Alex Steinleitner

Successful treatment of immunologic abortion with low-dose intravenous immunoglobulin

OBJECTIVE To evaluate the efficacy of low-dose intravenous immunoglobulin (IVIG) treatment in older women with immunologic abnormalities and recurrent spontaneous abortion (RSA), a condition referred to as immunologic abortion. DESIGN Prospective clinical trial. SETTING Outpatient referral practice. PATIENT(S) Forty-seven women were enrolled in the study. The mean age of the women was 37 years (range, 28-45 years), and the mean number of prior miscarriages was 3.7. Immunologic abnormalities included antiphospholipid antibodies (32%), antithyroid antibodies (53%), antinuclear antibodies (28%), antiovarian antibodies (2%), increased natural killer cells (40%), increased immunoglobulin (Ig)M level (28%), and increased CD4/CD8 T-cell ratio (15%). One patient had IgA deficiency, and three women had endometriosis. Thirty-one of the 47 patients (66%) had more than one immunologic abnormality. INTERVENTION(S) Treatment with IVIG at a dose of 0.2 g/kg within 2 weeks of attempted conception. Once conception was achieved, IVIG treatment was continued on a monthly basis at the same dose through 26-30 weeks of gestation. MAIN OUTCOME MEASURE(S) Successful pregnancy or recurrent abortion. RESULT(S) Of the 47 women, 36 received initial IVIG treatment, and 24 subsequently became pregnant. Of these women, 20 continued IVIG treatment through 26-30 weeks of gestation, and 19 (95%) had a successful term pregnancy. Four women discontinued IVIG therapy after 10-12 weeks of gestation, and 3 (75%) had a successful pregnancy outcome. Of the 11 women who refused IVIG therapy, 7 became pregnant, and all 7 miscarried. The difference in pregnancy success rate between the IVIG-treated and untreated groups was significant (P=.001). Three women had adverse reactions during the low-dose IVIG infusion, and these reactions resolved when the IVIG brand was changed. Fetal abnormalities were not observed. CONCLUSION(S) Low-dose IVIG therapy is beneficial for older women with immunologic abortion. The optimum duration of IVIG treatment in these women requires further study.

The effect of peritoneal fluid from patients with endometriosis on murine sperm-oocyte interaction.

It has been demonstrated that PF contains some factor or factors that interfere with effective gamete interaction as determined by an in vitro animal assay. PF from patients with mild endometriosis has an increased activity of this substance and/or additional inhibitory factors. In endometriosis, this peritoneal fluid factor or factors appear to be filterable and to a significant degree heat-labile. This observation may be of importance in explaining subfertility associated with early stages of endometriosis.

Reduction of primary postoperative adhesion formation under calcium channel blockade in the rabbit

Preliminary studies in a hamster model have demonstrated calcium channel blocking agents to be potent inhibitors of primary post-traumatic peritoneal adhesion formation. The present investigation was designed to extend these observations to an extensively studied model, the rabbit, and to evaluate the optimal route of administration of these drugs for intraabdominal surgery. Rabbits were subjected to a standardized traumatic lesion of the left uterine horn. Subsequently, animals were divided into the following treatment groups: subcutaneous vehicle control (n = 7), intraperitoneal (ip) vehicle control (n = 8), subcutaneous verapamil treatment (n = 6), low-dose (2.5 micrograms/kg/hr) ip verapamil treatment (n = 10), and high-dose ip (25 micrograms/kg/hr) verapamil treatment (n = 6). All animals were reexplored at 1 week postop for evaluation of adhesion formation (scale: 0 to 4+). Calcium channel blockade-treated animals formed significantly fewer adhesions (0.45) than controls (3.93) (P less than 0.01). There was no significant difference between animals treated with sc with verapamil sc and those treated with low- or high-dose verapamil ip (0.33 vs 0.20 vs 1.0). These data confirm our preliminary results, suggesting that calcium channel blockade potently modulates peritoneal healing and regeneration. Furthermore, intraperitoneal delivery and systemic administration appear equipotent in this model. Further study of these agents as potential adjuvants for intraperitoneal surgery is indicated.

Synergistic effect of intraperitoneally administered calcium channel blockade and recombinant tissue plasminogen activator to prevent adhesion formation in an animal model.

Previous reports have shown the benefits of calcium channel blockers and recombinant tissue plasminogen activator to prevent postoperative adhesion formation in animal models. To assess the potential benefit of synergistic therapy for the prevention of postoperative adhesion formation, these agents were studied in a rabbit uterine horn model. Four groups of New Zealand White rabbits (n = 8 per group) had a bilateral devascularization injury to the uterine horns. Before closure saline solution, verapamil hydrochloride (2.5 mu/kg/hour), recombinant tissue plasminogen activator (4 mg total dose), or a combination of verapamil and recombinant tissue plasminogen activator at the stated doses were instilled by means of an Alzet osmotic pump x 200 hours. Adhesion scores were evaluated after this time period by estimating the total uterine horn surface involved in adhesions at a terminal laparotomy and by clinically grading the response to determine whether minimal adhesions formed. Results of the total uterine horn surface scores were (mean score +/- SE): saline solution, 44% +/- 3.7%; verapamil, 19% +/- 4.8%; recombinant tissue plasminogen activator, 11% +/- 3.6%; combined, 3% +/- 1% (p less than 0.01 to control and p less than 0.05 to single-drug therapy). Results of the number of animals per group with minimal adhesions were as follows: saline solution, 0; verapamil, 1; recombinant tissue plasminogen activator, 3; combined, 8 (P less than 0.01). These results show a synergistic benefit of verapamil and recombinant tissue plasminogen activator to prevent postsurgical adhesion formation when delivered via the intraperitoneal route.

The use of calcium channel blockade for the prevention of postoperative adhesion formation

Prevention of postoperative adhesion formation is an issue of fundamental concern to the reproductive surgeon. The disappointing results of current adjunctive regimens have prompted a search for more potent antiadhesion therapies. Administration of nifedipine hydrochloride, a prototypical calcium channel blocking agent, to hamsters receiving a standardized traumatic lesion of the left uterine horn significantly inhibited primary adhesion formation as compared to control animals. These preliminary results suggest that calcium channel blockade may have the potential to favorably influence events related to peritoneal repair; further study of these agents as surgical adjuvants in the treatment of chronic pelvic adhesive disease is indicated.

Intravenous immunoglobulin (IVIG) therapy for immunologic abortion

Abstract Recurrent pregnancy loss associated with immunologic abnormalities has been termed immunologic abortion. Immunologic abortion occurs primarily in women over the age of 30 years and may affect either natural or in-vitro fertilization (IVF)-induced pregnancy. In this article, we review the humoral and cellular immunologic abnormalities that have been associated with this form of recurrent abortion, and we discuss treatment options for women with this disorder. In particular, we have focused on intravenous immunoglobulin (IVIG) treatment for immunologic abortion. We analyzed 14 studies of IVIG therapy for recurrent loss of natural or IVF-induced pregnancies. Factors associated with successful use of IVIG were: (a) Older mean patient age; (b) inclusion of women with immunologic abnormalities; (c) initiation of IVIG therapy prior to conception; and (d) repeated administration of IVIG at physiologic intervals during pregnancy. When used according to these parameters, IVIG therapy is safe and effective for women with immunologic abortion. Appropriate patient selection and rational timing of IVIG administration are crucial factors that determine the success of this treatment.

Reduction of primary posttraumatic adhesion formation with the prostacyclin analog iloprost in a rodent model

Recent evidence suggests that inhibition of postsurgical adhesion formation may be effected by modulation of the activities of inflammatory cells contributing to mesothelial repair. Iloprost, a stable analog of prostacyclin, has been shown to exert vasodilatory, antiinflammatory, fibrinolytic, and antithrombotic influences. To determine whether these properties of iloprost might protect mesothelial surfaces from perioperative damage and hence prevent adhesion formation, we evaluated the effect of iloprost on peritoneal healing in a hamster model for primary pelvic injury. Perioperative iloprost therapy significantly reduced posttraumatic adhesion formation when compared with that in vehicle-treated controls. Dose-response studies demonstrate adhesion prevention with doses ranging from 0.04 to 4 mg/kg per 8 hours given subcutaneously over the course of 3 days. These data demonstrate that iloprost is a potent positive modulator of peritoneal healing after pelvic trauma. Further studies to characterize the potential application of iloprost as an adjuvant in reproductive surgery are indicated.

Case report: Treatment of congenital vas obstruction with sperm aspiration, nonstimulated in fitro fertilization, and nonsurgical tubal embryo transfer

Among the factors that can explain differences between spontaneous and induced pregnancies, the characteristics of the infertile population can play an important role, and recently some studies (3,4) have shown that infertile couples have a higher risk of obstetrical complications than fertile couples even without IVF. We want to point out the fact that the method of calculating the duration of IVF pregnancies can also be involved. Usually, the term of IVF pregnancies is estimated by adding 14 days to the date of oocyte retrieval to obtain a theorical number of weeks of amenorrhea. This supposes that ovulation occurs at the 14th day in natural cycles on average. However, the literature is not totally consistent on this point. For example, Spira et al. (5) found a mean hypothermic phase of 18 days for 894 patients trying to obtain a natural pregnancy. In the study of 162 IVF singleton pregnancies conceived in Clamart, France, between 1987 and 1989, the prematurity rate (<37 weeks) changed from 10.7% when we added 14 days to 7.5 and 5.7% when we added 16 and 18 days, respectively. When we did the same calculation on the 916 singleton pregnancies in the French collaborative study (2), we observed the rates of 12.2, 9.3, and 7.8% when we added 14, 16, and 18 days, respectively, to the day of oocyte retrieval. In fact, the choice of retrieval day or reimplantation day as a reference can change the ratio of prematurity. A difference of 4 days in the mode of calculation of the term can halve the global prematurity rate, which can be explained by the high number of births occurring between 36 and 37 weeks of amenorrhea. It can also decrease early prematurity. Even if prematurity cannot be explained only by differences in the date of ovulation, further studies are needed to find a dating system allowing a nonbiased comparison between birth resulting from assisted and birth from natural conception. 4. Williams M, Goldman M, Mittendorf R, Monson R. Subfertility risk of low birth weight. Fertil Steril 1991 ;56(4):668-671 5. Spira A, Spira N, Papiernik-Berkauer E, Schwartz D: Pattern of menstrual cycles and incidence of congenital malformation. Early Hum Dev 1985;1l:317-324

Detection of human leukocyte antigen class I messenger ribonucleic acid transcripts in human spermatozoa via reverse transcription-polymerase chain reaction*†*Supported by grants HD24495 and HD24180 from the National Institutes of Health, Bethesda, Maryland.†Presented at the 41st Annual Meeting of The Pacific Coast Fertility Society, Indian Wells, California, April 14 to 18, 1993.

OBJECTIVE To determine by reverse transcription-polymerase chain reaction (PCR) whether human leukocyte antigen (HLA) class I messenger RNA (mRNA) is present in mature human spermatozoa. DESIGN Mature human spermatozoa was isolated from donor semen using a swim-up technique. Total RNA was extracted via guanidinium isothiocyanate-cesium chloride ultracentrifugation. By the method previously validated in our laboratory, reverse transcription-PCR was performed using primers specific for HLA class I transcripts. Positive control cells included a choriocarcinoma cell line (JEG) and human fetal tissue. Transformed peripheral blood lymphocytes (PBL) were used as a negative control for somatic cellular contamination. RESULTS Human spermatozoa were positive for HLA class I (-G and -B) mRNA by reverse transcription-PCR, consistent with the positive controls. We did not detect any mRNA for beta-actin, retinoblastoma (RB), CD4, or kappa light chain genes in the sperm complementary DNA samples, verifying that the class I mRNA detected was not due to somatic cellular contamination of the purified sperm samples. CONCLUSION These experiments provide the first evidence that mRNA for HLA class I molecules are present in mature human spermatozoa. The physiological role of these transcripts is unknown at present. Further experiments characterizing the expression of HLA class I (-G and -B) mRNA in oocytes and preimplantation embryos are in progress.

Enhanced gamete interaction in the sperm penetration assay after coincubation with pentoxifylline and human follicular fluid**Presented at the 46th Annual Meeting of The American Fertility Society, Washington, DC, October 15 to 19, 1990.

OBJECTIVE To evaluate the effect of pentoxifylline and heat-inactivated human follicular fluid (FF) on performance in the sperm penetration assay (SPA) as a paradigm for the effect of these agents on human sperm-egg interaction in vivo and in vitro fertilization. DESIGN Semen specimens from men undergoing SPA testing for evaluation of suspected male factor infertility were coincubated with neat medium or media supplemented with pentoxifylline or human FF in a nonblinded manner. PARTICIPANTS Twenty male factor infertility patients. INTERVENTIONS Semen specimens were preincubated with: [1] pentoxifylline 0.25 mg/mL; [2] 10% human FF; [3] pentoxifylline+human FF; and [4] neat Biggers, Whitten, and Whittingham medium. MAIN OUTCOME MEASURES Differences in the rate of penetration of zona-free hamster oocytes. RESULTS Preincubation with either human FF or pentoxifylline produced a significant improvement in hamster egg penetration rates. Coincubation with a combination of human FF and pentoxifylline resulted in a significant enhancement of penetration as compared with single agent treatment. CONCLUSIONS Coincubation of sperm with human FF and pentoxifylline may provide a means of enhancing sperm activity for insemination and assisted reproduction.