I’m sure many of you will identify with my history below and this is for anyone interested in finding out how you may be helped.
Brief history.
36 year old living in South Wales, UK.
Husband age 46 (fit and healthy), has 19 year old son from previous
relationship.
TTC 7 years.
My relevant past medical history : allergic individual!, Toxic Shock
Syndrome age 15 but tubal pathology OK, mild endometriosis (patch up
around liver causes pain during AF)
2002/2003 : Ovulation Induction x3 - all negative
IUI x3 - all negative
Feb 2004 : IVF (2 fresh Grade 1 embryos) - negative
May 2004 : IVF (2 frozen Grade 1 embryos) - miscarried at 5 weeks
Oct 2004 : IVF (2 fresh Grade 1 embryos) - negative
Jan 2005 : ICSI due to motile but erratic sperm! Aspirin
for the first time(2 fresh Grade 1 embryos) - negative
I hope the information detailed below gives some idea of the theory of immunological issues related to infertility and the practicalities of testing and treatment from a UK perspective.
This treatment is not approved by the HFEA (and so is not offered by UK physicians) largely based on the lack of randomised-control trials, although my personal feeling is that if it is so successful then it would be unethical to give people dummy treatment. Dr Beer’s success rates speak for themselves.
My experience is that firstly you need a supportive consultant who ideally will agree to be the referring physician, to take blood (you then arrange for it to be shipped overnight to USA) and to prescribe and monitor treatment / coordinate fertility treatment according to the protocol proposed by Dr Beer. If your own Dr won’t agree there are 4 registered supporting Dr’s in London, one in Nottingham and one in Liverpool.
There is a detailed online form to fill in, then he may require a medical report from your consultant and following this will order tests, consult with you (usually via the telephone unless he happens to be in his London clinic) and suggest a protocol of treatment.
Apparently the turn around is quite fast with treatment ordered approximately one month from the date of submitting the forms. I managed to get my consultant’s full support, submitted the forms last week and am currently awaiting a medical report and a day 26 hysteroscopy / endometrial biopsy.
As you can see from the treatment section at the bottom it is a complex (and expensive) business although I figure with the huge success rates it is worth paying the equivalent of maybe even a couple of IVF cycles for. After all with the correct treatment you’re not just talking about a few percent more, the chances of having a baby are at least twice as good and often more than that!
This is a summary of all the information that I’ve found useful. It is mainly a collaboration of information taken from Dr. Beer’s website (www.repro-med.net) and a very helpful and active site at http://health.groups.yahoo.com/group/immunologysupport/ where I would recommend looking at the message board and the online files.
Please note that although I have checked the text for errors this is simply my understanding of the issues and you would be well advised to visit the official sites.
INTRODUCTION TO DR. BEER AND THE CENTER
THE ALAN E. BEER CENTER FOR REPRODUCTIVE IMMUNOLOGY AND GENETICS researches and treats couples who experience recurrent miscarriages, multiple pregnancy losses or repeated in vitro fertilization failures.
Through science and a deep understanding of the role of the immune system in pregnancy, we help such couples achieve a successful pregnancy.
Dr. Beer has researched this topic for more than 30 years and with his treatments, he has achieved successful pregnancies in more than 85% of the couples he has treated. His research shows that there are five categories of immune problems that can cause pregnancy loss, IVF failures and infertility.
Dr. Beer has spent his entire academic life analyzing the impact of the immune system on infertility and the success or failure of a pregnancy. He has dedicated his professional life to analyzing couples with infertility, IVF or implantation failures and recurrent pregnancy losses who have been told by the medical community that their problem was due to bad luck or nature's way, and that they should try again.
Although I have learned much about infertility and pregnancy losses by studying healthy couples who get pregnant easily and then lose every pregnancy through miscarriage, my research has taught me much more. There are couples who are an unlucky match for each other who produce embryos that are misinterpreted by the immune system as foreign objects or even cancer cells. These embryos are repudiated and each attempt at pregnancy makes the problem worse until the uterus behaves like a "den of lions" and every pregnancy attempt fails. This occurs even when beautiful embryos are produced in the test tubes following in vitro fertilization.
Some of our patients tell us they have heard many of the following statements:
1. You were unlucky this time, try again.
2. It is God's will; you can always adopt.
3. It was meant to be.
4. The baby was abnormal.
5. The body knows when a baby needs to be rejected.
6. Next time we will try more progesterone.
7. If you miscarry frequently we will try IVF-ET.
8. Next time we will try donor eggs; your eggs are too old.
9. Next time we will try aspirin and heparin.
10. Next time we will try IVIg.
Our research is showing that there may be additional options.
A TYPICAL PATIENT
The patients that I see are 38.6 years plus or minus 2 years. They have been unsuccessful 4.4 plus or minus 2 times and are near the end of their reproductive career, bruised, abused, and often without hope. Most of them can be helped by finding out what is wrong, and if there is a problem, providing them with the understanding and offering of the proper immune treatment.
SERVICES
The Alan E. Beer Center for Reproductive Immunology and Genetics provides state-of-the-art immunological evaluation and monitoring, counseling and treatment for couples who have experienced infertility, assisted reproductive technology failures, repeated pregnancy losses, unexplained intrauterine fetal deaths and intrauterine growth retardation. Services for registered patients of our research program include
Specialized Immunological Evaluations, Tests and Treatments.
Co-management of Pregnancies and Assisted Reproductive Technology Procedures with patients' physicians.
Counseling for women with autoimmune disorders such as lupus and rheumatoid arthritis who are contemplating a pregnancy.
Administrative Assistance regarding insurance.
Pathological Consultation of pregnancy tissues obtained at the time of miscarriage or uterine curettage to determine if an immune process caused the miscarriage.
CHECKLIST – factors related to immunological problems
Recurrent Pregnancy Loss. A couple has experienced a pregnancy naturally or with assisted reproduction and miscarried after the pregnancy was confirmed. The length of pregnancy is unimportant
Secondary Miscarriage. A couple has one or two live-born children and experiences infertility, implantation failure or a miscarriage either before or after the live-born child. The length of pregnancy at time of miscarriage does not matter.
IUFD (Intrauterine Fetal Death). The death of an embryo after a heart beat was established. The length of the pregnancy at the time of the death of the embryo does not matter.
Second Trimester Fetus Loss. Death of a baby in the uterus after 3 months gestation or after 12 weeks gestational age. The ultrasound measurement of age is not important since many of these babies with second trimester death grow slowly (intrauterine growth retardation or small for dates).
Pregnancy Loss with Conventional or Optimal Treatment. Examples of conventional treatment: Progesterone, HCG, Estradiol or other Hormone Therapies. Losses with optimal immune therapy: Aspirin Therapy, Prednisone (steroid) Therapy, or Intravenous Immune Therapy-IVIG.
Prior Loss of Chromosomally Normal Infants. Genetic, chromosomal or karyotypic analysis of the baby showed it to be a normal female or male.
Positive Placental Pathology. To answer this you must have available the pathology report of the "Products of Conception" obtained at the time of a D&C (Dilatation and Curettage) at the time of the miscarriage or death of the fetus. A mention of any of the following features is a yes answer to this question. These include: Decidual Necrosis; Villitis; Intervillositis; Thrombosis; Villositis; Perivillitis; Fibrin Deposition or Abnormal Trophoblast Morphology.
IVF-ET Failure Assisted reproduction procedures that have failed including: IVF (In Vitro Fertilization), ET (Embryo Transfer), GIFT (Gamete Intrafallopian Transfer), ZIFT (Zygote Intrafallopian Transfer) and IUI (Intrauterine Insemination). Failure = No pregnancy or a positive pregnancy test that subsequently became negative or a successful pregnancy that ended in miscarriage.
Pelvic Inflammation or Endometriosis. Pelvic Inflammation = a history of sexually transmitted diseases such as Strep, Chlamydia, Mycoplasma, Ureaplasma or other Sexually transmitted diseases that led to scarring or pelvic adhesions. Endometriosis = mild to severe seen at the time of surgery.
History of Blood Clotting Problem Occurring at any age or any time. This condition resulted in Phlebitis (inflammation of the veins) or blood clots in the arteries or veins.
Autoimmune Disorders. This includes: Lupus, Rheumatoid Arthritis, Crohn's Disease, Mixed Connective Tissue Disorder, Raynaud's Disease, Ulcerative Colitis, Chronic Fatigue Syndrome, sore joints, skin rashes, hives etc.
Thyroid Problems. This includes: overactive or underactive thyroid conditions, Hashimoto's Thyroditis (thyroid inflammation), thyroid cancer or thyroid antibodies. Being on or off thyroid medications does not matter.
Flu-Like Illness. During pregnancy or following insemination or following embryo transfer, including: achiness, headache, fever, chills, body pain, joint pain or stiffness.
Family History of Infertility or Miscarriage. Mother, sisters, grandmother or aunts in the female or male.
AN INTRODUCTION TO IMMUNE PROBLEMS
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.
OVERVIEW / 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.
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.
CATEGORIES OF IMMUNE PROBLEMS
Category 1 Immunological Problems
- HLA Compatibility as a Cause for Recurrent Spontaneous Pregnancy Loss
- DQ alpha matching in the couple. This results in a lack of blocking antibody to pregnancy, and the pregnancy fails
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.
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.
Category 2 Immunological Problems
- Antibodies to Phospholipids. These are the glue molecules for implantation and placentation.
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 people 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.
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
- Autoimmune Response to Nuclear Components
These women have developed antibodies to the baby's DNA or DNA breakdown products and this problem is reflected by a positive Anti-nuclear antibody test (ANA). This is often with a speckled pattern. We also advise that women have testing to double-stranded DNA, single-stranded DNA, polynucleotides and histones
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.
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:
Homongeneous: 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
This is a group of women with anti-sperm antibodies or antibodies to the phospholipid ethanolamine
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.
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
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.
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.
Consequences
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.
TESTING
INDICATORS FOR IMMUNE TESTING
The indications are as follows: (a)Two miscarriages or two IVF or GIFT failures after age 35 or three miscarriages or IVF or GIFT failure before age 35, (b)poor egg production from a stimulated cycle (less than 6 eggs), (c)one blighted ovum, (d)idiopathic infertility, (e)previous immune problems (ANA positive, rheumatoid arthritis, and/or lupus), (f)previous pregnancies that have shown retarded fetal growth, and (g)one living child and repeat miscarriages while attempting to have a second child.
SPECIFIC TESTS
A. DQ Alpha
This test measures whether the DNA of the couple is too closely matched. These tests give you back two numbers for both members of the couple. In a normal pregnancy the father's DNA in the baby tells the mother's body to set up a protective reaction around the developing embryo. If the father's DNA is too closely matched to the mother's, there is a good chance that the embryo created by them is unable to differentiate itself from the mother's body. The mother's body then rejects the embryo because it cannot identify the embryo as a baby.
Each person gets two DQ numbers from their respective parents. Similarly, when couples try to have a baby, they also give DQ numbers to their fetus. These numbers are, for example, 1.1, 1.2, 1.3, 1.4, 2, 3 or 4. Although there are breakdowns of the 2's, 3's and 4's, many scientists find that only the 1's are significant, so they break those down to one more decimal. Presently DQ Alpha testing is identifying more and more numbers, for example, DQ 4.0, 4.1, 4.2 and 4.3.
B. Leukocyte Antibody Detection
The immunological chain reaction caused by the DQ Alpha match problems is measured by this test.
C. Reproductive Immunophenotype
This checks for the presence of Natural Killer Cells. In most cases, Natural Killer Cells are good because they keep the body from developing cancer. In this case, however, the body goes overboard and kills the embryo or interferes with your endocrine system that produces hormones essential for pregnancy.
These tests measure the following CD (Cell Designation) levels:
CD-3 (normal 63-86)
CD-4 (normal 31-53)
CD-8 (normal 17-35)
CD-19 (normal 3-8 )
C56 (normal 3-12) these are the Natural Killer Cells
CD3/IL2-R (normal 0-5)
CD19/CD5 (normal 0-10), high numbers in this category interfere with the reproductive hormones necessary for pregnancy.
D. ANA (Antinuclear Antibody)
This test checks for problems similar to lupus and rheumatoid arthritis or other similar immunological diseases that can also result in pregnancy losses or infertility. This test becomes weakly positive in women with infertility and in women with recurrent pregnancy losses. It is usually reported as ANA positive with at titer 1:40 or higher with a speckled pattern. This pattern is not typical of lupus or rheumatoid arthritis or other immunological disorders.
E. Anti-DNA/Histone Antibodies
If a woman reacts to the broken down DNA (histones) and it is a speckled pattern, then she is showing a reaction to her own embryos.
F. APA (Antiphospholipid Antibodies)
When this test is positive, the woman's blood clots too fast cutting off support to the baby. These antibodies also cause the embryo to attach too weakly to the uterus.
G. Natural Killer Cell Assay
This test determines the killing power of a woman's Natural Killer Cells in the test tube.
12% of women with recurrent pregnancy losses and 35% of women with three or more IVF failures have elevations in NK cells and these cells demonstrate aggressive killing of targets and placental cells when tested in vitro.
The Natural Killer cells are cultured with varying numbers of target cells that they can kill. This is called the Effector/Target Cell ratio and is given a number of 50:1, 25:1 and 12:1. In a separate panel of cultures IgG is added at 6.25 mg/ml (corresponding to an in vivo administered dosage of 25 grams once) or 12.5 mg/ml (corresponding to an in vivo administered dosage of 25 grams of IVIg for 3 consecutive days). The percentages of the target cells killed are calculated for both panels of cells, those with and those without IVIg.
H. TJ6 Protein
There is another cell in the lining of the uterus that produces a protein called TJ6. This protein production is stimulated by Progesterone that helps in controlling NK cells by attaching to their DNA and breaking up the NK cell's development. This TJ6, which is a small protein, has the main task of controlling the NK cells.
I. Other Tests
It is important that the woman have other tests that are widely available in all laboratories. These are the Lupus Anticoagulant Antibody, Hormone Antibody Assay, APTT (a blood clotting test) and an antithyroid antibodies.
LABORATORY BLOOD TESTS
Shipping instructions will be sent to patients based on their physician's order(s).
How to Transport Bloods
PLEASE NOTE: all laboratory testing must be scheduled with our office. We are not responsible for unscheduled testing/test results. Our laboratory is closed on weekends. We will not accept any mail that does not have a return address. Please remember to put your return address on anything you send to us.
a. Shipping Information
Specimen should arrive within 18 hours after being drawn; we require shipment by Overnight Courier, e.g., Federal Express.
Do not spin down red tops (must remain sterile).
b. Packaging information
Each tube must be labelled with the following:
Date and time of drawn
Patient name
Physician / referring clinic
IMPORTANT: tubes not labeled with patient name will automatically be discarded and no tests will be run. It is the patient's responsibility to see that the tubes are properly labeled. We do not take responsibility if tests are not performed due to improper labeling of tubes.
Lay tubes on their side, not upright
Package to protect specimens from heat and cold
Label package: "DO NOT REFRIGERATE OR FREEZE"
c. Shipping address
Clinical Immunological Laboratory
Attn: SVIL
3333 Green Bay Rd.
North Chicago, IL 60064
If you follow the above instructions everything should go smoothly.
Prices for Tests
Program costs will vary for each patient as treatments are individually based. There are, however, some basic charges you should expect. There will be an initial medical review of your registration materials and medical records. This charge will range from $100 to $300, depending on how extensive the review is. Once the review is complete, we will send you a letter of recommendations for additional testing; prices for testing are often in the range of $3,000 for you and your spouse. When all the test results have been reviewed, you will be contacted to set up an initial consultation. The initial consultation fee is approximately $550. During the consultation, your plan of treatment will be determined and further charges will be discussed with you at that time. Please note, in addition to charges for tests such as placental immunopathology ($400) and/or endometrial biopsy ($280) there will be an additional $250 charge for reviewing the test results.
London Clinic Prices
As above, program costs will vary for each patient as treatments are individually based. Listed below are some basic charges you should expect.
Initial consultation £300
Follow-up consultation £150
Blood Tests:
Cardiolipin antibodies £50
Anti DNA histones ; DNA ab – DS £55
ANA £25 Thyroid panel/antithyroid antibodies £90
Fasting free insulin £40
Serotonin level — plasma £60
TH1/TH2 cytokine assay £250
Cytotoxicity assay NK cells and K562 cells £250
NK assay panel follow-up £210
Shipping charge £60
IMMUNE PATHOLOGY EVALUATION OF THE ENDOMETRIUM
Introduction
Immune pathology studies of a biopsy of the endometrium (uterine lining) in women with recurrent pregnancy losses, IVF failures and implantation failures show that lymphocytes can damage the lining as well as the embryo. These lymphocytes are not seen in the uterus of fertile women. To find if a woman has this problem an endometrial biopsy is done by a gynecologist on cycle day 26 or a few days before menstruation.
These unwanted immigrant cells that take up house-keeping in the uterus are:
1. Activated macrophages that secrete IL-1 (toxic to the lining and to the embryos);
2. CD 56+ Natural Killer cells that secrete tumor necrosis factor alpha (toxic to the embryos and uterine tissue). These cells can cause stromal hemorrhages, subchorionic hemorrhages and early premenstrual spotting;
3. Mast cells (associated with hives and rashes in the skin of allergic individuals), when present in the uterus, cause stabbing pains, bad premenstrual syndrome, severe cramping and ill feelings after intrauterine insemination or embryo transfer.
Most individuals with category 5 immune problems have increased numbers of natural killer cells in the blood, and increased cytotoxicity (killing power) of these cells when tested in the NK assay. Some women, who have had category 5 immune problems for a long time, have natural killer cells that have migrated to the uterus and are living there as "tissue residents."
Background
At the time of ovulation the uterus and the endometrial lining are prepared for implantation. The glands and the endometrium are thickened to 10-14 mm, have formed three zones, blood vessels and blood flow have entered zone three and the glands are producing rich sugar-like secretions to nourish the embryo until it implants. New molecules are forming on the lining to make it receptive and sticky (integrins) for the embryo. Heparin molecules are arriving into the uterus to help cross link the embryo with the lining. Lymphocytes are arriving (TH-2) that will secrete cytokines (growth molecules) that help with implantation and growth of the embryo. All of this can be seen by immune pathology and can be seen as in good order. Immune pathology can also find the TH-1 natural killer cells that do not put the uterus and the lining in good order.
Two percent of unfortunate women that I see have a chaotic situation in the uterus. The lining development is disordered because of NK cells that have taken up residence there. NK cells live in the uterine glands, lining and in the stroma (soon to become decidua). This stroma is the tissue that nourishes the glands and the lining. It will soon nourish the placenta and we call this tissue decidua. When the embryo arrives, these NK cells are activated and secrete Tumor Necrosis Factor alpha, which causes a breakdown in the lining of the uterus, the glands and the stroma. When the stroma breaks down, hemorrhages and blood cysts appear. This can cause severe cramping and some bleeding. This results in the uterus becoming a hostile environment for the embryo. Pregnancies fail very early or do not occur at all.
Women at Risk for NK Cells in Uterine Tissue
Women who are at risk for having NK cells in the uterine tissue are:
1. Women with a known autoimmune disorder such as fibromyalgia, lupus, rheumatoid arthritis, Crohn's Disease, thyroiditis, chronic fatigue syndrome, Raynaud's disease, mixed connective tissue disorder and ulcerative colitis;
2. Women with a history of dysplasia of the cervix, carcinoma in situ of the cervix or papilloma virus infections (HPV);
3. Infertile women with endometriosis prior to their first assisted reproductive technology (ART) or IVF cycle;
4. Women with recurrent spontaneous abortions who lose their pregnancies earlier and earlier or who have secondary infertility;
5. Women with two IVF failures;
6. Women with repeated implantation failures;
7. Women who experience flu like symptoms with implantation, transfer or implantation failure;
8. Women who experience stabbing pelvic pains or intense cramping with inseminations or embryo transfers;
9. Women who experience strange symptoms in abdomen, pelvis and legs of cramping, jitteriness, jerking or strange traveling sensations in the skin post intrauterine insemination or post transfer.
In many women, all of these situations and complaints are discounted and minimized by most reproductive endocrinology or OB/GYN doctors. These symptoms are not in your head as figments of your imagination. They are real and demand attention and workup.
What can Diagnose this Problem?
1. An endometrial biopsy done two or three days before expected menses or, at the latest, on the first day of menstruation of a normal non-conception cycle.
2. An endometrial biopsy done 10-14 days post transfer when the pregnancy test is negative and before menstruation begins.
How is the Biopsy Done?
The information on how the biopsy is done is intended for registered patients of our program.
1. The instruments used by the doctor are a disposable Endometrial Suction Curette or a Novak curette. The biopsy is done in the doctor's office or at the hospital.
2. The doctor places the tissue in 10% formalin. He/she can send the tissue directly to my laboratory, or it can be sent to his/her pathologist to be embedded in paraffin blocks and the paraffin blocks can be sent.
The tissue should be sent by overnight mail to
Alan E. Beer, M.D.
Medical Associates Infusion Center
15151 National Ave. #2
Los Gatos, CA 95032
Prior to shipping a pathology specimen, you should contact us and register your information. If a specimen arrives without a completed patient registration packet, then the specimen will not be submitted for a pathology evaluation.
3. When the test results are available, someone from our office will contact you. However, it is a good practice to contact us at (408) 356-9500 if you do not hear from us more than three weeks from your specimen ship date.
TREATMENT
INTRODUCTION TO MEDICATIONS
Progesterone – suppositories twice daily from egg collection (if IVF) to 16 weeks pregnant.
Aspirin – orally from cycle day 1 daily throughout pregnancy.
Calcium – orally daily throughout pregnancy.
Prednisolone (Steroid) – orally daily from cycle day 6 until 10-12 weeks pregnant.
Heparin (Anticoagulant) – subcutaneous injection daily from cycle day 6 until at least 10 weeks pregnant.
LIT (Lymphocyte Immunization Therapy) – subcutaneous injection twice preconception separated by I month then a booster and 5-7 weekly up to 12 weeks pregnant.
Humira / Enbrel (originally developed for use in Rheumatoid Arthritis, blocks tumor necrosis factor alpha) – subcutaneous injection twice weekly at least one month prior to cycle of conception up to 6 weeks pregnant.
IVIg (Intravenous Immunoglobulin G) – intravenous infusion on cycle day 10 then to days before embryo transfer (if IVF) and every 3 weeks until 10-12 weeks pregnant.
Fish Oil (helps to control excess production of tumor necrosis factor alpha) – orally, daily.
NB LIT and IVIg very likely require a trip to London for UK patients
IMMUNOLOGICAL CATEGORIES DEFINING TREATMENT
Category 1
LIT
Aspirin
Progesterone
Category 2
Heparin
Aspirin
Calcium
Progesterone
Category 3
Prednisolone
Aspirin
Calcium
Progesterone
Category 4
LIT
IVIg
Prednisolone
Heparin
Aspirin
Calcium
Progesterone
Category 5
LIT
IVIg
Aspirin
Progesterone
PLUS Humira or Enbrel if CD56+ cells in uterus (NKU’s)
