectin in couples with unexplained recurrent spontaneous abortion and to evaluate the impact of low mannan-binding lectin levels on future pregnancy outcome.

STUDY DESIGNS

Mannan-binding lectin levels were measured in 217 women with unexplained recurrent spontaneous abortion and 111 of their husbands and were compared with corresponding measurements in 104 couples with uncomplicated reproductive histories and 210 blood donors. An investigation of the genetic polymorphism, which is largely responsible for serum mannan- binding lectin levels, was done by polymerase chain reaction methods with DNA from a subset of the patients and control subjects. Information was collected about the outcome of the patients' next pregnancies, together with perinatal data concerning the patients' first birth that occurred before or after being assigned to the study.

RESULTS

Among women with recurrent spontaneous abortion, 18.9% of the women had mannan-binding lectin levels of </= 100 ng/mL compared with 12.2% of control subjects ( P =.02). An investigation of mannan-binding lectin levels and genetic analyses gave no evidence that paternal mannan- binding lectin deficiency plays a role for recurrent spontaneous abortion. Patients with mannan-binding lectin levels of </=100 ng/mL had a higher abortion rate than patients with normal mannan- binding lectin levels (P <.05). The median birth weight of children who were born at term of women with recurrent spontaneous abortion was 287 g less in women with mannan-binding lectin levels of </= 100 ng/mL than that of patients with normal mannan-binding lectin levels (P =.04).

CONCLUSION

Low maternal serum mannan-binding lectin levels exhibit a negative impact on pregnancy outcome in women with unexplained recurrent spontaneous abortion.

Some thoughts on the reproductive autoimmune failure syndrome (RAFS) and Th-1 versus Th-2 immune responses

PROBLEM

The concept of immunologically induced reproductive failure has remained very controversial. Especially the question whether abnormal immune function can cause infertility has recently been subject to strong disagreement. This opinion piece is an attempt to reconcile difference of opinion by integrating clinical data from the human experience with well-established experimental models in animals.

METHOD OF STUDY

Review of published literature.

RESULTS

Experimental animal data, especially in the mouse, have suggested that normal pregnancy requires a switch to an immune response with T helper (Th)-2 preponderance. Recent data from the human experience suggest that infertility, repeated pregnancy loss and certain complications of pregnancy may be the consequence of abnormal Th-1 preponderance. In analogy, to animal models, immunologic reproductive failure in humans, may therefore not be the consequence of specific autoantibody abnormalities or natural killer (NK)-cell abnormalities, but the reflection of a misdirection of a more broadly based immune response.

CONCLUSIONS

Under such a model, both diagnosis and treatment of immunologically induced forms of reproductive failure require re-evaluation. Such a model, however, provides a satisfactory explanation for contradictory findings in the human experience that have led to strong disagreements among investigations.

The immunological "Wars of the Roses": disagreements amongst reproductive immunologists

The relevance of abnormal autoimmune function to reproductive function in the female has over recent years become an increasingly controversial and contentious issue. Opposing views have led to a polarization of opinions which, at times, resulted in publications of rather vocal opinions by individuals as well as societal committees. This communication is an attempt to reconcile these, at times diametrically opposing opinions, in a concept of (auto)immune-driven reproduction failure, which could explain and unify these opposing opinions and, thus, hopefully end the ongoing "immunological wars of the roses".

Autoantibody studies of female patients with reproductive failure

The aim of this study was to investigate the prevalence and character of autoimmune derangements in women with reproductive failure. A total of 108 females (age range 17-43, mean 27.5 years), including 16 with primary menstrual cycle disturbances and polycystic ovaries (PCO), 20 with polycystic ovary syndrome (PCOS), 38 with endometriosis (E), and 34 with chronic anovulation, luteal phase insufficiency, subfertility or unexplained infertility (INF) were investigated. A control group of 392 women was formed from an unselected population sample (age range 17-43, mean 31.0 years). All sera were tested by indirect immunofluorescence method to assess common autoantibodies: nuclear (ANA), smooth muscle (SMA), parietal cell (PCA), thyroid microsomal (TMA), reticulin (ARA), mitochondrial (AMA) and liver/kidney microsomal autoantibodies (LKMA). Enzyme-linked immunosorbent assay was used to detect antibodies against beta2-glycoprotein I (anti-beta 2GPI) and carbonic anhydrase (anti-CA). Our results showed that 40.7% of patients' sera and 14.8% of control sera contained one or more common autoantibodies, ANA and SMA were most frequently detected (difference between two groups P<0.005). Anti-beta 2GPI were found in eight cases (7.4%), including two patients with INF but without other autoantibodies. Anti-CA were revealed in nine cases (8.3%) including patients' PCOS, E and INF. A comparison of patients' clinical data with antibody assay results did not reveal any significant associations. Our results indicate a high prevalence of autoimmune reactions in women with reproductive failure due to the most common causes PCO, PCOS and E as well as in unexplained infertility. This might reflect the propensity to develop autoimmune reactions in such patients, including pathogenic autoimmune reactions to specific target antigens.

Prospective pregnancy outcome in untreated recurrent miscarriers with thyroid autoantibodies

The purpose of this study was to determine the prevalence of thyroid antibodies in women with recurrent miscarriage and to observe whether their presence was predictive of future pregnancy outcome. A total of 870 consecutive, non-pregnant women with a history of three or more pregnancy losses and normal parental karyotypes were investigated for the presence of thyroglobulin antibodies (TgAb) and for thyroid microsomal antibodies (TmAb). Thyroid antibodies were found in 162 (19%) women. TgAb only were found in eight women (5%); TmAb only in 98 (60%) and both TgAb and TmAb were found in 56 (35%). Thirteen women had a history of thyroid disease and a further 15 women were found to have abnormal thyroid function. All 28 were excluded from the pregnancy outcome study. Among the remaining 134 thyroid antibody positive women, 36 women were not tested and normal thyroid stimulating hormone results were obtained for 98. In the group proven euthyroid, 14 of 24 untreated pregnancies resulted in live births (58%). Among the 710 thyroid antibody negative women, 47 of 81 untreated pregnancies resulted in live births (58%). The future risk of pregnancy loss in women with unexplained recurrent miscarriage is not affected by their thyroid antibody status.

Increased prevalence of thyroid antibodies in euthyroid women with a history of recurrent in-vitro fertilization failure

This study was undertaken to evaluate whether the presence of thyroid antibodies in euthyroid women is associated with an adverse outcome in an in-vitro fertilization (IVF)-embryo transfer programme. In 24 women (study group: mean age +/- SD: 31.5 +/- 4.4 years) who failed to conceive after having three or more cycles of IVF and embryo transfer, serum concentrations of thyroglobulin (TG), thyroid peroxidase antibodies (TPO) and anticardiolipin antibodies (IgG and IgM) were measured using commercially available kits. The control group comprised 24 consecutive patients without endocrine dysfunction (mean age +/- SD: 30.3 +/- 4.1 years) seeking infertility treatment in our department of assisted reproduction. All patients in both the study and the control groups were determined to be euthyroid by demonstrating normal concentrations of thyroid-stimulating hormone (TSH). In the study and control groups respectively, 13 and two patients demonstrated positive titres of TG, TPO or both thyroid antibodies (Fisher's exact test: P = 0.002). Mean serum concentrations of TG were significantly increased in the study group compared to the control subjects (156 +/- 167 IU/ml versus 33.5 +/- 32.0 IU/ml; U-test: P = 0.009). Serum concentrations of TPO and anticardiolipin antibodies were similar in both groups. Our investigations revealed that thyroid antibodies might be independent markers for reproductive failure in an IVF-embryo transfer programme.

Immunodiagnostic evaluation in women with reproductive failure

PROBLEM

Several immunological factors have been associated with diagnostic subpopulations of reproductive failure. It is important to determine a trend of immunological abnormalities among these subpopulations. The purpose of this study is to assist in the selection of treatment for patients suspected of having specific diagnoses of reproductive failure.

METHOD OF STUDY

Blood samples from 591 patients were evaluated for the presence of antiphospholipid (APA), antinuclear (ANA), and antithyroid (ATA) antibodies, as well as for lupus anticoagulant (LA), embryotoxic factors (ETF), and elevated levels of natural killer (NK) (CD56+) cells, and all tests were performed as a panel. The patients were grouped into the following diagnostic categories: recurrent pregnancy loss (n = 302), IVF/ET failure (IVFf, n = 122), unexplained infertility (n = 97), ovarian dysfunction (n = 47), and endometriosis (n = 23). The thresholds for positivity and the prevalence of the tested factors among normal healthy populations have been established by testing 100 or more healthy male and female individuals with each one of the tests used (general population control). All tests as panel were performed on 20 normal fertile female individuals as controls (fertile female controls).

RESULTS

Of all patients with reproductive failure, 75.6% had at least one abnormal test. The most frequent abnormal result was found to be the elevation of NK (CD56+) cells (37%), followed by ANA (34%), APA (24%), ATA (19%), and ETF (11%). Of the recurrent pregnancy loss patients, 74.2% had at least one positive abnormal result from all of the tests performed: overall, 70% of women with IVF failure had at least one abnormal test; of patients diagnosed with unexplained infertility, approximately 81% had at least one abnormal result; 74.4% of the patients with ovarian dysfunction and 52% of the patients with endometriosis had at least one abnormal result. From normal fertile controls, 10% showed at least one abnormal test result.

CONCLUSION

APA, ANA, ATA, ETF, and elevated NK (CD56 ) cells are significantly more prevalent among women experiencing reproductive failure than among the control group and normal healthy individuals.

Human reproductive failure is not a clinical feature associated with beta(2) glycoprotein-I antibodies in anticardiolipin and lupus anticoagulant seronegative patients (the antiphospholipid/cofactor syndrome)

It has been suggested that patients with clinical features suggestive of antiphospholipid syndrome but being lupus anticoagulant (LA) and anticardiolipin (aCL) negative, should be tested for antibodies to beta(2) glycoprotein-I (abeta(2)GP-I), a protein involved in the binding of antiphospholipid antibodies (aPL) to phospholipid surfaces. This was investigated in the present study where a total of 385 women aged </=40 years were included. Of these, 175 were experimental subjects and 210 were controls. The former comprised the following two study groups: 100 spontaneous recurrent aborters (group one), and 75 patients with repeated failure of embryo transfer (group two). Controls included three groups of women: 100 normal healthy parous women with no previous abortion (group three), 60 infertile patients achieving a live birth with their first in-vitro fertilization (IVF)/embryo transfer attempt (group four), and 50 patients with recurrent abortion who tested positive for aPL (LA and/or aCL) (positive controls, group five). Only one patient among recurrent aborters (group one) tested positive for abeta(2)GP-I. All women in groups two, three and four were negative for abeta(2)GP-I screening. As expected, prevalence of patients testing positive for abeta(2)GP-I was significantly higher in group five than among the other groups of patients (P < 0.001). No differences were observed regarding the prevalence of abeta(2)GP-I positive sera in the subgroup of patients having aCL and those having the LA in group five. It is concluded that abeta(2)GP-I screening in first-trimester recurrent abortion or in failure of implantation after IVF is not warranted in patients without aPL as detected by standard antiphospholipid assays.

Antiphospholipid antibodies and reproduction

The antiphospholipid antibodies (APA) are acquired antibodies against a phospholipid which has been associated with slow progressive thrombosis and infarction in the placenta. Clinical features (venous or arterial thrombosis, recurrent fetal loss, thrombocytopenia) in conjunction with positive laboratory findings (positive IgG or IgM anticardiolipin antibodies, or positive lupus anticoagulant tests) will satisfy criteria for diagnosis of the antiphospholipid antibody syndrome (APS). A number of studies report the incidence of antiphospholipid antibodies in different patient populations: normal obstetrical patients (5.3% of 7278 women), women with recurrent pregnancy loss (20% of 2226 women), women with systemic lupus erythematosus (37% of 1579 women) and, more recently, women undergoing in vitro fertilization (24% of 3343 women). As in all autoimmune syndromes it is possible that APA are secondary to some underlying disease or that they are instrumental in the pathogenesis of the various manifestations. The most commonly proposed mechanisms of antiphospholipid antibody induced thrombosis include decreased prostacycline production by endothelial cells, increased thromboxane production by platelets, and decreased protein C activation. More recently it has been demonstrated that certain phospholipids are exposed on the endothelial surface and may alter implantation during in vitro fertilization. Treatment with subcutaneous heparin and aspirin has been shown to benefit women with recurrent pregnancy loss and APA resulting in successfully deliveries of approximately 75%. Several trials of treatment with heparin and aspirin in women with positive APA undergoing IVF have been completed. Although none of the studies were randomized, prospective, blinded trials there does not appear to be a significant difference in implantation rate, pregnancy rate, or ongoing pregnancy rate. This subject remains, however, an area of active investigation as antiphospholipid antibodies have been shown to interact with syncytiotrophoblast and cytotrophoblast layers and could theoretically affect implantation.

Autoantibody screening for infertility: explaining the unexplained?

Several laboratories currently offer panels of serum autoantibody assays to screen women with unexplained infertility and those undergoing in vitro fertilization (IVF). Offering these tests implies that they have predictive value for the outcome of proposed infertility treatments such that the results of the testing would alter clinical management. Because screening for antiphospholipid antibodies adds expense to already costly procedures, it is an appropriate time to review the justification for the use of these panels.

Anti-endometrial autoantibodies in women with a diagnosis of infertility

PROBLEM

The purpose of this study was to investigate the frequency of anti-endometrial antibodies (AEA) in infertile women.

METHOD OF STUDY

Sera from fertile women (n = 6), and from patients with ovulatory dysfunction (n = 11), tubal obstruction (n = 9) and unexplained infertility (n = 5) were investigated for the presence of anti-endometrial membrane antibodies. We used two human endometrial cancer cell lines and human endometrial cells from gynecological biopsies as an antigenic source for analysis. The immunoenzymatic assay (ELISA) was performed with cultured endometrial cells in monolayers. Immunoblot analysis was performed with these two cell lines.

RESULTS

A good correlation between the response with each cell line and with human endometrial cells was obtained, indicating that the antigens analyzed were probably similar. Endometrial antibodies were detectable in a high percentage of women with tubal obstruction (77.8 and 66.7%, respectively) and ovulatory dysfunction (54.5 and 45.5%, respectively). Unexplained infertility showed anti-endometrial immunological response (40 and 60%, respectively). Some endometrial antigens in infertile women are the target for autoimmune response. The serum from a patient with tubal obstruction and ovulatory dysfunction showed two antigens by immunoblot, with molecular weights of 97 and 50 kDa.

CONCLUSION

The presence of anti-endometrial antibodies, detected by ELISA, is associated with infertility, mainly with ovulatory dysfunction and tubal obstruction. Some endometrial antigens may be involved in these two pathologies.

Thyroid antibodies and their relation to antithrombin antibodies, anticardiolipin antibodies and lupus anticoagulant in women with recurrent spontaneous abortions (antithyroid, anticardiolipin and antithrombin autoantibodies and lupus anticoagulant in habitual aborters)

OBJECTIVE

This study was undertaken to evaluate the incidence of thyroid autoantibodies in women with a history of recurrent spontaneous abortions (RSA) and to investigate their relationship to non-organ specific autoantibodies.

STUDY DESIGN

28 euthyroid non-pregnant habitual aborters were analysed for thyreoglobulin (TG), thyroid peroxidase antibodies (TPO), and autoantibodies to thromboplastin, cardiolipin and lupus anticoagulant. 28 multigravidae without previous abortions or endocrine dysfunctions served as controls.

RESULTS

11 of 28 women with recurrent spontaneous miscarriage (39%), but only 2 of 28 controls (7%) (Chi square test: p < 0.01) demonstrated positive titres of TG, TPO, or both antibodies, 12 patients were positive for antithrombin antibodies and 3 for anticardiolipin. Only one women was lupus anticoagulant positive. No significant correlation between thyroid antibody positivity and positivity for antiphospholipids (Fisher's exact test: p = 0.441), anticardiolipin (p = 0.664) or lupus coagulant (p = 0.607) was found.

CONCLUSIONS

The incidence of thyroid antibodies in euthyroid women with recurrent pregnancy loss appears to be significantly increased compared with controls of reproductive age without previous abortions. No correlation between the presence of thyroid autoantibodies and non-organ specific autoantibodies could be established.

Recurrent fetal loss and antiphospholipid antibodies: clinical and therapeutic aspects

Recurrent fetal losses indicate screening for antiphospholipid antibodies, especially after the third consecutive fetal loss, or when they occur after 12 weeks gestation or when the mother presents with thrombosis or other ailments of antiphospholipid syndrome. Fetal loss may be caused by thromboses of placental vasculature. There is no agreement concerning the mechanism of thromboses: protein C pathway and/or annexin V are the best candidates. When fetal loss occurs early during gestation, murine models suggest that antiphospholipid antibodies can also act on trophoblasts by inhibiting syncytia formation. Among the high risk patients with more than two fetal losses, an association of aspirin and heparin given early during gestation is successful in 70–80% of cases.

[Obstetrical complications of antiphospholipid syndrome]

Spontaneous miscarriages and fetal deaths take part of the definition of the antiphospholipid syndrome. Preeclampsia, fetal distress, preterm delivery, intrauterine growth retardation, mother's or newborn's vascular thrombosis are also included in the spectrum of clinical events linked to the antiphospholipid antibodies in pregnant women. The pathogenesis is not fully understood, but involves interactions between antibodies and phospholipidic molecules that are complexed to plasmatic proteins of the coagulation, or present on endothelial cell and platelet surfaces. The poor spontaneous prognosis of pregnancy in the context of the antiphospholipid syndrome is dramatically improved by preventive treatment. Therapeutic options are not codified and are various combinations of low-dose aspirin, heparin, steroids, intravenous immunoglobulins, and fish-oil derivatives. Excellent obstetrical care is mandatory in every case.

Sperm, nuclear, phospholipid, and red blood cell antibodies and isotype RF in infertile couples and patients with autoimmune rheumatic diseases

PROBLEM

To determine if measuring of nonorgan-specific autoantibodies is useful for better understanding and management of unexplained infertility.

METHODS

Sera were obtained from 70 infertile couples, 57 rheumatic patients, and 76 fertile donors. Sperm antibodies (SA) were detected by the tests of Kibrick and Friberg, anti-histones, anti-cardiolipin antibodies, and RF isotypes by ELISA, antinuclear antibodies by indirect immunofluorescence, and anti-red blood cell antibodies by Capture-R.

RESULTS

Multiple autoimmune reactivity (both partners positive and/or more than one type of autoantibody involved), higher than naturally occurring in fertile individuals, was found in 55% of the idiopathically infertile couples. IgA-RF was the dominant autoimmune marker. SA revealed similar rates in patients with rheumatic diseases and in infertiles with or without other autoantibodies.

CONCLUSION

Although no single autoimmunity marker could predict occurrence of SA, the coincidence of enhanced polyclonal autoimmunity in both partners of infertile couples might potentiate their negative effect on reproduction.

Human autoantibodies recognizing human and mouse preimplantation stages

PROBLEM

To find out whether autoantibodies against human preimplantation stages are present in some human sera and, if so, whether the antibodies could be capable to affect the egg development and/or to trigger an activation of the complement system at the procedures of assisted conception.

METHODS

1. Immunohistochemistry on blots of human preimplantation stages. 2. Immunohistochemistry on paraffin sections of human and mouse preimplantation stages. 3. Culture of mouse morulae to analyze complement activation.

RESULTS

1. Some human sera contained autoantibodies against human preimplantation stages. 2. Human-mouse cross-reacting antibodies against preimplantation stages occurred. 3. Immune complexes, formed on mouse preimplantation stages, activated the complement systems in egg cultures, resulting in a damaging of the eggs.

CONCLUSION

The presence of natural autoantibodies to preimplantation stages may be associated with reproduction failure, caused by a direct effect by the autoantibodies and/or an activation of the uterine complement system by the immune complexes formed.

Laboratory evaluation of women experiencing reproductive failure

Reproductive life table analysis indicates that the majority of reproductive failures result from post fertilization failures, whether before or after implantation. It is important to have a set of tests to clarify the diagnosis of the reproductive failure so that appropriate therapy can be instituted. To determine the frequency of abnormal immunologic tests among women experiencing reproductive failure, 108 patients were evaluated for the presence of antiphospholipid antibodies (APA); lupus anticoagulant (LA); thyroid-thyroglobulin and microsomal antibodies (TGT); embryotoxic factor (ETA); and systemic CD56+/CD16- cells. The frequency of abnormal results obtained from testing for APA, LA, TGT, ETA, and CD56+/CD16- cells among 108 patients with diagnoses of recurrent pregnancy loss (RPL)(n = 45), unexplained infertility (n = 45) including IVF failure (n = 10), endometriosis (n = 10), premature ovarian failure (n = 5), and polycystic ovaries (n = 3) were compared with 15 normal controls. Seventy of one hundred eight (65%) women experiencing reproductive failure had at least one positive test, compared to 1 of 15 (7%) controls (P = 0.0001). Presence of phospholipid antibodies was the most frequently abnormal result followed by elevated CD56+/CD 16 cells. The prevalence of a particular abnormal test varied among the diagnoses. The most frequent abnormal test among women with RPL was an increased percentage of CD56+/CD16- cells (40%), followed by APAs (29%), TGT (9%), and ETA (7%). The most frequent abnormal result among women with unexplained infertility was the presence of APAs (42%), followed by CD56+/CD16- cells (16%), ETA (16%), and TGT (9%). APA, CD56+/CD16- cells, ETA, and TGT are useful tools to assist in the diagnosis of reproductive failure.

Antiphospholipid antibody prevalence in patients with IVF failure

Antiphospholipid antibodies (APAs) have been associated with reproductive wastage. The purpose of this study was to establish the prevalence of APAs in women who have had at least 12 embryos transferred during several in vitro fertilization (IVF) cycles without ensuing pregnancy. Sera from 42 women with IVF failure and 42 women who successfully conceived after IVF were tested for the presence of APAs by ELISA. Successful post-IVF pregnancy was determined by obtaining two consecutive rising beta-hCG levels followed by an ultrasound to confirm a viable conceptus. The sera were tested for three isotypes of antibody: IgA, IgG, and IgM against seven phospholipids: cardiolipin (CL), phosphatidylethanolamine (PE), phosphatidylinositol (PI), phosphatidic Acid (PA), phosphatidyl-glycerol (PG), phosphatidylcholine (PC), and phosphatidyl-serine (PS). From the IVF failure group, 11/42 (26.2%) were positive for APAs. From the control group, 2/42 (4.8%) were found positive only for IgA against PE. The difference between IVF failure and successful IVF groups was significant (P = 0.01). These results suggest that antiphospholipid antibodies should be considered an important marker for increased risk of IVF failure. Patients who are involved with an IVF program should be tested for the presence of APAs prior to initiation of an IVF cycle.

Premature ovarian failure

Premature ovarian failure (POF) is common, affecting approximately 1% of women. It is defined as gonadal failure before the age of 40 and patients may clinically present with either primary or secondary amenorrhoea. This review concentrates on the clinical aspects of POF, with sequential discussion on the aetiology and epidemiology, clinical manifestations and relevant investigations, concluding with an overview of management. In addition, the scientific basis for our current understanding of POF is summarized to provide a comprehensive overview of the diverse pathophysiological mechanisms that may underlie this disorder. Despite the heterogeneity of causes of POF, the fundamental treatment principles are the same. In this review the initiation of hormone replacement therapy in the younger woman and the importance of long term follow-up and treatment are emphasized.

HLA-DPB1 polymorphisms on the MHC-extended haplotypes of families of patients with Graves' disease: two distinct HLA-DR17 haplotypes

HLA-DPB1 polymorphisms were investigated in 217 members of 21 multiplex families of patients with Graves' disease, who had previously been haplotyped, using in vitro enzymatic DNA amplification and hybridization with sequence-specific oligonucleotide probes. Using the strategy of group-specific amplification, we were able to assign 19 DPB1 alleles with the use of 13 sequence specific oligonucleotide probes. No recombination was found between HLA-DPB1 and the HLA-DR/DQ complex in 243 informative meioses. HLA-DPB1*0401 was found to be the most common allele followed by DPB1*0101, *0201 and 0402 with allele frequencies of 0.4214, 0.1132, 0.1069 and 0.1006, respectively. Besides the strong linkage disequilibrium between HLA-DPB1*0101 allele and the HLA-B8, DR17/DQ2 haplotype; HLA-DPB1*0202 and *1101 alleles were also found to be significantly associated with HLA-B18 and DR7 with Pc < 0.001 and Pc < 0.009, respectively. HLA-DR17/DQ2 was found to be more commonly associated with HLA-DPB1*0101 on the Affected haplotypes (from family members affected with Graves' disease) while associated with DPB1*0401 on the Ab + ve haplotypes (deduced from thyroid autoantibody positive unaffected members). The differences in the frequency of this preferential association on the Affected and Ab + ve haplotypes was statistically significant (ch 2 = 10.18, df = 2, P < 0.007). Though it is rater unlikely that the HLA-DPBI polymorphism by itself could contribute a direct role towards the genetic susceptibility for the development of autoimmune thyroid disease, it could serve as a marker in identifying family members with the HLA-DR17/DQ2 haplotype who are more likely to develop Grave's disease or thyroid autoantibodies.

Immunoregulation of mammalian fertility

Fertility management is a global issue of agricultural, medical, economic, and social consequence. Although many methods have been devised to both inhibit and assist reproduction, more acceptable alternatives are needed. Regulation by immune intervention is a promising technology as applied to livestock, pets, wildlife, and human beings. Outcome is dictated by site within the reproductive axis that is targeted. Fertility is suppressed by immunization against gonadotropin-releasing hormone, gonadotropins, prostaglandin F2 alpha, oxytocin, gonadotropin receptors, and gamete/embryonic antigens. It also is possible to lyse gonadal cells with ligand-antibody hybrid molecules. Ovulation rates are enhanced by vaccination with inhibin. Antibodies to sex steroid hormones have yielded mixed results. Perhaps recombinant viral vectors can be used to deliver reproductive immunogens. A new and simple technique to generate sustained autoimmune reactions to hormones and cellular antigens entails direct gene transfer into somatic cells. Evolving advances in reproductive immunology and biotechnology should furnish us with novel nonsurgical contraceptives and profertility agents that can be efficiently and safely implemented.