There are five categories of immune problems that can cause pregnancy loss, IVF failures and infertility. Category 1 is the least severe, while Category 5 is the most severe. Without treatment, a woman with Category 1 problems can experience recurrent pregnancy loss, which may activate other categories of immune problems from Category 2, 3, 4 or 5.
The following documents, tables and figures explain the immune problems of categories 1 - 5, and are an introduction to the treatments involved and the success rates of parenthood.
Function of HLA Antigens
All cells of the body have on their surfaces proteins or peptides called HLA (human leukocyte antigens). These are depicted in the figure below. These antigens serve as antennae or "fly paper" that recognize and capture foreign interlopers--such as germs, viruses or cancer cells--that get into our bodies. With the new captured information, these cells signal the immune system to make antibodies (IgM, IgG and IgA) against the germ, virus or cancer cell.
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HLA Antigens: serve as antennae to recognize foreign germs or viruses entering the body.
Communicate this information to the white blood cells to initiate an immune response.
A pregnancy must also be recognized as a foreign being (father puts HLA antigens on the placenta that are different from those of the mother). When this applies, the mother makes an antibody called a blocking antibody that attaches to the placenta and makes it look to her like a "wolf in sheep's clothing." The antibody she makes in this circumstance does not kill; it protects the baby and makes the placental cells grow faster.
When the father's HLA antigens placed on the placenta are too similar to the mother's HLA antigens, she does not make the antibody. In this circumstance the baby is not protected, the placental cells are not stimulated to grow and the baby dies. She interprets the pregnancy as "altered self" (i.e., a cancer cell). Therefore, when the cells of the baby die, she activates other immune problems from Category 2, 3, 4 or 5 where the natural killer cells that she was born with are now misinterpreting the baby as a cancer. This occurs in couples sharing DQ alpha HLA antigens.
Immune Response to Pregnancy (Alloimmunity)
* Function: to alert the mother to react to the baby as a baby, not as an infection.
* Consequence: blocking antibody production (crossmatch positive by flow cytometry).
Immune Response to Infection (Infectious Immunity)
* Consequences: antibody production (gamma globulins) that destroys the germ or virus and remains in the body as a memory if the germ or virus returns.
Category 1 Immunological Problems
HLA Compatibility as a Cause for Recurrent Spontaneous Pregnancy Loss
The HLA antigens on the placenta cells made by the father are called HLA-G. When the couple shares DQ alpha antigens in common, the G molecule put on the placental cells by the father is too similar to the G molecule that the woman's father put on her placenta to sustain her in her mother's uterus.
As a result, she does not make the blocking antibody, the baby dies, and her immune system recognizes the placenta as "altered self" (i.e., a cancer cell) and category 1 problems move on to worsen to categories 2, 3, 4 and 5 (see diagram below).
Consequences
1. Inadequate blocking antibody formation.
2. Ineffective camouflage of placenta.
3. Placental cells fail to grow and divide.
4. Death of placental cells.
5. Activation of category 2, 3, 4 and 5 immune problems.
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HLA-G: Message sent from father to stimulate blocking antibody.
Blocking Antibody: Protects and stimulates the growth of placental cells.
Placental Cell Death: Consequences of low blocking antibody.
Category 2 Immunological Problems
Antiphospholipid Antibodies
Repeated miscarriages, IVF failures, endometriosis and anything that causes tissue injury can lead to the formation of antibodies to phospholipids. These are called antiphospholipid antibodies. Phospholipids are important molecules in the membranes of all cells, and antibodies to these important molecules can derange cell function, cause inflammation and can even cause blood to clot too quickly.
Many patients with autoimmune diseases also have tissue injury and make antiphospholipid antibodies. This is how antiphospholipid antibodies were discovered. Certain patients with lupus made antibodies that caused their blood to clot too quickly. This antibody is now called the "lupus anticoagulant antibody." When the test for this antibody is positive, most peole think they have lupus. However, in our experience, the majority of patients with this antibody have produced it because of infertility, IVF failures or recurrent pregnancy losses, not because they have lupus or other autoimmune diseases.
In our experience 22% of women with recurrent pregnancy losses have antiphospholipid antibodies. The incidence of this problem increases in women by 15% with each pregnancy that is lost. It is a significant consequence of infertility, implantation failures and recurrent pregnancy losses.
There are six different phospholipid molecules that have very important functions in cell membranes and intracellular organelles. The phospholipid molecules are
1. Cardiolipin
2. Ethanolamine
3. Glycerol
4. Inositol
5. Phosphatidic Acid
6. Serine
Cell death or cell injury can lead to the production of antibodies to all or any one of these molecules. These antibodies disrupt cell functions and increase the clotting speed of blood. This can cause chaos early in pregnancy.
The antibodies first produced are called gamma globulin M (IgM). These antibodies circulate in the blood and protect the blood environment. As the problem get worse, the IgM antibodies mature and produce gamma globulin G (IgG). These primarily in the lymphatic system and the lymph nodes. IgG antibodies go on to produce gamma globulin A (IgA), as the immunity completes its development. The IgG antibodies live in and protect the organs, including the reproductive tract.
As shown in the diagram, Serine and Ethanolamine are phospholipids that serve as glue molecules in allowing the placenta to be securely attached to the uterus during implantation. They also allow the cytotrophoblast to change into a new cell, the syncytiotrophoblast, which begins to feed the baby by transporting nutrition from the mother's blood into the baby.
Antibodies to these phospholipids prevent secure attachment or often totally prevent attachment. In addition, antibodies to these phospholipids prevent the cytophoblast from forming into the syncytiotrophoblast, which is needed to feed the baby. We have found that when this problem is diagnosed there is now a reason that is 97% effective in causing pregnancies to fail early.
Category 3 Immunological Problems
Positive Antinuclear Antibody (ANA)
Category 3 immune problems occur in 22% of women with recurrent pregnancy losses and nearly 50% of women with infertility and IVF failures. Women with this problem make antibodies to DNA, or DNA breakdown products in the embryo or in the pregnancy. These antibodies form first in the blood as IgM. As the problem gets worse they appear as IgG and live in the lymphatic system and lymph nodes. With more losses they form IgA antibodies which have their home and action in the organs including the uterus. These antibodies can be against pure double stranded DNA (ds DNA), single stranded DNA (ss DNA), or smaller molecules called polynucleotides and histones that make up the single strands (see diagram).
Consequences
* Antinuclear Antibody (ANA) positive, speckled pattern.
* Autoantibody to DNA leads to inflammation in the placenta.
* Autoimmune disease screening in the woman is negative (No evidence of lupus or rheumatoid arthritis).
A blood test determines the presence of antibodies to polynucleotides, histones and DNA. This process involves running 27 different tests on a sample of blood.
The presence of antibodies is also tested for by doing the ANA test. This is a less sensitive test but one that many doctors have already done on their patients before we ever see them.
The test is reported as a titer and a pattern. Any titer above 1:40 is significant. The titers can get into the thousands such as 1:2,500. This simply means that the test is positive when the blood serum is diluted many times.
The pattern is reported as homogeneous, nucleolar or speckled:
* Homogeneous: the antibody is to the ss DNA or ds DNA.
* Nucleolar: the antibody is directed to the polynucleotides.
* Speckled: the antibody is directed against the histones.
Some women demonstrate a mixed pattern of speckled/homogeneous.
These same antibodies appear positive in women with lupus, rheumatoid arthritis, Crohn's disease and other autoimmune diseases. They are usually in high titers. Pregnancy losses, infertility and IVF failures cause the titers to be much lower and a low positive titer does not mean that you have or are getting an autoimmune disease; however, this is ruled out during the testing.
In women with autoimmune diseases these antibodies cause inflammation in joints and organs. In women with no autoimmune diseases but a positive antibody, the antibody causes inflammation around the embryo at the time of implantation or in the placenta after implantation. This inflammation is exactly the same as occurs if you get a splinter under your fingernail. The tissue around the splinter gets hot, red and swollen and it happens quickly.
Category 4 Immunological Problems
Autoimmune Response to Sperm Antigen
Ten percent of women with infertility, implantation failures and recurrent pregnancy losses have produced antibodies to sperm. When this happens, a couple is unable to conceive normally, even if they had no problems with conception in the past. The antibody to sperm is often associated with antiphospholipid antibodies to the phospholipids serine and ethanolamine. Antibodies to sperm should be suspected
* if women have antibodies to serine and or ethanolamine,
* in women with poor post coital tests (sperm are dead or not moving in the cervical mucus), and
* in women whose spouses have antisperm antibodies.
Being exposed to antibody coated sperm dispensed by the male seems to encourage women to make antisperm antibodies on their own. When antisperm antibodies develop, they will inactivate or attack sperm from the husband and any donor (i.e., they are not partner specific). Testing for antisperm antibodies in women is done from a blood sample. There are more than five different methods to determine if antisperm antibodies are present. The most sensitive and reliable methods are
1. immunobead binding antisperm antibody assay, and
2. flow cytometry detection of antisperm antibodies.
The presence of antisperm antibodies in women strongly predicts that she will also have category 5 immune problems.
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Consequences
* Sperm antibody test positive.
* Sperm antibody positive by flow cytometer.
* Couple is unable to conceive normally.
* Multiple failed pregnancy through IVF, IUI, GIFT or ZIFT.
Category 5 Immunological Problems
* Introduction
* Chapter 1: CD 56+ Natural Killer Cells
* Chapter 2: CD 19+ 5+ B Cells (1)
* Chapter 3: CD 19+ 5+ B Cells (2)
Introduction
There are 30 different types of lymphocytes (CD designations) that make up the immune system. A balanced functioning of these white blood cells keeps a person healthy. Two of these cell types can cause infertility, implantation failures and miscarriages (see diagram below). Women are born with these cell types. In some women, they increase in numbers and activity and result in reproductive failures.
Types of white blood cells include the following:
1. TH-2 ("T Helper 2")
The response is a balanced correct response during pregnancy (Category 1).
2. TH-1 ("T Helper 1")
The response is a cyto-toxic autoimmune response that can lead to infertility, implantation failure and miscarriage (categories 2, 3, 4 and 5).
3. CD3, CD4, CD8
Control production of blocking antibody response; a correct response.
4. CD19+ 5+
Produce antiphospholipid antibodies (Category 2) and anti-DNA and histone antibodies (Category 3). It also produces antisperm antibodies.
5. CD56+, CD57+
Are natural killer cells.
Please see A Guide to Interpreting the Results of the Reproductive Immunophenotype for more information on lymphocytes.
Chapter 1: CD 56+ Natural Killer Cells
Problem
1. Increase in number 2-12% normal. Above 12% see infertility and pregnancy losses.
2. Increase in cytotoxicity in NK assay. Cytotoxicity above 15% at 50:1 can damage the embryo.
3. These cells usually reside in the blood; however, in 2% of women they are so activated they live in the uterus. This is determined by an endometrial biopsy on day 26 of a normal cycle and by the TJ-6 test which finds women whose Natural Killer Cells have become the most activated.
4. They produce toxic Cytokines (TH-1 cytokines) including Tumor Necrosis Factor (TNF) Alpha.
Consequences
1. Prevent implantation.
2. Cause miscarriages by damaging the placental cells, causing decidual necrosis, damage the yolk sac.
3. Later in pregnancy they cause slowness of the heart rate of the baby, cause an irregular shaped gestational sac that is smaller than normal and amniotic fluid volume that is too small.
4. They induce subchorionic hemorrhages which can cause spotting, bleeding and can be seen easily on ultrasound.
5. In some women they can affect the DNA in the eggs so that fragmentation, slow cell division, arrested cell division and poor quality embryos are seen.
Chapter 2: CD 19+5+ B Cells (1)
Problem
1. Normal numbers are 2% - 10%. Women with problems have increases in cell numbers above 10%.
2. These cells produce antibodies to hormones necessary for pregnancies to develop safely. These antihormone antibodies are against estradiol, progesterone, and Human Chorionic Gonadotropin (HCG).
3. These antibodies lower hormone levels and lead to luteal phase deficiencies, slow rising HCG levels when pregnant, poor stimulation during ovulation induction cycles and poor lining development by ultrasound evaluation.
Consequences
1. Resistant ovary syndrome or premature ovarian failure. Day 3 FSH and Estradiol levels are too high.
2. Poor egg quality in IVF. Fewer eggs recovered, slow division following IVG, fragmentation of embryos, poor quality embryos, fragile when frozen and thawed, multiple failed transfer cycles with no positive BHCG or slow rising BHCG.
3. Lining fails to develop adequate thickness, adequate layers or adequate blood flow to zone three.
Chapter 3: CD 19+5+ B Cells (2)
Problem
1. Normal numbers are 2 - 10%.. Women with problems have increases in cell numbers above 10%.
2. Produce antibodies to neurotransmitters, including serotonin, endorphins and enkaphlans.
3. These antibodies cause the ovaries to be resistant to stimulation, cause a poor lining to develop, interfere with the muscle development of the uterus, and prevent blood flow to the lining of the uterus and muscle at the time of implantation.
4. These antibodies can cause depression, fibromyalgia, sleep disorders, increasing PMS symptoms and night sweats.
[/b]Consequences[/b]
1. Follicles stimulate poorly and require heavy doses of fertility drugs to awaken.
2. Endometrial lining is thin; it rarely gets above 7 mm.
3. Three zones of the endometrial lining do not develop.
4. Blood vessels do not enter zone three.
5. Uterine smooth muscle remains quiet and does not contract three times in two minutes.
6. Eggs are of poor quality, fertilize in vitro with difficulty, divide slowly or incompletely, are low grade embryos and embryos fragment.
7. Women are depressed, sleep poorly, panic easily and experience symptoms of achiness and fibromyalgia.
