association between endometrial and peripheral blood ... · recurrent pregnancy loss, repeated...
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Association between endometrial and peripheral blood immune profiles and reproductive outcome in patients with
recurrent pregnancy loss, repeated implantation failure and infertility MD Salazar
1, A Skariah
1, Y Hussein
1, H Elazzamy
2, S Dambaeva
2, K Beaman
2, A Gilman-Sachs
2, J Kwak-Kim
1,2
1Reproductive Medicine and Immunology, Department of Obstetrics and Gynecology,
2Department of Microbiology and Immunology, Chicago Medical School at Rosalind Franklin University of Medicine and Science, N. Chicago, USA
PROBLEM Implantation can only take place in a receptive uterus. In humans, the uterus becomes receptive during the mid-secretory phase
of the menstrual cycle, commonly known as the window of implantation. Several efforts have been made to find the best way to
evaluate the endometrial receptivity and improve the outcome of assisted reproductive technology. The endometrial immune
profile focuses on the IL-15 and Il-18 environment during the window of implantation. In the mid-luteal phase, stromal and endo-
thelial endometrial cells secrete IL-15, Fn-14, IL-18, and TWEAK at specific levels. Increased IL-15 allows the recruitment and
maturation of uNK cells. IL-18 and mature uNK cells stimulate Th2 cytokine production and lead to a predominantly Th2 balance.
This equilibrium promotes immunotrophism and angiogenesis, while inhibiting inflammatory and cytotoxic pathways. According to
a previous study the endometrial immune profile is established by a step-by-step procedure first considering the IL-18/TWEAK
mRNA ratio (reflecting local angiogenesis and possibly a Th1 deviation), then the CD56+ cell count (reflecting uNK cell mobiliza-
tion), and finally the IL-15/Fn-14 mRNA ratio (indicative of uNK cell maturation and uNK cytotoxic activation). This study reported
that the Endometrial immune profile was dysregulated in 81.7% of the RIF patients compared to controls; over activation was di-
agnosed in 56.6% and low activation in 25%. We previously reported that an abnormal increase in peripheral blood NK levels,
NK cytotoxicity and Th/Th2 cells ratio are associated with RPL, RIF and infertility. Therefore, we aimed to investigate if the endo-
metrial immune profile is associated with the peripheral blood immune profile and reproductive outcome in women with infertility,
RPL and RIF.
CONCLUSIONS
Figure 2. Endometrial immune profile among the groups
Figure 3. Association between endometrial immune profile and peripheral blood immune profile MATERIAL AND METHODS Design: Prospective cohort study
Study population: A total of 218 women (age 36.7±5.0) were enrolled in the Reproductive Medicine and Immunology at
RFUMS and Clinica las Condes, Santiago de Chile from November 2015 to August 2017. Women were divided into 4 groups
according to their reproductive history and included: controls (n=10, fertile women with at least one full term pregnancy), infertile
(n=61, failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or ther-
apeutic donor insemination), RPL (n= 83, ≥ 2 spontaneous abortions) and RIF (n=64, ≥ 3 unsuccessful IVF/FET cycles). From
the 218 women that were enrolled, 32 women lost follow up, 78 women have pending conception cycles and 10 controls had no
conception cycles. Then, we followed up 98 women that went through a conception cycle ≤6 months after endometrial biopsy.
Patient treatment was individualized based on their peripheral blood immune profile, presence of thrombophilias, autoantibodies
status and hormonal needs and briefly consisted in the use of: luteal support with high dose of progesterone and estradiol, low
molecular weight heparin, low dose aspirin, vitamin E and anti-inflammatory medication or immune modulators (Prednisone,
IVIG, Tacrolimus, Plaquenil).
Laboratory: Endometrial biopsy was performed in mid-luteal cycle to determine their endometrial immune profile. The collected
endometrial tissue was investigated for routine pathology evaluation and endometrial dating, and molecular analysis. mRNA
was extracted from the endometrial tissue and converted into cDNA. IL-18, IL-15, fibroblast growth factor-inducible 14 (Fn14)
and TNF weak inducer of apoptosis (TWEAK) were analyzed by quantitative RT-PCR. In addition, peripheral blood immuno-
phenotype, NK cytotoxicity, and intracellular cytokine expression were analyzed by flow cytometry.
Statistical analysis: Differences between the groups were estimated using one-way ANOVA for continuous variables and Chi-
square for categorical variables. Statistical significance was set at P˂0.05.
RESULTS
Figure 4. Conception cycle outcome
Dysregulated endometrial immune profile is associated with infertility, RPL and RIF.
The endometrial gene expression is not correlated with the peripheral blood immune profile therefore we speculate the endome-
trial gene expression study may detect local dysregulated endometrial immune responses.
Lower peripheral blood NK cytotoxicity levels are associated with successful conception cycles.
The pregnancy rate after the personalized immune treatment of over active endometrial immune profile is similar to that of wom-
en with normal endometrial immune profile.
Further study is needed for the therapeutic modality of women with low endometrial immune profile.
No dysregulation
IL-18/TWEAK= 0.03-0.12
IL-15/Fn-14= 0.3-3
Over Immune activation
IL-18/TWEAK >0.12
±IL-15/Fn-14>3
Low Immune activation
IL-15/Fn-14 <0.3
±IL-18/TWEAK < 0.02
Figure 1. Endometrial Immune profile
Figure 9. Association between endometrial immune
profile and conception cycle outcome
Figure 5. Association between reproductive failure and
conception cycle outcome
Figure 6. Association between cycle type and
conception cycle outcome
Figure 7. Association between over-immune endometrial
activation and conception cycle outcome
Figure 8. Association between low-immune endometrial
activation and conception cycle outcome
Figure 10. Association between peripheral blood
immune profile and conception cycle outcome