For my birthday I have decided to give you all the gift of heavy reading. Enjoy!
On August 29, 2014 I got a telephone call and an e-mail from Dr. Jeffrey Braverman that changed my life forever. We have reasons for why my body has terminated every single pregnancy I have had since the Miracle Toddler was born – including one using donor eggs from a proven 24-year old donor with a history of excellent egg quality – and why I have gotten sick with each of those pregnancies. We have a diagnosis or, rather, diagnoses, and we have a general framework of the immune protocol he proposes we use for a frozen embryo transfer (FET) using one of the two frozen embryos we have left from our donor-egg IVF cycle or a fresh IVF cycle if we choose to try anew with my eggs.
My diagnosis and the report on the LP’s and my reproductive immunology consult is multi-faceted and somewhat complicated, at least for a lay person like me. What follows is my attempt to explain the various components of our immune system that are at play in my diagnosis, how they are supposed to work and why they are not working properly in my case. All of this is based on my discussions with Dr. Braverman, the report his office prepared for us, a review of information published on the Braverman IVF and Reproductive Immunology website and my other independent research.
I am not a doctor. What follows is not medical advice or opinion and should not be interpreted as such.
T cells are a type of lymphocyte that have a T-cell receptor on their surface, distinguishing them from other lymphocytes. T cells mature in the thymus, hence their “T” designation.
There are a number of different kinds of T cells but for today I will be focusing on T1 helper (Th1) and T2 helper (Th2) cells. T helper cells are also known as CD4 T cells (because of the type of glycoprotein* they express on their surface, being CD4). When T helper cells are activated, they release cytokines (more on that group of glycoproteins* in a moment).
In very general terms, T1 helper cells help our bodies fight off intracellular troublemakers such as bacteria and protozoa while T2 helper cells fight off the extracellular rogues such as parasites.
* Non-sequitur: I’ve been working on a lawsuit recently about glycoprotein technology licensing, the science of which I have struggled with at times but which now seems so much more relevant to me. How serendipitous! Or is that just another example of life’s surreal ironies?
Cytokines are a family of glycoproteins or small proteins involved in cell signalling within the human body. Although hormones are also involved in cell signalling, cytokines and their functions are distinct from hormones. There are many types of cytokines, including interferons (IFNs), chemokines, interleukins (ILs), tumor necrosis factors (TNFs) and lymphokines.
Cytokines are produced and released by cells – including immune system cells – and affect other cells (including the cells that release them in some cases). They act through receptors and can regulate other cells’ responsiveness, growth and maturation. Some of them even modulate the activity of other cytokines.
Certain kinds of cytokine receptors are associated with inflammation. This can occur locally as a temporary response or at a systemic level where one or more autoimmune conditions or events may exist. Others respond to the presence of antibodies (immunoglobulins). Some are associated with growth factors. In short, there are a variety of cytokines and cytokine receptors with an array of functions, some of which are critical to the healthy operation of the human immune system.
Imbalances in the levels of certain cytokines has been associated with infertility, recurrent pregnancy loss and complications of pregnancy. For example, high levels of cytokines associated with inflammation can lead to a diagnosis of systemic or chronic inflammation. Although some inflammation is needed for embryo implantation and the successful establishment of a pregnancy, too much inflammation can make proper implantation and the healthy development and maturation of an embryo impossible.
Dr. Braverman’s office looks at cytokine levels on both an intracellular (between the cells) and serum (within the cells) basis. It appears to me that in reproductive immunology at this point the cytyokines that attract considerable attention include:
- TNF (tumor necrosis factor), sometimes referred to as TNFa or TNF alpha, is a jack-of-all trades cytokine, performing a vast array of functions in the immune system’s operation and responding to other cytokines, such as interleukins
- ILs (interleukins), which are largely produced by T-helper (CD4) cells
- IFNs (interferons), which can trigger protective functions of our immune system and also activate other cytokines (including natural killer cells – more on those characters in a moment)
At the time of our immune testing this summer, my intracellular cytokine ratios showed a Th1 bias. In particular, I had several elevated TNFa and IFNy ratios. I also had elevated serum levels of several cyotokines and chemokines that are consistent with the Th1 bias of my immune system. I also have elevated levels of several pro-inflammatory cytokines, including IL-17 and IL-6. My IL-8 level is also borderline.
Natural Killer (NK) Cells
Natural killer (NK) cells are a type of cytotoxic lymphocyte. They are not to be confused with NKT cells (natural killer T cells), which are horses of a different colour who will not get much airtime here today.
All human beings have (or should have) NK cells. Women have two kinds – uterine NK cells (uNK) and the same kind men have, peripheral blood NK cells (pbNK). The pbNK are those NK cells measured by blood tests. The NK Activity Assay measures NK cell cytotoxic activity (NKa) through activation and suppression at four ratios (50:1, 25:1, 12.5:1 and 6.25:1).
There is an important functional distinction between uNK and pbNK. In the human body, activation of pbNK primarily results in a cell-killing or cytotoxic function. This is a good thing when our immune systems function properly and, for example, our pbNK cells are activated to destroy cancer cells.
The uNK cells’ role is different. Activation of uNK cells results in the production of cytokines and other elements required to support the transformation of blood vessels in the uterus that are critical to viable, successful pregnancies. Current literature suggests that without the adequate activation of uNK cells, deep implantation of the embryo and its normal growth and development may not be possible. According to Dr. Braverman and his research team, the failure of uNK cells to be adequately activated can result in miscarriage, intrauterine growth restriction (IGR) and preeclampsia.
When the uNK are adequately activated, cytokines are secreted, among other things. Together the elements transform spiral arteries within the uterus from a tightly coiled state into plush superhighways to transport the high volumes of blood needed to support an embryo’s growth in the uterus. This process is regulated by interactions between uNK cells and the burrowing owls of human reproduction – the trophoblast cells (trophoblasts form part of human embryos).
My NK cell cytotoxic activity (NKa) is highly elevated (98th and 99th percentile for the 50:1 and 25:1 ratios). In the NKa Assay my NK cells responded much better to intravenous immunoglobulin (IVIg) than to intralipids but their cytotoxic activity was nevertheless reduced (less than 15%) by intra-lipids.
Human Leukocyte Antigens (HLAs)
HLAs are a family of genes that are located on the 6th chromosome. According to Dr. Braverman’s website, HLAs “encode for proteins that play a key role in the regulation of immune responses”.
“Alleles” are copies of HLAs that vary among members of the human population. “Haplotypes” are complex combinations of specific HLA alleles, which combine within individuals and vary among us. Variance has proven to be bad for transplant patients except perhaps for those receiving transplants of organs into “immune-privileged sites”.
In contrast, variance – especially with respect to certain HLAs and their friend, killer immunoglobulin-like receptors (KIRs – more on them below) – appears to be critical to human reproduction. Apparently Darwin was onto something.
HLA matching matters because the human immune system is always on the lookout for the expression of HLA proteins on the surface of cells within our bodies. To simplify somewhat, when our immune systems detect proteins or parts of proteins (peptides) that are “self” peptides on the surface of a cell, the cell is ignored because it is not deemed to be a threat to the system. When a “non-self” peptide is detected, an immune response may follow in which the cells that contain those “non-self” peptides on their surface are destroyed. A healthy body’s response to cancerous cells is an example of this process.
Human embryos containing maternal and paternal genetic material – including HLA alleles from each contributor – result in the embryos’ peptides being recognized as “non-self” by the mother’s immune system. That is true so long as there are sufficient differences between the genetic material that each parent contributed to the embryo.
If so, events occur within the uterus – which is believed to be an “immune-privileged site” – that foster an “active, dominant tolerance” of the “non-self”-peptide-containing embryo. This is accomplished by the production of immune-suppressive regulatory (Treg) cells. It is believed that as an “immune-privileged site”, the Treg cells in the uterus are of a particular nature known as iTregs (no credit is due to Steve Jobs, to my knowledge).
When there is insufficient dissimilarity (a conspicuous lack of “mismatches”, particularly among the Class II HLAs, being all of the ones that start with “D”) between the genetic material that mom and dad contributed, generation of iTreg cells does not occur and the necessary “active, dominant tolerance” that is believed to be essential to deep embryo implantation and healthy embryo and fetal development in the uterus does not result. In short, couples who share significantly matches alleles for certain HLAs often suffer infertility and recurrent implantation failure and pregnancy loss.
Historically, reproductive immunology and its adherents have made a fair bit of noise about HLA matches being associated with infertility and recurrent pregnancy loss. Although this may remain an issue for couples with significant numbers of HLA matches, as I understand my discussions with Dr. Braverman to date, current literature and research flag the importance that couples have sufficient mismatches of certain HLAs believed to be correlated with pregnancy loss and complications.
A lack of mismatches or insufficient mismatches can result in the woman’s immune system failing to recognize as “non-self” embryos created with the insufficiently mismatched man’s sperm. If this happens, the normal protective or tolerant function of the immune system is not triggered and implantation either cannot occur or will not progress to the point of deep or successful implantation. If pregnancy has occurred, it will fail as the placental cells do not grow and the embryo cannot survive.
The LP and I have been diagnosed with 0-1 HLA mismatches and no DRB sypertype mismatches. As a result, we are very unlikely to have a successful pregnancy using the LP’s sperm, even if we use a young, healthy, proven donor’s egg.
I also have a number of alleles and/or transhaplotypes associated with autoimmune conditions, including Graves disease, Hashimoto’s thyroiditis, primary antiphospholipid syndrome, celiac disease, TTP and Behcet’s disease. To date, I have not been diagnosed with any of those and may never develop them.
Thankfully, I do not have any HLA class II HY-restricting (HYrHLA) alleles, an alloimmune condition that I was fearful of given that we had a first-born son (after only 2 pregnancy losses) and have had six pregnancy losses since then.
Killer Immunoglobulin-like Receptors (KIRs)
As I understand it, KIRs are expressed by the uNK as a result of interactions between a particular HLA known as HLA-C located on embryos’ trophoblast cells and certain proteins on the uNK cells. Like HLAs, KIRs are a family of genes that vary between human beings.
According to Dr. Braverman’s website, “[t]he numbers and types of KIR genes that a person possesses determines, in part, how strongly their NK cells react to another cell displaying HLA-C.” Further, Dr. Braverman and his research team note that “the combination of the 1) KIR haplotype of the mother and of 2) the HLA-C genotype of both the father and the mother has a significant impact on the risk for defective placentation which can manifest as recurrent miscarriage, [IGR] and/or preeclampsia.”
Certain KIR haplotypes of mothers combined with certain mom/dad HLA-C genotypes are particularly problematic. As I understand it, the AA maternal haplotype (I received the same gene from both parents) is particularly problematic and puts a mother in the highest risk category for infertility and implantation failure.
The KIR AA haplotype predisposes a mother to inefficient activation of uNK cells by HLA-C on the trophoblast cells. This then leads to defective cytokine production by the uNK cells, the effect of which, in part, is defective implantation. The effect is worse if a fetus contains more HLA-C2 alleles than the mother (due to the father’s contribution of an HLA-C2 allele).
I have been diagnosed as having the KIR AA haplotype. Half of our embryos will have the same HLA-C2 as me; 25% will have more than me and only 25% will have less than me. Enough said.
In case all of the issues identified above are not enough, Dr. Braverman advised me that the machinations of my immune system during the Miracle Toddler’s pregnancy likely created a cell memory. The effect of this in subsequent pregnancies may be a successive strengthening of the inflammatory and cytotoxic immune response to our embryos. This would explain why I have felt sicker after each of the past 6 pregnancies have failed and why the lifespan of our embryos seems to be getting shorter with each pregnancy.
Despite the bad news concluding each of the topics I have covered above, Dr. Braverman said our situation is “treatable”. He has recommended four treatments:
- Neupogen (Filgrastim)
- Administered subcutaneously (by injection)
- Indicated for patients who do not produce enough white blood cells (not my issue)
- Found to assist prevent miscarriage in women with a history of recurrent pregnancy loss
- Aimed at overcoming the issues resulting from the AA haplotype and our significant lack of HLA-C mismatches
- Believed to assist in improving uterine lining (not my issue) and egg quality
- FDA category C drug, meaning “Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.”
- Steroids (likelyPrednisone)
- Administered orally
- A “low” dose, likely 10-20 mg per day
- Reduces inflammation and suppresses immune overactivity
- FDA category C drug
- Lovenox (low molecular weight heparin)
- Administered subcutaneously
- Provides a variety of benefits according to Dr. Braverman, who said that he prescribes it for all or virtually all of his patients
- Believed by Dr. Braverman to support function of other medications in my cocktail
- FDA category B drug, meaning “Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.”
- Administered intravenously
- Once per week
- Akin to mayonnaise by my estimation, it contains fats in fluid form and maybe a little voodoo
- Aimed at moderating NK cell activity
- Also believed to be helpful in regulating systemic inflammation
- FDA category C drug (for reasons that escape me)
As of right now, we are in the process of having our remaining two embryos (Gertrude and Alice) transported professionally (for a hefty chunk of change) from California to Manhattan.
Meanwhile, I continue my search for a qualified surgeon in my area (where surgery would be 100% covered by my health care) to perform a laparoscopy to excise any endometriosis lesions found in that surgery (if any). If such a person exists and the surgery can be scheduled within the next two or three months, I will have it done here. Assuming at least one of Gertrude and Alice has survived their journey, I will then do a FET cycle with Dr. Braverman and the RE at his Manhattan clinic after a 6-week recovery period.
If I cannot have the surgery done here in the near future, I will do a FET cycle with Dr. Braverman and the RE at his Manhattan clinic and hope it works. Again, this assumes the survival of at least one of Gertrude and Alice.
If it does, this blog will likely become annoying or painful (or both) to some readers who, as I do now, feel left behind by all of their fellow RPL/IF sufferers (sorry, pregnant pals, but I know you remember what that was like). If it does not, I will either:
- have the surgery here (if a capable surgeon exists here and I have moved up the wait list sufficiently to make that a realistic option);
- have the surgery in the U.S. unless we have no embryos left (in which case it may finally be time to give up); and
- do our last FET with either Gertrude or Alice (assuming that both embryos make it next week and from that point forward).
Meanwhile, I wait. Despite having a fair bit of practice with this, it does not come easily to me. Can you hear the gritting of my teeth?