MicroRNAs isolated from peripheral blood in the first trimester predict spontaneous preterm birth.

OBJECTIVE: To predict spontaneous preterm birth among pregnant women in an African American population using first trimester peripheral blood maternal immune cell microRNA. STUDY DESIGN: This was a retrospective nested case-control study in pregnant patients enrolled between March 2006 and October 2016. For initial study inclusion, samples were selected that met the following criteria: 1) singleton pregnancy; 2) maternal body mass index (BMI) <30 kg/m2; 3) blood sample drawn between 6 weeks to 12 weeks 6 days gestation; 4) live born neonate with no detectable birth defects. Using these entry criteria, 486 samples were selected for study inclusion. After sample quality was confirmed, 139 term deliveries (38-42 weeks) and 18 spontaneous preterm deliveries (<35 weeks) were selected for analysis. Samples were divided into training and validation sets. Real time reverse transcription quantitative polymerase chain reaction (rt-qPCR) was performed on each sample for 45 microRNAs. MicroRNA Risk Scores were calculated on the training set and area-under-the-curve receiver-operating-characteristic (AUC-ROC) curves were derived from the validation set. RESULTS: The AUC-ROC for the validation set delivering preterm was 0.80 (95% CI: 0.69 to 0.88; p = 0.0001), sensitivity 0.89, specificity of 0.71 and a mean gestational age of 10.0 ±1.8 weeks (range: 6.6-12.9 weeks). When the validation population was divided by gestational age at the time of venipuncture into early first trimester (mean 8.4 ±1.0 weeks; range 6.6-9.7 weeks) and late first trimester (mean 11.5±0.8 weeks; range 10.0-12.9 weeks), the AUC-ROC scores for early and late first trimester were 0.79 (95% CI: 0.63 to 0.91) and 0.81 (95% CI: 0.66 to 0.92), respectively. CONCLUSION: Quantification of first trimester peripheral blood MicroRNA identifies risk of spontaneous preterm birth in samples obtained early and late first trimester of pregnancy in an African American population.

Peripheral blood cell microRNA quantification during the first trimester predicts preeclampsia: Proof of concept.

OBJECTIVE: We investigated the capacity of microRNAs isolated from peripheral blood buffy coat collected late during the first trimester to predict preeclampsia. STUDY DESIGN: The cohort study comprised 48 pregnant women with the following pregnancy outcomes: 8 preeclampsia and 40 with normal delivery outcomes. Quantitative rtPCR was performed on a panel of 30 microRNAs from buffy coat samples drawn at a mean of 12.7±0.5 weeks gestation. MicroRNA Risk Scores were calculated and AUC-ROC calculations derived. RESULTS: The AUC-ROC for preeclampsia risk was 0.91 (p<0.0001). When women with normal delivery and high-risk background (those with SLE/APS, chronic hypertension and/or Type 2 Diabetes) were compared to women who developed preeclampsia but with a normal risk background (without these mentioned risk factors), preeclampsia was still predicted with an AUC-ROC of 0.92 (p<0.0001). CONCLUSION: MicroRNA quantification of peripheral immune cell microRNA provides sensitive and specific prediction of preeclampsia in the first trimester of pregnant women. With this study, we extend the range during which disorders of the placental bed may be predicted from early to the end of the first trimester. This study confirms that buffy coat may be used as a sample preparation.

Early first trimester peripheral blood cell microRNA predicts risk of preterm delivery in pregnant women: Proof of concept.

OBJECTIVE: We investigated the capacity of first trimester peripheral blood mononuclear cell (PBMC) microRNA to determine risk of spontaneous preterm birth among pregnant women. STUDY DESIGN: The study included 39 pregnant women with the following delivery outcomes: 25 with a full term delivery (38-42 weeks gestation) 14 with spontaneous preterm birth (<38 weeks gestation). Of the 14 women experiencing spontaneous preterm birth, 7 delivered at 34-<38 weeks gestation (late preterm) and 7 delivered at <34 weeks gestation (early preterm). Samples were collected at a mean of 7.9±3.0 weeks gestation. Quantitative rtPCR was performed on 30 selected microRNAs. MicroRNA Risk Scores were calculated and Area-Under the Curve-Receiver-Operational-Characteristic (AUC-ROC) curves derived. RESULTS: The AUC-ROC for the group delivering preterm (<38 weeks) was 0.95 (p>0.0001). The AUC-ROC for early preterm group (<34 weeks) was 0.98 (p<0.0001) and the AUC-ROC for the late preterm group (34-<38 weeks) was 0.92 (p<0.0001). CONCLUSION: Quantification of first trimester peripheral blood PBMC MicroRNA may provide sensitive and specific prediction of spontaneous preterm birth in pregnant women. Larger studies are needed for confirmation.

First-trimester maternal cell microRNA is a superior pregnancy marker to immunological testing for predicting adverse pregnancy outcome.

Patients at risk of immune-mediated pregnancy complications have historically relied on the use of peripheral blood immunological assays for diagnosis and pregnancy monitoring. However, these tests often fail to identify many at-risk patients, achieving moderately predictive receiver operating characteristic (ROC) curve AUCs of 0.60-0.70. We previously demonstrated that a microRNA panel comprising 30 microRNAs successfully predicts pregnancy outcome in the first trimester. In our current study we constructed a smaller, more clinically useful seven-microRNA panel from the original panel of 30 microRNAs with equivalent sensitivity and specificity. To select optimal microRNAs for a smaller panel, quantitative RT-PCR on 30 microRNAs was first performed on 48 patients (191 samples) with concurrent immunological testing: TNFα/Il-10 ratio, IFNγ/Il-10, CD56+16+%, NK 50:1 cytotoxicity and T regulatory cells. MicroRNAs were separated into clusters associated with: Th1/Th2 response; T regulatory cell percent; pregnancy risk; treatment response. Seven most differentially expressed microRNAs were selected. The seven microRNA scoring system was then applied to 39 patient samples in the first trimester of pregnancy (19 healthy deliveries, 8 miscarriages, 12 preeclampsia [7 late-onset and 5 early-onset]) and 20 samples in the preconception period (2-10 weeks before conception). Predictive value was assessed. ROC curves for the seven-microRNA panel achieved AUC 0.92 for miscarriage and 0.90 for preeclampsia (blood drawn 34.9±19.2 days post-implantation). For samples measured preconception, ROC curve analysis demonstrated AUC 0.81 for adverse pregnancy outcome. Maternal PBMC microRNA can identify high-risk patients likely to benefit from immunotherapy with improved sensitivity and specificity compared with standard immune assays.

First trimester PBMC microRNA predicts adverse pregnancy outcome.

PROBLEM: Prior to the end of the first trimester, pathogenic mechanisms may commit pregnancies to adverse outcome such as pre-eclampsia and miscarriage. A long-term search for biomarkers predicting these adverse outcomes has not identified any that reliably succeed prior to the beginning of the second trimester. MicroRNAs, with their important role as regulators of signaling and metabolic pathways within living cells, may offer a new approach. METHODS: Optimal maternal PBMC microRNA markers were investigated using a series of sequential experiments, and 30 microRNAs were selected based on these results. Quantitative RT-PCR was then performed on these 30 microRNAs for 39 patients [19 healthy deliveries, 12 pre-eclampsia (seven late onset and five early onset) and eight miscarriages] during the first trimester of pregnancy. Results were scored, and their predictive values assessed. RESULTS: MicroRNA quantification in the early first trimester (mean 34.9 ± 19.2 days post-implantation) predicted miscarriage and late pre-eclampsia with a P value of P < 0.0001 and achieved an AUC of 0.90 for miscarriage and 0.90 for late pre-eclampsia. CONCLUSION: MicroRNA quantification of maternal blood cells offers the clinician a single test result that is simple to interpret and available much earlier in pregnancy than previously obtainable. In addition, it is the only early pregnancy marker, to date, that can successfully predict late pre-eclampsia. Although the studies that we report are preliminary, we hope that future research will build upon our discoveries and enhance the power of maternal cell microRNA to predict adverse pregnancy outcome in the clinic.

The multiple faces of the decidual natural killer cell.

The decidual NK (dNK) cell is called on to support placental growth by providing an array of growth factors that directly transform the spiral artery and direct trophoblast invasion. Successful transformation is dependent upon adequate stimulation paradoxically stimulating the cell for placental support rather than cytotoxicity. With the identification of its supportive role, the presence of an intact cytotoxic mechanism has been confusing. Investigators have found that the cell remains fully capable of cytotoxic responses particularly in response to pathogen-specific signals. We postulate a dual threshold model where moderate stimulation results in release of stimulatory factors supporting placentation while intense stimulation, particularly triggered through pathogen-specific receptors, restores the cell to its protective, cytotoxic, role. Individual dNK cells mature attaining the capacity to respond to the delivery of cognate signals. The process, known as 'licensing' tunes responsiveness to the degree to which stochastically selected inhibitory receptors block cytotoxic response to self. A changing licensing milieu within the decidua may result in altered and unsuitable receptor expression. We postulate that a heterogeneous population of dNK cells where cells inappropriately licensed for the milieu contributes to pathology.

Die-off ratio correlates with increased TNF-α:IL-10 ratio and decreased IVF success rates correctable with humira.

BACKGROUND: Human embryos develop at varying rates in culture, with only a fraction of the eggs retrieved developing to 'transfer quality' embryos. We investigated whether the ratios between the number of eggs retrieved or the number of pro-nucleate embryos formed and the number of Day 3 embryos with ≥5 cells [oocyte 'die-off ratios' (DOR)] were correlated with the chance of IVF success, independent of other factors such as embryo grade score and patient's age. We also investigated what factors may be correlated with this ratio. METHODS: 608 IVF fresh cycles in subfertile women were retrospectively evaluated. For each cycle, an oocyte DOR number was calculated as follows: Number of eggs retrieved divided by the number of Day 3 embryos with ≥5 cells. This number was correlated with the subsequent success rates for the index cycles. A 'post-fertilization' or 'embryo' die-off ratio (EDOR; the number of pro-nucleate embryos/the number of day 3 embryos ≥5 cells) was also calculated. RESULTS: The oocyte DOR showed a reverse linear correlation with IVF live birth rate. Live birth rate = (-5.75; DOR) +71.6 (with DOR > 1; P ≤ 0.005; R = -0.87). In addition, the oocyte DOR continued to show an inverse correlation with success rates even when embryo quality and patient's age were held constant. The post-fertilization or EDOR also continued to show a statistically significant negative correlation with live birth rate (R = -0.91; P ≤ 0.01). The preconception TNF-α:IL-10 ratio, an immmunologic marker (drawn 3.3 ± 2.6 months preconception), was more strongly correlated with high oocyte DOR than either age or number of eggs retrieved (P = 0.04, 0.14, 0.72, respectively). When anti-TNF-α therapy (Humira) was given preconception, the oocyte DOR's negative effect on live birth rate was nearly eliminated (correlation coefficient between oocyte DOR and live birth rate: cycles using no Humira, R = -0.90, P ≤ 0.006; cycles using Humira, R = 0.25, P ≤ 0.55). CONCLUSIONS: In subfertile women undergoing IVF, the oocyte DOR may help predict IVF success rates. This factor may offer an additional tool to help improve implantation rate, clinical pregnancy rate, live birth rate, and live birth rate per embryo transferred for an upcoming IVF cycle. Although many mechanisms may contribute to the oocyte DOR's negative effect on IVF success rates, its correlation with elevated preconception TNF-α:IL-10 ratio and correction with Humira suggests a strong immunologic component that may be treatable.

Intravenous immunoglobulin for repeated IVF failure and unexplained infertility.

PROBLEM: We set out to determine whether intravenous immunoglobulin (IVIG) improves in vitro fertilization (IVF) success rates in women with a difficult history of multiple (≥ 2) prior IVF failures and /or 'unexplained' infertility. METHOD OF STUDY: A total of 229 women with multiple IVF failures (3.3 ± 2.1) and/or unexplained infertility (3.8 ± 2.7 years) were given IVIG on the day of egg retrieval, and the subsequent IVF success rates were compared with published success rates from the Canadian database (CARTR). RESULTS: The pregnancy rate per IVIG-treated cycle was 60.3% (138/229), and the live birth rate per IVIG-treated cycle was 40.2% (92/229). This is a significantly higher success rate compared to the Canadian average (30% live birth rate; CARTR statistics from 2010; P = 0.0012). In cases where a single embryo was transferred, pregnancy rate using IVIG was almost twofold the CARTR pregnancy rate [(61%(20/33) to 34.9% (428/1225)]. In cases where two high quality (≥ Grade 3) day 5 blastocysts were transferred, nearly a 100% pregnancy rate was achieved using IVIG (30/31). CONCLUSION: IVIG may be a useful treatment option for patients with previous IVF failure and/ or unexplained infertility. The data confirm previously published studies at other centers.

Elevated preconception CD56+ 16+ and/or Th1:Th2 levels predict benefit from IVIG therapy in subfertile women undergoing IVF.

PROBLEM: We sought to answer two questions: First, is there a group of patients who benefit from intravenous immunoglobulin (IVIG) in IVF? Second can this group of patients be identified by preconception blood testing? METHOD OF STUDY: A total of 202 IVF cycles in subfertile women were divided into four groups. Group I: 62 cycles with preconception Th1:Th2 ratio and/or % CD56(+) cell elevation using IVIG; Group II: 27 cycles with similar Th1:Th2 and/or % CD56(+) cell elevation not using IVIG; Group III: 71 cycles with normal Th1:Th2 and/or % CD56(+) cell levels using IVIG; Group IV: 42 cycles with normal Th1:Th2 and % CD56(+) levels not using IVIG. These groups were similar with regard to patient age, diagnosis, and past failure history. RESULTS: The implantation rate (number of gestational sacs per embryo transferred, with an average of two embryos transferred per cycle) was 45% (55/123), 22% (12/54), 54% (75/139), and 48% (40/84) for Groups I-IV, respectively. The clinical pregnancy rate (fetal heart activity per IVF cycle started) was 61% (38/62), 26% (7/27), 69% (49/71), and 71% (30/42), respectively. The live birth rate was 58% (36/62), 22% (6/27), 61% (43/71), and 71% (30/42), respectively, and the live birth per embryo transferred was 40% (49/123), 13% (7/24), 43% (60/139), and 48% (40/84), respectively. There was a significant improvement in implantation, clinical pregnancy, live birth rate and live birth rate per embryo transferred for Group I versus Group II (P = 0.0032, 0.0021, 0.0017, and 0.0002, respectively) and for Group II versus Group IV (P = 0.0021, 0.0002, <0.0001 and <0.0001, respectively). There was no significant difference in success rates between Groups I and III (P = 0.085, 0.23, 0.45, 0.34, respectively) and between Groups III and IV (P = 0.22, 0.48, 0.17, 0.31, respectively). CONCLUSION: In subfertile women with preconception Th1:Th2 and/or % CD56(+) cell elevation, IVF success rates are low without IVIG therapy but significantly improve with IVIG therapy. In patients with normal Th1:Th2 and normal CD56(+) cell levels, IVF success rates were not further improved with IVIG therapy. IVIG may be a useful treatment option for patients with previous IVF failure and preconception Th1:Th2 and/or NK elevation. Preconception immune testing may be a critical tool for determining which patients will benefit from IVIG therapy. Prospective controlled studies (preferably double-blind, stratified, and randomized) are needed for confirmation.

Birth defect rates in women using Adalimumab (Humira(®) ) to treat immunologic-based infertility in IVF patients.

PROBLEM: This study compares the birth defect rate in women using preconception TNF-α inhibitor (Adalimumab) during an in vitro fertilization (IVF) cycle to a similar population of women not using these immunologic therapies. METHOD OF STUDY: One hundred subfertile women aged ≤38years experienced ongoing pregnancies of which 36 resulted in twin pregnancies (136 babies). These successful cycles were divided into two different treatment groups: group I comprised 31 cycles (23 ICSI) using preconception Adalimumab (Humira) with or without pre- or post-conception intravenous immunoglobulin (IVIG) (last dose of Humira given 65.3±41.5days before embryo transfer). Group II comprised 69 cycles (58 ICSI) with no exposure to Humira or IVIG. Group I included all eligible fresh cycles containing at least five 5-celled embryos on day 3. Group II had similar entry criteria, but eligible cycles were randomly selected owing to a larger population size. Patients were later contacted by the clinic for neonatal health information. RESULTS: Delivery outcomes were as follows: group I experienced one case of DiGeorge syndrome (chromosome 22 deletion) that was electively terminated out of 41 babies (10 sets of twins) delivered. Group II experienced one case of neonatal heart defect and another case of Edward's syndrome (Trisomy 18) out of 95 babies (26 sets of twins) delivered. The anomaly rate was 2.44% (1/41) and 2.11% (2/95) for groups I and II, respectively, comparable to the expected birth defect rate for the normal IVF population. CONCLUSION: Preconception TNF-α inhibitor does not appear to increase the birth defect rate in women undergoing IVF. A larger, clinical trial with blinded delivery assessment is needed to confirm these safety conclusions.

Low circulating CD4(+) CD25(+) Foxp3(+) T regulatory cell levels predict miscarriage risk in newly pregnant women with a history of failure.

PROBLEM The purpose of this study was to determine whether quantification of peripheral blood Treg cell levels could be used as an indicator of miscarriage risk in newly pregnant women with a history of immunologic reproductive failure. METHOD OF STUDY Fifty-four pregnant women with a history of immunologic infertility and/or pregnancy loss were retrospectively evaluated (mean age: 36.7 ± 4.9 years, 2.8 ± 2.5 previous miscarriages; 1.5 ± 1.9 previous IVF failures). Twenty-three of these women experienced another first trimester miscarriage, and 31 of these women continued their current pregnancies past 12 weeks ('pregnancy success'). The following immunologic parameters were assessed in the first trimester: NK cell 50:1 cytotoxicity, CD56(+) 16(+) CD3(-) (NK), CD56(+) CD3(+) (NKT), TNFα/IL-10, IFNγ/IL-10, CD4(+) CD25(-) Foxp3(+) , total CD4(+) Foxp3(+) (CD4(+ ) CD25(+) Foxp3 plus CD25(- ) Foxp3(+) ), and CD4(+) CD25(+) Foxp3(+) levels. RESULTS Patients with successful ongoing pregnancies experienced a mean (CD4(+) CD25(+) Foxp3(+) ) 'Treg' level of 0.72 ± 0.52%, while those that miscarried in the first trimester experienced a mean Treg level of 0.37 ± 0.29% (P = 0.005). Markers not significantly different between the loss and success groups were NK 50:1 cytotoxicity (P = 0.63), CD56(+) 16(+) 3(+) NK cells (P = 0.63), CD56(+) 3(+) NKT (P = 0.30), TNFα(+) IL-10(+) (P = 0.13), IFNg(+) IL-10(+) (P = 0.63), and CD4(+) 25(-) Foxp3(+) cells (P = 0.10), although total CD4(+) Foxp3(+) levels remained significant (P = 0.02) and CD4(+) 25(+) Foxp3(+) showed the most significant difference (P = 0.005). Mean day of blood draw was 49.2 ± 36.1 days pregnant (median 39.0 days). In addition, patients with a low Treg level (<0.7%) in the first trimester experienced a significantly lower ongoing pregnancy rate than those with a higher Treg level (>0.7%) in the first trimester [44% (15/34) versus 80% (16/20); P = 0.01]. Of the 18 successful pregnancies with sequential Treg results, 85% (11/13) showed a T-regulatory-cell-level increase (mean Treg change 0.33 ± 0.32), while only 40% (2/5) of the failed pregnancies showed a Treg increase (mean Treg change -0.08 ± 0.28; P = 0.02). CONCLUSIONS From these data, we propose that CD4(+) CD25(+) Foxp3(+) T regulatory cells may serve as a superior pregnancy marker for assessing miscarriage risk in newly pregnant women. Larger follow-up studies are needed for confirmation.

Degree of TNF-α/IL-10 cytokine elevation correlates with IVF success rates in women undergoing treatment with Adalimumab (Humira) and IVIG.

PROBLEM: In this retrospective observational study, we investigate whether the degree of preconception cytokine elevation predicts the risk of IVF failure. METHOD OF STUDY: Seventy-six women undergoing fresh IVF/ICSI cycles (≤41 years, good responders with ≥5 embryos on day 3, each with ≥5 cells with a normal endometrium) and preconception tumor necrosis factor (TNF)-α/IL-10 cytokine elevation [PMA/ionomycin stimulated CD3(+) CD8(-) ; TNF-α/IL-10 ratio above 30.6 (normal range 13.2-30.6)] were retrospectively evaluated. This high cytokine population was divided into two subgroups. Group I included 39 women with severe preconception and pre-treatment TNF-α/IL-10 cytokine elevation >39.0 (mean 47.5 ± 7.5 pre-treatment, mean 31.5 ± 9.4 post-treatment) treated with preconception Adalimumab (Humira(®) ) and intravenous immunoglobulin (IVIG). Group II included 37 women with a moderate TNF-α/IL-10 ratio >30.6 and ≤39.0 (mean 35.2 ± 2.2 pre-treatment, mean 28.8 ± 8.5 post-treatment) treated with preconception Adalimumab and IVIG. Groups I and II were comparable in relation to baseline IVF characteristics and patient history. RESULTS: The implantation rate (number of gestational sacs per embryo transfer, with an average of two embryos transferred per cycle) was 43% (36/83) for Group I and 56% (44/78) for Group II. The clinical pregnancy rate (fetal heart activity per IVF cycle started) was 67% (26/39) for Group I and 73% (27/37) for Group II. The delivery rate was 56% (22/39) for Group I and 68% (25/37) for Group II. The live birthrate per embryo transferred was 36% (30/83) for Group I and 45% (35/78) for Group II. Comparing Groups I and II, there was non-significant increase in implantation rate, clinical pregnancy rate, delivery rate, and live birthrate per embryo transferred (P = 0.1, 0.6, 0.4, and 0.3, respectively). However, when the subgroup with the least optimal cytokine conditions (Group I with inadequate cytokine suppression) was compared to the subgroup with the most optimal cytokine conditions (Group II with adequate cytokine suppression), the increase in implantation rate reached statistical significance [41% (19/46) to 64% (29/45); P = 0.04]. The reduction in TNF-α/IL-10 ratio following immunotherapy was highly significant (P < 0.0001). CONCLUSION: The degree of preconception TNF/IL-10 elevation may correlate with an increased risk of IVF failure. Elevated TNF-α/IL-10 ratios can be corrected with therapy. It may be possible to improve IVF success rates by modulating high cytokine levels. Although our pilot database is small, the trends in the data are consistent and compelling. Larger studies are needed for confirmation.

A retrospective analysis of fondaparinux versus enoxaparin treatment in women with infertility or pregnancy loss.

PROBLEM: We compared the pregnancy success rates and safety parameters of fondaparinux versus enoxaparin, combined with immunotherapy, in patients with a history of miscarriage and/or infertility and coagulant defects. METHOD OF STUDY: A total of 127 pregnancies in 110 patients with a history of miscarriage and/or infertility were retrospectively evaluated. Of these, 29 pregnancies used fondaparinux 2.5 mg daily and 98 pregnancies used enoxaparin 30 mg twice daily. RESULTS: The pregnancy success rate was 59% (17/29; 95% CI, 41-75%) for patients receiving fondaparinux and 58% (57/98; 95% CI, 48-68%) for patients receiving enoxaparin. No difference was detected in birth weight (2.7 +/- 0.8 and 2.9 +/- 0.6 kg, respectively) or gestational age at delivery (37.3 +/- 2.2 and 37.7 +/- 2.1 weeks, respectively). No birth defects, severe bleeding-related complications, or serious allergic reactions were observed. CONCLUSION: In patients with a history of miscarriage, infertility, and coagulant defects receiving immunotherapy, fondaparinux resulted in successful pregnancy outcomes comparable with enoxaparin therapy. Although no difference in outcome was observed in our analysis, a much larger study is required to achieve statistical power.

Treatment with adalimumab (Humira) and intravenous immunoglobulin improves pregnancy rates in women undergoing IVF.

PROBLEM: The purpose of this study was to investigate whether treatment with TNF-alpha inhibitors and/or intravenous immunoglobulin (IVIG) increases in vitro fertilization (IVF) success rates among young (<38 years) women with infertility and T helper 1/T helper 2 cytokine elevation. METHOD OF STUDY: Seventy-five sub-fertile women with Th1/Th2 cytokine elevation were divided into four groups: Group I: Forty-one patients using both IVIG and Adalimumab (Humira), Group II: Twenty-three patients using IVIG, Group III: Six patients using Humira, and Group IV: Five patients using no IVIG or Humira. RESULTS: The implantation rate (number of gestational sacs per embryo transferred, with an average of two embryos transferred by cycle) was 59% (50/85), 47% (21/45), 31% (4/13) and 0% (0/9) for groups I, II, III and IV respectively. The clinical pregnancy rate (fetal heart activity per IVF cycle started) was 80% (33/41), 57% (13/23), 50% (3/6) and 0% (0/5) and the live birth rate was 73% (30/41), 52% (12/23), 50% (3/6) and 0% (0/5) respectively. There was a significant improvement in implantation, clinical pregnancy and live birth rates for group I versus group IV (P = 0.0007, 0.0009, and 0.003, respectively) and for group II versus group IV (P = 0.009, 0.04 and 0.05, respectively). CONCLUSION: The use of a TNF-alpha inhibitor and IVIG significantly improves IVF outcome in young infertile women with Th1/Th2 cytokine elevation.

Treatment with tumor necrosis factor inhibitors and intravenous immunoglobulin improves live birth rates in women with recurrent spontaneous abortion.

PROBLEM: The purpose of this study was to investigate whether treatment with tumor necrosis factor (TNF) inhibitors combined with intravenous immunoglobulin (IVIG) increases live birth rates among women with recurrent spontaneous abortion (RSA) concurrently treated with anticoagulants (AC). METHOD OF STUDY: Seventy-five pregnancies in patients with a history of RSA were retrospectively evaluated. The population was divided into three groups: group I: 21 patients treated with AC (anticoagulants), group II: 37 patients treated with AC and IVIG, and group III: 17 patients treated with AC, IVIG and the TNF inhibitor Etanercept (Enbrel) or Adalimumab (Humira). In groups II and III, IVIG was administered at least once during the cycle of conception and/or at least once after a positive pregnancy test. In group III, either Adalimumab or Etanercept was administered by subcutaneous injection according to standard protocols. Statistical analysis of pregnancy outcome was performed using Fisher's exact test. RESULTS: Patient populations in the three treatment groups were similar in terms of age, past miscarriages, inherited thrombophilia and autoimmunity. The live birth rate was 19% (4/21) in group I, 54% (20/37) in group II, and 71% (12/17) in group III. There was significant improvement in pregnancy outcome in group II versus group I (P = 0.0127) and in group III versus group I (P = 0.0026). The live birth rate in group III compared to group II was not significantly different (P = 0.3723). Side effects of AC, IVIG and TNF inhibitor treatment were minimal in these patients, and no birth defects were identified in their offspring. CONCLUSION: In women with RSA, addition of either IVIG or a TNF inhibitor + IVIG to the AC regimen appears to improve live birth rates compared to the treatment with AC alone. The positive effect of IVIG and TNF inhibitor therapy on pregnancy outcome merits further study in prospective clinical trials.

Update on treatment of immunologic abortion with low-dose intravenous immunoglobulin.

PROBLEM: Recurrent spontaneous abortion associated with immunologic abnormalities has been termed immunologic abortion. Previously we showed that treatment with low-dose intravenous immunoglobulin (IVIG) appears to be beneficial for older women with immunologic abortion. We now report the results of IVIG treatment in a larger group of women with this disorder. METHOD OF STUDY: A total of 99 women were prospectively evaluated for immunologic abortion, which was defined as three or more miscarriages and the presence of specific immunologic abnormalities. Prior to the next conception, patients were treated with IVIG at a dose of 0.2 g/kg. Once conception was achieved, IVIG treatment was continued on a monthly basis through 26-30 weeks of pregnancy. RESULTS: The average age of the women was 37 years (range: 28-49), and the average number of miscarriages was 3.8 (range: 3-12). Of the 99 women, 72 received initial IVIG treatment, and 50 subsequently became pregnant. Of these women, 42 (84%) had a successful term pregnancy. Of the 27 women who refused IVIG therapy, 20 became pregnant and 18 (90%) miscarried. The difference in pregnancy success rate between the IVIG-treated and untreated groups was significant (P = 0.001). Four women had mild allergic reactions during IVIG infusion, and these reactions resolved when the IVIG brand was changed. Fetal abnormalities were not observed. CONCLUSION: We conclude that low-dose IVIG therapy is safe and effective for older women with immunologic abortion.