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.

Antiphospholipid antibodies (APA) and recurrent pregnancy loss: treating a unique APA positive population.

BACKGROUND: Recurrent pregnancy loss (RPL) has been associated with antiphospholipid antibodies (APA) including anticardiolipin and lupus anticoagulant. Therapy using heparin and aspirin has been shown to significantly improve the live birth rate. We evaluated whether other APA should be considered as a basis for treatment in women with RPL. We also assessed the efficacy of heparin and aspirin therapy compared with aspirin alone in these women. METHODS: A two-centred, prospective, cohort evaluation of 79 women with two or more consecutive pregnancy losses who underwent a complete evaluation for RPL that was negative except for positive APA. Women with RPL and APA to cardiolipin (CL), phosphatidyl serine (PS) and/or lupus anticoagulant (LAC) treated with heparin and aspirin (group 1) were compared with those with other positive APA (to phosphatidyl inositol, phosphatidyl glycerol and/or phosphatidyl ethanolamine) treated with heparin or aspirin (group 2) or treated with aspirin alone (group 3). RESULTS: There were no significant differences in patients' demographics between groups. There were 19 viable infants born to 25 women (76%) in group 1, 18 viable infants born to the 28 women (64%) in group 2, and 12 viable infants born to the 26 women (46%) in group 3. Only the comparison between group 1 and group 3 reached statistical significance (P = 0.03). CONCLUSION: APA other than CL, PS and LAC may be associated with RPL.

Autoimmune factors in assisted reproduction.

The present review highlights recent studies that investigated the possible influences of autoimmune factors in reproductive success or failure. These factors include antiphospholipid antibodies, antithyroid antibodies, antinuclear antibodies, antisperm antibodies, and antiovarian antibodies. The majority of recent work has focused on these potential autoimmune factors; however, controversy still exists over indicated testing and treatment options. An association of antiphospholipid antibodies and recurrent pregnancy loss has been established, and treatment with subcutaneous heparin appears most efficacious. Other autoimmune factors are under investigation as markers of in vitro fertilization failure. Limited data from treatment trials are presented.

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.

Immunological testing and treatment in reproduction: frequency assessment of practice patterns at assisted reproduction clinics in the USA and Australia.

BACKGROUND: The roles that alloimmunity and autoimmunity may play in reproductive failure, including recurrent pregnancy loss and failed IVF, have not been clearly established. To help define practice patterns, we investigated what tests clinicians in the USA and Australia were offering, to which patients (diagnostic groups) the tests were recommended, and in what situations immunological/anticoagulation treatment was advised. METHODS: A five section survey was completed by senior physicians attending the annual national fertility society meetings in the USA and Australia. Results were tabulated and analysed. RESULTS: Antiphospholipid antibody testing was offered to patients with recurrent pregnancy loss by almost all physicians surveyed. Patients with previous failure of IVF were tested much less often. Other immune tests (embryotoxic assay, natural killer cells and leukocyte antibodies) were ordered by none of the Australian participants and approximately 25% of the American participants. The use of immunotherapy and anticoagulation therapy for patients who tested positive for various immunological tests was also evaluated for frequency of use and reported secondary complications. CONCLUSIONS: Large, well-structured studies examining the benefits of immunological evaluation and treatment are necessary before definite recommendations can be made.

Autoimmune factors in reproductive failure.

The present review highlights recent studies that investigated the possible influences of autoimmune factors in reproductive success or failure. These factors include antiphospholipid antibodies, antithyroid antibodies, antinuclear antibodies, antisperm antibodies, and antiovarian antibodies. The majority of recent work has focused on these potential autoimmune factors; however, controversy still exists over indicated testing and treatment options. An association of antiphospholipid antibodies and recurrent pregnancy loss has been established, and treatment with subcutaneous heparin appears most efficacious. Other autoimmune factors are under investigation as markers of in-vitro fertilization failure. Limited data from treatment trials are presented.

Quantification of immunoglobulins and cytokines in human cervical mucus during each trimester of pregnancy.

OBJECTIVES: Our aims were to determine immunoglobulin and cytokine levels in cervical mucus obtained from women during each trimester of pregnancy and to compare these levels with those reported in normally menstruating women and in women taking oral contraceptives. STUDY DESIGN: Cervical mucus samples were collected at specified intervals from 36 pregnant women. An enzyme-linked immunosorbent assay was used to quantitate the presence of immunoglobulins A and G and interleukins 1 beta, 6, and 10 in cervical mucus. RESULTS: Immunoglobulin A in cervical mucus remained stable during each trimester of pregnancy (26 mg/dL). Cervical mucus immunoglobulin G decreased from a first-trimester high of 44.4 mg/dL to lower levels in the second and third trimesters. Levels of interleukin 1 beta increased significantly from the first trimester (4261 pg/mL) to 12,899 pg/mL in the second trimester (P <.01). CONCLUSION: These data suggest a possible correlation of reproductive hormones and immunologic factors in the female reproductive tract during pregnancy.

The predictive value of five different urinary LH kits in detecting the LH surge in regularly menstruating women.

OBJECTIVES: To compare the predictive value of five different urinary LH kits at detecting the LH surge in regularly menstruating, reproductive-age women. DESIGN: Single center, prospective study. SETTING: University of Tennessee, Obstetrics and Gynecology department. INTERVENTION: Eleven regularly menstruating women collected urine daily from cycle days 10 through 18. Urinary LH was quantitated by radioimmunoassay. Transvaginal sonography was performed to document ovulation. Three different lots of Clear Plan Easy, OvuKit, OvuQuick, Sure Step, and EZ LH were evaluated. MAIN OUTCOME MEASURE: Correlation of urinary LH test kit results with urine LH value determined by RIA. RESULTS: Peak urinary LH values by RIA ranged from 13.5 mIU/mL to 73.0 mIU/mL. The lowest level detected as positive by LH kits ranged from 25.5 mIU/mL to 48.7 mIU/mL. Lot-to-lot variations were rare. Follicular collapse occurred within 24 hours of the urinary LH peak in 8 of 10 (80%) and by 48 hours in the remaining 2 subjects. CONCLUSIONS: The percentage of LH surges detected by urinary LH kits ranged from 50% to 100%. The lowest LH value detected as positive varied almost twofold between different kits. Manufacturers should indicate the detection limit of their kits in mIU/mL.

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.

Antithyroid antibodies do not affect pregnancy outcome in women undergoing assisted reproduction.

The purpose of this study was to determine the association of antibodies to thyroglobulin and thyroid peroxidase and pregnancy outcome in women undergoing assisted reproductive techniques. The study included three centres and retrospectively evaluated patient sera for antithyroid antibodies, then related the results to pregnancy outcome. Enzyme-linked immunosorbant assays for thyroglobulin and thyroid peroxidase antibodies were performed using two different commercially available kits. Controls included 200 healthy women of reproductive age. Women (n = 873) who were undergoing assisted reproductive techniques for pelvic adhesions, endometriosis, ovarian dysfunction, or unexplained/other were included. All women utilized a standard regimen of gonadotrophin releasing hormone agonist down-regulation followed by ovulation induction. Embryos were cultured for 3 days, at which time embryo transfer occurred. Statistical analysis utilized the two-tailed Fisher's exact test. Antithyroid antibodies were positive in 143 of 873 (16.4%) women undergoing assisted reproductive techniques while 29 of 200 (14.5%) normal controls were positive (not significant). Deliveries were achieved in 396 of 730 (54.2%) of women who had no thyroid antibodies versus 78 of 143 (54.5%) of women who had thyroid antibodies (not significant). No difference in biochemical pregnancies (not significant) or clinical pregnancy losses (not significant) were detected. Antithyroid antibodies were found no more frequently in women undergoing assisted reproductive techniques than in normal controls. There were no differences in pregnancy outcome based on antithyroid antibody positivity in women undergoing assisted reproductive techniques. These data do not support the testing or treatment for antithyroid antibodies of women undergoing assisted reproductive techniques.

Recurrent pregnancy loss: an update.

This review highlights recent studies that investigate causes and treatments for recurrent pregnancy loss. Generally the causes of recurrent pregnancy loss are classified as genetic, endocrinologic, anatomic, immunologic, microbiologic, and environmental. The majority of recent work has focused on potential autoimmune and alloimmune causes; however, controversy still exists over appropriate testing and treatment. Reports have investigated the potential associations between autoimmune factors (antithyroid antibodies and antiphospholipid antibodies) and alloimmune factors (natural killer cells, cytotoxic T cells, and embryotoxic factors) and recurrent pregnancy loss. Increasingly, clinical reports are suggesting intravenous immunoglobulin as a potential treatment for these immunologic problems. Several lines of investigation have suggested certain hypercoagulable states as causative of recurrent pregnancy loss. New studies relating recurrent pregnancy loss to endocrinologic aberrations (hyperprolactinemia and hyperandrogenism) as well as social/environmental factors (stress, caffeine use, tobacco use, human immunodeficiency virus, and history of induced abortion) have been made. A summary of proposed evaluation and treatment options is presented.

Hypercoagulable state mutation analysis in white patients with early first-trimester recurrent pregnancy loss.

OBJECTIVE: Antiphospholipid antibodies (APA) and other coagulation abnormalities have been associated with an increased risk of venous, arterial, and placental thrombosis and recurrent pregnancy loss (RPL). Factor V Leiden (a point mutation [1691G-->A] in the factor V gene), the prothrombin 20210G-->A mutation, and homozygosity for a common polymorphism in the methylene tetrahydrofolate reductase (MTHFR) gene (677C-->T) have been associated with arterial and venous thrombosis and arterial occlusive disease. We explored an association between these markers of thrombophilic states and RPL. DESIGN: Prospective case-control evaluation. SETTING: University-associated private practice. PATIENT(S): Fifty nonpregnant women with three or more pregnancy losses and 50 healthy, nonpregnant controls. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Anticardiolipin and antiphosphatidylserine antibodies were detected in serum by ELISA. Polymerase chain reaction was performed to identify the factor V Leiden (1691G-->A) mutation, the thermobile MTHFR (677C-->T) mutation, and the prothrombin 20210G-->A mutation. RESULT(S): The following were identified by restriction fragment-linked polymorphism analyses: 1 (2%) factor V Leiden heterozygosity; 1 (2%) prothrombin 20210G-->A heterozygosity; and 4 (8%) thermolabile MTHFR homozygosity. None of these mutation frequencies in women with RPL were statistically significantly different from controls. CONCLUSION(S): These data suggest that factor V Leiden, thermolabile MTHFR (677C-->T), and prothrombin 20210G-->A are not found at an increased frequency in women with a history of early RPL.

Screening for hypothyroidism in infertile women.

OBJECTIVE: To determine the frequency of an elevated thyroid-stimulating hormone (TSH) level in 704 patients seeking treatment for infertility. STUDY DESIGN: Sera from 704 women evaluated for infertility were assayed for TSH levels using radioimmunoassay (normal, 0.45-4.09 mIU/mL). All women had at least one year of infertility. Women with a known history of thyroid disease were excluded from the review. RESULTS: Sixteen of 704 patients (2.3%) had elevated TSH levels and were treated with levothyroxine to normalize TSH. None of these women had overt clinical signs or symptoms of hypothyroidism. Of these women, 11 of 16, or 69%, had ovulatory dysfunction, and 7 (64%) later became pregnant while on thyroid replacement. Five of 704 (0.7%) women with infertility who presented without a history of ovulatory dysfunction had elevated TSH levels, and none became pregnant with treatment. CONCLUSION: The prevalence of elevated TSH in 704 women with at least one year of infertility was 2.3%. The majority of women diagnosed with hypothyroidism (11 of 16, or 69%) had ovulatory dysfunction. With treatment for hypothyroidism, successful pregnancies resulted in 7 of 11 (64%) of patients. Women with infertility and ovulatory dysfunction should be screened for hypothyroidism. Screening for hypothyroidism as part of a routine infertility workup in women with normal ovulatory function will yield few abnormal tests.

Increased prevalence of antithyroid antibodies identified in women with recurrent pregnancy loss but not in women undergoing assisted reproduction.

OBJECTIVE: To assess the prevalence of antibodies to thyroglobulin and thyroid peroxidase (or microsomal) in women with recurrent pregnancy loss and women undergoing assisted reproductive techniques (ART) compared with healthy controls. DESIGN: Retrospective, two-centered study. SETTING: University-affiliated private patient centers. PATIENT(S): Included were 700 women with a history of two or more consecutive pregnancy losses, 688 women with a history of infertility who were undergoing ART, and 200 healthy, reproductive-aged female controls. INTERVENTION(S): Blood was collected before ART cycles, frozen, and assayed. MAIN OUTCOME MEASURE(S): Standardized ELISAs were used to measure antithyroid antibodies and TSH levels. Statistical analysis was performed with use of the two-tailed Fisher's exact test. RESULT(S): Antithyroid antibodies were identified in 29 of 200 (14.5%) of controls and 158 of 700 (22.5%) of women with recurrent pregnancy loss and 132 of 688 (19.2%) of women undergoing ART. Less than 20% of the women with antithyroid antibodies were clinically hypothyroid. CONCLUSION(S): Antithyroid antibodies are identified more frequently in women with recurrent pregnancy loss than in controls but not in women undergoing ART. These autoantibodies may be markers of autoimmune activation and have been associated with an increased risk of pregnancy loss and postpartum thyroid disease.

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.

Antiphospholipid antibodies and reproduction: the antiphospholipid antibody syndrome.

In women who have a diagnosis of APS (both clinical and laboratory criteria) the chance for successful pregnancy is reduced. In these cases, treatment appears to be a clear option, particularly in the case of prior thromboembolic events. The current preference of treatment for women with RPL and aPL antibodies is subcutaneous heparin and aspirin. This treatment should begin with a positive pregnancy test and continue postpartum. It is unclear, at this time, what treatment, if any, is required for women who do not meet all the criteria for diagnosis of APS, but who are known to have aPL antibodies. In some cases, these women were tested because of a prior false-positive test for syphilis, with subsequent identification of aPL antibodies. More recently, women undergoing IVF were tested and found to have an increased incidence of aPL antibodies. It was suggested that aPL antibodies are associated with infertility and failure to implant. However, a summary of published reports indicate that positive aPL antibodies in patients undergoing IVF do not influence ongoing pregnancy rates. This subject, however, remains an area of active investigation because aPL antibodies were shown to interact with the syncytiotrophoblast and cytotrophoblast layers and could, theoretically, after implantation.

Gonadotropins do not induce antiphospholipid antibodies.

PROBLEM: To determine whether the increased incidence of antiphospholipid antibodies (APAs) in women undergoing assisted reproduction might be secondary to superovulation with gonadotropins, predisposing women to an abnormal immune response and thus inducing APAs. METHOD OF STUDY: Women undergoing assisted reproduction with gonadotropins for the first time were selected and tested before the initiation of the stimulation cycle, during the cycle, and at the end of the cycle (group 1). Women who had undergone gonadotropin stimulation at least 60 days earlier (group 2) and normal, nonpregnant, fertile women (group 3) also were evaluated. Serum samples were assayed by the enzyme-linked immunosorbent assay method. RESULTS: Ten (20%) of 50 women in group 1 were positive for APAs. The 10 women who were positive for APAs remained positive throughout the treatment cycle. Positive antibodies were identified in 12 (24%) of 50 women in group 2, not significantly different from group 1 (P = 0.81). Antibodies were present in 2 of 50 normal fertile control subjects, significantly less frequently than in group 1 (P < 0.03) and in group 2 (P < 0.01). CONCLUSIONS: These data suggest that gonadotropin administration and/or the ovarian response to stimulation does not predispose women to the induction of APAs. Moreover, the incidence of APAs in this population, which is higher than that found in normal fertile women, cannot be explained by cycle-induced events.