Are cytokines and growth factors responsible for the detrimental effects of hydrosalpingeal fluid on pregnancy rates after in vitro fertilization-embryo transfer?

OBJECTIVE: To characterize the secretion of cytokines and growth factors in hydrosalpingeal fluid. DESIGN: Retrospective analysis. SETTING: Hospital-based infertility practice. PATIENT(S): Ten infertile women who underwent laparoscopic aspiration of their hydrosalpingeal fluid before salpingectomy or neosalpingostomy. INTERVENTION(S): Samples were cryopreserved, then thawed and centrifuged to remove cellular debris. MAIN OUTCOME MEASURE(S): The supernatants were analyzed for the presence of human interferon-gamma, epidermal growth factor, transforming growth factor-beta2, and tumor necrosis factor-alpha by quantitative enzyme immunoassay kits. RESULT(S): Interferon-gamma and transforming growth factor-beta2 were not detected in any of the hydrosalpingeal fluid samples. Epidermal growth factor was present in 5 of 10 hydrosalpingeal fluid samples, with a mean (+/- SE) concentration of 26.7+/-11.4 pg/mL. Tumor necrosis factor-alpha was detected in 7 of 10 samples, with a mean (+/- SE) concentration of 6.2+/-3.6 pg/mL. Three of the 10 samples contained both tumor necrosis factor-alpha and epidermal growth factor. CONCLUSION(S): For the first time, we described the absence of interferon-gamma and transforming growth factor-beta2, and the presence of epidermal growth factor and tumor necrosis factor-alpha in human hydrosalpingeal fluid. Because the fundamental role of the human fallopian tube is secretory in nature, the alteration in substances secreted from the tubal epithelium that reflux into the uterine cavity may explain the deleterious effects that hydrosalpingeal fluid has on pregnancy rates after IVF-ET.

Abdominal pregnancy on the bladder wall following embryo transfer with cryopreserved-thawed embryos: a case report.

OBJECTIVE: To describe the occurrence and management of an abdominal pregnancy of the bladder after ET with cryopreserved-thawed embryos. DESIGN: Case report. SETTING: Infertility program in a tertiary care hospital. PATIENT(S): A woman with secondary infertility and a history of breast cancer. INTERVENTION(S): Transfer of cryopreserved-thawed embryos was performed, serial serum hormonal measurements were obtained, methotrexate was given IM, operative laparoscopy was performed. MAIN OUTCOME MEASURE(S): Documentation of abdominal pregnancy after transfer of cryopreserved-thawed embryos and its successful laparoscopic management. RESULT(S): Abdominal pregnancy occurred after ET of cryopreserved embryos in a patient with mild tubal disease. Diagnosis and management using laparoscopy were achieved. CONCLUSION(S): Abdominal pregnancy can occur using ET of cryopreserved-thawed embryos in a patient with mild tubal disease. If anatomically accessible, such a pregnancy can be managed successfully laparoscopically.

The effect of endometriosis, its stage and activity, and of autoantibodies on in vitro fertilization and embryo transfer success rates.

OBJECTIVES: To analyze IVF cycle parameters, including pregnancy rates (PR), in women with and without endometriosis and to evaluate the effect of the stage and activity of endometriosis and of autoantibodies. DESIGN: A retrospective analysis of 237 consecutive IVF cycles (193 patients), 119 in women with and 118 without endometriosis. The endometriosis group was further subdivided according to the stage and activity of the disease and autoantibody positivity. SETTING: Hospital-based and freestanding IVF programs with the same IVF team. PATIENTS: One hundred ninety-three women of reproductive age undergoing IVF; 84 had prior diagnosis of endometriosis, and 109 had other indications for IVF. Within the endometriosis group, 40 did and 44 did not have evidence of active disease. Autoantibodies were measured in 50 patients. INTERVENTIONS: The IVF protocol was standard with GnRH agonist administered from the midluteal phase of the preceding cycle. Variables included the method of ET and the use of corticosteroids. MAIN OUTCOME MEASURES: Number of follicles produced, number of eggs retrieved, fertilization rates, number of embryos transferred, and PR per transfer. RESULTS: There was no difference between groups in the response to stimulation, number of oocytes retrieved, number fertilized, and number cleaved. The overall PR was 27% per transfer; it was similar in women with and without endometriosis (29% and 25%, respectively). There was also no difference in PR according to the stage or activity of the disease. However, PR in autoantibody-positive and -negative patients were significantly different (22.9% and 45.7%, respectively). Among autoantibody-positive patients treated with corticosteroids, 8 of 10 conceived. CONCLUSIONS: This study confirms previous reports that IVF success rates are comparable in women with and without endometriosis regardless of the activity and stage of the disease. However, our study also indicates that autoantibodies may affect adversely implantation of embryos and that this effect can be overcome by administration of corticosteroids.

Expression of inhibin/activin system messenger ribonucleic acids and proteins in ovarian follicles from women with polycystic ovarian syndrome.

The role of inhibin, activin, and follistatin in the pathophysiology of polycystic ovary syndrome (PCOS) was investigated by examining the expression of human inhibin/activin subunit, follistatin, and type II activin receptor (ActRII and -IIB) messenger ribonucleic acid (mRNA) signals (via in situ hybridization) and encoded proteins (via immunocytochemistry) in ovarian follicles (n = 42) from 6 women diagnosed with PCOS. The localization patterns in cellular compartments were compared to those in small antral follicles of comparable size (3-7 mm; n = 40) from 17 normal human ovaries. In small antral follicles of both normal and PCOS ovaries, mRNA signals for all three subunits of inhibin and activin (alpha, beta a, and beta b) were expressed in granulosa cells, whereas in the thecal cell layer, only alpha-subunit mRNA was expressed. The relative intensity of the alpha-subunit mRNA signal was distinctly different in granulosa and thecal cells between PCOS and normal follicles; in small antral follicles of normal ovaries, the alpha-subunit mRNA signal was stronger in the granulosa cell layer than in the thecal cells, and the reverse was found in the polycystic follicles. A light follistatin mRNA signal was found in the granulosa cells of normal small antral follicles, but no follistatin mRNA was detected in any cell type of PCOS follicles. ActRII and -IIB mRNAs were not detected in any cell layer in either normal or PCOS follicles. There were no notable differences in the protein localization pattern of the inhibin/activin system between the PCOS and normal ovaries. In both types of follicles, follistatin and alpha-, beta a-, and beta b-subunit cytoplasmic staining were observed in granulosa cells, as were their corresponding messages, with the exception of the undetectable follistatin mRNA signal in the PCOS follicles. In both normal and PCOS follicles, follistatin and beta a-subunit cytoplasmic staining were occasionally found in thecal interna cells, with no corresponding localization of mRNA, and alpha-subunit protein was not detected in thecal cells despite the presence of the alpha-subunit mRNA. ActRII and -IIB protein localizations were not examined due to the lack of available antisera. These results suggest that granulosa cells of small antral follicles are less active in polycystic than in normal ovaries with respect to inhibin alpha-subunit and follistatin mRNA expression. A consequence of these differences could be an increase in the availability of activin, relative to inhibin, in the arrested follicles in PCOS.

Expression of the genes encoding the insulin-like growth factors (IGF-I and II), the IGF and insulin receptors, and IGF-binding proteins-1-6 and the localization of their gene products in normal and polycystic ovary syndrome ovaries.

To discern the potential role of the insulin-like growth factors (IGFs) in polycystic ovary syndrome (PCOS), we examined the expression of the genes encoding the IGFs, IGF receptors (IGFr), insulin receptor (Ir), and IGF-binding proteins (IGFBPs-1-6) as well as the localization of the gene products in specific cellular compartments of normal and PCOS human ovaries. Messenger ribonucleic acid (mRNA) was localized by in situ hybridization with specific 35S-labeled human antisense RNA probes, and protein was detected by immunohistochemistry using specific antisera. Thecal cells, but not granulosa cells (GC), of small antral follicles (3-6 mm) from PCOS ovaries expressed both IGF-I and IGF-II transcripts. Abundant IGF-Ir mRNA was found only in GC, IGF-IIr mRNA was found in both granulosa and thecal cells, and Ir mRNA was detected in all cell types, including granulosa, thecal, and stromal cells. Localization of the gene products revealed no IGF-I immunoreactivity; however, immunostaining for each of the other gene products was colocalized with its corresponding mRNA. The cellular distribution of mRNA and protein in PCOS follicles was indistinguishable from that observed in small antral follicles from normal ovaries. In dominant follicles, however, IGF-I mRNA was no longer detectable, but abundant IGF-II mRNA was expressed exclusively in GC. Although IGF-Ir mRNA was expressed in GC, IGF-IIr mRNA was found in both granulosa and thecal cells. In follicles taken from PCOS ovaries, no IGFBP-1 mRNA was detected, IGFBP-2 mRNA was abundant in both granulosa and thecal cells, moderate IGFBP-3 mRNA was found only in thecal cells, IGFBP-4 and -5 mRNAs were present in all cellular compartments, and IGFBP-6 mRNA was not detected. Localization of the gene products by immunostaining revealed that each protein colocalized with its corresponding mRNA. The cellular distribution of IGFBP mRNA and protein in PCOS follicles was also indistinguishable from that in small antral follicles of normal ovaries, but remarkable differences were found in dominant follicles, where abundant IGFBP-1 mRNA was seen exclusively in GC, IGFBP-2 mRNA in thecal cells, and IGFBP-3 mRNA in both granulosa and thecal cells. Moderate expression of the IGFBP-4 and IGFBP-5 genes was seen in all cell types, including stromal cells, but no IGFBP-6 mRNA was detected. Again, each of the gene products colocalized with its corresponding mRNA. We conclude the following.(ABSTRACT TRUNCATED AT 400 WORDS)

Mechanisms of cellular insulin resistance in human pregnancy.

OBJECTIVES: The cellular mechanism(s) of insulin resistance developed during pregnancy were studied by investigating the functionality of insulin receptors and glucose transport. STUDY DESIGN: Abdominal adipose tissue was obtained from eight lean pregnant and nine control subjects, matched for insulin resistance by intravenous glucose tolerance testing. Insulin receptor binding and glucose transport were measured in freshly isolated adipocytes. Receptor kinase activity was measured on partially purified receptors. Data were analyzed by Student t test. RESULTS: High-affinity insulin receptors were reduced in cells from pregnant compared with normal controls (2.0 +/- 0.4 vs 5.8 +/- 1.3 x 10(4) sites per cell, p < 0.05). Kinase activity of insulin receptors was unaltered in pregnancy. Adipocytes from pregnant subjects displayed a threefold decrease in insulin sensitivity for glucose transport (median effective concentration 324 +/- 93 vs 93 +/- 14 pmol/L, p < 0.025) and a reduction in maximal insulin-stimulated glucose transport (1.58 +/- 0.15 vs 2.33 +/- 0.24 pmol/10(5) cells/10 seconds, p < 0.025). CONCLUSIONS: These results show that adipocytes from pregnant subjects exhibit decreased insulin receptor number and an impaired insulin sensitivity in the absence of functional alterations of receptor kinase activity.

Expression of inhibin/activin subunits and follistatin messenger ribonucleic acids and proteins in ovarian follicles and the corpus luteum during the human menstrual cycle.

The physiological role of intraovarian activin (beta/beta) and inhibin (alpha/beta) dimers in humans in unclear. The identification of follistatin as a beta-subunit-specific high affinity binding protein has added complexities for the interpretation of in vitro studies concerning the functionalities of these ovarian peptides. We, therefore, have attempted to define in vivo compartmental distributions of gene expression and protein localization for inhibin and activin subunits (alpha, beta A, and beta B) concurrent with follistatin in ovarian follicles and corpus lutea obtained from a large number of human ovaries. In situ hybridization and immunohistochemistry were used for detecting the expression of genes encoding inhibin/activin subunits and follistatin and their gene products, the proteins. Granulosa cells of small antral follicles (1-8 mm) were found to express mRNA for alpha-, beta A-, and beta B-subunits as well as follistatin, and the strongest signals were localized in the cumulus granulosa cells. In the thecal cell layer, only alpha-subunit mRNA was detected. Proteins were localized in cellular compartments corresponding to their mRNA, but in addition, proteins for beta A-subunit and follistatin were detected in the thecal cell layers in the absence of gene expression, an observation compatible with a paracrine action. Thus, granulosa cells of the small antral follicle have the potential to form all dimers of inhibin and activin, and their autocrine and paracrine actions may be modulated by follistatin in both granulosa cell and thecal cell layers. With the development of a dominant follicle, remarkable switches in subunit gene expressions occurred; beta B-subunit mRNA was no longer detectable in any cell type, and beta A-subunit expression emerged in the thecal cells along with continued abundant expression of beta A-subunit and follistatin in the granulosa cells. Proteins were found only in granulosa cells corresponding to their mRNAs. In the corpus luteum, the inhibin/activin alpha- and beta A-subunits and follistatin mRNA and proteins were expressed exclusively in the luteinized granulosa cells. Luteinized thecal cells were devoid of detectable mRNA message or proteins. Thus, the inhibin-activin-follistatin system in the corpus luteum appears to function in an autocrine fashion.(ABSTRACT TRUNCATED AT 400 WORDS)

Expression of insulin-like growth factor-I (IGF-I) and IGF-II and the IGF-I, IGF-II, and insulin receptor genes and localization of the gene products in the human ovary.

We examined the expression of the genes encoding the insulin-like growth factors (IGFs) and their receptors (r) and the localization of their gene products in specific cellular compartments of the human ovary. mRNA was localized by in situ hybridization with specific human 35S-labeled antisense RNA probes, and protein was detected by immunocytochemistry with specific antisera. We studied 34 follicles (10 ovaries), which included both dominant and small antral follicles. In dominant follicles, no IGF-I mRNA was seen in either thecal or granulosa cells (GC), but IGF-Ir mRNA was expressed in GC. In contrast, abundant IGF-II mRNA was found exclusively in GC, whereas the IGF-IIr gene was expressed in both thecal cells and GC. Insulin receptor mRNA was widely distributed and expressed in all cell types, including stromal cells. Small antral follicles contained both IGF-I and IGF-II mRNA, which was restricted to thecal cells. Although IGF-Ir message was detected only in GC, IGF-IIr mRNA was expressed in both granulosa and thecal cells. As in dominant follicles, insulin receptor mRNA was found in thecal, granulosa, and stromal cells. No IGF-I immunoreactivity was seen in either dominant or small antral follicles; however, immunostaining for the other gene products demonstrated that each of these proteins colocalized with its corresponding mRNA. Thus, the relative distribution of ligand and receptor transcripts and protein in cellular compartments of the human ovary observed in this study supports the presence of an intraovarian IGF system and suggests that both autocrine and paracrine mechanisms of IGF action occur between GC and thecal cells. We conclude that 1) IGF-II, rather than IGF-I, is the principal IGF in human ovarian follicles, being synthesized in thecal cells in small antral follicles and in GC in dominant follicles; 2) in small antral follicles, IGF-II acts in an autocrine fashion in thecal cells and in a paracrine fashion in GC; 3) in dominant follicles, granulosa-derived IGF-II acts in an autocrine manner in GC; and 4) the presence of transcripts and proteins corresponding to the IGF and insulin receptors in cellular compartments of human ovaries may also provide target sites for the action of circulating ligands with a potential extraovarian role in the regulation of folliculogenesis.

Cellular mechanisms of insulin resistance in polycystic ovarian syndrome.

Insulin resistance is a predominant feature in women with polycystic ovarian syndrome (PCO). The cellular mechanisms for this insulin resistance have not been defined. In this study, major steps in the insulin action cascade, receptor binding, kinase activity, and glucose transport activity were evaluated in isolated adipocytes prepared from PCO subjects (n = 8) without acanthosis nigricans and in a group of age and weight-matched controls [normal cycling (NC) n = 8]. The PCO group was hyperinsulinemic and displayed elevated insulin responses to an iv glucose load. The binding of 125I-insulin to adipocytes was similar in cells from PCO and NC subjects. In PCO, autophosphorylation of the insulin receptor-subunit in the absence of insulin was normal but a significant decrease (30% below control) in maximal insulin stimulated autophosphorylation was observed. However, receptor kinase activity measured against the exogenous substrate poly glu:tyr (4:1) was normal. Cells from PCO subjects transported glucose at the same rate, in both the absence and presence of a maximal insulin concentration, as those from NC subjects. Strikingly, there was a large rightward shift in the insulin dose-response curve for transport stimulation in PCO cells (EC50 = 87 +/- 14 pmol in NC vs. 757 +/- 138 in PCO, P less than 0.0005); 8-fold greater insulin concentrations were required to attain comparable glucose transport rates in cells from PCO against NC. In conclusion, our results suggest that insulin resistance in PCO, as assessed in the adipocyte, is accompanied by normal function of insulin receptors, but involves a novel postreceptor defect in the insulin signal transduction chain between the receptor kinase and glucose transport.

The correlation between lupus anticoagulant and autoantibodies.

The presence of a positive lupus anticoagulant (LA) has recently been associated with reproductive failure. LA positivity and reproductive failure have also been associated with autoantibody abnormalities, especially antiphospholipid autoantibodies. Because the correlation between LA and autoantibody positivity has remained controversial, we retroactively investigated 326 sera of patients with reproductive failure for correlation between lupus anticoagulant and 15 autoantibodies separately for IgG, IgM, and IgA isotypes. LA by TTI and APTT correlated significantly (p less than 0.0001). Among 18 antiphospholipid isotypes, 6 (33%) correlated significantly with TTI, 5 (28%) with APTT, and 3 (17%) both with TTI and APTT. Among 15 isotypes to histone subfractions, 4 (27%) correlated significantly to TTI, 3 (20%) to APTT, and 2 (13%) to both LA assay methods. Of 12 isotypes to antipolynucleotide antibodies, 2 (17%) correlated significantly to TTI, 1 (8%) to APTT, and none to both assay methods. The correlation between LA and autoantibodies was less striking among LA-positive than LA-negative sera. LA by both TTI and APTT was primarily found to correlate with IgG and IgA autoantibodies. This occurs in decreasing frequency to phospholipids, histones, and polynucleotides. At abnormal levels of LA (by either method) the correlation with autoantibody levels is less pronounced and appears closer with IgM autoantibodies to histones and polynucleotides than antibodies to phospholipids. We conclude that the correlation between LA and autoantibodies, especially antiphospholipid antibodies, is less pronounced than often reported in the literature. Patients suspected to suffer from reproductive failure due to abnormal autoimmunity have to be screened not only with LA and/or selected antiphospholipid autoantibodies, but with a more comprehensive autoantibody profile.

The relationship between autoantibodies and intrauterine growth retardation in hypertensive disorders of pregnancy.

Abnormal levels of autoantibodies have recently been demonstrated in patients with hypertensive disorders of pregnancy and patients whose fetuses have intrauterine growth retardation. We determined total immunoglobulin levels (immunoglobulin G, immunoglobulin M, and immunoglobulin A) and a broad panel of autoantibodies (six antiphospholipid, four antihistone, and four antipolynucleotide antibodies) in 50 normotensive pregnant females, 19 patients with preeclampsia, and 18 patients with chronic hypertension to examine the relationship to intrauterine growth retardation. Mothers who were delivered of infants with intrauterine growth retardation demonstrated significantly more autoantibody abnormalities in the two hypertensive groups and in the normotensive control group as compared with patients delivered of appropriately grown infants. The most frequently observed autoantibody abnormalities were antiphospholipid antibodies and the most frequently observed among those were immunoglobulin G isotypes. Total immunoglobulin levels in both hypertensive and normotensive groups were identical. These results suggest a close association between the degree of B-cell activation and both severity of hypertensive diseases and development of intrauterine growth retardation in their offspring.

The prevalence of autoantibodies and lupus anticoagulant in healthy pregnant women.

Abnormal autoantibodies have recently been implicated in pregnancy wastage. The normal autoantibody profile of pregnancy has so far, however, not been established. We investigated the effect of pregnancy on autoantibody production prospectively and longitudinally. Forty-three healthy pregnant women were compared with 50 nonpregnant healthy controls matched for age, race, and various obstetric and medical indices. All sera were tested for total immunoglobulin (Ig) levels; IgG, IgM, and IgA isotypes of autoantibodies to six phospholipids; total histone and four histone subfractions; and four polynucleotides. Plasma samples were evaluated for the presence of lupus anticoagulant. Total IgG decreased significantly in pregnant patients. The majority of autoantibody levels in pregnant women were within normal nonpregnant ranges. Only a few autoantibodies were increased in early pregnancy, including IgG antiphosphatidylinositol and H 2B, IgM antiphosphatidylinositol and phosphatidic acid, and IgA antiphosphatidylinositol and H 4. Most autoantibodies, although increased at term, were still within the normal nonpregnant range. Normalizing the data for expanded plasma volume did not significantly alter these results. Adjustment regression analysis excluded age, race, and various medical and obstetric indicators as confounding variables for autoantibody levels. The expected and observed prevalence of positive autoantibody levels in pregnant women was not significantly different from that of nonpregnant controls. None of the pregnant women demonstrated positive lupus anticoagulant. We conclude that in normal pregnancy between 16 weeks' gestation and term, autoantibody levels are largely within the normal range. Alterations occur, if at all, at the time of delivery.

Reproductive failure because of autoantibodies: unexplained infertility and pregnancy wastage.

Abnormal polyclonal B cell activation has been demonstrated in patients with endometriosis. To determine whether the noted B cell abnormalities were primarily a feature of the disease endometriosis or its manifestations of infertility and pregnancy wastage, we investigated antibody profiles in 26 female patients with unexplained infertility (group A) and 24 patients with unexplained pregnancy wastage (group B) but without documented endometriosis. Group A and B patients exhibited an unusual incidence of gammopathies (10 of 26 patients in group A and 11 of 24 in group B), with a majority representing immunoglobulin M gammopathies. Mean immunoglobulin M values were significantly elevated in both groups (p less than 0.03 and p less than 0.05, respectively, Student t test), whereas immunoglobulin G was significantly increased only among group B patients (p less than 0.05, Student t test). Lupus anticoagulant by tissue thromboblastin inhibition test was abnormally elevated in 2 of 26 group A and 2 of 24 group B patients. Activated partial thromboplastin time values were abnormal in only 3 of 26 group A and 2 of 24 group B women. Immunoglobulin G, immunoglobulin M, and immunoglobulin A autoantibodies to two phospholipid antigens, five histones, and four polynucleotide autoantibodies were detected in 23 of 26 (88%) group A patients and 17 of 24 (70.8%) group B patients. We conclude that some patients with unexplained infertility and pregnancy wastage suffer from polyclonal B cell activation. It is therefore tempting to speculate that autoantibody abnormalities may be causally related to infertility and pregnancy loss.

The thromboelastogram and circulating lupus anticoagulant.

Abnormal lupus anticoagulant (LA) levels, as measured with the activated partial tissue thromboplastin and tissue thromboplastin inhibition tests, are associated with a predisposition toward thromboembolic phenomena. Thromboelastogram (TEG) measurements have been proposed as a standardized assay to predict such a predisposition. We therefore correlated LA and TEG assessments in 46 women who were either apparently healthy controls or who had abnormal LA levels with such conditions as endometriosis and repeated pregnancy wastage. The coefficient of correlation (Rho) was .3282 (P = .025). Seven patients with an abnormal LA demonstrated a normal TEG, and eight with a normal LA exhibited an abnormal TEG. Only nine had concomitant LA and TEG abnormalities. We conclude that LA and TEG apparently are not interchangeable as predictors of a hypercoagulable state. While this study did not address which of the two assays has a better predictive value for thromboembolic phenomena, it suggested that each can identify a different patient population.

Danazol but not gonadotropin-releasing hormone agonists suppresses autoantibodies in endometriosis.

The effect of treatment with danazol (n = 10) or gonadotropin-releasing hormone agonists (GnRH-a) (n = 10) on autoantibody (AA) production (IgG, IgM and, IgA to 6 phospholipids, 5 histones, and 4 polynucleotides) in endometriosis was evaluated blindly in a longitudinal, prospective, randomized study. Clinical improvement, ovarian suppression, and resolution of endometriosis were comparable in both groups. Approximately 50% of patients had significant AA abnormalities initially. During treatment with danazol but not GnRH-a, AA gradually decreased in concentration and in number/patient. Total immunoglobulin levels (IgG, IgM, and IgA) also decreased only in the danazol group. This study indicates that danazol, but not GnRH-a, lowers abnormal AA associated with endometriosis.

Definition of normal autoantibody levels in an apparently healthy population.

Clinically asymptomatic women with laboratory abnormalities in autoantibody profiles have recently been shown to experience reproductive failure. The evaluation of autoantibody panels and the establishment of normal cutoff values in clinically apparently healthy populations has therefore achieved increasing importance. Investigation of 400 clinically asymptomatic patients (200 females and 200 males) for the presence of autoantibodies to six phospholipids, five histone subfractions, and four polynucleotides revealed a nonparametric distribution of autoantibodies primarily for antiphospholipids and antihistone antibodies. This observation suggests that widely used parametric methods for the determination of normal autoantibody levels are inadequate and will give an unreasonably high incidence of abnormal results. Consequently, rather than the widely used 95% confidence interval, we used the 99% confidence interval (based on medians) to determine the upper limit of normal for various autoantibodies. This resulted in the detection of four to 13 positive patients (out of 400) per antigen, for a positivity rate of 1-3%. A more rigid definition of normal and abnormal autoantibody levels is essential to pursue accurately diagnostic and therapeutic considerations concerning the newly evolving concept of subclinically abnormal autoimmunity.

The reproductive autoimmune failure syndrome.

The association between reproductive failure and abnormal autoimmune function has been recognized for decades in association with such established autoimmune diseases as systemic lupus erythematosus. Recent investigations have expanded this association to women who demonstrate similar humoral abnormalities as patients with defined autoimmune diseases but do not express any of the clinical symptoms required for the diagnosis of an autoimmune disease. The observation that abnormal autoimmune function in clinically asymptomatic patients can lead to reproductive failure has led us to define the reproductive autoimmune failure syndrome as a diagnostic entity. The present article summarizes evidence suggesting that the occurrence of reproductive autoimmune failure syndrome may be teleologically related to the woman's need for increased self-tolerance in face of antigenic exposure to the maternal haplotype of the fetus during normal pregnancy. This need for increased self-tolerance is documented by higher normal autoantibody levels in women than in men and may also be responsible for the highly increased incidence of autoimmune diseases in women in comparison with men. Under this concept, abnormal autoimmune function may lead to reproductive failure at different stages of the reproductive process, depending on the quality and possibly quantity of the abnormal autoimmune response.

Autoantibodies and common idiotypes in men and women with sperm antibodies.

Antisperm antibodies have been implicated as a causative factor of infertility and pregnancy wastage. Since concomitant autoimmune phenomena were reported in men with antisperm antibodies, we investigated known antisperm antibody-positive sera from 25 women, 27 men, and the respective seminal plasma samples. The investigated autoimmune panel included a search for antinuclear antibodies, autoantibodies (in IgG, IgM and IgA isotypes) to seven phospholipids (cardiolipin, phosphatidylserine, phosphatidylglycerol, phosphatidylcholine, phosphatidylethanolamine, phosphatidylinositol, and phosphatidic acid), to four histone subfractions (H1, H2A, H3, H4), and to four polynucleotides [ssDNA, dsDNA, poly(I), and poly(dT)], total immunoglobulin levels, and sperm antibody titers. The sera were also evaluated for the presence of a common anti-deoxyribonucleic acid antibody, and anticardiolipin antibody idiotypes. Levels of sperm antibody titers were significantly lower in women than in men. Both men and women with antisperm antibodies demonstrated elevated total IgG levels compared with those of normal control subjects. Only women showed elevated levels of total IgM. Sera from 24% of women and 11% of men with antisperm antibodies demonstrated antinuclear antibody titers greater than 1:40. The most striking autoantibody abnormalities were found among antiphospholipid antibodies. Sera from women with antisperm antibodies demonstrated higher autoantibody production than was found in their male counterparts. A significant correlation was found between antisperm antibodies and IgM anticardiolipin and IgA anti-phosphatidylinositol in women and between sperm antibodies and IgA phosphatidylserine antibodies in men. The presence of anticardiolipin and anti-deoxyribonucleic acid antibody idiotypes was significantly more frequent in women than in men. By means of discriminant analysis and variables selected by this mathematical model, the identification of 24 of 25 women and 26 of 27 men with antisperm antibodies was correctly predicted. These results suggest that women and men respond differently to sperm antigens. The apparent cross-reactivity between sperm antibodies and other autoantibodies, usually associated with autoimmune disease, suggests that a polyclonal B cell activation, similar to that seen in autoimmune diseases, occurs in patients with sperm antibodies.