Antibodies Against Annexin V, Cardiolipin and b
2-Glycoprotein 1 or APC-Resistance in Patients with Recurrent Miscarriage or In-Vitro-Fertilization-Failures
W. M. Halbmayer, W. Feichtinger, C. Kindermann, B. Prendinger and M. Böhm
Background
Antibodies against annexin-V, a potent anticoagulant abundant in placental tissues, were recently controversially reported to be associated with recurrent abortions or failures of in-vitro-fertilization (IVF) attempts [1, 2]. Recognition by anti-annexin V antibody of adhered annexin V on trophoblast cell structures might represent a potential pathologic mechanism by which these antibodies can cause defective pla- centation [3].
Objective
To evaluate the prevalence of annexin V antibodies in women with early recurrent pregnancy losses and/or recurrent IVF-failures.
Material and Methods
We screened 56 women (34.7 +/- 4.3 years of age: mean +/- 1 SD) with recurrent IVF failures and/or early pregnancy losses for:
쐌 APC-resistance: original clotting assay with factor V deficient plasma predi- lution.
쐌 Lupus anticoagulant: dilute Russells Viper Venom Time screening and con- firmatory test and Kaolin Clotting Time.
쐌 Antibodies against annexin V IgG/IgM isotypes: ELISA-research kit using micro ELISA plates coated with highly purified human recombinant Annexin V and affinity purified goat antibodies specific fur human IgG/IgM Fcg coupled to HRPO.
쐌 Antibodies against cardiolipin IgG/IgM and b
2-glycoprotein 1 IgG/IgM: com- mercially available ELISA test kits using micro ELISA plates coated with cardio- lipin and human b
2gp-1 and purified antibodies specific fur human IgG/IgM Fcg coupled to HRPO.
All together the 56 women have had 67 pregnancies (1.2 +/- 1.6 mean +/- 1 SD), 9 ectopic pregnancies (0.2 +/- 0.5), 4 deliveries (0.07 +/- 0.3), 43 early miscarriages
I. Scharrer/W. Schramm (Ed.)
34thHemophilia Symposium Hamburg 2003
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(0.8 +/- 1.3) and 180 IVF attempts (3.2 +/-2.2) when they entered the hemostaseo- logical evaluation.
Fourty-two (75%) of these women had another IVF-attempt after the hemosta- seological evaluation and received low molecular weight heparin (40 mg Enoxaparin »Lovenox«) subcutaneously once daily and/or low-dose (100 mg o.d.) aspirin in the case of positivity for APC-resistance, lupus anticoagulant or anti- bodies against annexin V, cardiolipin or b
2-glycoprotein-1.
Results
In 21 women out of 56 (37.5%) »defects« could be detected.
Table 1. Prevalence of »defects«
n %
Annexin V Ab. 1/56 2
Cardiolipin Ab. 7/56 12
ß2-gp1 Ab. 3/56 5
LA 8/56 14
APCR 8/56 14
No statistically significant difference between women with- and without hemosta- seological »defect« was identified concerning the patient’s age or the number of previous pregnancies, ectopic pregnancies, deliveries, miscarriages or IVF-attempts (Table 2).
Table 2. Data and patient’s history of women with and without »defect« (mean+/-1 SD)
n age pregn. ectop. p. delivery miscarriage IVF no defect 35 34.7+/-4.3 1.1+/-1.7 0.1+/-0.3 0.09+/-0.4 0.7+/-1.4 3.3+/-2.1 with defect 21 35.5+/-4.2 1.3+/-1.2 0.2+/-0.7 0.05+/-0.2 0.9+/-1.0 3.2+/-2.0
Fisher’s n.s. n.s. n.s. n.s. n.s. n.s.
Exact Test
Interestingly, the next IVF-attempt after hemostaseological evaluation showed a trend of more pregnancies within the group of women with »defect« (Table 3).
Table 3. Outcome of next IVF attempt in women with and without »defect«
n another IVF pos.pregn.test normal preg. early miscarriage no defect 35 26 (74%) 10/26 (38%) 9/10 (90%) 1/10 (10%) with defect 21 17 (81%) 9/17 (53%) 6/9 (67%) 3/9 (33%)
Fisher’s Exact Test n.s. n.s. n.s.
104 W.M. Halbmayer et al.
The reason for this trend might be the therapy (aspirin and/or low molecular heparin), which has been given to women with detected »defects«. We found a bet- ter IVF-outcome (more positive pregnancy-tests) among women receiving low molecular heparin as a »mono-prophylaxis« of venous thromboembolism (Table 4, Fig. 1).
Table 4. Effect of Enoxaparin or Enoxaparin and Aspirin in women with »defect« and another IVF attempt.
n pos.pregn.test early miscarriage
Enoxaparin 9/17 (53%) 8/9 (89%) 3/9 (33%)
Enoxaparin + ASS 5/17 (29%) 1/5 (20%) 0/5 (0%)
Fisher’s Exact Test p < 0.02 n.s.
The only woman with an elevated anti-Annexin V (IgG) level has had 7 IVF attempts previously and received 40 mg Enoxaparin (Lovenox) subcutaneously once daily during the 8
thIVF, which resulted in a healthy pregnancy.
Antibodies Against Annexin V, Cardiolipin and b2-Glycoprotein 1 or APC-Resistance 105
89
20
33
0
0 10 20 30 40 50 60 70 80 90
%
positive pregnancy test early miscarriage
Enoxaparin
Enoxaparin + ASS
n.s.
p < 0.02
Fig. 1. Effect of Enoxaparin or Enoxaparin and Aspirin in women with »defect«
Conclusion
Our findings suggest that among women with recurrent miscarriages and recurrent IVF failures anti-annexin V antibody positivity is less prevalent than APC-resis- tance, lupus anticoagulant or elevated levels of antibodies against cardiolipin or ß
2-glycoprotein-1 and that the IVF-result in women with APC-resistance, lupus anticoagulants or elevated levels of antibodies against annexin V, cardiolipin or
b2-glycoprotein-1 might be positively influenced by low molecular weight heparin.
References
1. Matsubayashi H, Arai T, Izumi S, Sugi T, McIntyre JA, Makino T. Anti-annexin V antibodies in patients with early pregnancy loss or implantation failure. Fertil Steril 2001; 76: 694-9.
2. Di Simone N, Castellani R, Caliandro D, Caruso A. Monoclonal anti-annexin V antibody inhibits trophoblast gonadotropin secretion and induces syncytiotrophoblast apoptosis.
Biol Reprod 2001; 65: 1766-70.
3. Arnold J, Holmes Z, Pickering W, Farmer C, Regan L, Cohen H. Anti-beta 2 glycoprotein and anti-annexin V antibodies in women with recurrent miscarriage. Br J Haematol 2001; 113:
911-4.
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