Excerpt: The Selective Use of Heparin/Aspirin Therapy, Alone or in Combination with Intravenous Immunoglobulin G in The Management of Antiphospholipid Antibody Positive Women Undergoing In Vitro Fertilization

William Matzner, MD
Dr. William Matzner, Simi Valley, CA

Excerpt: The Selective Use of Heparin/Aspirin Therapy, Alone or in Combination with Intravenous Immunoglobulin G in The Management of Antiphospholipid Antibody Positive Women Undergoing In Vitro Fertilization

This is an excerpt of an article originally published in American Journal of Reproductive Immunology and was co-authored by Dr. William Matzner.  The full article is available here. 

INTRODUCTION

Despite the introduction of enhanced protocols for ovarian stimulation, improved embryo culturing techniques, assisted hatching and intracytoplasmic sperm injection, the national average birthrate per completed cycle of In Vitro Fertilization (IVF) and Embryo Transfer (ET) has minimally improved over the last few years and is still not much above 20% per egg retrieval (1).  The successful implantation of a morphologically normal embryo transferred to the uterus remains the bottleneck in every IVF program.

For several years, researchers have shown a link between abnormalities relative to the woman’s immune system and recurrent pregnancy loss (2-5).  More recent data suggests that the immunologic pathophysiology associated with recurrent pregnancy loss and early implantation failure may be similar.  Clearly, implantation failure at a preclinical stage is often misdiagnosed as “infertility”.  Perhaps the term Failed Pregnancy Recognition (FPR) would be more appropriate in such cases.  It is likely that immunologic deficiency plays a significant role in a variety of implantation related problems, including but not limited to; FPR, biochemical pregnancy, blighted ovum and first trimester miscarriage (4-9).

Bustillo, et al. reported a five fold increase in the prevalence of APA seropositivity in 84 women who failed to conceive following the transfer of twelve or more embryos over a number of IVF/ET cycles (10).  Sher, et al. described a high prevalence of antiphospholipid antibodies (APA) in women with pelvic organic disease who underwent in vitro fertilization (IVF) and embryo transfer (ET), and demonstrated a three fold improvement in clinical PR with the first IVF cycle when H/A was administered to APA+ women under the age of 40 years (7), suggesting that autoimmune mechanisms associated with early implantation failure are potentially treatable.

It has been demonstrated that APA+ patients undergoing IVF benefit from H/A therapy (7), therefore, we tested all IVF candidates prior to commencing their first IVF attempt. Over the years, we noted a trend from the results in our clinic suggesting that women who possessed IgG or IgM antibodies to phosphoserine (PS) or phosphoethanolamine (PE), had lower pregnancy rates than women with any other APA. With this observation, and Coulam, et. al. reported success using intravenous immune globulin (IVIg) on unselected patients who had failed several IVF attempts (11), we attempted to establish specific criteria for which patients might benefit from H/A along with IVIg. IVIg was felt to be an appropriate immune modulator because it has been proven useful in a variety of autoimmune disorders such as Kawasaki’s disease, idiopathic thrombocytopenic purpura and Wiskott-Aldrich syndrome.  Although the mechanism of action is unclear, it is believed that the anti-idiotype antibodies in the IVIg play an immune modulating function (12).   The specific objectives of this analysis are: 1) To determine whether the effect of H/A therapy was influenced by the phospholipid (PL) epitope against which the APA were directed as well as the gammaglobulin isotype involved; and 2) To ascertain whether H/A treated, APA+ women who failed to conceive following two consecutive IVF cycles of treatment, would experience improved birthrates following the combined administration of H/A and IVIg during the third consecutive IVF attempt, and to establish if any particular APA type predicts which women may benefit from IVIg therapy.

MATERIALS AND METHODS

A study was undertaken, involving 687 APA+ women (age range 29-40 years, mean age 36.25 years) who underwent IVF/ET at Pacific Fertility Medical Center during a four year period commencing January 1992.  Cases of male infertility, ovum donation and gestational surrogacy were excluded. The  data analysis was conducted in three phases.

Phase I

Six hundred eighty seven (687) women who tested APA+ to one or more PL epitope each underwent < 2 IVF cycles for a total of 1050 completed treatment cycles.  All women were offered treatment with heparin and aspirin.  Those who accepted were put into Group A and those that declined were placed in Group B.  Six hundred three (603) of these women (Group A) underwent a total of 923 IVF cycles of treatment where H/A alone was administered, while the remaining 84 women (Group B) underwent 127 IVF cycles where H/A was not administered.

Phase II

We evaluated whether IVF outcome following two consecutive cycles of H/A therapy was influenced by the APA profile (i.e. the specific PL epitope to which APA were directed and the associated gammaglobulin isotype). Since the number of individual APA sub-profiles was quite large, the sub-groups were too small to permit statistical comparison in patients who had APA directed against multiple phospholipids. In addition, it would be difficult to ascertain if one specific PL influenced outcome in the presence of other PLs.   Accordingly, Group C represents those 322 women from Group A  who each tested positive to only one APA.

Phase III

Group D represents one hundred twenty one (121) women from Group C  who did not achieve viable pregnancies in Phase II (i.e. following two consecutive IVF attempts), where immunotherapy was confined to H/A alone.  These women received IVIg in combination with H/A during their third consecutive IVF cycle.

LABORATORY EVALUATION

All women underwent serum follicle stimulating hormone (FSH) and estradiol (E2) measurements (by radioimmunoassay or enzyme assay) on day two or three of a prior menstrual cycle.  Only those women who had a serum FSH concentration of < 10mIU/ml and a plasma E2 of < 70pg/ ml on cycle day three, were included in the study.  All women underwent APA testing using an enzyme-linked immunosorbent assay for antibodies to the following six phospholipid epitopes: cardiolipin (CL), phosphoserine (PS), phosphoglycerol (PG), phosphoethanolamine (PE), phosphatidic acid (PA), and phosphoinositol (PI), as previously described in detail (13).  Antiphospholipid antibody seropositivity (APA+) was defined by the detection of APA measuring > two (2) standard deviations from the mean to IgA, IgM and/or IgG isotypes.  Borderline values were defined as >2 SD above the mean, and positive values were defined as >3 SD above the mean of normal controls. The control group for the APA assay consisted of non-infertility patients who had no history of clinical or subclinical autoimmune disease, or recurrent pregnancy loss.

Each time the ELISA assay was performed, both known negative and positive controls were run simultaneously for each epitope and isotype.  This was important to assess the performance of the antigen coated on each plate, the antibody conjugates, the pipetting technique, washing method, incubation times, incubation temperature and substrate.

Cervical or semen specimens were cultured for Ureaplasma, Chlamydia and Gonococcus, in all cases.  Male partners all underwent semen analyses to exclude male factor infertility.

DETERMINANTS OF OUTCOME

The number of babies born per transferred embryo, was determined in order to provide a measure of the viable implantation rate.  Multiple births and miscarriages were documented.  A successful IVF outcome was defined as a live birth.

TREATMENT

All patients underwent controlled ovarian hyperstimulation (COH) with menotropins, preceded by pituitary down regulation with gonadotrophin releasing hormone agonist (GnRHa) by a previously described protocol (14).

All patients included in this study were APA+ and received aspirin 81 mg po qd and heparin 5000 U sq bid, starting on day two of Controlled Ovarian Hyperstimulation.  Heparin was withheld on the morning of egg retrieval, and reinstated that same evening while aspirin was withheld from the ninth day of menotropin stimulation and was reinstated on the evening following egg retrieval.  H/A was discontinued if pregnancy did not occur as evidenced by rising quantitative human chorionic gonatotropin (HCG) blood levels measured respectively on the 8th and 10th day postET. Patients with a positive HCG blood test continued with H/A treatment through the diagnosis of a clinical pregnancy, 3-4 weeks post ET.  H/A was continued until, at least the 10th gestational week.  H/A treatment was monitored as previously described (7).

STATISTICAL METHODS

Data was placed into two-by-two tables; and analyses between and within groups were performed using the Chi Squared test for significance.  P values below 0.05 were considered to indicate statistical significance.  Analysis was performed using the CHITEST and CHIINV functions of Microsoft Excel 97 for Windows. 

About William L. Matzner, M.D., PhD, FACP 

Dr. William Matzner works in the area of healthcare economics consulting at Healthcare Analytics, LLC, in California. He graduated Phi Beta Kappa from Stanford University. He received his M.D. with Honors from Baylor College of Medicine. In 1988, he was the Solomon Scholar for Resident Research at Cedar Sinai Medical Center. Dr. Matzner subsequently was awarded a PhD in Neuro Economics from Claremont Graduate University. He is board certified in Internal Medicine and Palliative Medicine. He has researched and published extensively on the issue of reproduction and immunology in medical literature. He has been in private practice since 1989, specializing in Reproductive Immunology and Internal medicine. 


Consulting Website: https://healthcareanalytics.biz
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William Matzner, MD (Simi Valley, California), has been practicing medicine since 1989, Internal Medicine and Reproductive Immunology. M.D. with Honors from Baylor College of Medicine.

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