Systemic lupus erythematosus and secondary antiphospholipid syndrome in native sisters with reduced fertility.

OBJECTIVE: Systemic lupus erythematosus (SLE) and secondary anti-phospholipid syndrome (APS II) can cause increased morbidity and mortality of the fetus. We followed the course of fertility of two sisters with these two basic diseases. METHODS: In the Center for Immunology of Reproduction, we confi rmed both sisters had increased levels of some selected anti-phospholipid antibodies (against phosphatidylserine, phosphatidylethanolamine, phosphatidylinositol, DL-glycerole, anexin V, phoshatidic acid, cardiolipin, beta2-glycoprotein I), anti-nuclear, and anti-DNA antibodies. During the established immunosuppressive and hormonal therapy at the time of SLE remission, both sisters became pregnant. There was a physiological progression of pregnancy until the 19th week. RESULTS: At the 20th week of pregnancy, the older sister miscarried again, and the younger sister developed hypertension in the 31st week of pregnancy which was terminated by caesarean section. CONCLUSION: In our causal evaluation, we addressed two serious autoimmune diseases (SLE, APS II) in two sisters and described their course of pregnancy. However, only one of them became a happy mother.

H3K4me2 accompanies chromatin immaturity in human spermatozoa: an epigenetic marker for sperm quality assessment.

Chromatin remodeling, including histone post-translational modifications, during spermatogenesis can affect sperm quality and fertility, and epigenetic marks may therefore be useful for clinical evaluations of sperm. Together with histone hyperacetylation, the dimethylation of histone H3 on lysine K4 (H3K4me2) is also required during protamination. Accordingly, we evaluated the utilization of this epigenetic mark for the identification of sperm with decrease quality and immature chromatin. In this study, 99 semen samples, including 22 normozoospermic (N), 63 asthenozoospermic (A), and 14 oligoasthenozoospermic (OA) samples, were comprehensively analyzed with respect to H3K4me2 levels, DNA damage (DNA fragmentation index, DFI), and sperm immaturity (high DNA stainability, %HDS), as determined by a sperm chromatin structure assay using flow cytometry. We detected a significant relationship between H3K4me2 and %HDS (r = 0.47; p < 0.001). Furthermore, we observed negative correlations between H3K4me2 and sperm concentration, motility, and mitochondrial activity (p < 0.05). The increase in immaturity as semen quality decreased (N > A > OA) indicates the importance of chromatin immaturity and histone code deviations in sperm evaluations. Using various approaches, our study elucidated H3K4me2 as a molecular marker of sperm quality with potential use in reproductive medicine.Abbreviations: A: asthenozoospermic; AO: acridine orange; ART: assisted reproductive therapy; BWW: Biggers-Whitten Whittingham; DAPI: 4',6' -diamidino-2-phenylindole; DFI: DNA fragmentation index; H3K4me2: dimethylation of lysine K4 on histones H3; HDS: high DNA stainability; HRP: horseradish peroxidase; MACS: magnetic-activated cell sorting; N: normospermic; NGS: normal goat serum; OA: oligoasthenozoospermic; PTM: post-translational modification; SCSA: sperm chromatin structure assay; SUTI: sperm ubiquitin tag assay; TBS-T: TBS with 0.5% Tween-20.

Follicular fluid levels of anti-Müllerian hormone, insulin-like growth factor 1 and leptin in women with fertility disorders.

Anti-Müllerian hormone (AMH), insulin-like growth factor 1 (IGF1) and leptin are produced in the granulosa cells of follicles and play an important role in the growth and maturation of follicles. The aim of our study was to monitor AMH, IGF1 and leptin levels in a group of healthy women and compare them to a group of women with fertility disorders. The second aim was the evaluation of biomarker levels in relation to the identified cause of infertility. Totally, 146 females were enrolled into our study. Seventy-two healthy controls and seventy-four females with fertility disorders were divided into four subgroups: anovulation, endometriosis, fallopian tube damage, unknown reason. IGF1 was the only biomarker with significantly lower levels throughout the entire group with fertility disorders. We did not identify any statistically significant differences for AMH and leptin. Regarding subgroups, significant differences were only observed in the group of anovulatory women. AMH and leptin showed higher levels while IGF1 showed lower levels. In conclusion, levels of AMH, IGF1 and leptin found in follicular fluid are sensitive markers for anovulatory fertility disorders. AMH, IGF1 and leptin levels in follicular fluid have no relation to the fertility disorders caused by endometriosis, fallopian tube damage or disorders with unknown etiology. ABBREVIATIONS: AMH: anti-Müllerian hormone; IGF1: insulin-like growth factor 1; PCOS: polycystic ovary syndrome.

Anti-Müllerian hormone in serum and seminal plasma in comparison with other male fertility parameters.

Anti-Müllerian hormone (AMH) is a factor most associated with female fertility and especially with the ovarian reserve. AMH is also used as a parameter of fertility in men as it arises from the epithelium of the seminiferous tubules that contain Sertoli cells which produce the AMH. To investigate the relationship between AMH production and sperm related parameters we compared the AMH levels in serum and seminal plasma between a group of healthy males (n=65) and male patients (n=68) of infertile couples with semen pathology. We assessed the following fertility parameters: sperm count (SC), presence of intra-acrosomal enzymes (IAE), and antispermatozoal antibodies (ASA). Infertile men were divided into four subgroups according to: SC less than 15 million, SC less than 15 million and lack of IAE, SC less than 15 million and presence of ASA, presence of all three pathological parameters. The mean AMH serum level in the healthy group was 6.95 ng/ml and no significant difference was observed in serum AMH levels. The mean AMH seminal plasma level in the healthy group was 14.21 ng/ml. We observed a statistically significant decrease in the group with a SC with less than 15 million (3.29 ng/ml, p=0.0001) sperm, in the group with SC less than 15 million sperm and lack of IAE (3.95 ng/ml, p=0.0046), and in the group with all three pathological parameters (2.65 ng/ml, p=<0.0001). No significant difference was observed in the group with SC less than 15 million sperm and ASA positivity (11.41 ng/ml, p=0.3171). In conclusion AMH serum levels do not correlate with any of the observed parameters. AMH levels in seminal plasma positively correlate with the pathological SC and with SC pathology and IAE together.

Effect of long-term using of hormonal contraception on anti-Müllerian hormone secretion.

Anti-Müllerian hormone (AMH) is an important factor associated with female fertility and the ovarian reserve. There are several past studies available concerning the influence of hormonal contraception (HC) on serum AMH levels. Recent studies have reported that AMH levels in women using HC can be about 30% lower compared to those not using HC. However, earlier studies showed no reduction in AMH levels in HC users. We decided to evaluate the effects of long-term HC use (mean duration of HC use: 11.4 years) on AMH levels in women. To exclude potential shorter and reversible decreasing effects of HC on fertility function, we decided to include women in the study who had stopped using HC 1 year before the AMH sample collection. We examined 105 women who used HC and 44 women who had never used HC. The median concentration of AMH in the group of long-term users of HC was 2.89 and 3.37 ng/ml in the group of women who had never used HC. We found no statistically significant difference (p = 0.3261). In conclusion, we observed no negative impact of HC on the AMH serum levels. AMH can be used as an ovarian reserve marker for these women.

The role of antiphospholipid antibodies (aPls) in infertile women: the long-lasting experience.

Antiphospholipid antibodies (aPls) are generally characterized as heterogeneous and non-specific autoantibodies directed against various phospholipids such as cardiolipin, ph-serine, ph-inositol, ph-acid, ph-glycerol, ph-sphyngomyelin, ph-choline, annexins, and co-factor ß2-glycoprotein I. aPls occur not only during autoimmune diseases but also during infectious diseases, essential hypertension, neurological complication, metabolic diseases, some drug abuse, and transplant loss. aPls are very often found in connection with reproductive failure such as repeated pregnancy loss and/or missed abortion, intrauterine fetal death, in preeclampsia, and repeated delivery of hypothrophic fetus. The presence of aPls, thrombosis, and fertility failure create primary or secondary antiphospholipid syndrome. This article explains some aspects and clinical and laboratory significance of the aPls in female infertility.

Quantification of circulating fetal DNA as a tool for potential monitoring of pregnant patients with antiphospholipid antibodies.

Apoptosis of tissues of fetal origin is thought to be one of the main sources of cell-free fetal DNA (cffDNA) in maternal circulation, impaired apoptosis is also involved in the mechanisms contributing to recurrent spontaneous miscarriages (RSM) associated with antiphospholipid syndrome (APS). The APS increases the risk for preeclampsia nine times. In preeclampsia, the elevated levels of cffDNA were described by different authors. To our knowledge, cffDNA in pregnant patients with APS was never studied. In our pilot study, we focused on the levels of cffDNA in four pregnant patients with treated primary APS and compared them with values obtained in twenty-one healthy subjects of comparable gestation age (the third trimester of pregnancy). We supposed that the increase of cffDNA concentration in our treated patients would signalize the elevated apoptosis of fetal tissues as in other pathological changes of placentation. The aim of our pilot study was to determine cffDNA concentrations in patients with treated APS and to compare them with values detected in healthy pregnant women of comparable gestation age in order to discover potential non-physiological elevations in patients. The elevated values of cffDNA were not observed in our patients (p value = 0.4363, Mann-Whitney test). All patients delivered healthy children. The measurement of concentrations of cffDNA seems to be a promising tool for monitoring of therapy effectiveness in pregnant women with APS but evaluation of randomized controlled trials would be necessary to determine the specificity and the sensitivity of this test.

Some immunological properties of female saliva and its effect on sperm motility.

BACKGROUND: In this study, we investigated pH, levels of IgA, IgG, IgM, lysozyme and spermagglutinating antibodies in human saliva of healthy women, with or without hormonal contraception (HC) and their effect on sperm motility. METHODS AND RESULTS: Saliva was collected immediately after waking up from 59 healthy randomly selected women. We measured pH in sera and in saliva as well as immunoglobulin G, A and M levels in saliva by radial immunodiffusion. Sperm - saliva capillary penetration test in native saliva served for examination of sperm motility, indirect-MAR test for detection of sperm antibodies in sera, and in saliva, both observed by inverted microscope. The average pH values in native saliva according to the menstrual cycles were: from 2-5 days 6.896, from 6-17 days 7.027, and from 18 and more days 7.17. Rapid decrease of sperm motility was registered in acidic saliva in comparison with alkaline. The average concentration of IgA, IgG, IgM and lysozyme slightly differed in women with or without hormonal contraception. Moderate decreasing of sperm motility was found in saliva with higher levels of IgA. No sperm agglutinating antibodies in saliva and in serum were detected in all subjects. CONCLUSIONS: The pH of saliva is influenced by several causes (hormonal, immunological, microbiological factors, by meal and drinks, smoking, etc.). We demonstrated that sperm motility is lower in acidic saliva. pH is markedly changed during various days of menstrual cycles. We proved individual high levels of saliva IgA. Human saliva used as coital lubricant decreases sperm motility, but does not replace a local form of contraception.

Hyperstimulation syndrome: the levels of inhibin A and B in sera and follicular fluids.

Ovarial hyperstimulation syndrome (OHSS) represents a serious problem encountered during in vitro fertilization (IVF). We examined 10 patients with OHSS and 50 women also hormonally stimulated in the process of IVF who had no complications. In all women, we evaluated the number of obtained oocytes and the level of inhibins A and B in sera and follicular fluid collected at the time of ovarial puncture, the day embryo transfer and on the day of positivity for hCG. The level of inhibin B in both fluids was significantly higher (t = 0.0403) in women with high quality of oocytes. The higher level of inhibin A was detected in patients with OHSS at the time of oocyte collection and on the day of embryo transfer. Inhibin B was elevated only at the time of oocyte collection. The levels of inhibin A and B were identical in follicular fluids collected from both ovaries. We observed no statistically significant differences between the levels of inhibin A and B in follicular fluids of women in the absence of OHSS. Evaluation of serum levels of inhibin A and B at the time of oocyte collection may contribute to the prognosis and prevention of OHSS.

Recurrent pregnancy loss, plasminogen activator inhibitor-1 (-675) 4G/5G polymorphism and antiphospholipid antibodies in Czech women.

PROBLEM: This study compares the frequencies of plasminogen activator inhibitor-1 (-675) 4G/5G polymorphism and its relationship with eight antiphospholipid antibodies (aPLs) in serum of 157 patients with repeated pregnancy loss (RPL). METHOD OF STUDY: PAI-1 (-675) 4G/5G polymorphism was determined using standard PCR-RFLP method. Enzyme-linked immunosorbent assay was used for the detection of aPLs against ph-serine, ph-ethanolamine, ph-inositol, ph-DL-glycerol, phosphatidic acid, annexin V, cardiolipin, and beta2-GPI. Allelic frequency and distribution of genotypes were calculated. The prevalence of the risk conferring 4G allele and 4G/4G homozygous genotype in patients and controls was compared, and the correlation between aPLs positivity and PAI-1 4G/4G genotype was tested by chi-square test. RESULTS: Statistically highly significant correlation between RPL and PAI-1 (-675) 4G/4G genotype was found. No correlation between PAI-1 (-675) 4G/5G polymorphism and the presence of antiphospholipid antibodies in RPL patients was observed. CONCLUSIONS: PAI-1 (-675) 4G/4G homozygous genotype increases the risk of RPL independently from the aPLs positivity.

Screening tests of reproductive immunology in systemic lupus erythematosus.

Female patients in reproductive age with systemic lupus erythematosus and fertility complications together are observed by rheumatologists, gynecologists, and reproductive immunologists. The paper notes the presence of autoantibodies to zona pellucida, to phospholipids (phosphatidyl serine, phosphatidyl ethanolamine, phosphatidyl inositol, phosphatidyl glycerol, phosphatidic acid, annexin V, beta-2 glycoprotein I, and cardiolipin) and of isoantibodies to sperm cells. Isoantibodies to sperm cells are not significantly predominant, but autoimmunity is well expressed in IgG positivity against phosphatidyl inositol, phosphatidyl ethanolamine, phosphatidyl serine, cardiolipin, and beta-2 glycoprotein I, as well as antizona pellucida antibodies in IgG isotype. According to the levels of autoantibodies we have to choose preventive treatment to protect mother and her foetus.

Sperm cells induce distinct cytokine response in peripheral mononuclear cells from infertile women with serum anti-sperm antibodies.

BACKGROUND AND AIMS: Anti-sperm antibodies in can markedly reduce the likelihood of natural conception. The etiology of this anti-sperm immunity in human females is unknown. We compared the cytokine response of peripheral blood mononuclear cells (PBMCs) from infertile patients with or without anti-sperm antibodies (ASA) and fertile women. METHODOLOGY/PRINCIPAL FINDINGS: We cultivated the PBMCs together with sperm antigens (whole cells or cell lysate), and screened the supernatants for 40 cytokines by antibody array. When stimulated with whole sperm cells, the PBMCs from patients with ASA produce less IL-3, IL-11, IL-13, ICAM-1, GCSF and more IL-2, IL-4 and IL-12p70 as compared to healthy women. PBMCs from patients with ASA produce typically less IL-13, IL-7, IL-17 and MIG, and more MIP-1ß and IL-8, as compared to PBMCs from patients without ASA. In response to sperm cell lysate, PBMCs from infertile women without ASA respond initially by increase in production of growth factors (GCSF, GM-CSF and PDGF-BB) followed by increase in chemokines (e.g. IL-8, MCP-1 and MIP-1ß). CONCLUSIONS: Cellular immune responses to sperm antigens, measured by production of cytokines, differ among infertile women with ASA, infertile women without ASA and healthy women. This difference could play an important role in the initial steps of the infertility pathogenesis.

Urgent termination of pregnancy in pre-eclampsia and panel of antiphospholipid antibodies.

PROBLEM: The present work was undertaken to investigate the occurence of autoantibodies to eight various phospholipids in time of urgent termination of the pregnancy (sectio caesarea) in patients in reproductive age with severe preeclamptic symptoms. METHOD OF STUDY: Autoantibodies against annexin V, ph-serine, ph-ethanolamine, ph-inositol, ph-DL-glycerol, cardiolipin, beta2-glycoprotein I (beta2-GPI), and phosphatidic acid were studied by ELISA methods. RESULTS: Increased levels of IgA-beta2-glycoprotein I, IgG-beta2-glycoprotein I, IgG- anti-ph-serine, and IgG-anticardiolipin were found in sera of preeclamptic women in the time of urgent sectio caesarea when compared to the control group with physiological pregnancy. CONCLUSION: Supposed increase in various antiphospholipid antibodies (aPLs) levels due to the stress during the short time of admission and a need for a quick medical decision to terminate the pregnancy was not unambiguously proven, but our results are evidently influenced by the current urgent life-saving treatment.

TH1-TH2 response and the atopy risk in patients with reproduction failure.

PROBLEM: Enhanced TH2 activity is characteristic for atopic diseases and is observed also in physiological pregnancy. The immune causes of repeated pregnancy losses and/or repeated in vitro fertilization failure may be associated with TH2 hypoactivity. The association with frequency of atopic diseases is unclear. METHOD OF STUDY: Intracellular production of IL-4 and IFN-gamma by peripheral CD4+ T lymphocytes was studied, as well as serum levels of total and allergen specific IgE. Simultaneously skin prick tests with inhalant allergens were performed, and clinical features of atopy were registered by means of a questionnaire. RESULTS: Lower intracellular production of IL-4 by peripheral CD4+ T cells and lower frequency of elevated total and allergen specific IgE were found in women with reproduction failure compared to controls, as well as lower frequency of some symptoms possibly associated with atopy. CONCLUSION: Our study showed the presence of TH2 hypoactivity in women with reproduction failure, which may be associated with lower occurrence of atopic diseases.

Sperm antibodies, intra-acrosomal sperm proteins, and cytokines in semen in men from infertile couples.

PROBLEM: The aim of this study was to investigate seminal sperm-agglutinating antibodies, intra-acrosomal proteins, sperm head abnormalities, and cytokines (IL-1beta, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70 TNF-alpha, and IFN-gamma) in men from infertile couples. METHOD OF STUDY: The direct mixed anti-immunoglobulin reaction test for IgG, IgA, and IgE in semen, and immunocytochemical method using monoclonal antibodies and indirect immunofluorescence for the examination of intra-acrosomal proteins in the spermatozoa were used. Cytokines in seminal plasma were determined by multiplex immunoanalytic xMAP (LUMINEX) technology. RESULTS: Sperm-agglutinating antibodies, IgG and IgA, in seminal plasma were found to be more in asthenospermatic and oligoasthenospermatic men than in normospermatic men. Sperm head pathology and very low amounts of acrosomal proteins were frequently detected in pathologic semen samples. Cytokine levels defined as 'high' (based on the 75 percentile for each cytokine in all groups) were obtained especially for IL-8, IL-5, IL-6, and IL-10. The high cellularity in semen was correlated with higher IL-5. CONCLUSION: Immunologic cause of male infertility is a very important risk factor in the pathogenesis of sperm cells. Sperm autoantibodies and the presence of intra-acrosomal factors must be studied together, cytokines according to accessory cellularity in the semen.

Antibodies against laminin-1 and sperm, intraacrosomal proteins in semen from infertile couples.

Seminal sperm-agglutinating antibodies along with IgG antibodies against laminin-1 and intraacrosomal sperm proteins were examined in seventy-one men from infertile couples. The direct mixed antiimmunoglobulin reaction test for IgG, IgA, and the commercial ELISA method for detecting IgG antibodies against laminin-1 in seminal plasma were used. Intraacrosomal proteins in the sperm heads were detected by immunofluorescence using monoclonal antibodies. Cellular elements other than spermatozoa, collectively referred to as "round cells" were also examined. In association with a group of oligoasthenospermatic men, positive levels (44%) of antibodies against laminin-1 of the IgG isotype in seminal plasma were found in conjunction with increased cellularity in semen. Interestingly, the elevated levels of anti-laminin-l IgG and sperm agglutinating positivity were not correlated. The use of antibodies against sperm antigens targeted to adhesive molecules such as laminin-1 contributes to diagnosing reproductive failure. Detection of intraacrosomal proteins very often correlates to the state of semen pathology and inflammation.

Cell-free fetal DNA in maternal plasma during physiological single male pregnancies: methodology issues and kinetics.

OBJECTIVE: To analyze methodological influences and characterize the concentrations of cell-free fetal DNA (cffDNA) circulating in maternal plasma at different gestational ages in physiological pregnancies. METHODS: We investigated 238 independent samples from single male-bearing pregnancies of different gestation age. In the other 50 pregnancies, the samples were collected three times during pregnancy (at all trimesters) to evaluate the kinetics of cffDNA. The manual and automated DNA extraction methods (Roche) were compared. cffDNA was amplified using real-time PCR method and Y-specific sequences SRY and DYS14. Total cell-free DNA circulating in maternal plasma was determined by the use of the GADPH sequence. RESULTS: The elevation in the concentration of cffDNA during pregnancy with the highest value in the third trimester was observed independently on the DNA extraction method and on the Y-specific amplified sequence. The same is documented for the percentage of fetal DNA in total cell-free DNA in maternal plasma. It increases also in successive trimesters (8.3, 10.7 and 23.2%). CONCLUSIONS: We discuss methodological problems and describe statistical parameters of cffDNA concentrations in maternal plasma during pregnancy as the basic information for comparison with pregnancies having a pathological outcome.

Recurrent pregnancy loss and frequency of eight antiphospholipid antibodies and genetic thrombophilic factors in Czech women.

PROBLEM: The aim of this study was to investigate frequencies of eight antiphospholipid antibodies (aPLs) in serum, four genetic thrombophilic factors and their mutual relation in 206 patients with repeated pregnancy loss (RPL). METHOD OF STUDY: Enzyme-linked immunosorbent assay was used for detection of aPLs against ph-serine, ph-ethanolamine, ph-inositol, DL-glycerol, phosphatidic acid, anti-annexin V, cardiolipin, and beta2-GPI. FV 1691G>A (Leiden mutation), FII 20210G>A mutation, MTHFR 677C>T and MTHFR 1298A>C variant genotypes were determined using a melting curve analysis of the PCR amplification product detected by the fluorescence resonance energy transfer. Genotypic distribution and allelic frequencies were calculated. Correlation between aPLs and thrombophilic factors was tested by chi-square and Fisher exact test. RESULTS: Our results show significantly increased prevalence of aPLs against ph-inositol (17-19.6% dependent on number of spontaneous miscarriages) and against ph-serine (18-25%). aPLs in IgG prevail. In 96% of the studied group, at least one risk factor was found (either aPLs positivity or thrombophilic factor). Both aPLs and thrombophilic factors were present in 43%. In the group of women with three or more RPLs, strong positive correlation of aPLs positivity and thrombophilic risk factors was observed. CONCLUSION: Antiphospholipide antibodies and genetic thrombophilic factors are important risk factors in the pathogenesis of RPL. Both autoantibodies against various kinds of phospholipides and genetic thrombophilic factors must be studied together in diagnosis of RPL for appropriate treatment.

Leukemia inhibitory factor gene mutations in the population of infertile women are not restricted to nulligravid patients.

OBJECTIVE: Leukemia inhibitory factor (LIF) is one of the key cytokines in the embryo implantation regulation. We investigated the prevalence of the LIF gene mutations in the population of infertile women that consisted of nulligravid and secondary infertile patients. STUDY DESIGN: We designed a LIF gene mutation screening method that is based on the Temperature Gradient Gel Electrophoresis (TGGE). The population to screen consisted of 176 infertile women including group A of 147 nulligravid women and group B of 29 women with secondary infertility that had a history of either miscarriage or an ectopic pregnancy but no live births. The control population was comprised of 75 healthy fertile subjects. The groups of fertile controls and infertile patients were compared for statistically significant differences using the t-test. RESULTS: Six potentially functional LIF gene mutations, the G to A transitions at the position 3400 leading to the valin to methionin exchange at codon 64 (V64M) in the AB loop region of the LIF protein, were detected. All of the six positive women were infertile. Four of them were nulligravid and two of them had history of spontaneous conception followed by early miscarriage. No positive TGGE samples were identified in the control group, which means that the frequency of functionally relevant mutations of the LIF gene in infertile women is significantly enhanced in comparison with controls (P<0.05, t-test). CONCLUSION: The results suggest that the LIF gene mutations affect fertility. Even though they occur infrequently, their impact on molecular events during early phases of pregnancy should be further established.

Anti-phospholipid antibodies against phosphatidylinositol, and phosphatidylserine are more significant in reproductive failure than antibodies against cardiolipin only.

PROBLEM: The humoral immune response to phospholipids was investigated in women with reproductive failure [1073 women after one in vitro fertilization (IVF), 853 women after two and more IVF, 627 women after three and more repeated spontaneous miscarriages or missed abortions, 412 women after diagnostic laparoscopy] and compared with that of 391 healthy fertile women. METHOD OF STUDY: Sera from all women in the study were tested by enzyme-linked immunosorbent assay (ELISA) for the detection of IgG, IgA, and IgM isotypes of antibodies against seven phospholipids (aPLs), i.e. cardiolipin, L-phosphatidylserine, phosphatidylglycerol, phosphatidylinositol, phosphatidylethanolamine, phosphatidylacid as well as against beta2-glycoprotein I. RESULTS: Patients after two and more IVF (48 and 50%, respectively), patients with three and more repeated spontaneous miscarriages (50 and 46.5%, respectively) are associated with significantly higher serum levels of aPLs against inositol, and L-serine (P < 0.01). A quarter of them were positive for three and more aPLs. CONCLUSION: It seems that determination of aPLs only against cardiolipin in reproductive failure is not sufficient for obstetric-gynecology diagnosis as the primary anti-phospholipid syndrome. Our long-ranging study (from 1998 to 2003) shows the necessity to test for a complete aPLs profile. Sera from patients after two and more IVF procedures, and sera from women after three and more repeated abortions are immunologically more active than sera from women after one unsuccessful IVF and sera from women after diagnostic laparoscopy. This important result is very significant for future treatment.