Intravenous immunoglobulin use in patients with unexplained recurrent pregnancy loss.

Autor: Banjar S; Division of Clinical Immunology and Allergy, Department of Internal Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.; Division of Clinical Immunology and Allergy, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada., Kadour E; Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Bnai-Zion Medical Center, Rishon-Le-Zion, Israel.; Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel., Khoudja R; Division of Clinical Immunology and Allergy, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada., Ton-Leclerc S; Faculty of Medicine, McGill University, Montreal, Québec, Canada., Beauchamp C; Ovo Clinic, Montréal, Québec, Canada.; Obstetrics and Gynaecology Department, University of Montreal, Montreal, Quebec., Beltempo M; Division of Neonatology, Montreal Children's Hospital - McGill University Health Centre, Montreal, Québec, Canada., Dahan MH; Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montréal, Québec, Canada., Gold P; Department of Allergy and Immunology, Montreal General Hospital, Montreal, Quebec, Canada., Jacques Kadoch I; Ovo Clinic, Montréal, Québec, Canada.; Obstetrics and Gynaecology Department, University of Montreal, Montreal, Quebec., Jamal W; Clinique OVO, Montréal, Québec, Canada.; Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada., Laskin C; TRIO Fertility, Toronto, Ontario, Canada.; Deptartments of Medicine and Obstetrics & Gynecology, University of Toronto, Toronto, Canada., Mahutte N; The Montreal Fertility Centre, Montreal, Quebec, Canada., Reinblatt SL; Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montréal, Québec, Canada., Sylvestre C; Ovo Clinic, Montréal, Québec, Canada.; Division of Reproductive Endocrinology and Infertility, University of Montreal, Montreal, Quebec, Canada., Buckett W; Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, McGill University Health Centre, Montréal, Québec, Canada.; McGill University Health Care Reproductive Center, Montreal, Quebec, Canada., Genest G; Division of Clinical Immunology and Allergy, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.
Jazyk: angličtina
Zdroj: American journal of reproductive immunology (New York, N.Y. : 1989) [Am J Reprod Immunol] 2023 Aug; Vol. 90 (2), pp. e13737.
DOI: 10.1111/aji.13737
Abstrakt: Problem: Recurrent pregnancy loss (RPL) affects up to 4% of couples attempting to conceive. RPL is unexplained in over 50% of cases and no effective treatments exist. Due to the immune system's pivotal role during implantation and pregnancy, immune-mediated RPL may be suspected and immunomodulatory treatments like intravenous immunoglobulin (IVIg) have been administered but remain controversial. The goal of our study was to evaluate our center's 6 year-outcomes and to develop a framework for IVIg use in RPL.
Method of the Study: Retrospective, single-center cohort study. All patients having received IVIg for unexplained RPL at the McGill Reproductive Immunology Clinic (MRIC) from January 2014 to December 2020 were included if maternal age was <42 years, body mass index (BMI) < 35 kg/m 2 , non-smoker and having had ≥3 consecutive RPL despite previous treatment with aspirin and progesterone. IVIg 0.6-0.8 g/kg was given prior to conception and monthly during pregnancy until 16-20 weeks' gestation. We compared IVIg treated patient's outcomes to a separate "natural history cohort". This cohort was composed of patients consulting at the McGill recurrent pregnancy loss clinic and the MRIC over a 2-year period (January 2020 to December 2021) with similar inclusion criteria as the treatment cohort but did not receive IVIg or other immunomodulatory treatments. The association of IVIg with outcomes (compared to no IVIg) was evaluated among the groups of patients with primary RPL and secondary RPL. The primary outcome was live birth rate (LBR), secondary outcomes included IVIg safety, obstetrical, and neonatal complications.
Results: Among 169 patients with unexplained RPL that were included in the study, 111 had primary RPL (38 exposed to IVIg and 83 controls) and 58 had secondary RPL (nine exposed to IVIG and 49 controls). Among patients with primary RPL (n = 111), the LBR was 64.3% (18/28) among patient exposed to IVIg compared to 43.4% (36/83) in controls (p = 0.079); regression analysis adjusting for BMI and number of previous miscarriages showed benefit favoring the use of IVIg (OR = 3.27, CI 95% (1.15-10.2), p = 0.03) when evaluating for live birth. In the subgroup of patients with ≥5 previous RPL and primary RPL (n = 31), IVIg was associated with higher LBR compared to control (10/15 (66.7%) vs. 3/16 (18.8%); p = 0.0113) but not the in the sub-group of patients with <5 miscarriages and primary RPL (8/13 (61.5%) vs. 33/67 (49.3%); p = 0.548). IVIG treatment did not improve LBR in patients with secondary RPL in our study (3/9 (33.3%) vs. 23/49 (47%); p = 0.495). There were no serious adverse events in the IVIg treatment group, obstetrical/neonatal complications were similar between groups.
Conclusion: IVIg may be an effective treatment for patients with RPL if appropriately used in specific groups of patients. IVIg is a blood product and subject to shortages especially with unrestricted off-label use. We propose considering IVIg in well-selected patients with high order RPL who have failed standard medical therapy. Further mechanistic studies are needed to understand immune-mediated RPL and IVIg's mode of action. This will enable further refinement of treatment criteria and the development of standardized protocol for its use in RPL.
(© 2023 The Authors. American Journal of Reproductive Immunology published by John Wiley & Sons Ltd.)
Databáze: MEDLINE
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