Transcript HOWEVER, THIS ALONE DOES NOT DETERMINE

Is there a role for
thrombophilia/autoimmune
testing in ART?
Prof. Juan A Garcia-Velasco
IVI-Madrid - SPAIN
Learning Objectives
• To understand the implications of
thrombophilia/autoimmune testing in RIF and
available tests
• To review the current evidence on
trombophilia/autoimmune treatment in RIF
Controversy
….1978
Future
Controversial issue
Substantial knowledge and progress has been
made in:
o simplifying diagnostic approach of the couple
o understanding folliculogenesis
o controlling hormones
o facilitating egg retrieval and embryo transfer
o culturing embryos up to blastocyst stage
Still a lot to learn from:
o endometrial receptivity
o embryo beyond morphology
Implantation
Learning objectives
 Understand implantation failure
 Define autoimmunity and thrombophilia
 Evaluate prevalence vs causative role
 Analyze NK cell testing
 Treatments risks and efficiency
Implantation
embryo quality
Endometrial
receptivity
Transfer
efficiency
Implantation failure?
ANALYSIS OF 20,718 CYCLES – SINGLE CENTER
A)
Cumulative probability of live-birth (%)
Survival Function
100
92% CLBR
IVF
79% CLBR
80
69% CLBR
52% CLBR
60
40
20
10
15
20
25
30+
5
Embryos transferred needed to reach live-birth
Garrido et al. Fertil Steril 2011
Seed or the soil?
Implantation failure?
Egg donation – 15,792 cycles
97% CLBR
85% CLBR
65% CLBR
Controversial issue
a) We cannot ask embryos more than what they can do
b) There are other factors that may contribute:
- endometrium
- embryo tranfser efficiency
- maternal tolerance to pregnancy?
Controversial issue
DOCTORS
PATIENTS
What to test
 Anti-thyroid antibodies
 NK cell testing
 Antiphopholipid antibodies
 Thrombophilic disorders
What is autoimmunity?
Failure to recognize our own constituent parts
as self – immune response against cells
o coeliac disease, DM type 1, SLE…
o high level autoimmunity is unhealthy,
but low level might be beneficial
• recognizes neoplastic cells
• rapid response in early stages of infection
• ……
TAI (thyroid autoimmunity)
Euthyroid, subfertile women with TAI show similar live
birth rates than control women
Kolibianakis et al. Eur J Endocrinol 2010
How pregnancy occurs
Peter Medawar, 1953
“fetus as foreign body”
1.Totally compatible with the mother
2.Uterus immunologically privileged
3.Placenta as a barrier
4.Pregnancy alters maternal
immune response
“Cooperation venture between fetal antigens and maternal immune cells”
Parham 2004
Immunomodulating agents
1. Steroids
2. IVIG
3. anti-TNF a
- modulation of complement activation
- suppression of idiotypic antibodies
- saturation of Fc receptors on
macrophages
- suppression of various inflammatory
mediators, including cytokines,
chemokines, and metalloproteinases
NK cells: uterine & blood
• Both –peripheral and uterine- are part of the immune system
• Both express surface antigen CD56
• BUT: phenotypically and functionally different
uNK and pNK: different?
Peripheral NK
<10% resemble uNK
90% are CD56dim and CD16+
Significant cytotoxic activity
Uterine NK
appear in midsecretory phase
80% are CD56bright and CD16Little cytotoxic activity
Express KIR, ILT-2, NK G2 and
HLA-C, HLA-E and HLA-G
peripheral NK
Association between pNK number or activity and RM/infertility
Kwak 1995
Aoki 1995
Ntrivalas 2001
Yamada 2003
Shakar 2003
Beer 1996
Matsubayashi 2001
Ntrivalas 2001
Emmer 2000
Souza 2002
Wang 2008
Vujisic 2004
uterine NK
Association between uNK number or activity and RM/infertility
Clifford 1999
Quenby 1999
Quenby 2005
Tucerman 2007
Ledee-Bataille 2005
Michimata 2002
Shimada 2004
Matteo 2007
1. Tremendous inconsistency
2. Causative role for NK cells
in reproductive problems?
NK cells and infertility
Relevant citations on uNK and pNK (n=783)
Tang et al Hum Reprod 2011
NK cells and infertility
• The prognostic value of measuring pNK and uNK cell
number or activity remains uncertain
• Value of abnormal test for pNK?
– stress, COH…
• No consensus on what an abnormal NK cell test result is
– 12% (5-29%)? why?
• Important differences in the analysis and interpretation
• Considerable heterogeneity among studies
Tang et al Hum Reprod 2011
NK cells and infertility
No clinical evidence but…biological plausibility?
• uNK abundant at implantation
• Interact with extravillous
thophoblast cells
• Different uNK cell population in
deciduas from normal/miscarriage
• Regulate angiogenesis
• Trophoblast cells express Ag
recognized by uNK
Bulmer 2005
Moffett-King 2002
Quack 2001
Hanna 2006, Quenby 2009
Hiby 2010
IVIG: implantation failure
Stephenson & Fluker. Fertil Steril 2000
IVIG: recurrent miscarriage
Stephenson et al. Hum Reprod 2010
What is a thrombofilia?
Hypercoagulability or prothrombotic state
o increased risk for thrombosis
o only develop in presence of other risk factors
• high estradiol concentrations
• pregnancy
• obesity
•……
o a significant proportion of population has a
detectable abnormality, asymptomatic
Thrombofilia panel
• ACA and lupus anticoagulant
• Antithrombin III deficiency
• APCR (if positive, factor V Leiden)
• protein C and S
• plasma homocysteine
• screening for MTHFR and factor II.
Prevalence studies
Factor V Leiden and prothrombin gene G20210A and IVF
ART outcome
Ricci et al. Hum Reprod 2011
Thrombophilias in ART
n=6,092
RISK FOR ART FAILURE
8 case-control
3 cohort NO
Di Nisio et al. Blood 2011
Thrombophilias in ART
Di Nisio et al. Blood 2011
Thrombophilias in ART
Thrombophilias in ART
 RIF show higher prevalence of antiphospholipid Ab (OR 3.3)
 No association between thrombophilias and ART outcome in
cohort studies
AAS / LMWH
364 women
Unexplained recurrent miscarriage
RCT
Kaandorp et al. NEJM 2010
AAS / LMWH
Kaandorp et al. NEJM 2010
Treatment risks
Heparin
• thrombocytopenia
• bleeding
Corticoids
• fluid retention
• HTA
• mood swings
• weight gain
• risk of infections
• high blood sugar
• cleft palate
IVIGs
• headache
• dermatitis
• pulmonary edema
• anaphylactic react.
• hepatitis
• acute renal failure
• venous thrombosis
• aseptic meningitis
• risk of diabetic newborn
Our data - IVI
o 2001 to 2011
o 636 RM (> 2 misc) and 513 RIF (at least 4 GQE)
o Panel:
- Mutations: Factor V, MTHFR (C677T) and prothrombin (G20210A)
- ATIII, prot C and S, ACPR, ACA and lupus anticoagulant, homocysteine
o Exclusion factors:
- abnormal karyotype
- ultrasound visible hydrosalpinx
- intramural fibroids (>3cm or >2 fibroids under 3cm)
- endometrial polyps of an size
- any previous pregnancy (RIF)
Recurrent implantation failure
Our data - IVI
n = 114
Hyperhomocysteinemia
Homozygous Factor II
Heterozygous Factor II
29.8%
0.9%
3.5%
Homo MTHFR
Hetero MTHFR
Homo Factor V Leyden
Hetero Factor V Leyden
ACA IgG
ACA IgM
11.4%
36%
0%
0.9%
0.9%
2.6%
Lupus anticoagulant
Protein S
Protein C
ACPR
0.9%
5.3%
0%
1.8%
Self-created “trap”
How to counsel a woman who has tested positive?
Our data – IVI (egg donor)
n=10,537
Our data – IVI (PGS)
RIF
Blastocyst
PGS
P-value
43
48
----
Mean age (SD)
35.3±2.9
35.2±3.5
----
Nº of transfers (%)
36 (83.7)
43 (89.6)
----
----
57.3
----
1.9±0.7
1.7±0.6
----
Ongoing PR/ET(%)
12/36 (33.3)
23/43 (53.5)
0.0579
LBR (%)
12/43 (27.9)
23/48 (47.9)
0.0402
Implantation rate (%)
12/67 (22.1)
26/71 (36.6)
Nº of cycles
% abnormal embryos
Mean ET (DS)
0.0112
* One-side Fisher´s test
Rodrigo et al. ESHRE O-192
CCS (SNPs array)
≥38 years
RM
RIF
Who may benefit
o we clearly do not know (if any)
o most RIF show very good outcome after appropriate
embryo selection or even oocyte donation
o may be a subpopulation of “unexpected” RIF
- autoimmune disease?
- unable to diagnose today
- empiric approach useless
Guidelines
o RCOG – 2011
“This remains a research field and testing for uNK
cells should not be offered routinely in the investigation
of recurrent miscarriage.”
o ASRM – 2012
“Treatments with no proven benefit include
leukocyte immunization and IVIG therapy”
Conclusions
Hippocrates
“First, do no harm”
“Primum non nocere”
Archie Cochrane
Evidence Based Medicine
Conclusions
o Most women with RIF are eager to try any form of
treatment
o There could be a potential in adequately screened
group of women
o To determine which women might benefit from
manipulation of the maternal immune system, further
research is urgently needed
o There is little evidence to support any particular test
or immunomodulatory treatment in couples with RIF;
they should be restricted to formal research studies.
Thank you!
Affected neonates
Borchers et al. J Autoimm 2010