Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Tennessee Medical Center, Memphis, Tennessee, USA
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Abstract |
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Key words: anticoagulation therapy/immunology/immunotherapy/infertility/recurrent pregnancy loss
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Introduction |
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Autoimmune abnormalities (antiphospholipid, antithyroid, antinuclear and antisperm antibodies) have been investigated for possible associations with reproductive failure. The `reproductive autoimmune failure syndrome' was originally described (Gleicher et al., 1989) in women with endometriosis, infertility and increased autoantibodies. These studies and others led many authors to recommend immunological testing for specific autoantibodies to screen women with infertility. However, after a decade of research, the predictive value of these tests is still questionable and under debate. In the absence of conclusive clinical data, many patients have come to expect (or request) multiple immunological tests. Physicians often feel compelled to perform these tests upon patient request for various reasons.
Antiphospholipid antibodies (APA) are acquired antibodies, IgG, IgM and/or IgA against phospholipids which have been associated with a slow progressive thrombosis and infarction in the placenta. The diagnosis of APA syndrome is based on both clinical manifestations and laboratory detection of abnormal antibodies. Several published reports indicate that positive APA are found more frequently in patients undergoing IVF when compared with controls. However, the positive APA do not appear to influence pregnancy outcome in most studies (Gleicher et al., 1994; Birdsall et al., 1996
; Denis et al., 1997
; Kowalik et al., 1997
; Kutteh et al., 1997
; Hornstein et al., 2000
).
Autoantibodies to thyroglobulin and thyroid peroxidase are found in patients with Hashimoto's thyroiditis, Graves' disease, postpartum thyroiditis, and in some normal individuals. A correlation between the presence of thyroid antibodies and first trimester pregnancy loss has been reported, but other causes of miscarriage were not investigated (Stagnaro-Green et al., 1990). Antithyroid antibodies, acting as a marker for autoimmune diseases, might play a role in implantation failure. These antibodies might be responsible for either maternal hormonal imbalance, trophoblast invasion abnormalities or placental thrombosis.
Antisperm antibodies have been reported to be involved in infertility. The prevalence and presumed significance reported depend on the population evaluated, the source of the specimen tested (serum, cervical mucus, semen), as well as the method of testing chosen (Krapez et al., 1998; Hjort, 1999
). Antisperm antibodies have been identified in 1015% of males experiencing infertility and 1520% of women with unexplained infertility.
Alloimmunity refers to an adaptive antigen-specific response against the alloantigens of another individual. In order for a successful pregnancy to occur, it has been proposed that the mother's immune system must either ignore or protect her developing fetus. An active response by the cellular immune system in response to paternal/embryonic antigens has therefore been proposed to promote fertility and to protect against failure. As a result of such theories, several investigators have suggested the need for specialized tests.
Thus, two categories of immunological tests have emerged: those that propose to test for some autoimmune abnormality (antiphospholipid, antithyroid, antinuclear antibody, antisperm antibody) and those that test for some other immune abnormality (natural killer cells, immunophenotypes, antipaternal cytotoxicity, embryotoxic factors). However, immunological testing is not the only source of much confusion: immunological/anticoagulation treatments are the subject of much research and controversy. Proposed treatments include leukocyte immunotherapy, intravenous immunoglobulin (IVIG) or any combination of heparin, aspirin and steroids.
Practice patterns vary from clinic to clinic, state to state and country to country. Since immune testing and treatment for patients with recurrent pregnancy loss (RPL) or patients undergoing assisted reproductive technologies is still controversial, we elected to conduct a survey to investigate the following objectives: (i) to ascertain how practice patterns of immunological testing and treatment in reproductive centres in the USA and Australia vary; (ii) to determine how frequently these studies are recommended; and (iii) to investigate the pattern of treatment approaches in both countries.
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Materials and methods |
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Participants
Surveys were distributed to senior reproductive endocrinologists from the USA attending the Annual Meeting of American Society of Reproductive Medicine. Identical surveys were distributed to senior physicians practising reproductive medicine at the Australian Fertility Society Meeting. All of the physicians at both meetings, who received a survey, responded to the questionnaire. Participants were asked to respond to the survey based on their current practice pattern. Only one senior physician from each programme was allowed to participate in this survey.
Clinical definitions
For the purposes of the survey, `recurrent abortion' was considered as any woman who had three or more miscarriages. A `miscarriage history' included any woman with at least one miscarriage at less than 20 weeks. A patient who was being evaluated prior to her first assisted reproduction cycle was considered an `assisted reproduction patient with a new work-up.' Any patient with a history of at least one failed IVF cycle was included in the group of `assisted reproduction patients with failed IVF'. `General infertility' patients included all patients with at least 1 year of unprotected intercourse without conception (including patients diagnosed with polycystic ovarian disease, hyperprolactinaemia, anovulation and endometriosis). `Unexplained fetal death' included women with a history of at least one pregnancy loss at more than 20 weeks. Patients who presented to the clinic requesting immune testing, regardless of the diagnosis or financial class, were included in the category of `patient request'.
Laboratory criteria
Survey participants were instructed to utilize laboratory criteria adopted by their centre when considering positive or negative results. Each centre may have relied on different laboratory criteria, which may have influenced positive and negative results. However, addressing these differences was not within the scope of this survey. Positive APA included IgG, IgM, and/or IgA antibodies against cardiolipin, phosphatidyl serine, phosphatidyl ethanolamine and others that were ordered by the clinician. Positive lupus anticoagulant and antithyroid antibodies were considered positive based on laboratory tests used by each centre. Antisperm antibodies included any test for antisperm antibodies ordered by the clinician including circulating antibodies in the male and female serum, secretory antibodies in seminal plasma or cervical mucus, and direct antibodies on the sperm of the IgG, IgA or IgM class. Threshold levels for embryotoxic factors, natural killer cells, and leukocyte antibodies were those utilized by each laboratory. As this survey was designed to determine practice patterns, no effort was made to standardize these tests.
Statistics
Surveys were collected and results were manually tabulated to determine the frequency of positive and negative responses. Simple percentages were used to report the frequency. For comparison of responses between the USA and Australia, data were analysed using the two-tailed Fisher's exact test. P 0.05 was considered significant.
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Results |
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Complications reported
Only one of the Australian physicians surveyed reported a complication in a patient with systemic lupus erythematosus who received heparin anticoagulation therapy. She had uterine muscle atrophy (abnormally thin uterine muscle wall), placenta accreta and fetal demise at time of Caesarean section. Also, one of the 112 American centres surveyed reported a mortality with heparin therapy for an IVF patient, one reported hepatitis with IVIG therapy and two reported strokes in patients while on heparin therapy (Table VI).
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Discussion |
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In our survey, all of the Australian participants and most of the American participants would offer immunological evaluation for APA to women with a history of three or more pregnancy losses. This high degree of concurrence seems appropriate based on published studies in the literature (Kutteh et al., 1999a). However, similar attempts to correlate autoantibody status with reproductive outcome during IVF have produced mixed results. It has been suggested that autoimmune antibodies may affect implantation failure in IVF embryo transfer cycles (Birkenfield et al. 1994
; Geva et al., 1995
), whereas other studies have shown no correlation (Gleicher et al., 1994
; Birdsall et al., 1996
; Denis et al., 1997
; Kowalik et al., 1997
; Kutteh et al., 1997
). The risk of implantation failure in patients undergoing IVF has been correlated with the incidence of positive APA in these patients (Coulam et al., 1997
). However, many studies concur that 2025% of all women undergoing IVF have positive APA as compared to controls (5%) (Kutteh et al., 1999a
). In a prospective study of 790 patients undergoing IVF, it was demonstrated that elevated APA levels were not associated with any change in successful pregnancy rates or pregnancy loss rates (Denis et al., 1997
). This finding was confirmed by two independent studies (Elder-Geva et al., 1999
; Chilcott et al., 2000
). A recent meta-analysis concluded that measuring APA in all patients undergoing IVF was not warranted (Hornstein et al., 2000
). Moreover, IVF failure in the presence of APA does not satisfy the criteria for APA syndrome (Wilson, et al., 1999
)
A substantial proportion of the Australian and American participants recommend immune testing in patients who failed IVF. It is interesting to note that immunological testing in the case of one or more failed IVF cycles was not restricted to a few large clinics with a special interest in this area of reproductive medicine, for example, over half of the programmes in the USA initiated immunological testing in women after one failed IVF cycle independent of the programme size. Moreover, it is significant that over two-thirds of physicians in either country would initiate immunological testing on patient request. The American Society for Reproductive Medicine Practice Committee Opinion concluded that `the assessment of antiphospholipid antibodies is not indicated among couples undergoing IVF and therapy is not justified' (American Society for Reproductive Medicine Practice Committee Report, 1999). However, a rebuttal to this (American Society for Reproductive Immunology Antiphospholipid Antibody Committee, 2000
) concluded that the data suggesting the usefulness of APA in the management of IVF patients is still controversial and that intensive immunological research in this field is warranted. A recent report suggested that before reaching any conclusions a number of testing issues need to be addressed, including validity of screening tests, laboratory assay standardizations, threshold separating normal and abnormal values and the consistency in the association between the factor and the outcome in all reported studies (Hill and Scott, 2000
). The prevalence of antithyroid antibodies has been reported as 1520% in normal pregnant women compared with 2025% in women with a history of recurrent miscarriages and 20% in women undergoing IVF. It was reported that only 9% of 108 infertile women had antithyroid antibodies compared to 15% of normal controls (Roussiv et al., 1996
). In a study of 873 women undergoing assisted reproduction who were euthyroid (based on a normal thyroid-stimulating hormone) there were no differences in IVF outcome (pregnancy, miscarriage, biochemical loss or not pregnant) based on antithyroid antibody positivity (Kutteh et al., 1999b
). Moreover, in a prospective study, it was concluded that the future risk of pregnancy loss in euthyroid women with RPL was not influenced by their antithyroid antibody status (Rushworth et al., 2000
)
In the past, corticosteroids were used in an effort to decrease the concentration of antisperm antibodies. However, the beneficial role of steroids in the treatment of antisperm antibodies has been challenged and the efficacy of treatment is uncertain (Bals-Pratsch et al., 1992; Lahteenmaki et al., 1995
). Other treatments such as intrauterine insemination, IVF and intracytoplasmic sperm injection have been advocated by some for antisperm antibodies. Overall, the role that antisperm antibodies play in reproductive performance remains unclear (Kutteh, 1999
).
Other immune testing includes assays for embryotoxic factors, leukocyte antibodies, and immunophenotypes (including natural killer cells). These assays were among the immunological tests originally offered by some investigators to patients with RPL, and their use has recently been offered to patients with infertility or failed IVF. However, the literature is not clear concerning their value in either group of patients. Coulam et al. reported significantly lower delivery rates in infertile patients without RPL if natural killer cell concentrations were >12% (Coulam et al., 1995). Another group assessed the predictive value of `reproductive immunophenotypes' in 1000 patients undergoing IVF. No relationship was found between the immunophenotype results and pregnancy outcomes including CD56+ natural killer cells, CD4+ or CD8+ T cells or gamma/delta cells (Hill and Scott, 2000
). Until further studies are appropriately performed, routine testing of peripheral blood immunophenotypes for RPL, infertility, or implantation failure should be considered as experimental.
Leukocyte immunotherapy was introduced initially in the treatment of patients with RPL in order to present an allogenic stimulus to the maternal immune system. It was proposed that this stimulation would induce blocking antibodies which would protect fetal trophoblasts and thus prevent pregnancy wastage. Allogenic leukocyte immunotherapy marginally increased the successful delivery rate in 430 couples with recurrent miscarriages in controlled randomized trials (Recurrent Miscarriage Immunotherapy Trialists Group, 1994). In the largest double-blinded, randomized clinical trial of leukocyte immunotherapy in women with RPL, 131 pregnant patients were studied (Ober et al., 1999
). Successful delivery occurred in 36% of the treatment group and 48% of the control group. It was concluded that paternal leukocyte immunization did not improve successful pregnancy outcome in women with unexplained RPL.
IVIG was introduced in the treatment of patients with RPL with negative APA or patients with RPL with positive APA who failed aspirin and heparin treatment. The role of IVIG immunotherapy preceding IVF for patients with repeated failure of embryo transfer was not found to be an effective tool in prevention of repeated implantation failures (Balasch, et al., 1996). Aspirin therapy alone has been reported to improve ovarian responsiveness, uterine blood flow, ovarian blood flow, implantation and pregnancy rates in patients undergoing IVF, irrespective of their immunological testing status (Rubinstein et al., 1999
). Of the surveyed clinicians, 6178% utilized aspirin for treatment of women with reproductive failure, even though placebo-controlled trials of aspirin treatment in patients with unexplained recurrent early miscarriage (<13 weeks gestation) failed to demonstrate a significant improvement in the live birth rate of women who took aspirin (251/367, 68.4%) compared with those that did not (278/438, 63.5%) (Rai et al., 2000
). Other studies have not demonstrated a benefit of aspirin, heparin, or steroids with increased implantation or pregnancy rates (Mottla et al., 1996
; Kutteh et al., 1997
). Sher et al. (1998) claimed an increase in pregnancy rates in patients with recurrent IVF failure who were treated with aspirin, heparin and IVIG only if these patients had positive APA. However, both of the studies reported are non-randomized case series (Sher et al., 1994
, 1998
) and in others the number of patients recruited was relatively small (Geva et al., 2000
). The role of immunotherapy and anticoagulation for patients undergoing IVF who are seropositive for APA seems to be limited.
These data suggest that immunological factors associated with infertility are still under investigation and more time is needed to establish evidence-based testing and treatment. Ten to thirty per cent of the Australian and American clinics advertise immunological testing and treatment of infertile couples. Recent studies and meta-analysis have reported the limited benefits of such testing and treatment. We plan to repeat this survey in 2 years to determine what impact these recent reports may have on practice patterns as far as immunological work-up and treatment of reproductive failure is concerned.
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Acknowledgements |
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Notes |
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References |
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Submitted on March 29, 2001; accepted on June 26, 2001.