Recurrent pregnancy loss evaluation combined with 24-chromosome microarray of miscarriage tissue provides a probable or definite cause of pregnancy loss in over 90% of patients.

STUDY QUESTION: Will the addition of 24-chromosome microarray analysis on miscarriage tissue combined with the standard American Society for Reproductive Medicine (ASRM) evaluation for recurrent miscarriage explain most losses? SUMMARY ANSWER: Over 90% of patients with recurrent pregnancy loss (RPL) will have a probable or definitive cause identified when combining genetic testing on miscarriage tissue with the standard ASRM evaluation for recurrent miscarriage. WHAT IS KNOWN ALREADY: RPL is estimated to occur in 2-4% of reproductive age couples. A probable cause can be identified in approximately 50% of patients after an ASRM recommended workup including an evaluation for parental chromosomal abnormalities, congenital and acquired uterine anomalies, endocrine imbalances and autoimmune factors including antiphospholipid syndrome. STUDY DESIGN, SIZE, DURATION: Single-center, prospective cohort study that included 100 patients seen in a private RPL clinic from 2014 to 2017. All 100 women had two or more pregnancy losses, a complete evaluation for RPL as defined by the ASRM, and miscarriage tissue evaluated by 24-chromosome microarray analysis after their second or subsequent miscarriage. PARTICIPANTS/MATERIALS, SETTING, METHODS: Frequencies of abnormal results for evidence-based diagnostic tests considered definite or probable causes of RPL (karyotyping for parental chromosomal abnormalities, and 24-chromosome microarray evaluation for products of conception (POC); pelvic sonohysterography, hysterosalpingogram, or hysteroscopy for uterine anomalies; immunological tests for lupus anticoagulant and anticardiolipin antibodies; and blood tests for thyroid stimulating hormone (TSH), prolactin and hemoglobin A1c) were evaluated. We excluded cases where there was maternal cell contamination of the miscarriage tissue or if the ASRM evaluation was incomplete. A cost analysis for the evaluation of RPL was conducted to determine whether a proposed procedure of 24-chromome microarray evaluation followed by an ASRM RPL workup (for those RPL patients who had a normal 24-chromosome microarray evaluation) was more cost-efficient than conducting ASRM RPL workups on RPL patients followed by 24-chromosome microarray analysis (for those RPL patients who had a normal RPL workup). MAIN RESULTS AND THE ROLE OF CHANCE: A definite or probable cause of pregnancy loss was identified in the vast majority (95/100; 95%) of RPL patients when a 24-chromosome pair microarray evaluation of POC testing is combined with the standard ASRM RPL workup evaluation at the time of the second or subsequent loss. The ASRM RPL workup identified an abnormality and a probable explanation for pregnancy loss in only 45/100 or 45% of all patients. A definite abnormality was identified in 67/100 patients or 67% when initial testing was performed using 24-chromosome microarray analyses on the miscarriage tissue. Only 5/100 (5%) patients, who had a euploid loss and a normal ASRM RPL workup, had a pregnancy loss without a probable or definitive cause identified. All other losses were explained by an abnormal 24-chromosome microarray analysis of the miscarriage tissue, an abnormal finding of the RPL workup, or a combination of both. Results from the cost analysis indicated that an initial approach of using a 24-chromosome microarray analysis on miscarriage tissue resulted in a 50% savings in cost to the health care system and to the patient. LIMITATIONS, REASONS FOR CAUTION: This is a single-center study on a small group of well-characterized women with RPL. There was an incomplete follow-up on subsequent pregnancy outcomes after evaluation, however this should not affect our principal results. The maternal age of patients varied from 26 to 45 years old. More aneuploid pregnancy losses would be expected in older women, particularly over the age of 35 years old. WIDER IMPLICATIONS OF THE FINDINGS: Evaluation of POC using 24-chromosome microarray analysis adds significantly to the ASRM recommended evaluation of RPL. Genetic evaluation on miscarriage tissue obtained at the time of the second and subsequent pregnancy losses should be offered to all couples with two or more consecutive pregnancy losses. The combination of a genetic evaluation on miscarriage tissue with an evidence-based evaluation for RPL will identify a probable or definitive cause in over 90% of miscarriages. STUDY FUNDING/COMPETING INTEREST(S): No funding was received for this study and there are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: Not applicable.

'Non-criteria' aPL tests: report of a task force and preconference workshop at the 13th International Congress on Antiphospholipid Antibodies, Galveston, TX, USA, April 2010.

Abstract: Current classification criteria for definite APS recommend the use of one or more of three positive standardized laboratory assays, including anticardiolipin antibodies (aCL), lupus anticoagulant (LA), and antibodies directed to ß(2)glycoprotein I (anti-ß(2)GPI) to detect antiphospholipid antibodies (aPL) in the presence of at least one of the two major clinical manifestations (i.e., thrombosis or pregnancy morbidity) of the syndrome. Several other autoantibodies shown to be directed to phospholipids and/or their complexes with phospholipids and/or to proteins of the coagulation cascade, as well as a mechanistic test for resistance to annexin A5 anticoagulant activity, have been proposed to be relevant to APS. A task force of worldwide scientists in the field discussed and analyzed critical questions related to 'non-criteria' aPL tests in an evidence-based manner during the 13th International Congress on Antiphospholipid Antibodies (APLA 2010, 13-16 April 2010, Galveston, Texas, USA). This report summarizes the findings, conclusions, and recommendations of this task force.

Production of predominantly polymeric IgA by human peripheral blood lymphocytes stimulated in vitro with mitogens.

Human peripheral blood lymphocytes (PBL) were cultured for various time periods (up to 8 d) in the presence of pokeweed mitogen (PWM), lipopolysaccharide, or Epstein-Barr virus. Cell-free supernates were fractionated on a standardized ultrogel AcA 22 column and the proportion of polymeric and monomeric IgA was determined by radioimmunoassay. The results demonstrate that PBL stimulated with these mitogens produce IgM and IgG with molecular characteristics identical to those found in serum, but that the IgA produced is predominantly of the polymeric type. To prove that this IgA represented disulfide bond-linked polymers rather than aggregated monomers, we have demonstrated that the high molecular weight IgA (a) maintains its polymeric form upon treatment with acidic buffers, (b) contains J chain, a glycoprotein associated only with polymeric immunoglobulins, and (c) dissociates to the monomeric form upon reduction of disulfide bonds. After 1 wk in culture, approximately 60% of the PWM-stimulated cells that contained IgA were positive for IgA2, whereas 40% were IgA1 positive as determined by immunofluorescence. Therefore, peripheral blood contains a population of lymphocytes with the potential to display, after appropriate stimulation and differentiation, characteristics similar to IgA cells found in external secretory tissues. The demonstration of the presence of such cells in the peripheral circulation suggests that these cells are precursors of IgA-producing plasma cells with the potential to populate mucosal tissues.

Autologous antibodies eluted from membrane fragments in human ovarian epithelial neoplastic effusions. II. Tissue specificity and reactivity.

Cyst and ascitic fluids from patients with ovarian epithelial neoplasms were studied to determine whether they contained immunoglobulins with antitumor activity. The results demonstrated the presence of autologous antibodies bound to the cellular membrane fragments obtained from human ovarian neoplastic effusions. Membrane fragments were prepared from more than 60 samples of human ovarian effusions, and the amounts of membrane-bound IgG and IgA were determined. Six fluids obtained from patients with malignant ovarian neoplasms were selected for large-scale preparation of IgG, on the basis of the quantity of fluid available (greater than 200 ml) and amount of membrane-bound IgG (greater than 400 ng/ml) determined by enzyme-linked immunoassay. The antibodies were strongly reactive with cell-surface antigens on 4 different human ovarian cell lines, 4 surgical specimens of human ovarian adenocarcinoma, and 2 human ovarian tumors grown in athymic BALB/c mice, as demonstrated by indirect immunofluorescence. The antibodies did not react, or reacted only weakly, with tissue preparations from 4 normal human ovaries, other nonovarian normal or neoplastic tissues, and nonovarian human cell lines. These studies indicate that patients with ovarian cancer have the capability to recognize and form antibodies against autologous ovarian tumor-associated antigens.

Biosynthesis of J-chain in human lymphoid cells producing immunoglobulins of various isotypes.

The relationship between synthesis, secretion, and subcellular localization of J-chain, IgM, IgA, and IgG was investigated in cultures of PWM-stimulated human PBL and in lymphoblastoid cell lines. Cells were examined for surface, cytoplasmic, and secreted immunoglobulins (Igs) and J-chain by immunofluorescence and radioimmunoassay (RIA). By these techniques, J-chain was detected in cells that produce polymeric or monomeric Igs. In PWM-stimulated PBL the synthesis of J-chain paralleled the production of Igs. In both PWM-stimulated (for 2 days) and unstimulated PBL, equal proportions of free and disulfide-linked J-chain were found. Increased amounts of intracellular J-chain were produced at later stages in PWM-stimulated PBL and J-chain occurred mostly in a free form. In tissue culture fluids, J-chain was not secreted in a free form but was always disulfide-linked to polymeric Igs. In lymphoblastoid cell lines, J-chain was present in a disulfide-linked form in IgM and IGA producers, but in IgG cells and in an IgM cell line (DAUDI) that did not secrete IgM but expressed it on the cell membrane, intracellular J-chain was present in free form. Although various proportions of polymeric and monomeric IgA were seen in culture fluids from IgA-secreting cell lines, intracellular IgA occurred mostly in a monomeric form. Further studies revealed that the ability to produce polymers was not equally distributed among all cells and might vary according to their content of J-chain and stage of maturation. Subcellular fractionation and subsequent analyses for J-chain and Ig in PWM-stimulated PBL and in IgM or IgG-producing cell lines revealed that these proteins were associated with fractions that contained ribosomes, cell sap, and low molecular weight RNA. In lysates of IgG and J-chain producing cells grown in the presence of 3H-labeled amino acids, intracellular J-chain was not disulfide-linked to IgG.

Glucocorticoids inhibit lipopolysaccharide-induced production of tumor necrosis factor-alpha by human fetal Kupffer cells.

Inflammatory mediators, such as interleukin-1 beta (IL-1 beta) and tumor necrosis factor-alpha (TNF alpha) are secreted by fixed tissue macrophages and exhibit local autocrine and paracrine effects as well as distant endocrine effects. Human fetal Kupffer cells, the fixed tissue macrophages of the liver, may play a role as modulators of immune and endocrine function in early embryonic and fetal development. In the present study we isolated human fetal Kupffer cells to greater than 90% purity and prepared short term cultures to investigate the effect of glucocorticoids on the secretion of the cytokine TNF alpha. Fetal Kupffer cells secreted TNF alpha and IL-1 beta after culture with bacterial lipopolysaccharide (LPS), indicating that these cells express mature macrophage function. Cortisol and dexamethasone dramatically suppressed the LPS-stimulated secretion of TNF alpha by fetal Kupffer cells. The inhibitory effects of glucocorticoids appeared to be specific, since estrogen, progesterone, and testosterone had no effect on LPS stimulation of TNF alpha production. None of the steroids tested altered basal production or enhanced the LPS-stimulated production of TNF alpha by fetal Kupffer cells. The inhibition by glucocorticoids could be reversed by the addition of RU 486, indicating that this effect was mediated by the glucocorticoid receptor. These results demonstrate that human fetal macrophages demonstrate mature macrophage function in early gestation; they can be activated to produce TNF alpha by a well characterized modulator of cellular function (LPS) and suppressed by glucocorticoids.

Mucosal immunity in the female genital tract: relevance to vaccination efforts against the human immunodeficiency virus.

The development of vaccines that induce specific immune responses in the genital tract secretions would have far-reaching implications for the prevention of AIDS and other sexually transmitted diseases. Most of the currently studied vaccines utilize systemic routes of immunization that are of limited value for the prevention of mucosa-contracted diseases. The relative contribution of antigen-sensitized cells and IgA-committed lymphocytes from IgA inductive sites (e.g., Peyer's patches and rectal tonsils) to remote or adjacent effector sites (e.g., salivary glands and female genital tract) as manifested by the appearance of corresponding secretory antibodies has not been studied in humans despite its unquestionable practical importance. Exploitation of immunization routes that are effective for induction of mucosal immune responses and reflect our current knowledge of the origin of antibodies and of specific antibody-forming cells in mucosal tissues is likely to reduce the incidence of many infectious diseases including AIDS.

Mucosal immunity in the female reproductive tract: correlation of immunoglobulins, cytokines, and reproductive hormones in human cervical mucus around the time of ovulation.

Mucosal surfaces serve as the portal of entry for many viral, bacterial, and parasitic infections. Understanding the immunity at mucosal membranes is essential to enhancing protection and decreasing infections. To evaluate the humoral and cellular immunity in the female reproductive tract, 15 reproductive-age women with a history of regular, cyclic monthly menses were recruited for this study. The presence of immunoglobulins and cytokines in cervical mucus was correlated with the production of reproductive hormones in sera. Cervical mucus specimens were collected at each daily visit beginning on cycle day 8 and continuing for 5 days postovulation. Volunteers were monitored by daily urinary LH testing coupled with transvaginal ultrasonography to ascertain follicular collapse. The cervix was washed in sterile saline before aspirating the cervical mucus from the cervical canal. Collection volumes ranged between 50 and 800 microl and were considered to represent the total mucus produced. Estradiol displayed the characteristic biphasic pattern with a peak before ovulation and in the luteal phase. Both IgG (30 mg/dl) and IgA (15 mg/dl) had a biphasic pattern with peak immunoglobulin levels detected 1 day before the estradiol peak and increasing again just after ovulation. Peak interleukin 10 (40 pg/ml) levels corresponded precisely with estradiol peak levels just before ovulation. Peak interleukin 1beta (1.3 ng/ml) levels occurred approximately 1 day before the estradiol peak. No apparent pattern in interleukin 6 (150 pg/ml) could be ascertained. Our data suggest a correlation between the IgG and IgA immunoglobulin levels, interleukin 1beta and interleukin 10, in the female reproductive tract and estradiol levels in the circulation. The increase in immunoglobulins and cytokines occurs approximately 1 day before the peak estradiol production before ovulation. These data suggest a role for cytokines and hormones in the regulation of reproductive tract immunity.

Antiphospholipid antibodies and reproduction.

The antiphospholipid antibodies (APA) are acquired antibodies against a phospholipid which has been associated with slow progressive thrombosis and infarction in the placenta. Clinical features (venous or arterial thrombosis, recurrent fetal loss, thrombocytopenia) in conjunction with positive laboratory findings (positive IgG or IgM anticardiolipin antibodies, or positive lupus anticoagulant tests) will satisfy criteria for diagnosis of the antiphospholipid antibody syndrome (APS). A number of studies report the incidence of antiphospholipid antibodies in different patient populations: normal obstetrical patients (5.3% of 7278 women), women with recurrent pregnancy loss (20% of 2226 women), women with systemic lupus erythematosus (37% of 1579 women) and, more recently, women undergoing in vitro fertilization (24% of 3343 women). As in all autoimmune syndromes it is possible that APA are secondary to some underlying disease or that they are instrumental in the pathogenesis of the various manifestations. The most commonly proposed mechanisms of antiphospholipid antibody induced thrombosis include decreased prostacycline production by endothelial cells, increased thromboxane production by platelets, and decreased protein C activation. More recently it has been demonstrated that certain phospholipids are exposed on the endothelial surface and may alter implantation during in vitro fertilization. Treatment with subcutaneous heparin and aspirin has been shown to benefit women with recurrent pregnancy loss and APA resulting in successfully deliveries of approximately 75%. Several trials of treatment with heparin and aspirin in women with positive APA undergoing IVF have been completed. Although none of the studies were randomized, prospective, blinded trials there does not appear to be a significant difference in implantation rate, pregnancy rate, or ongoing pregnancy rate. This subject remains, however, an area of active investigation as antiphospholipid antibodies have been shown to interact with syncytiotrophoblast and cytotrophoblast layers and could theoretically affect implantation.

Characterization of immunoglobulins and cytokines in human cervical mucus: influence of exogenous and endogenous hormones.

Mucosal immunity in the female reproductive tract is influenced by immunoglobulins (Igs), cytokines, and reproductive hormones. Previous studies of reproductive-aged women demonstrated that IgA and IgG increases in cervical mucus corresponded to elevated levels of IL-1beta which occurred 1 day before the peak of endogenous estradiol production prior to ovulation. We sought to determine the effect of exogenous hormones on reproductive tract immunity in women on oral contraceptive pills (OCPs) and to compare the results with respect to naturally cycling women. Twelve women of reproductive age who had negative cervical cultures, a normal pap smear, and agreed to abstain from sexual intercourse during the study initiated OCPs. Cervical mucus and vaginal washes were collected at six intervals (2-3 days apart) throughout the treatment cycle. Fifteen naturally cycling women had similar samples collected prior to, during, and subsequent to ovulation. Cervical mucus samples were assayed for IgA, IgG, IL-1beta, IL-6, and IL-10 by enzyme-linked immunosorbent assay (ELISA). IgA, IgG and IL-1beta levels in women on OCPs paralleled increasing levels of norethindrone. Mean values of IgA increased from a low of 14.4+/-3.1 to 41.1+/-9.4 mg/dl and decreased significantly after the cessation of the pills (P < 0.001). In naturally cycling women, the largest quantities of Igs were detected prior to ovulation. By comparison, mean values of IgA in the cervical mucus of women on OCPs (24.4 mg/dl) exceeded peak levels of IgA in the cervical mucus of naturally cycling women (14.6 mg/dl). IgA was the predominant Ig detected in cervical mucus of women on OCPs. Both immunoglobulins in each group exhibited changes relative to their hormonal status. The increased levels of IgA in the cervical mucus of women on OCPs may explain the clinical observation of a lower incidence of sexually transmitted diseases.

Prevalence of elevated anticardiolipin antibodies in pregnant women with unexplained elevations of alpha-fetoprotein.

The goal was to determine what proportion of pregnant women with unexplained elevations of maternal serum alpha-fetoprotein (MSAFP) have increased levels of anticardiolipin antibodies (ACA), and if this might explain the increased prevalence of adverse pregnancy outcomes. Maternal serum alpha-fetoprotein levels of 12,295 pregnant women were evaluated at 15-19.5 gestational weeks. Elevated readings (> 2.5 MOM) were identified in 190 women (1.5%) and 86 (0.7%) of these had unexplained causes. Specimens (80) were recovered and ACA levels for cardiolipin were determined using enzyme-linked immunosorbant assay. Positive IgG ACA were identified in 10 out of 80 cases (12.5%) of elevated MSAFP; 3 out of 80 cases (3.8%) had positive IgM ACA. The control women with normal MSAFP levels had positive IgG ACA in 3 of 86 cases (3.5%) and 1 of 86 cases (1.2%) for IgM. Women with increased MSAFP and positive ACA had infants with an average birth weight of 2684 +/- 889 g compared to 2793 +/- 847 g in women with increased MSAFP and normal ACA. No significant differences in IgG ACA were found in pregnant women with unexplained elevated MSAFP (10/80, 12.5%) compared to women with normal MSAFP (3/86, 3.5%). As expected, lower birth weight was identified in women who had elevated MSAFP (2738 +/- 868 g) vs. women with normal MSAFP 3181 +/- 1082 g (P = 0.004), independent of ACA positivity.

Autoantibody screening for infertility: explaining the unexplained?

Several laboratories currently offer panels of serum autoantibody assays to screen women with unexplained infertility and those undergoing in vitro fertilization (IVF). Offering these tests implies that they have predictive value for the outcome of proposed infertility treatments such that the results of the testing would alter clinical management. Because screening for antiphospholipid antibodies adds expense to already costly procedures, it is an appropriate time to review the justification for the use of these panels.

Induction of specific immune responses in the genital tract of women after oral or rectal immunization and rectal boosting with Salmonella typhi Ty 21a vaccine.

The purpose of this study was to determine the efficacy of intestinal tract immunization in the induction of specific antibodies in human female genital tract secretions. Live attenuated typhoid vaccine Ty 21a was administered to three groups of healthy female volunteers, who were not using hormonal contraceptives. Group 1 included 15 women vaccinated orally. Group 2 included seven of the same women, who were vaccinated rectally 6 months later. Group 3 included 11 volunteers, who were vaccinated rectally. Salmonella-specific antibodies of IgG and IgA were measured in vaginal lavage and cervical mucus after oral or rectal primary vaccination. Salmonella-specific antibodies measured 1 month after rectal booster vaccination demonstrated significant increases in vaginal fluids and cervical mucus and were dominated by IgA. These results indicate that specific antibodies in the human female genital tract induced by primary vaccination can be enhanced by subsequent rectal administration of vaccines.

Monosomy 7 syndrome associated with congenital adrenal hypoplasia and male pseudohermaphroditism.

BACKGROUND: Bone marrow monosomy 7 is an uncommon disorder of the pluripotent stem cells that leads to frequent childhood infections and leukemia. Primary adrenal hypoplasia occurs very rarely and is incompatible with life. Male pseudohermaphroditism results from inadequate androgen secretion or inappropriate androgen action. We report a case of monosomy 7, adrenal hypoplasia, and male pseudohermaphroditism. CASE: An infant was born with sexual ambiguity and bilateral inguinal masses. Bone marrow karyotype was 45, XY,-7. Serum testosterone level was low normal. The infant died on the fourth day of life. Autopsy revealed severely hypoplastic adrenal glands, inguinal testes, and a vaginal pouch. CONCLUSION: Monosomy 7 and male sexual ambiguity are reported in association with primary adrenal hypoplasia of the cytomegalic (X-linked) type.

Mature cystic teratoma of the fallopian tube associated with an ectopic pregnancy.

We describe the occurrence of a mature cystic teratoma of the fallopian tube discovered at laparoscopy for an ectopic pregnancy. Only five previous reports of this concurrence have been found in the medical literature. We review the reported cases of tubal teratoma and summarize all cases found with an ectopic tubal pregnancy.

Multiples of the median: an alternative method for reporting antiphospholipid antibodies in women with recurrent pregnancy loss.

OBJECTIVE: To determine whether using multiples of the median (MoM) is a useful method of standardization for reporting antiphospholipid antibody results. METHODS: Each antibody was measured by enzyme-linked immunosorbent assay using the Harris calibration set no. 2, with values recorded as phospholipid units and as MoM. The levels of antiphospholipid antibodies were compared in 100 nonpregnant women diagnosed with recurrent pregnancy loss (three or more spontaneous, consecutive losses) and 100 nonpregnant parous women with no history of reproductive problems (controls). Results were analyzed based on phospholipid units for immunoglobulin (Ig) G and IgM and were considered positive if phospholipid units were at least 20 or if MoM was at least 2.5. All lower values were considered negative. RESULTS: When results were calculated using at least 2.5 MoM as positive, none of the controls had positive levels. Overall, IgG anticardiolipin identified the largest number of women with elevated antiphospholipid antibodies. Immunoglobulin G antiphosphatidyl glycerol was more "selective" when elevated since none of the controls were positive by either analysis; however, only half of the subjects determined to be positive using anticardiolipin were identified. CONCLUSION: The MoM method of reporting results may be more useful than phospholipid units for IgG or IgM.

Secretory immune system of the female reproductive tract: I. Immunoglobulin and secretory component-containing cells.

We have investigated tissues from the female reproductive tract to determine whether the distribution of cells involved in the formation of secretory immunoglobulin A (IgA) molecules is analogous to that described for intestines, bronchus, and mammary and salivary glands. Fresh tissues from fallopian tube, ovary, uterus, and vagina were obtained, and sections were stained with fluorochrome-labeled polyclonal or monoclonal antibodies specific for IgG, IgA, IgA1, and IgA2 subclasses; IgM; secretory component; and J chain. Subepithelial plasma cells were identified in each specimen of fallopian tube, endocervix, ectocervix, and vagina. Approximately two-thirds of the immunoglobulin-positive cells contained IgA and J chain, indicating that they produced polymeric IgA. In comparison to tissues such as spleen and bone marrow, where IgA1-positive cells are produced, we found a high proportion of IgA2-positive cells in fallopian tube, cervix, and vagina. Epithelial cells in fallopian tube and endocervix contained secretory component. These data indicate that secretory IgA, which provides the first line of defense against invading pathogens, is produced locally in tissues of the female reproductive tract.

Antiphospholipid antibody panels and recurrent pregnancy loss: prevalence of anticardiolipin antibodies compared with other antiphospholipid antibodies.

OBJECTIVE: To describe the prevalence of antiphospholipid antibodies in addition to cardiolipin in women with recurrent pregnancy loss. DESIGN: Retrospective data analysis of test results from an antiphospholipid antibody panel. SETTING: A university-based private patient referral center. PATIENTS: Included 866 women with a history of recurrent pregnancy loss and 288 parous women without a history of reproductive problems. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Enzyme-linked immunosorbent assay, with referenced standards and known positive and negative sera on each plate, was used to measure anticardiolipin, antiphosphatidyl inositol, antiphosphatidylglycerol, antiphosphatidylserine, and antiphosphatidylethanolamine. Statistical analyses used the two-tailed Fisher's exact test. RESULTS: Positive anticardiolipin antibodies were detected in 17.3% of patients with recurrent pregnancy loss compared with only 4% in the control population. Eighty-seven of the 866 women (10.1%) were negative for anticardiolipin antibodies but had positive levels of another antiphospholipid antibody. Isolated positive antibody levels occurred most frequently in the immunoglobulin (Ig) G class of phosphatidylinositol, cardiolipin, and phosphatidylethanolamine. Isolated IgA was only found in phosphatidylethanolamine. CONCLUSION: In women with recurrent pregnancy loss, 150 of 866 (17.3%) had positive anticardiolipin antibodies. Additionally, 87 of 866 (10.1%) women were positive for another antiphospholipid antibody. Patient demographics were similar in both groups. We emphasize the importance of careful standardization, quality control, and interpretation of positive results.

The role of antisperm antibodies in infertility.

OBJECTIVE: To discuss the role of antisperm antibodies (Ab) in infertility, including proposed mechanisms of antisperm Ab formation, assays for their detection, and treatments for immune-mediated infertility. DESIGN: Major studies in the published literature and data from The University of Texas Southwestern Medical Center, Division of Reproductive Endocrinology. Reports were reviewed that investigated the development and impact of alloimmunity and autoimmunity to spermatozoa in men and alloimmunity in women and the current methods of treatment for resultant subfertility. RESULTS: The exposure of spermatozoal antigens to the mucosal and systemic immune systems results in development of immunity to a multiplicity of spermatozoal epitopes. The evaluation of studies that examine the role of antisperm Ab in infertility is complicated by the lack of standardization of antisperm Ab assays and the difficulty in identifying those epitopes for antisperm Ab binding that are responsible for subfertility. Sperm-associated antisperm Ab and antisperm Ab in cervical mucus (CM) reduce sperm mobility and may also impair sperm-ovum interaction. The clinical significance of serum antisperm Ab in both men and women, however, is controversial. Current therapy for antisperm Ab associated infertility is empiric and largely unproven. CONCLUSIONS: Antisperm Ab on the sperm surface and in CM are implicated in the pathogenesis of a subset of patients with infertility. Further studies that determine the clinically relevant sites of antisperm Ab interaction will aid in directing the treatment of subfertility mediated by antisperm Ab.

beta2-Glycoprotein 1 as a marker of antiphospholipid syndrome in women with recurrent pregnancy loss.

OBJECTIVE: To determine if beta2-glycoprotein 1 (beta2-GP1) antibodies are a better marker of the antiphospholipid antibody syndrome (APS) in women with recurrent pregnancy loss (RPL). DESIGN: Evaluation and testing of sera from women with RPL. SETTING: A university-affiliated reproductive endocrinology practice. PATIENT(S): 90 women with RPL; 45 women met criteria for APS and 45 women met criteria for RPL without antiphospholipid antibodies (APA). Both groups were of similar age and had a similar history of RPL. INTERVENTION(S): Patient sera were obtained from women with RPL and were tested for APA and beta2-GP1. MAIN OUTCOME MEASURE(S): A standard antiphospholipid antibody assay was employed to detect the presence of immunoglobulin (Ig)G, IgM, and IgA antibodies in serum against cardiolipin, phosphatidyl inositol, phosphatidyl glycerol, phosphatidyl serine, and phosphatidyl ethanolamine. Samples were also assayed with a commercial beta2-GP1 assay for IgG antibodies. RESULT(S): Among the 45 women with APS, 10 (22.2%) had positive IgG antibodies for beta2-GP1. Only 1 woman (2.2%) of 45 was positive for beta2-GP1 among the control group of women with RPL but negative APA. There was no correlation noted among the beta2-GP1-positive patients for a specific phospholipid antibody or isotype. CONCLUSION(S): These data suggest that IgG beta2-GP1 antibodies are less sensitive than antiphospholipid antibodies for the diagnosis of APS.