Ingrid Granne

ST2 and IL-33 in Pregnancy and Pre-Eclampsia

Normal pregnancy is associated with a mild systemic inflammatory response and an immune bias towards type 2 cytokine production, whereas pre-eclampsia is characterized by a more intense inflammatory response, associated with endothelial dysfunction and a type 1 cytokine dominance. Interleukin (IL)-33 is a newly described member of the IL-1 family, which binds its receptor ST2L to induce type 2 cytokines. A soluble variant of ST2 (sST2) acts as a decoy receptor to regulate the activity of IL-33. In this study circulating IL-33 and sST2 were measured in each trimester of normal pregnancy and in women with pre-eclampsia. While IL-33 did not change throughout normal pregnancy, or between non-pregnant, normal pregnant or pre-eclamptic women, sST2 was significantly altered. sST2 was increased in the third trimester of normal pregnancy (p<0.001) and was further increased in pre-eclampsia (p<0.001). This increase was seen prior to the onset of disease (p<0.01). Pre-eclampsia is a disease caused by placental derived factors, and we show that IL-33 and ST2 can be detected in lysates from both normal and pre-eclampsia placentas. ST2, but not IL-33, was identified on the syncytiotrophoblast layer, whereas IL-33 was expressed on perivascular tissue. In an in vitro placental perfusion model, sST2 was secreted by the placenta into the ‘maternal’ eluate, and placental explants treated with pro-inflammatory cytokines or subjected to hypoxia/reperfusion injury release more sST2, suggesting the origin of at least some of the increased amounts of circulating sST2 in pre-eclamptic women is the placenta. These results suggest that sST2 may play a significant role in pregnancies complicated by pre-eclampsia and increased sST2 could contribute to the type 1 bias seen in this disorder.

Do women with ovaries of polycystic morphology without any other features of PCOS benefit from short-term metformin co-treatment during IVF? A double-blind, placebo-controlled, randomized trial

BACKGROUND Women with ovaries of polycystic morphology (PCO), without any other features of polycystic ovary syndrome (PCOS), respond similarly to women with PCOS when stimulated with exogenous gonadotrophins, and both groups share various endocrinological disturbances underlying their pathology. In women with PCOS, metformin co-treatment during IVF has been shown to increase pregnancy rates and reduce the risk of ovarian hyperstimulation syndrome (OHSS). The aim of this study was to investigate whether metformin co-treatment before and during IVF can also increase the live birth rate (LBR) and lower severe OHSS rates for women with PCO, but no other manifestations of PCOS. METHODS This study was a double-blind, multi-centre, randomized, placebo-controlled trial. The study population included 134 women with ovulatory PCO (and no evidence of clinical or biochemical hyperandrogenism) undergoing IVF treatment at three tertiary referral IVF units. The primary outcome was LBR. RESULTS In total, 134 women were randomized, 69 to metformin and 65 to placebo. There were no statistically significant differences between the two groups in baseline characteristics. With regard to IVF outcome, no significant improvements were found in the metformin group when compared with the placebo group. In particular, there was no difference between the groups in rates of live birth [metformin n = 27 (39.1%), placebo n = 30 (46.2), (95% confidence interval 0.38, 1.49, odds ratio = 0.75)], clinical pregnancy [metformin n = 29 (42.0%), placebo n = 33 (50.8%)] or severe OHSS [metformin n = 6 (8.7%), placebo n = 5 (7.7%)]. CONCLUSIONS There appears to be no benefit in metformin co-treatment before and during IVF in women with PCO without any other features of PCOS. Clinical Trials.gov: NCT01046032.

Medical adjuncts in IVF: evidence for clinical practice

The cross-talk between the embryo and the endometrium, leading to implantation, is a complex, dynamic and highly controlled phenomenon. Over the last decade, a large amount of translational and clinical research has been carried out in an attempt to increase the likelihood of pregnancy in in vitro fertilisation (IVF). The purpose of this article was to review the literature on the effectiveness of adjuvant therapy in IVF and to provide fertility professionals with evidence-based guidance and recommendations. Clinicians who decide to prescribe therapies for which the evidence base is weak, should make patients aware of this lack of knowledge and potential adverse effects. There is a need for good clinical trials in many of the areas surrounding medical adjuncts in IVF to resolve the empirical/evidence divide.

Interleukin-1 family cytokines and their regulatory proteins in normal pregnancy and pre-eclampsia

Maternal systemic inflammation is a feature of pre‐eclampsia, a condition in pregnancy characterized by hypertension and proteinuria. Pre‐eclampsia is caused by the placenta; many placental factors contribute to the syndromes progression, and proinflammatory cytokines have been identified previously as one such mediator. The interleukin (IL)‐1 family of cytokines are key regulators of the inflammatory network, and two naturally occurring regulatory molecules for IL‐1 family cytokines, IL‐1RA and sST2, have been found previously to be elevated in maternal blood from women with pre‐eclampsia. Here we investigate more recently identified IL‐1 family cytokines and regulatory molecules, IL‐1RAcP, IL‐37, IL‐18BP, IL‐36α/β/γ/Ra and IL‐38 in pre‐eclampsia. Pregnant women have more circulating IL‐18BP and IL‐36Ra than non‐pregnant women, and sIL‐1RAcP is elevated from women with pre‐eclampsia compared to normal pregnancies. The placenta expresses all the molecules, and IL‐37 and IL‐18BP are up‐regulated significantly in pre‐eclampsia placentas compared to those from normal pregnancies. Together, these changes contribute to the required inhibition of maternal systemic cytotoxic immunity in normal pregnancy; however, in pre‐eclampsia the same profile is not seen. Interestingly, the increased circulating levels of sIL‐1RAcP and increased placental IL‐18BP and IL‐37, the latter of which we show to be induced by hypoxic damage to the placenta, are all factors which are anti‐inflammatory. While the placenta is often held responsible for the damage and clinical symptoms of pre‐eclampsia by the research community, here we show that the pre‐eclampsia placenta is also trying to prevent inflammatory damage to the mother.

Embryo cryopreservation: evidence for practice.

1a Systematic review and meta-analysis of randomized controlled trials (RCTs). 1b At least one RCT. 2a At least one well-designed, controlled study without randomization. 2b At least one other type of well-designed, quasiexperimental study. 3 Well-designed, non-experimental, descriptive studies, such as comparative studies, correlation studies or case studies. 4 Expert committee reports or opinions and/or clinical experience of respected authorities.

Detection of Soluble ST2 in Human Follicular Fluid and Luteinized Granulosa Cells

Follicular fluid (FF) contains various cytokines that are involved with folliculogenesis, some of which have been shown to be associated with oocyte quality and the implantation potential of a resulting embryo. Several IL-1 family members have previously been identified in FF. This study investigates a newly identified member of the family, IL-33, and its receptor ST2, comparing values to those of FF Granulocyte-Colony Stimulating Factor (G-CSF) – a known predictor of Assisted Reproductive Technology (ART) success. FF was collected from patients undergoing in vitro fertilisation/intra-cytoplasmic sperm injection (IVF/ICSI) at oocyte retrieval to analyse IL-33 and sST2 expression in human follicles. sST2, but not IL-33, is highly increased in the FF compared to plasma levels (up to 7.9-fold), with higher levels in larger follicles (p<0.05). Furthermore, we identify that human luteinised granulosa cells are one possible source of the FF sST2, as these cells express and secrete sST2 when cultured ex vivo. FF associated with oocytes which when fertilised develop into good quality embryos have higher sST2 levels than those which are graded average (p<0.01). These embryos were transferred to the patient and levels of FF sST2 compared between successful and unsuccessful ICSI cycles. However unlike G-CSF, sST2 levels cannot be used to predict cycle outcome.

Measurement of sST2 is comparable to PlGF in the diagnosis of early-onset pre-eclampsia.

A diagnostic test to confirm pre-eclampsia would be beneficial for the clinical management of the syndrome. The Triage PlGF test is able to confirm pre-eclampsia with high accuracy, with the greatest efficacy at <35weeks gestation. We recently found that the anti-inflammatory protein sST2 is elevated in the plasma of pre-eclamptic women compared to normal controls. Here sST2 and PlGF are compared in early-onset and late-onset pre-eclamptic women. sST2 was found to be an equally good diagnostic tool for early-onset (sST2 AUC 0.944 versus PlGF AUC 0.995; not significant) but not late-onset disease.

An altered endometrial CD8 tissue resident memory T cell population in recurrent miscarriage

When trying to conceive 1% of couples have recurrent miscarriages, defined as three or more consecutive pregnancy losses. This is not accounted for by the known incidence of chromosomal aneuploidy in miscarriage, and it has been suggested that there is an immunological aetiology. The endometrial mucosa is populated by a variety of immune cells which in addition to providing host pathogen immunity must facilitate pregnancy. Here we characterise the endometrial CD8-T cell population during the embryonic window of implantation and find that the majority of cells are tissue resident memory T cells with high levels of CD69 and CD103 expression, proteins that prevent cells egress. We demonstrate that unexplained recurrent miscarriage is associated with significantly decreased expression of the T-cell co-receptor CD8 and tissue residency marker CD69. These cells differ from those found in control women, with less expression of CD127 indicating a lack of homeostatic cell control through IL-7 signalling. Nevertheless this population is resident in the endometrium of women who have RM, more than three months after the last miscarriage, indicating that the memory CD8-T cell population is altered in RM patients. This is the first evidence of a differing pre-pregnancy phenotype in endometrial immune cells in RM.

Ethical and practical considerations in prescribing animal-derived medication

There are many reasons why providing a patient with enough information to allow them to make an informed decision about their treatment is central to good medical care. Some of these have origins in the law: certainly, informing a patient of the risks involved in a procedure or with taking a certain drug is essential in order to avoid charges of negligence should an adverse event causing harm occur. However, the duty of consent goes beyond this. It is no longer acceptable for a doctor to adopt a paternalistic approach in deciding what treatment should be prescribed. This is based on the principle of autonomy: a well-informed competent patient is best placed to assess their own best interests and consent to, or refuse, treatment accordingly. Patients who are involved in treatment choices and feel that they have made the best decision for themselves are more likely to comply with the treatment, particularly if this involves long-term medication. The article by Vissamsetti et al in this journal makes it clear that the presence of animal-derived ingredients in prescription drugs is one piece of information that some patients need in order to make an informed decision about treatment.1 This may be for religious or non-religious (vegetarian or vegan diet) reasons. In their article, 40% of urology patients in one area of the UK had dietary restrictions to the use of animal products, with only 10% of these willing to take drugs containing animal products. The large percentage of non-meat eaters in …

GWAS meta-analysis highlights the hypothalamic-pituitary-gonadal axis (HPG axis) in the genetic regulation of menstrual cycle length

The normal menstrual cycle requires a delicate interplay between the hypothalamus, pituitary, and ovary. Therefore, its length is an important indicator of female reproductive health. Menstrual cycle length has been shown to be partially controlled by genetic factors, especially in the follicle stimulating hormone beta-subunit (FSHB) locus. GWAS meta-analysis of menstrual cycle length in 44,871 women of European ancestry confirmed the previously observed association with the FSHB locus and identified four additional novel signals in, or near, the GNRH1, PGR, NR5A2 and INS-IGF2 genes. These findings confirm the role of the hypothalamic-pituitary-gonadal axis in the genetic regulation of menstrual cycle length, but also highlight potential novel local regulatory mechanisms, such as those mediated by IGF2.