Download Evidence-based guidelines for the investigation of recurrent

Evidence-based guidelines for the
investigation of recurrent miscarriage
ESHRE Special Interest Group for Early Pregnancy
(SIGEP).
Dr. S. Arefi
Assistant Prof. , Affiliated
researcher
‫‪Common Case‬‬
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‫علی و مریم ‪ 3‬سال است که ازدواج کرده اند‪.‬‬
‫بیمار دو بار سقط خودبخودی حدود ‪ 10-9‬هفته داشته اند‪.‬‬
‫پزشک جهت بیمار به طور ‪empiric‬در حاملگی بعدی‬
‫اسپیرین و سیکلوژست شروع کرد ‪.‬‬
‫بیمار مجددا در ‪ 7‬هفتگی ‪ Blighted ovum‬شد‪.‬‬
‫چه تصمیمی برای بیمار می گیرید؟‬
FAQ
• Do we need to postponed the workups till 3th
abortion?
• Do we need to do all investigations in all
patients with RSA?
Immunology , Inflammation
implantation
Seminal fluid
• The seminal plasma introduced during intercourse in the mouse, pig and
human female reproductive tract has been shown to induce local
inflammatory changes .
Robertson SA, et al . J Reprod Fertil. 1996
A considerable proportion of the transforming growth factor (TGF)-β
synthesized in prostate in humans , secreted into the fluids that contribute
to the ejaculate . The TGF-β are key regulators of several aspects of the
immune responses including lymphocytes, macrophages and dendritic cells.
Letterio J,Annu Rev Immunol. 1998
TGF-β also promotes conversion of CD16+ peripheral blood natural killer
(NK) cells into CD16- NK cells in vitro . TGF-β derived from seminal plasma
may affect the maternal immune response in pregnancy through promoting
type 2 and/or Th3 immunity to paternal antigens from the outset of their
introduction to the female genital tract.
Robertson SA,J Reprod Immunol. 2002
Th1 response is mediated by
pro-inflammatory cytokines
such as interleukin 1 (IL1), IL2,
IL6, IL12, IL15, IL18, interferon-γ
(IFNγ), and tumor necrosis
factor-α (TNFα), Elevated proinflammatory cytokine/
chemokine expression, as well
as an increasing Th1
inflammatory response is
necessary for the acquisition of
uterine receptivity.
Th2 response is characterized by
the involvement of regulatory
cytokines such as IL4, IL5, IL10,
IL13, and granulocyte
macrophage colony stimulating
factor (GM-CSF) and is therefore
known also as antiinflammatory. Th2-humoral
inflammation is required for
pregnancy maintenance
local injury
• Mechanical endometrial injury (biopsy/scratch or
hysteroscopy►inflammatory response and high level of
endometrial proinflammatory cytokines, such as interleukin-6
(IL-6), leukemia inhibitory factor (LIF), and tumor necrosis
factor-α (TNF-α). The pro-inflammatory TNFα enhances the
expression of other cytokines/chemokines that recruit, in turn,
macrophages and DCs to the site of injury. These immune cells
secrete different factors that on the one hand may affect uNK
cell differentiation and on the other stimulate the luminal
endometrial cells to produce adhesion molecules enabling the
attachment of the embryo to the uterine lining, facilitating
implantation .
van Mourik MS et al, J Leukoc Biol. 2009.
Hysteroscopy : endometrial injury ,
implantation
The value of hysteroscopy in patients with
Repeated IVF Failure
S.Arefi et al .TUMJ,2008
Findings on hysteroscopy in patients with in vitro
fertilization by intra cytoplasmic single sperm
injection and embryo transfer failures
S. Arefi et al, SMJ 2008;
Repeated IVF failure and impact of hysteroscopy
S.Arefi et al ,IJRM,2008
Relation of Inflammation and Implantation: Serum CRP
level at the day of ET
• Increasing Serum ratio of CRP level (as a
sensitive marker in inflammatory reactions) in
day of embryo transfer to the day of ovum
pick up (≥1.23) can predict the success in
patients undergoing IVF/ICSI.
- S. Arefi, et al , C-reactive protein level and pregnancy rate in
patients undergoing IVF/ICSI ,IJRM, 2010
The Contribution of the Endometrium to Embryo Implantation
Consecutive pregnancy rate is higher
than predicted in recurrent miscarriage
(RM)
Predicted
Compared with controls, RM was associated with
significantly higher endometrial PROK1 mRNA levels
and approximately
100-fold lower PRL levels
1 month
3 months
6 months
Fert patients
0.8%
8%
41%
RPL patients
13%
41%
68%
RPL = recurrent pregnancy loss; FER = fertile
INF = infertile without RPL
Salker et al. PLoS One 2010
Key point: The embryo selective function has been shown to be defective
in women with RM and fails to discriminate between high and low quality
embryos
Macklon et al. ESHRE 2013. Oral 098
The Contribution of the Endometrium
to Embryo Implantation (Review)
Excessive selectivity
RIF
Insufficient selectivity
Decidual Phenotype
Only the best
embryo will do
RM
Poor embryos
allowed to implant
Key point: In recurrent implantation failure (RIF), the decidual phenotypical
abnormalities may be opposite to those in recurrent miscarriage
Macklon et al. ESHRE 2013. Oral 098
Does the endometrium “choose”
the embryo?
Weimar et al
PLoS One 2012
Key point: Emerging evidence suggests that the endometrium “chooses” the embryo. Poor quality
embryos cause less migration in fertile women, but not in women with recurrent miscarriage (RM)
Macklon et al. ESHRE 2013. Merck Serono Satellite Symposium
The probable causes of Reduced endometrial receptivity
classified as two headings:
1- Morphological:
Thin endometrium, abnormalities within cavity like large Polyp, Myoma,
Adhesions, septum
2- Molecular :
-Altered expression of adhesion molecules , Integrines ,and immunological
factors
- Increase of natural killer cells activities
- Imbalance of cytokine networks (balance between IL-12 and IL-18)
- Auto antibodies like ASA, ACA,LAC,ANA, Anti DNA, Anti Zona* and Anti
ovarian antibodies*, β2-glycoprotein-I antibodies, Antibodies to annexin-V
* Arefi S,et al Intrafollicular fluid antigamete antibodies in infertile patient candidates for ICSI.
IJRM,2006 summer; 7(2): 101-110
* Arefi S,et al . Antizona pellucida antibodies in follicular fluid and outcome of ICSI.MEFS
Journal 2006; 11(1): 35-42
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Immunologic investigations
ESHRE Special Interest Group for Early Pregnancy (SIGEP).
• An excessive maternal immune response against paternal
antigens resulting in abnormal immune cells and cytokine
production (Laird et al., 2003)
• particular interest on Natural Killer (NK) cells:
1-phenotypic and functional differences between
peripheral and uterine NK cells
2-percentage of CD56+ NK cells in peripheral blood of
healthy individual varies from 5 to 29% and is affected by
sex, stress, ethnicity and age.
Tests to measure blood NK cells ,useful ?(Moffett et al.,
2004).
• Recent data have shown that a high number of uterine NK
cells is found in the endometrium of women with RM and
this could be reduced by therapy (Quenby et al., 2005).
Prospective trials are needed and endometrial sampling
should only be offered to women within the context of
research programs.
Other Investigations:
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Coagulation investigations
Endocrinologic investigations
Parental cytogenetic investigation
Histopathological and Cytogenetic
investigation of the product of conception
• Anatomical investigations
• Male investigation
Coagulation investigations
ESHRE Special Interest Group for Early Pregnancy (SIGEP).
• History of three or more early pregnancy
losses, before 10 weeks
• 1 or more unexplained deaths at ≥10 weeks
of a morphologically normal fetus
• 1 or more premature births at ≤34 weeks with
severe preeclampsia or placental insufficiency
should be offered a testing for:
LAC ,aCL, APA, to exclude an antiphospholipid
syndrome (APS)
wilson et al
Investigation Association of three polymorphisms of
Coagulation Factor XIII and recurrent pregnancy Loss
It has been shown no significant difference •
between case and control with regard to FXIII
G103T ,But it has been seen significantly more
polymorphism of A614T and C1694T in
patients with recurrent pregnancy loss.
Mahmood J.Tehrani, Raheleh Torabi, Soheila Arefi ,et al,Am J Reprod
immunology,2010
Analysis of Plasminogen activator inhibitor -1,integrin beta
3,beta fibrinogen and MTHFR in Iranian women with
recurrent pregnancy loss
It has been shown mutation of PAI-1 4 G allele (specially •
homozygot) and beta fibrinogen increase the risk of RSA.
Conversly integrin beta 3 polymorphism had a protective
role for RSA as it was significantly more frequent in
control group.
MTHFR 677C/T polymorphism was significantly more •
frequent in patient with RSA.Also significant correlation
between MTHFR 677C/T and 1298A/ C
polymorphism,but no meaningful association between
RSA and MTHFR 1298A/ C
Mahmood J. Terani,Raheleh Torabi,Amir H. Zarnani, Soheila Arefi, et al Am J
Reprod ,Immmunol ,2010
• Among the genetic causes of this condition, a
common one is polymorphism at position 677
in the methyl tetrahydrofolate reductase
(MTHFR) gene, which in the homozygous form
leads to a thermolabile enzyme variant
Makris, 2000
Association of ACE,PAI-1,and coagulation factor
XIII gene polymorphism and with recurrent
abortionin Iranian patients
Only Homozygosity for PAI-1 (4G/4G)has been
shown significantly more in Patient with RSA in this
study.
Soltanghoraee H.,Memariani T.,Aarabi M.,Hantoushzadeh S.,Arefi S.,et
al,Medical Journal of Reproduction and Infertility,2007
Anatomical investigations
ESHRE Special Interest Group for Early Pregnancy (SIGEP).
• Diagnosis: Traditionally, laparoscopy, HSG and/or hysteroscopy have
been used to these uterine malformations in women with RM.
• Ultrasound, and in particular 3D ultrasound, has become an
accurate, reproducible, non-invasive, out-patient method for the
diagnosis of congenital uterine anomalies (Salim et al., 2003). Using
3D ultrasound, it has been reported that women with a subseptate
uterus have a higher incidence of first trimester loss, whereas
women with an arcuate uterus have a greater proportion of second
trimester loss and preterm delivery (Woelfer et al., 2001). With
both arcuate and subseptate uteri, the length of the remaining
cavity was shorter, and the size of the fundal distortion was higher
in the RM group.
• Three-dimensional, extended field-of-view ultrasound method for
estimating large strain mechanical properties of the cervix during
pregnancy.
House M 2012
Endocrinologic investigations ESHRE
Special Interest Group for Early Pregnancy (SIGEP)
• Although hypothyroidism and well-controlled diabetes are not
associated with RM (RCOG, 1998), thyroid function tests and
HbA1C measurements are accurate and inexpensive and can still
be considered as part of the evaluation (Christiansen et al.,
2005).
In hypothyroidism, infertility is more likely a problem than
pregnancy loss.
• Obesity is associated with a statistically significant increased risk
of first trimester and recurrent miscarriage [odds ratios 1.2 and
3.5 (Lashen et al., 2004)
• The association between polycystic ovary syndrome (PCOS) and
RM could be secondary to the association between obesity and
miscarriage ( Bellver et al., 2003).
• Hypersecretion of LH, high androgen levels, hyperprolactinaemia and luteal phase defects (LPD) have been
associated with RM.
Parental cytogenetic investigation
ESHRE Special Interest Group for Early Pregnancy (SIGEP)
• Structural chromosome abnormalities, usually balanced
translocation.
• Four factors increase the probability of carrier status:
1-low maternal age at second miscarriage
2-history of three or more miscarriages
3-history of two or more miscarriages in a brother or
sister
4-history of two or more miscarriages in the parents of
either partner (Franssen et al., 2005).
• After one miscarriage, it is generally accepted to refrain
from karyotyping. The incidence of carrier status after
one miscarriage is 2.2% (Braekeleer de and Dao, 1990). It
is thus advised to refer for parental karyotype only when
the probability of carrier status is ≥2.2%
Histopathological investigation of the product of
conception
ESHRE Special Interest Group for Early Pregnancy (SIGEP
)
• Whilst it is routine practice to send products of conception for
histological examination, mainly to exclude a gestational
trophoblastic disorder, the usefulness of histopathogical
investigation of placental and/or fetal tissue in RM on future
pregnancy management for an individual couple remains to be
determined (Jauniaux et al., 1996; Jauniaux and Burton, 2005). New
morphologic classifications continue to be proposed (Hakvoort et
al., 2006). In couples with RM, there are a few reports showing an
increased incidence of thrombo-inflammatory lesions such as
perivillous fibrin deposition, chronic villitis and deciduitis (Doss et
al., 1995; Hustin et al., 1996), in particular, when the karyotype is
normal (Redline et al., 1999). Although these lesions support the
immunologic imbalance concept, the contribution of these
histological findings to the management of RM is limited and has
not been trialled prospectively.
Cytogenetic investigations of the
product of conception
ESHRE Special Interest Group for Early Pregnancy (SIGEP)
• The risk of live born trisomy following an aneuploidy in
a sporadic early pregnancy failure is around 2%
(Alberman, 1992).
• Chromosomal analyses of the products of conception
in couples with RM indicate that a normal conceptus
karyotype in a previous pregnancy is a predictor of
subsequent miscarriage (Morikawa et al., 2004).
• Women <36 years of age with RM have a higher
frequency of euploid miscarriage.
• The cost benefit of performing systematic karyotyping
of products of conception after one miscarriage on the
overall management of RM needs to be investigated
prospectively in large populations.
Other investigations
• High level of homocysteine (hyperhomocysteinaemia) can be
associated with RM
Nelen et
al., 2000
• Cytokine gene polymorphisms in recurrent spontaneous abortions
Choi YK, 2008
• Polymorphisms in VEGF, progesterone receptor and IL-1 receptor genes
in women with recurrent spontaneous abortion.
Traina E ,2010
• A lot of information is available about environmental toxins. The
association between miscarriage and ionizing radiation, organic
solvents, alcohol, mercury and lead is confirmed, whilst an association
to caffeine, hyperthermia and cigarette smoking is suspected
Gardella and Hill, 2000
• Low plasma folate levels have been associated with an increased risk of
first trimester miscarriage
George, 2002
Male factor evaluation?
• Recurrent pregnancy loss results as a factor of
a couple. It has been emphasized the
contribution of the male to implantation
failure, miscarriage, and congenital anomalies
suggested by recent literature. With further
investigation, evaluation of the male may be
considered a routine part of the evaluation in
the near future.
Puscheck EE, 2007
• A recent systematic review showed that sperm DNA
damage is associated with lower pregnancy rate of
natural, intrauterine insemination (IUI), and in vitro
fertilization (IVF), and an increased risk of pregnancy
loss in those couples undergoing IVF or
intracytoplasmic sperm injection (ICSI).
Zini A, Sigman M (2009)
conclusion
• The majority of RMs remain
unexplained .Even though a cause
of the RM can be found in up to
50% of the women, only for women
with RMs resulting from
antiphospholipid syndrome, a
potentially effective treatment
namely the use of anticoagulants is
available. Supportive care is
regularly offered to these women,
after which live birth rates up to
85% are reported .
Current guidelines from the
European Society of Human
Reproduction and Embryology
(ESHRE) and the Royal College of
Obstetricians and Gynaecologists ;
(RCOG), 2011.
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Arefi S, Modaressi M.H, Jeddi Tehrani M, et al. Clinical significant of
pericentric inversion of chromosome 9: A case report of recurrent abortion.
Medical Journal of Reproduction & Infertility 2003 Summer; 4(3): 251-258
Mahmood Jeddi Tehrani,Raheleh Torabi,Amir Hassan Zarnani ,Soheila
Arefi, et al, Analysis ofPlasminogen activator inhibitor -1,integrin beta 3
,beta Fibrinogen and MTHFR polymorphism in Iranian women with recurrent
pregnancy loss American Journal of Reproductive Immunology,1011
Memariani; Arefi; Aarabi; Hantoosh Zadeh; Akhondi; Modarressi
,Polymorphisms of plasminogen activator inhibitor-1, angiotensin converting
enzyme and coagulation factor XIII genes in patients with recurrent
spontaneous abortion, The Journal of Maternal-Fetal & Neonatal
Medicine,2010
Haleh Soltanghoraee, Soheila Arefi, Afsaneh Mohammadzadeh1 , Arman
Taheri., Hojat Zeraati, Seyed Behnam Hashemi, M.P.H., Mohammad Mehdi
Akhondi. Thyroid autoantibodies in euthyroid women with recurrent
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Polymorphisms of Coagulation Factor XIII and Recurrent Pregnancy Loss..AM
J Reprod Immunol 2010,Aprl 12
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Shirazi,Elham;Moshref Behzad,Narges;Jeddi-Tehrani, Serum leptin levels in
women with immunological recurrent abortion, Mahmood,Journal of
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M.The relationship between polymorphisms of blood coagulation factor V
gene and recurrent pregnancy losses, ,Journal of reproduction and infertility
,Vol 9 Issue 4,Jaunary/March 2009
Soltan Gharaei H., Arefi S., Mohammadzadeh A., Zonobi M., Zeraati
H.,Bahrami M.E., Prevalence of seven antibodies in women with recurrent
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Soltangharaee H, Memariani T, Aarabi M, Hantoushzadeh S, Arefi S, Aarabi
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factor XIII gene polymorphisms with recurrent spontaneous abortion in
Iranian patient. Medical Journal of Reproduction and Infertility 2007 winter;
7(4): 324-330
Samira Hosseini, Amir Hassan Zarnani, Hossein Asgarian-Omran, Zohreh
Vahedian-Dargahi, Mohammad Reza Eshraghian, Zahra Akbarzadeh-Pasha,
Soheila Arefi, Mahmood Jeddi-Tehrani, Fazel ShokriComparative Analysis
of NK Cell Subsets in Menstrual and Peripheral Blood of Patients with
Unexplained Recurrent Spontaneous Abortion and Fertile Subjects,Journal of
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