But sometimes a woman’s immune system has the opposite response and declares war on the sperm or the embryo. One of the best understood of these conditions is antiphospholipid syndrome (APS), a condition in which the mother’s body creates blood clots that cut off the blood supply to the placenta. With each attempted pregnancy, the mother’s antibody levels increase, making a successful pregnancy more and more unlikely. When this condition is recognized, usually after repeated miscarriages, it can be successfully managed with medication to enable a healthy pregnancy. Malfunctioning natural killer (NK) cells (a usually beneficial part of the immune system) is another type of autoimmune infertility.
Many doctors believe that women who have any type of autoimmune disease are at increased risk of developing an autoimmune infertility, which can cause recurrent miscarriages. Dr. Gleicher estimates that women with an autoimmune disease have, depending on which study you read, a 15 to 85 percent miscarriage risk once they conceive. “All major autoimmune diseases, even if they are under control at the time you are trying to conceive, can impact fertility, even at subclinical levels,” he says.
A Medical Controversy
These kinds of statistics might make it seem as if any woman with an autoimmune disease should be carefully tested prior to conceiving for autoimmune problems that can cause infertility. But many physicians are not convinced. Dr. Levi, for instance, a reproductive endocrinologist, says that in his opinion only 5 to 10 percent of infertility and recurrent miscarriage is caused by autoimmune diseases, and he says the medical literature supports this view. Most pregnancy losses, he points out, are caused by chromosomal abnormalities, hormonal problems, uterine problems, clotting, and genes.
He also cautions against over-testing. “If a woman has an autoimmune disease, we do not automatically test for the infertility type of autoimmune disease. If a woman has two consecutive miscarriages, or has three non-consecutive miscarriages, then we evaluate her for this. I don’t believe this is as predominate as some physicians make it out to be.” In fact, he says, “In the past two years I have not had a single patient with APS (antiphospholipids) though I have tested many for it. It’s simply not as common as some physicians want you to think.”
In particular, Dr. Levi is concerned about the use of IVIG (intravenous immunoglobulin—human antibodies derived from donor blood) as a treatment for autoimmune infertility. The theory behind this treatment is that the IVIG will block a woman’s own immune response which may be attacking the pregnancy. But Dr. Levi says that IVIG is unproven, and he wants women to know that this therapy is only sanctioned by the American Society for Reproductive Medicine if used as part of a regulated clinical trial for miscarriages.
Bottom line: Women who have a known or suspected autoimmune disease should consult with an ob/gyn before getting pregnant. For everyone else, it’s unlikely—though not impossible—that an autoimmune problem will affect plans for parenthood.
Stopping the Attack on Yourself and Your Baby
If you have an autoimmune disease or suspect that autoimmunity might be affecting your ability to conceive or carry a pregnancy, you should choose your specialist carefully. “There are REs [reproductive endocrinologists] who understand nothing about immunology, and there are rheumatologists who know nothing about reproduction,” says Dr. Gleicher. He recommends finding a specialist who understands both. But use caution and check the credentials of specialists who call themselves reproductive immunologists. “There’s no such specialty,” cautions Dr. Levi. “These are REs. There is no degree in this.”
The best place to start is with your own ob/gyn. Ask about your situation and bring up the subject of autoimmunity. If you experience two or more consecutive miscarriages, or three or more non-consecutive miscarriages, insist on seeing a reproductive endocrinologist. Then ask if an autoimmune problem might be responsible for your pregnancy losses.
Nancy Hemenway, executive director of INCIID (The International Council on Infertility Information Dissemination) was herself unable to have a successful pregnancy until she was diagnosed with and treated for two autoimmune conditions (APS and NK cells). Speaking from experience, she recommends that women who may be dealing with similar problems ask their reproductive endocrinologists to send their tests out for analysis to a lab that has expertise in dealing with them, since some of the tests are extremely sensitive. Your reproductive endocrinologist can consult with the American Society for Reproductive Immunology (theasri.org) to find and work with a qualified lab.
Hemenway also says women should be sure to ask how many patients the doctor has treated for autoimmune conditions, and what the success rates are—not just for pregnancy, but for live births. Because, after all, that’s what really matters.
A version of this article originally appeared in the July/August 2009 issue of Conceive Magazine. View the digital issue now!
Related Topics: Fertility Health; Fertility Threats; Thyroid and Infertility
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