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Role of Role of Immunotherapy Immunotherapy in ART in ART

한림의대 산부인과한림의대 산부인과 서 수 형서 수 형

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IntroductionIntroduction 1993, ASRM 1993, ASRM • Implantation rate Implantation rate perper ET: 10 ET: 10 –– 15% 15% enhanced protocols for COHenhanced protocols for COH improved embryo culture techniquesimproved embryo culture techniques assisted hatchingassisted hatching ICSIICSI

• morphologically normal embryo, not much morphologically normal embryo, not much above 20% per egg retrievalabove 20% per egg retrieval

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Historical reviewHistorical review

1978 Steptoe and Edward1978 Steptoe and Edward the first test tube baby was bornthe first test tube baby was born

1986 Navot et al1986 Navot et al ovum donation model ovum donation model –– window of embryo window of embryo transfertransfer

1986 Clark et al1986 Clark et al : : 1987 Allen et al1987 Allen et al development of animal model development of animal model for implantationfor implantation

1987 Gleicher et al1987 Gleicher et al increased prevalence of antiphospholipid increased prevalence of antiphospholipid antibody in patient with pelvic antibody in patient with pelvic endometriosisendometriosis

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Historical reviewHistorical review

1989 Navot et al1989 Navot et al uterine receptivity and embryonic-uterine receptivity and embryonic-uterine interactionuterine interaction

1991 Fisch et al1991 Fisch et al autoantibodies to phospholipid in autoantibodies to phospholipid in unsuccessful IVF-ET cyclesunsuccessful IVF-ET cycles

1992 Dwyer1992 Dwyer clinical use of intravenous clinical use of intravenous immunoglobulin for inflammatory immunoglobulin for inflammatory responseresponse

1994 De Placido et al1994 De Placido et al intravenous Ig use for IVF/ET intravenous Ig use for IVF/ET

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Historical reviewHistorical review

1994 Sher et al1994 Sher et al use of low dose heparin and aspirin use of low dose heparin and aspirin in IVF failure patients in IVF failure patients

1997 Bustilo et al1997 Bustilo et al use of GM-CSF in IVF failure patientsuse of GM-CSF in IVF failure patients

1998 Sher et al1998 Sher et al combination immunotherapy in IVF combination immunotherapy in IVF patient with antiphospholipid patient with antiphospholipid antibodyantibody

1999 Würfel et al1999 Würfel et al use of GM-CSF and G-CSF in use of GM-CSF and G-CSF in recurrent IVF failure grouprecurrent IVF failure group

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Complex immune mechanisms Complex immune mechanisms on implantation on implantation

local uterine and systemic immune local uterine and systemic immune responseresponse

• decreased in cell-mediated immunity decreased in cell-mediated immunity and increased in humoral immunityand increased in humoral immunity

• mediated by inhibitory subset of T-mediated by inhibitory subset of T-helper (TH cell) helper (TH cell)

• increased concentrations of PGEincreased concentrations of PGE2 2

and PGFand PGF22α at the implantation siteα at the implantation site• increase vascular permeabilityincrease vascular permeability

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Autoimmune disordersAutoimmune disorders

• estrogen regulate the synthesis of estrogen regulate the synthesis of Ig and production of autoantigensIg and production of autoantigens

• estrogens interacts with specific estrogens interacts with specific steroid receptors in steroid receptors in CD 8+ T cellsCD 8+ T cells and in and in CD 5+ B cellsCD 5+ B cells

• premature ovarian failure, premature ovarian failure, autoimmune endocrine diseaseautoimmune endocrine disease

• autoimmune disorders; high autoimmune disorders; high incidence of pregnancy wastage -incidence of pregnancy wastage - SLE, scleroderma, HashimotoSLE, scleroderma, Hashimoto’’s s thyroiditisthyroiditis

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Cellular surface Cellular surface phospholipidphospholipid

• functions; functions; adhesion molecule in the formation of adhesion molecule in the formation of myoblast and syncytiotrophoblastmyoblast and syncytiotrophoblast

• local or systemic tissue damage; local or systemic tissue damage; pelvic inflammatory disease, pelvic inflammatory disease, endometriosis, post-surgical endometriosis, post-surgical adhesionsadhesions

• converts from a bilaminar converts from a bilaminar configuration to a hexagonal phase II configuration to a hexagonal phase II structurestructure

• combine with lipoprotein; combine with lipoprotein; antigenic antigenic

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Platelet activation factor Platelet activation factor (PAF)(PAF)

• ether-linked phospholipidether-linked phospholipid• produced by produced by blastocyst, invading blastocyst, invading

trophoblast, adjacent deciduatrophoblast, adjacent decidua • facilitates implantation; facilitates implantation; increasing increasing

local consumption of thrombocyteslocal consumption of thrombocytes• promoting release of promoting release of PGEPGE22

• promotes local production of promotes local production of early early pregnancy factor, an pregnancy factor, an immunosuppressive glycoprotein immunosuppressive glycoprotein

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Antiphospholipid antibody Antiphospholipid antibody (APA)(APA)

• main antibody from non-specific main antibody from non-specific tissue injurytissue injury

• response to variety of phospholipids, response to variety of phospholipids, extra- and intracellularlyextra- and intracellularly

• APA seropositive; APA seropositive; 5 to 17%5 to 17% in general population in general population vs vs 59%59% in recurrent spontaneous in recurrent spontaneous abortion (RSA) groupabortion (RSA) group

• phospholipid epitopes; phospholipid epitopes; phosphoethanolamine, phosphoserin, phosphoethanolamine, phosphoserin, phosphatidic acid, phosphoinositol, phosphatidic acid, phosphoinositol, phosphoglycerol, cardiolipinphosphoglycerol, cardiolipin

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APA and pregnancy wastageAPA and pregnancy wastage

• transient production during ovarian transient production during ovarian stimulation and /or as a consequence of stimulation and /or as a consequence of oocyte retrieval oocyte retrieval disappearance within disappearance within several weeksseveral weeks

• bind with surface phospholipid on the bind with surface phospholipid on the trophoblast; trophoblast; direct cellular injury and direct cellular injury and inhibition of syncytia formationinhibition of syncytia formation

• platelet membrane and/or endothelial cell platelet membrane and/or endothelial cell wall damage; wall damage; indirect damage through indirect damage through intravascular thrombosisintravascular thrombosis

• inhibition of prostacyclin and inability to inhibition of prostacyclin and inability to activate protein C; activate protein C; hypercoagulable statehypercoagulable state

• interfere with the interfere with the adhesive propertyadhesive property of of phospholipid in the process of implantationphospholipid in the process of implantation

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Anticardiolipin antibody Anticardiolipin antibody (ACA)(ACA)

• the earliest of the APAs to be identified the earliest of the APAs to be identified • cardiolipin endomitochodrially bound and cardiolipin endomitochodrially bound and

deep seated within the cell deep seated within the cell • less antigenic and less likely form APAsless antigenic and less likely form APAs• less frequently detected than other APAsless frequently detected than other APAs• the least threat to the trophoblastthe least threat to the trophoblast• 6% positive in study group6% positive in study group vsvs

0 to 3 % in control group0 to 3 % in control group

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Lupus anticoagulant (LAC)Lupus anticoagulant (LAC)

• conglomerate of a wide variety of conglomerate of a wide variety of non-cardiolipin APAsnon-cardiolipin APAs

• diagnosing primary autoimmune diagnosing primary autoimmune states states relatively high concentrations relatively high concentrations of APAof APA

• lack of sufficient sensitivity and lack of sufficient sensitivity and specificity to diagnose low specificity to diagnose low concentrations of APAconcentrations of APA

• highly unreliable in assessing highly unreliable in assessing autoimmunity in association with autoimmunity in association with reproductive failure and infertilityreproductive failure and infertility

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Antithyroid antibody (TA)Antithyroid antibody (TA)

• prevalence of underlying prevalence of underlying subtle thyroid abnormality; subtle thyroid abnormality; 17%17%

• increased risk of spontaneous increased risk of spontaneous abortion abortion 13.3% 13.3% vsvs 3.3% 3.3% in in controlcontrol (p<.001) (p<.001)

• high incidence of reproductive high incidence of reproductive failure, recurrent miscarriages, failure, recurrent miscarriages, and IVF failureand IVF failure

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Human histocompatibility Human histocompatibility antigen HLA-Gantigen HLA-G

• HLA-G expression in early HLA-G expression in early cytotrophoblastcytotrophoblast

• shield the fetus from shield the fetus from rejection rejection eliciting local production of eliciting local production of

maternal suppressor cells maternal suppressor cells protective blocking antibodyprotective blocking antibody being nonrecognizablebeing nonrecognizable

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Peripheral blood Peripheral blood lymphocyteslymphocytes

• CD56+/CD16- T-lymphocyte CD56+/CD16- T-lymphocyte NK (natural killer) cellNK (natural killer) cell

• elevated NK cell; elevated NK cell; presence of presence of antiphospholipid antibody (APA)antiphospholipid antibody (APA)

• elevated CD19+/CD5+ B lymphocyte; elevated CD19+/CD5+ B lymphocyte; antibodies to DNA and DNA antibodies to DNA and DNA componentscomponents

• measuring NK cell; measuring NK cell; far easierfar easier than than quantitating APA levelsquantitating APA levels

• predictors of reproductive failure in predictors of reproductive failure in RSA and infertility with prior IVF failureRSA and infertility with prior IVF failure

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ImmunotherapyImmunotherapy

• heparinheparin• aspirinaspirin• intravenous Igintravenous Ig• corticosteroidscorticosteroids• GM-CSF/G-CSFGM-CSF/G-CSF

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HeparinHeparin• endogenous production by

trophoblast• inhibits biding of APA with

trophoblast• prevents APA from interfering with

syncytialization • counters APA interference with

phospholipid-induced decidual reactions

• promotes both early implantation and subsequent placentation

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AspirinAspirin • anti-thromboxane effects • inhibits platelet aggregation• counter APA-mediated

hypercoagulability in the choriodecidual space

• hemo-chorial relationship; established with placentation

• protect the trophoblast from damage after establishment of placentation

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Intravenous Intravenous immunoglobulinimmunoglobulin • passively transferred blocking or

anti-idiotypic antibodies• blockade of Fc receptors• enhancing suppressor T cell

function• down-regulation of B cell function• reduction of activation of

complement components• reduction of activation of NK cells

to activated killer (LAK) cells

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Intravenous Intravenous immunoglobulinimmunoglobulin

• i.v. Ig 500 mg/kg prior to embryo transfer

• repetitive i.v. Ig 500 mg/kg every 28 days until delivery or until 28-32 weeks of gestation

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CorticosteroidsCorticosteroids

• controversial and questionable• 60 mg of methylprednisolone for 4

days• diminish the uterine T-

lymphocytes• suppressing T-cell function;

decreased implantation rate and increased abortion rate

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GM-CSFGM-CSF • product of activated T-lymphocyte• proliferation and differentiation of

myeloid hematopoietic cells• produced by estrogen-primed

epithelial cell in the oviduct and uterus

• antibodies to T-suppressor (CD 8+) cells; increased abortion rate in mice

• monoclonal anti GM-CSF; increases abortion rate in mice

• anti CD 8+ treatment; block the protective effect of GM-CSF

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Incidence of Autoimmune Incidence of Autoimmune Antibodies Antibodies in Failed Embryo Transfer in Failed Embryo Transfer CycleCycle Birkenfeld et al; AJRI 1994, Mount Sinai Sch of Birkenfeld et al; AJRI 1994, Mount Sinai Sch of MedMed

Group I 56 patients who are failed to conceive following ET 18 (32.1%), positive for one or more Abs Group II 14 patients who have conceived following IVF-ET none of the patients positive for Ab’s (p<.02) Group III 69 patients who were new

candidates for IVF-ET 7 (10%), positive for autoimmune Ab’s (p<.003)

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Incidence of Autoimmune Incidence of Autoimmune Antibodies Antibodies in Failed Embryo Transfer in Failed Embryo Transfer CycleCycle Birkenfeld et al; AJRI 1994, Mount Sinai Sch of Birkenfeld et al; AJRI 1994, Mount Sinai Sch of MedMed

15 of the 18 positive patients subsequent IVF-ET cycle

10 mg of prednisolone + 80 mg of aspirin daily

beginning 2 weeks prior to the initiation of the cycle

7 (46.6%), conceived and ongoing pregnancy

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Antiphospholipid Antibody Antiphospholipid Antibody Treated Treated with Heparin and Aspirin with Heparin and Aspirin G Sher and M FeinmanG Sher and M Feinman Hum Reprod 1994, Pacific Fertility Med Hum Reprod 1994, Pacific Fertility Med CntrCntr

the first IVF-ET cycleELISA for six different

phospholipidsaspirin 81 mg orally q.d., and

heparin 5000 IU s.c. b.i.d.beginning on day 2 of COH

through the 34weeks of pregnancy

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Antiphospholipid Antibody Antiphospholipid Antibody Treated Treated with Heparin and Aspirin with Heparin and Aspirin G Sher and M FeinmanG Sher and M Feinman Hum Reprod 1994, Pacific Fertility Med Hum Reprod 1994, Pacific Fertility Med CntrCntr

prevalence of APA 53% in patients with organic pelvic

disease vs 14% without pathology viable pregnancy rate in APA

seropositive pts 49% in H/A group vs 16% in untreated group (p<.05) vs 27% in untreated seronegative group

(p<.001)

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Combined heparin/aspirin Combined heparin/aspirin and Ig G therapy in IVF and Ig G therapy in IVF with APA with APA G Sher et al; AJRI 1998, Pacific Fertility Med G Sher et al; AJRI 1998, Pacific Fertility Med CntrCntr

89 women <36 years of age, experienced 4 or more failed IVF/ET cycle

group A; 52 women – APA positivegroup B; 37 women – APA

negative live birth rate; A : B = 42% : 19% (p=.020)

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Combined heparin/aspirin Combined heparin/aspirin and Ig G and Ig G therapy in antithyroid therapy in antithyroid antibodyantibody G Sher et al; AJRI 1998, Pacific Fertility Med G Sher et al; AJRI 1998, Pacific Fertility Med CntrCntr

82 women <40 years of age with ATA but negative for APA

group A; 37 women - received H/A alone

group B; 45 women - received H/A with IVIg

live birth rate after single IVF/ET cycle

A : B = 27% : 51% (p=.027)

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Effect of APA in IVF Effect of APA in IVF : role of heparin and : role of heparin and aspirinaspirin W Kutteh et al; Hum Reprod 1997, W Kutteh et al; Hum Reprod 1997, MemphisMemphis Positive APA 18.8% of 191 patients in IVF group vs 5.5% of 200 normal control group 26% of APA+ in 200 women with recurrent pregnancy loss heparin and aspirin treatment no statistical differences in

implantation and pregnancy rate

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Birdsall in Oxford, Hum Reprod 1996; Birdsall in Oxford, Hum Reprod 1996; APAAPA

240 women <38years, fewer than three previous IVF cycles

APA, not associated with a failed IVF cycle or miscarriage

no association between the cause of infertility and the presence of APA

A Kowalik in Cornell, Fertil Steril 1997; ACA and antiphosphatidylserine

antibody no correlation between outcome and

the antibody isotype expressed

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A Denis and R Scott; Fertil Steril 1997, Pennsylvania

elevated APA levels, not associated with any change in PRs or pregnancy loss

rates

F Azem et al; AJRI 1998, Tel Aviv anticardiolipin antibody (ACA) with

abnormal embryo morphology 

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S Spandorfer and Z Rosenwaks; AJRI 1998, Cornell Univ.

GM-CSF by endometrial co-culture in IVF with multiple implantation failure

C Sjoblom et al; Hum Reprod 1999,

Sweden GM-CSF promotes blastocyst

development

 

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In-vitroIn-vitro processing of sperm with processing of sperm with autoantibodiesautoantibodiesM Almeida et al; Hum Reprod 1989, M Almeida et al; Hum Reprod 1989,

FranceFrance

20 infertile couples with anti-sperm antibodiesoverall fertilization rate 38.9% in post-migration (PM)14% in antibody-coating >70% group vs 60% in <70%post-migration immuno-depleted sperm

preparation (PMP) with Mage’s plate10 couples with PMP; containing <65% of

antibody-coated spermatozoa, 31% fertilizedfertilization rate; 10% in PM vs 26% in PMP