Joanne Y.H. Kwak

Immunophenotypic Profiles of Peripheral Blood Lymphocytes in Women With Recurrent Pregnancy Losses and in Infertile Women With Multiple Failed In Vitro Fertilization Cycles

In summary (1) Nonpregnant women with RSAs of unknown etiology have higher levels of CD56+ lymphocytes when compared to normal controls; (2) The levels of CD19+, CD56+, and CD56+/CD16+ PBL of pregnant women with RSA are significantly higher than those of multiparous pregnant normal controls; (3) Women with autoantibodies to phospholipids have significantly higher levels of elevated CD56+ and CD56+/CD16+ lymphocytes when compared to women without antiphospholipid antibodies; (4) Women with autoantibodies to nuclear components demonstrate higher numbers of CD19+/CD5+ cells compared to women without autoantibodies to nuclear components; (5) Idiopathic infertile women with multiple prior IVF failures demonstrate significantly higher levels of CD56+ pBL than normal fertile controls and the conception rate is much higher in those with CD56+ levels less than 12%; (6) Elevations of CD56+ lymphocytes to over 18% during a pregnancy is a good prognostic indicator of impending pregnancy loss. We have not seen a liveborn infant in women with levels of 18% or higher without IVIg therapy; and (7) Infertile and RSA women who fail alloimmune and autoimmune therapy have significant alterations in cellular and humoral immunity involving NK cells and CD19+/CD5+ B cells.

Up-regulated expression of CD56+, CD56+/CD16+, and CD19+ cells in peripheral blood lymphocytes in pregnant women with recurrent pregnancy losses

PROBLEM: To analyze immunophenotypic profiles of peripheral blood and humoral autoimmune responses in women with a history of recurrent spontaneous abortions (RSA).

Elevated Peripheral Blood Natural Killer Cells Are Effectively Downregulated by Immunoglobulin G Infusion in Women With Recurrent Spontaneous Abortions

PROBLEM: We investigated the hypothesis that elevated peripheral blood natural killer cells (NK) are decreased by immunoglobulin G infusion (IVIg) therapy in women with recurrent spontaneous abortions (RSA) and elevated NK cells.

Intravenous Immunoglobulin Inhibits Natural Killer Cell Activity In Vivo in Women With Recurrent Spontaneous Abortion

We previously reported elevation of natural killer (NK) cells in women with recurrent spontaneous abortion (RSA) of immune etiology. In this study, we investigated the effect of intravenous immunoglobulin G (IVIg) on peripheral blood NK activity in vivo in women with RSA. Blood was drawn prior to and 7–11 days after IVIg therapy in eight women with RSA. NK activity was measured using K562 as target cells for 51Cr‐release assays. Serum IgG concentrations were also measured. All received 400 mg/kg/day of IVIg for 3 consecutive days. 1) Seven of eight women became pregnant. Five delivered a live born infant. Three out of five women (60%) who delivered a live born infant showed a significant inhibition of NK cytotoxicity post IVIg and the rest did not show any changes; 2) NK cytotoxicity was significantly increased in a woman who miscarried again; 3) A woman who miscarried a chromosomally abnormal fetus showed a significant inhibition of NK cytotoxicity after IVIg; and 4) Serum IgG concentration increased significantly from 9.3 ± 3.0 mg/ml to 23.5 ± 5.1 mg/ml post IVIg therapy. IVIg effectively inhibits peripheral blood NK activity in vivo. These results are consistent with our previous finding showing that IVIg inhibits NK cell activity in vitro. Women with RSA and elevated NK cells may benefit from IVIg treatment.

Autoantibodies in women with primary recurrent spontaneous abortion of unknown etiology

A group of 153 women with 3 or more recurrent spontaneous abortions (RSAs) with unknown etiology and 90 normal multigravida controls were evaluated for antibodies to phospholipids and nuclear antigens. We demonstrate that women with recurrent spontaneous abortions showed significantly higher incidence of antibodies to phospholipids than normal multigravida controls. In contrast, the incidence of antibodies to polynucleotides and histones was not different between these two groups. These findings suggest that antiphospholipid antibodies are either epiphenomena or causally related to recurrent spontaneous abortions.

Reproductive outcome in women with recurrent spontaneous abortions of alloimmune and autoimmune causes: Preconception versus postconception treatment

Objectives: The null hypothesis is that treatment of women with recurrent spontaneous abortions with anticoagulation and immunosuppression will not increase the reproductive outcome if it is started preconceptionally. Study design: Ninety-four women with recurrent spontaneous abortion with autoimmune abnormalities comprised the study group. Group I began autoimmune therapy 48 hours after ovulation: heparin 5000 U twice daily, aspirin 80 mg daily, and prednisone 5 mg twice daily, with an increase to 10 mg twice daily when pregnant. Group II started the same medication after a positive pregnancy test. Group III received no medication. Controls were 19 women with no autoimmune abnormalities. The frequency of reproductive outcome was subject to multiple comparison by the Duncan test. Results: The percentages of live-born children in groups I, II, and III were 74%, 44%, and 11%, respectively. Conclusions: Preconception diagnostic work-up and treatment of autoimmune abnormalities in women with histories of recurrent spontaneous abortion is advocated.

Immunopathology of the implantation site utilizing monoclonal antibodies to natural killer cells in women with recurrent pregnancy losses.

PROBLEM: Placental lesions of 71 women with documented recurrent spontaneous abortions of unknown etiology were evaluated using immunohistochemical staining.

Autoantibodies to phospholipids and nuclear antigens in non-pregnant and pregnant Colombian women with recurrent spontaneous abortions

Autoantibodies to negatively charged phospholipids have been reported to be associated with thrombotic events, thrombocytopenia and adverse pregnancy outcome, such as intrauterine growth retardation and recurrent spontaneous abortions (RSAs). In this study, autoantibodies to 6 phospholipid antigens and antinuclear antibody (ANA) were tested in Colombian women with a history of RSAs. Sixty-eight non-pregnant and 25 pregnant women with a history of RSAs comprised the study group. Twenty-five non-pregnant normal healthy women and thirty-one normal pregnant women served as controls. The non-pregnant women with RSAs showed a higher incidence of autoantibodies to cardiolipin (23% positive) as compared with non-pregnant normal controls (0% positive; P < 0.005). The incidence of autoantibodies to cardiolipin (28%; P < 0.005), phosphatidylethanolamine (16%; P < 0.005), phosphatidylserine (16%; P < 0.05), phosphatidylglycerol (16%; P < 0.05), phosphatidic acid (16%; P < 0.01) and phosphatidylinositol (20%; P < 0.01), in the pregnant women with RSAs was significantly higher than that of normal pregnant controls. There was no difference in the incidence of ANA in either group. In conclusion, women with a history of RSAs have a higher incidence of autoantibodies to phospholipids when compared to pregnant and non-pregnant normal controls. Autoimmune serological work-up is indicated during pregnancy in women with a history of RSAs.

Impact of Age on Reproductive Outcome in Women With Recurrent Spontaneous Abortions and Infertility of Immune Etiology

The objective of this paper is to determine whether age has any impact on conception rate, pregnancy outcome, or autoimmune status in women with recurrent spontaneous abortions (RSA) and infertility of immune etiology. One hundred twenty‐four women with 3 or more RSA and 36 women with unexplained infertility were prospectively studied. Maternal anti‐paternal lymphocyte antibodies and autoantibodies to phospholipids and nuclear antigens were tested. All achieved an adequate alloimmune recognition after lymphocyte immunization and followed for 1 year with optimal preconception autoimmune treatment. Conception rate and pregnancy outcome were prospectively studied. 1) 10.1% of women with RSA and 30.6% of women with infertility failed to achieve a pregnancy after 1 year of trial (P=0.0084); 2) in women with RSA, the number of previous fetal death after 28 weeks of gestation was significantly higher in women who failed to achieve a pregnancy within 1 year when compared to women who became pregnant (P=0.0296). Conception rate was not different with advancing age; 3) women with infertility demonstrated significantly higher incidence of anti‐phosphatidylethanolamine antibody when compared to women with RSA (P=0.052); 4) in women with infertility, those who failed to achieve a pregnancy were significantly older (P=0.0012) and demonstrated a higher incidence of autoantibodies to phosphatidic acid than women with infertility who became pregnant (P=0.0339); 5) the subsequent spontaneous abortion rate while on optimal immune therapy was the same in the women with RSA (39.3%) and women with infertility (32%). Spontaneous abortion rate of women with RSA or infertility was not different among four age groups; 6) the presence of anti‐cardiolipin antibody (P=0.0055) and higher gravidity (P=0.0354) correlated significantly with pregnancy failure in women with a history of infertility. The prevalence of auto‐antibodies to phospholipids and nuclear components was not different among four age groups in women with RSA or infertility. Age does not affect pregnancy outcome or conception rate in women with RSA. In women with infertility of immune etiology, conception rate was significantly reduced over age 40 although pregnancy outcome was no different with advanced age.

IMMUNOLOGY OF NORMAL PREGNANCY

Reproductive immunology has become a mature discipline. It had its birth in the field of transplantation immunology. Scientists assumed that the fetus was a transplant and would follow the laws of rejection or acceptance, but many of these theories and hypotheses were difficult to validate and had to be discarded. Today, sophisticated immunological methods have been used by scientists to define more clearly the mechanisms of immunoregulation during a normal pregnancy, a failing pregnancy, and during implantation failure in women with idiopathic infertility undergoing in vitro fertilization. It is becoming clear that the embryonic cell, which attaches the embryo to the uterine lining and eventually forms the placenta, initiates responses that stimulate a T helper 2 (Th-2) suppressive response (Fig. 1). Human leukocyte antigen (HLA) DQ A1 compatibility between the mother and the fetus results in the destruction of the embryo during the early stages of pregnancy. 101 In this circumstance, compatibility seems to breed autoimmune cellular and humoral immune contempt that becomes more aggressive the greater the number of pregnancy failures the woman experiences. Figures 1 and 2 outline in simple form how the trophoblast chooses the immune responses that protect versus those that are cytotoxic and result in failure.