Intravenous Immunoglobulin Therapy for Recurrent Spontaneous Abortion: A Meta-Analysis

PROBLEM: Published randomized trials of the use of intravenous immunoglobulins (IVIG) as a treatment for recurrent spontaneous abortion (RSA) have produced conflicting results. The purpose of this study was to conduct a systematic review of the current evidence to evaluate the effectiveness of IVIG for RSA. METHOD OF STUDY: After a thorough search of the literature, four randomized, doubleblind trials comparing IVIG with placebo for treatment of RSA were included in the metaanalysis. Live birth rates for each treatment group were extracted, and the overall odds ratio (OR) and absolute treatment effect for IVIG were calculated. RESULTS: Two of the trials showed an increase in successful pregnancy outcome with IVIG treatment and two did not. The overall OR was 1.48 (95% CI, 0.84–2.60) in favor of IVIG, with an absolute treatment effect of 10.1% (95% CI, ?4.8–24.6). Excluding pregnancy failures with an obvious cause produced statistically significant results, but this approach may be subject to bias. CONCLUSION: This meta-analysis suggests that IVIG may have a role in the treatment of recurrent abortion, but as yet no conclusive evidence is available.     

复发性自然流产患者绒毛滋养细胞FasL的表达

目的探讨复发性自然流产患者(RSA)绒毛滋养细胞FasL的表达与正常者有无差异。方法应用免疫组化和RT-PCR法,检测RSA患者和正常早孕妇女的绒毛滋养细胞FasL在蛋白水平和mRNA水平的表达,并进行图象分析和比较。结果免疫组化结果显示,绒毛合体滋养细胞和细胞滋养细胞的胞浆和胞膜上均有FasL表达,FasL在2组的定位无差异,但正常组绒毛滋养细胞FasL表达(PU=18.03±4.69)强于RSA组(PU=13.59±3.73),P<0.050。RT-PCR结果表明RSA组绒毛组织FasL在mRNA水平的表达为0.18±0.05,低于正常组0.27±0.06,差异有显著性意义(P<0.01)。结论不明原因RSA患者的绒毛滋养细胞FasL表达弱于正常者,滋养细胞FasL的表达减少可能在复发性自然流产中起重要作用。     

复发性流产的免疫治疗效果分析

目的了解采用淋巴细胞对复发性流产进行主动免疫的疗效。方法采用丈夫外周血淋巴细胞治疗复发性流产,454例患者疗程结束并成功随访,妊娠至20周后者为治愈。结果 116（25.55%）例足月分娩,治愈率70.48%（未包括已孕20周内）。其间1例孕20周诊断无脑儿,1例孕26周超声示胎儿先天性左心发育不良,畸形率0.44%。结论免疫治疗是安全、有效的治疗复发性流产的方法之一,能确实解决病患实际问题。     

Fertility Among Women With Recurrent Spontaneous Abortions—The Effect of Paternal Cell Immunization Treatment

PROBLEM : The risk of women whose chief complaint is recurrent spontaneous abortions (RSA) for secondary infertility (infecundability) has not been evaluated prospectively. The effect of paternal mononuclear cell immunization on conception rates is unknown. METHOD : Two hundred women whose chief complaint was RSA were randomly assigned to be immunized with paternal mononuclear cells either before or after (up to 6 postmenstrual weeks) conception. Fertility rates (both conception and live birth) were evaluated for the group immunized before conception and compared to those for the control group, who were not immunized until after conception, using life table and multiple logistic regression analyses. RESULTS : Prospectively ascertained, age-related conception rates for nonimmunized RSA controls appeared to be similar to those for general populations. Immunization before pregnancy had no significant effect (power ± 14%) on rates of conception (66% before, 77% after) or time to conceive (median weeks before 19.5, after 27.0). Live birth rates (before 59%, after 63%) were also similar for both groups (P = 0.7). CONCLUSION : Women whose only prior complaint was RSA were not at high risk for secondary infecundability, and immunization did not alter either conception rates or time to conceive. Postponement of immunization until after conception did not affect live birth rates for women selected for study because they did not have a history of prior infecundability or early repeated miscarriages.     

Extracellular Matrix Protein-dependent Apoptosis of T Cells in Women with a History of Recurrent Spontaneous Abortion

PROBLEM: The purpose of the study was to determine the role of T-cell apoptosis in extracellular matrix (ECM) environment in pregnancy maintenance in women with a history of recurrent spontaneous abortion (RSA). METHOD OF STUDY: Thirty-nine non-pregnant women with the history of RSA (anatomic, genetic, endocrine and microbiologic causes were excluded) and 22 healthy women with the previous successful pregnancy outcome were studied. In addition, 21 women with the history of RSA were also studied at the beginning of their next pregnancy. We studied apoptosis of peripheral blood T cells after culture with monoclonal antibody (mAb) OKT-3 alone or with mAb OKT-3 following ECM proteins: collagen IV (C-IV) or fibronectin (Fn). We used Cell Death Detection ELISA for studying cell death in cell population. In addition, apoptotic peripheral blood T cells were identified by annexin V-PE staining protocol using flow cytometry. CD29+ and CD95+ T-cell surface receptors were also analyzed by flow cytometry. RESULTS: The significantly higher values of enrichment factor: mU of the sample (dying/dead cells) per mU of the corresponding control (viable cells) were observed after peripheral blood T-cell culture with C-IV (P = 0.0002) or Fn (P = 0.004) in samples of non-pregnant women with the history of RSA when compared with control women. The significantly higher values of enrichment factor were observed after peripheral blood T-cell culture with C-IV in samples of pregnant women with the history of RSA with successful pregnancy outcome when compared with pregnant women with the history of RSA with failed pregnancy outcome (P = 0.01). However, the percentage of apoptotic T cells stained by annexin V was significantly lower in non-pregnant RSA women compared with control (P = 0.0001). CD95 expression was significantly lower in non-pregnant RSA women compared with control (P = 0.01). CONCLUSIONS: Apoptosis of T cells might be an interesting possible explanation of successful pregnancy outcome in women with the history of RSA.     

Worldwide Collaborative Observational Study and Meta-Analysis on Allogenic Leukocyte Immunotherapy for Recurrent Spontaneous Abortion1

PROBLEM: Recurrent spontaneous abortion (RSA) is a common complication of pregnancy for which there is no known cure. Therefore, effective treatment is needed. Published results from controlled clinical trials of allogeneic leukocyte immunization of women suffering from RSA have given conflicting results. To address this controversy, the international raw data of all patients who had been entered into clinical trials that included a control group were collected and analyzed. The primary question to be answered was whether alloimmune stimulation of the female partner improves the subsequent live birth rate. METHODS: Fifteen clinical centers were identified worldwide because they controlled appropriate raw data. Consequently, nine randomized trials (seven double-blinded) were evaluated independently by two separate data analysis teams to assure conclusions were robust. One team also compared randomized trials to the results of six nonrandomized cohort-controlled studies to test for bias in nonrandomized trials. Factors predicting successful live births among couples with RSA were evaluated by logistic regression. RESULTS: Although the two independent analyses made use of different definitions and utilized different statistical methods, the results of both were similar. The live birth ratios (ratio of live births in treatment and control groups) with 95% confidence intervals (CI) were 1.16 (CI, 1.01-1.34, P = 0.031) and 1.21 (CI, 1.04-1.37, P = 0.024), respectively. The absolute differences in live birth rates between treatment and control groups were 8% and 10% in respective analyses. Results in randomized and nonrandomized trials were surprisingly similar despite significant differences in composition of control and treatment groups. Live birth rates were lower with older female partners, more than five abortions, with a positive ANA or with positive anticardiolipin antibodies. Live birth rates were higher if the female partner had prior to treatment serum antibodies to paternal leukocytes or converted from negative to positive with immunization. Approximately 0.5% of controls and 2.1% of treated patients experience side effects for a 1.6% treatment related effect. There was no evidence of an increased risk of adverse effects on the fetus. CONCLUSIONS: Two independent analyses of worldwide data on allogeneic leukocyte immunization for treatment of RSA suggest that alloimmunization may be an effective treatment. The treatment effect appears, however, to be small, and the data indicate that immunotherapy helps only 8% to 10% of affected couples. A current lack of diagnostic tests defining patients who most likely would benefit from immunotherapy, precludes the identification of a patient population that would benefit most from such treatment. The efficacy of treatment in such a subgroup could be expected to increase and could be of sufficient magnitude to allow the determination of more effective immunization protocols. This study does not exclude the possibility of a partial correction of a widely prevalent immunology defect by immunotherapy. The presence of such a defect would indicate a need for more effective therapy. The unexplained variation in pregnancy success rates of control groups among centers continues to present a statistical problem, limiting the statistical evaluation of retroactively obtained data.     

反复早期自然流产妇女血浆蛋白Z检测的意义

目的探讨反复早期自然流产妇女血浆蛋白Z（PZ）检测的意义。方法分别测定26例反复早期自然流产患者和30例相同孕周的正常妊娠妇女血浆PZ和纤维蛋白原（Fg）水平以及凝血酶原时间（PT）和活化的部分凝血活酶时间（APTT）,采用单因素方差分析和非参数检验比较两组之间各项指标水平的差异。结果反复早期自然流产组PT、APTT、Fg水平与正常妊娠组相比差异无统计学意义（P〉0.05）,但反复早期自然流产组血浆PZ平均水平显著低于正常妊娠组[（1.55±0.63）mg/Lvs（1.90±0.60）mg/L,F=4.57,P=0.037],且其血浆PZ中位水平（1.45mg/L,范围：0.62～3.25mg/L）也显著性低于正常妊娠组（1.74mg/L,范围：0.78～3.36mg/L）（χ^=25.485,P=0.019）;以PZ〈0.90mg/L作为PZ缺乏的标准,反复早期自然流产组有4例（15.4%）、正常妊娠组有1例（3.3%）血浆PZ缺乏,但二者差异无统计学意义（χ^=22.49,P=0.115）。结论反复早期自然流产患者常规凝血指标和PZ缺乏率与正常对照组无差异,但其血浆中抑制因子Ⅹa活性的PZ水平较低,表明其发病可能与低PZ水平有一定的关系。     

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.     

复发性流产病因学研究现状分析

复发性流产为临床较为常见的妊娠并发症之一,属于妊娠早期衰退孕囊死亡的一种普遍形式,具有较高发生率,其不仅易影响女性心理健康与生活质量,还将对其妊娠结局产生直接影响,严重者可导致不孕不育,影响家庭和谐。随着生殖遗传学、生殖免疫学、分子细胞学技术的发展,临床对该疾病的发病机制有了新的发现,故本文将分析复发性流产的病因以及发病机制,拟为临床诊治提供理论依据,以改善妊娠结局,提高保胎成功率,降低RSA发生率。     

Intravenous Immunoglobulin in the Prevention of Recurrent Spontaneous Abortion: The European Experience

PROBLEM: Clinical trials of the use of intravenous immunoglobulin (IvIg) in the treatment of recurrent spontaneous abortion (RSA) in Europe were reported and discussed. METHOD OF STUDY: A search of the published literature, combined with our own published and unpublished results, was performed. RESULTS: Two placebo-controlled trials have been concluded in Europe. One trial found high but equal success rates in both the IvIg and the placebo group. Another trial found that IvIg treatment may increase the success rate by 24% compared with placebo but that the result was not statistically significant, which might be due to the small number of patients. Reasons for the diverse results of the two trials were discussed. CONCLUSION: More and larger placebo-controlled trials of IvIg treatment in RSA are needed before drawing definitive conclusions.     

The Effectiveness of Allogeneic Leukocyte Immunization in Unexplained Primary Recurrent Spontaneous Abortion

PROBLEM: Unexplained primary recurrent spontaneous abortion (RSA) can be viewed as a partner-specific problem for which immunization with allogeneic leukocytes is being offered as therapy. Published data from randomized controlled trials have produced conflicting results regarding treatment effectiveness. The aim of this study was to perform a subgroup analysis of the data from a recent worldwide collaborative meta-analysis using the raw data for patients with primary RSA entered into randomized controlled trials of immunotherapy. METHODS: Data from randomized controlled trials in eight centers were included in this analysis. Individual patients were included only if they had had three or more spontaneous abortions, no previous pregnancy beyond 20 weeks' gestation, no identifiable cause for the abortions, and no evidence of antipaternal antibodies. Meta-analysis by centre and logistic regression analysis were performed to determine the overall effect of treatment in achieving live birth and to identify variables that affect the prognosis for a successful outcome. RESULTS: In the meta-analysis by center, immunotherapy significantly improved the live birth rate (common odds ratio = 1.94, 95% confidence interval (CI) = 1.20 to 3.12). In the analysis by patient, the likelihood of a successful outcome was also significantly better with treatment (relative risk = 1.46, 95% CI 1.19 to 1.69). The absolute treatment effect was 16.3% producing a number needed to treat of 6. The number of previous abortions had a significant negative correlation with live birth rate, such that for each additional pregnancy loss beyond three, the likelihood of live birth was reduced by 23%. CONCLUSION: Allogeneic leukocyte immunization is an effective treatment for unexplained primary RSA when pretreatment antipaternal antibodies are absent. Better diagnostic tests are required to identify patients who may derive maximal benefit from this therapeutic approach.     

Cell-Mediated Immunity to Human and Escherichia coli 60-kDa Heat Shock Protein in Women: Association with A History of Spontaneous Abortion and Endometriosis

PROBLEM: Heat shock proteins are expressed during early pregnancy and in peritoneal fluids from women with endometriosis. The relationship between a cell-mediated immune response to human 60-kDa heat shock protein (hsp60), spontaneous abortion, and endometriosis was examined. METHOD OF STUDY: Peripheral blood mononuclear cells (PBMCs) from 110 female partners of infertile couples undergoing in vitro fertilization and 41 fertile control subjects were incubated with human hsp60 or Escherichia coli hsp60. PBMC proliferation was measured by [³H]thymidine incorporation, and a stimulation index was calculated. RESULTS: Lymphocytes from 21.8% of the infertile women, as opposed to 7.3% of the fertile women, proliferated in response to human hsp60 (P = 0.05). In contrast, proliferation in response to the E. coli hsp60 was equivalent in both groups. Within the infertile group, the response to human hsp60 was 40.7% among women with a history of spontaneous abortion and only 12% in those with no history of spontaneous abortion (P = 0.003). There was no association between immunity to E. coli hsp60 and spontaneous abortion or between immunity to human hsp60 and therapeutic abortion or the cause of infertility. Immunity to the E. coli hsp60 was associated with endometriosis. CONCLUSIONS: A cell-mediated autoimmune response to human hsp60 is associated with a history of spontaneous abortion, whereas immunity to E. coli hsp60 was most prevalent in women with endometriosis.     

药物联合情绪管理疗法在治疗不明原因复发性流产的临床疗效观察

目的 探讨联合疗法在不明原因复发性流产中治疗的临床疗效。方法 选取2016年3月~2018年2月来自广元市中医医院60例不明原因的复发性流产患者设为观察组,采用药物联合情绪管理疗法治疗,将文献中采用相同疗法的63例设为文献观察组,采用通用治疗方案64例设为文献对照组,比较其发生副反应发生率及妊娠成功率。结果 观察组妊娠成功54例,妊娠成功率为90.00%（54/60）,高于文献对照组的76.56%（49/64）,差异有统计学意义（P＜0.05）;观察组副反应发生率为6.67%（4/60）,其中1例出现红疹,3例出现红肿硬结等不良反应,低于文献对照组的15.62%（10/64）,差异有统计学意义（P＜0.05）;观察组妊娠成功率及副反应发生率分别与文献观察组比较,差异无统计学意义（P＞0.05）。结论 联合疗法治疗不明原因习惯性流产方法可靠,疗效肯定,且不增加副反应,值得借鉴应用。     

Allogenic Lymphocyte Immunotherapy for Unexplained Recurrent Spontaneous Abortion: A Meta‐Analysis

Allogenic lymphocyte immunotherapy (LIT) as a treatment for unexplained recurrent spontaneous abortion (URSA) is still controversial due to the lack of enough controls to evaluate its effectiveness. Eighteen randomized, placebo‐controlled trials with LIT for URSA were included in the meta‐analysis. Live birth rates for each group were extracted, and the overall odds ratio (OR) for LIT was calculated. The success rate of treatment group was significantly higher (OR 3.74, 95% CI 3.07 ~ 4.57). LIT performed before and during pregnancy had dramatically improved the live birth rate in women with URSA (OR 4.67, 95% CI 3.70 ~ 5.90). The overall OR was 5.25 (95% CI 4.16 ~ 6.64), which supports a low dose of lymphocytes for treating URSA. Our results indicate that LIT provides a significantly beneficial effect over placebo for URSA. LIT given before and during pregnancy is superior to LIT given only before pregnancy, and the lower doses per treatment (less than 100 × 10⁶ lymphocytes or 100 mL peripheral blood) achieved a better outcome.     

精子抗原对RSA者和不孕症患者外周血单个核细胞产生IgE的影响

探讨精子抗原(SAg)对反复自然流产(RSA)者和不孕症患者外周血单个核细胞(PBMC)产生IgE的影响。用ELISA法分别测定36例RSA者,34例不孕症患者和22名正常妊娠者血清IgE和PBMC与SAg培养液中IgE水平。结果表明,血清IgE水平大于150 IU/mL的RSA者和不孕症患者与血清IgE水平≤150 IU/mL患者及早孕对照者相比,PBMC经SAg刺激后,培养液中IgE水平显著升高,提示SAg可诱导部分RSA和不孕症患者产生特异性IgE,这可能在RSA者和不孕症的发病机理中起一定作用。     

Influence of Histocompatibility Antigens in Recurrent Spontaneous Abortion Couples and on Their Reproductive Performances

PROBLEM: To determine if human leukocyte antigens (HLA) play any role in the aetiology of recurrent spontaneous abortion (RSA), a substantial group of RSA couples were studied, and their reproductive performances in a 3-year follow-up recorded. METHODS: HLA typing was performed for HLA-A, -B, and DR antigens in both partners of 75 couples with unexplained RSA, and compared with a control group of 30 fertile couples that never experienced abortion. A further 57 couples of this group were studied for their reproductive performance in a 3-year follow-up, and subdivided into three subgroups: 1) couples that achieved successful pregnancy during the follow-up; 2) couples that experienced abortion and no livebirth during the follow-up; and 3) couples that experienced infertility during the follow-up. RESULTS: There were no significant differences for antigen frequency in all the different HLA loci, and HLA antigen sharing between all the RSA couples and controls. Significant increase of sharing for HLA-DR locus was observed in the couples that aborted during the follow-up with respect to the couples that achieved livebirth and controls (P < 0.03 and P < 0.02 respectively), and significantly increased frequency of B44, DR5 antigen combination in the same comparison (P < 0.03). No significant differences were observed in terms of the interval between conceptions in couples without antigen sharing with respect to couples with 1, 2 or more antigens shared, and antigen sharing in Locus A, B or DR. CONCLUSIONS: The results suggest that gene(s) disadvantageous for reproduction may exist between the HLA-B and -DR chromosomal region which influences the pregnancy outcome in RSA couples, and that HLA-antigen sharing itself does not influence the outcome.     

Clinical Trial of Immunostimulation with a Biological Response Modifier in Unexplained Recurrent Spontaneous Abortion Patients

We determined clinically whether a killed streptococcal preparation (KSP), a biological response modifier, is as effective as paternal lymphocyte immunotherapy for unexplained recurrent pregnancy abortion (RSA) therapy. The success rate of adverse pregnancy in the study group of 23 RSA cases, who were administered low doses of KSP before and during early pregnancy, was statistically compared with that in a control group of 205 women who received paternal lymphocyte immunotherapy. The association of natural killer (NK) cell activity in the peripheral blood with pregnancy outcome was also assessed. The success rate in the study group was 73.9% (17/23), compared to 75.1% (154/ 205) observed for the controls (not significant). Most of the successful cases exhibited low levels of NK cell activity in the peripheral blood. Immunotherapy with low doses of KSP is as effective as that with paternal lymphocytes, providing a simple and safe alternative therapy for unexplained RSA. Suppression of NK cell activity by some immunoregulatory mechanism was also found to have potential benefit in terms of a successful pregnancy outcome.     

改良单向混合淋巴细胞培养在反复自然流产诊疗中应用

为了避免现行封闭抗体检测方法的不合理性,对其进行改进,将男方刺激细胞与妇女待测血清孵育,然后分离结合了封闭抗体的刺激细胞,将经或未经封闭抗体作用的男方刺激细胞分别与女方反应细胞在25%正常AB型血清同等培养条件下培养6d.改进后方法测得正常生育组与原发性反复自然流产组封闭效率阳性率为57.1%及12.3%,均数为7.53±10.30及—55.51±13.41.改进后方法的准确度(81.7%)、灵敏度(87.8%)及特异性(57.1%)均高于改进前.在分析白细胞免疫疗法免疫效果时发现,改进后的方法更能准确反应患者体内封闭效率逐渐上升趋势.改进后的封闭效率在评价反复自然流产治疗的临床疗效时优于改进前.