Imunological Infertility & Subfertility

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3 مردانه ناباروريھای با علت ايمنی شناختی Imunological Infertility & Subfertility in the Male Patient دکتر محمدمھدی محمدی LMD, PhD, MPH Session on the LABORATORY & INFERTILITY Ordibehesht 1391, 10th iqicl, Tehran

4 Physiologically y Proven but Clinically Unproven! Reproduction Immunology: Immu. disorders in Male in Female In Pregnancy In Fetus & Newborn Immunological Contraception

5 INFERTILITY Inability to conceive after a defined period of MARRIAGE 90% of healthy couples within 1 yr. 95% within 2 yrs.

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8 Normal Fertility depends on spermatogenesis maturation in epididymis coitus transport through female genital tract fertilisation implantation

9 Prize for 40 weeks of pregnancy! Thanks God, Praise belongs to Allah

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11 FERTILITY vs STERILITY ER FERTILE not pregnant probably pregnant pregnant MALE PARTN STE ERILE SU UBFERTILE not pregnant possibly pregnant probably pregnant not not not pregnant pregnant pregnant STERILE SUBFERTILE FERTILE FEMALE PARTNER

12 اتيولوژي: عوامل ژنتيک %5-10 % 5-10 عفوني علل %10-15 عيوب آناتوميک %15-20 اندوکرين اختالالت محيطی عوامل و

13 ASA A.S.A. When R They formed? Autoimmunity & Alloimmunity Evidences (in Human & in Animal Models)

14 ت ادل تفريط افراط تعادل Immunodeficiency (& Infection) Defence Allergy Malignancy Surveillance Autoimmunity

15 T B Deletion T B TH Negative e Selectionect Central Tolerance Unresponsiveness Anergy nhibitory Cytokines T B

16 Sequestration X-reaction reaction, Molecular Mimicry

17 These Sites Sequester Self Antigens, But Few Autoimmune Diseases Are Due to Release Of Hidden Self Antigens

18 Figure 13-20

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22 چند مفھوم: بازخوانی Antigen -- محرک سيستم ايمنی + + واکنشگربا محصوالت آن + Hapten Immunogen

23 Placental expression of complement regulatory proteins Membrane co-factor protein(cd46) Decay accelerating factor(cd55) Protectin( CD59)

24 Complement regulation CDs 55 & 59 inhibit MAC formation

25 Fas Fas-L interaction

26 Fas Fas-L interaction Fas structure and function Fas-L L structure t and function Fas-L tissue distribution

27 Cells expressing FAS-L(CD178): Activated T cell Activated NK cell Tumor cells Retinal cells Corneal cells Endothelial cells Placental cells Sertoli cells

28 Non Responsiveness in the Feto- Maternal Interface: 1. Activation of Innate Immunity 2. Lack of Classical MHC molecules 3. Functional Sequestration (Fas Dependent) 4. Presence of Specific Immune Factor (NK, TH2, Treg, Steroidal Suppressors, α-fp, hcc)

29 Immunological infertility The role of antisperm antibodies in male infertility

30 Risk Factors for A. S. A. production: Hereditary, in men Acquired (including Iatrogenic) Trauma, Varicocele, Tumors, Infection, Homos

31 Auto or homo-sensitization in animals (and in male volunteers) can be obtained with testicular homogenate or epididymal spermatozoa and complete Freund's adjuvant. Immune orchitis in spontaneous human pathology has also been reported. Vasectomy for the voluntary control of male fertility may be considered a particular form of experimental autoimmunization; and many vasectomized in dividuals develop antisperm antibodies.

32 Antisperm antibodies can: (i) be a mere epiphenomenon; (ii) be a factor aggravating a pathologic situation already able to cause infertility; (iii) play a pathogenetic role

33 If the antisperm autoimmane reaction represents the causal factor of infertility, Immunosuppressive therapy seems to give the most satisfactory results, administered either in high doses for a very short time period or in low doses over a prolonged period, or even after transient pharmacologically induced azoospermia.

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35 ASA A.S.A. Where R They Found? Male: Serum, Seminal Fluid, Sperm Surface Female: Serum, Mucous, Secretions, Follicular Fluids

36 ASA تستهاي اساس آگلوتيناسيون Agglu) (Preformed وجود (Head to Head, Tail to Tail, Mixed) اختلال در عملكرد اسپرم حضور خود ab تشخيص

37 Variations in A. S. A. Detection Systems: 1. Immuno Bead Tests 2. MAR Test 3. Kibrick Tests (C.A.T. & T. A. T.) 4. Sperm Immobilization Test 5. P.C.T. 6. ELISA & ELISA_LIKE 7. IFM 8. FCM

38 The secretory immune system of the Female e Genital Tract (from Stites)

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40 Positive mixed antiglobulin reaction (MAR) test Raw semen sample with latex beads coated with IgG seen bound to sperm surfaces, mainly tails (phase contrast, 40)

41 Immunobeads are polyacrylamide spheres with covalently bound rabbit antihuman immunoglobulins. Test is considered positive if at least 20% of motile spermatozoa have immunobead binding and is considered clinically significant when at least 50% of the motile spermatozoa are coated with immunobeads

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45 Agglutination Reported when motile sperm stick to each other in a definite pattern. Head-head Tail-tail Head-tail Immunological cause of infertility Done on several HPF 45

46 Tests for A. S. A. 1. ELISA & ELISA-Like Like Titer & Isotype- Topology? 2. Microscopic Immobilization 3. Agglutination Based (with or without indicators) usually qualitative rather than quantitative

47 Spermatozoa loaded with spermagglutinins stick to the glycoprotein filaments as soon as they come with contact with cervical mucus. Cervical mucus containing spermagglutinins provides the penetrating spermatozoa with the spermagglutinins and afterwards the spermatozoa stick to the glycoprotein filaments.

48 Diagnosing Immunological Infertility Antibodies in semen: IgG and IgAclass Antibodies in serum: agglutinating, g, cytotoxic (requiring complement) Current techniques in routine analysis of semen and serum

49 Detecting Antisperm Antibodies attached to Spermatozoa (direct tests)

50 Mixed Antiglobulin Reaction (MAR)

51 Schematic representation of the direct MAR test

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53 Immunobead test

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55 Detecting Antisperm Antibodies in Serum (indirect tests)

56 Indirect SpermMAR test

57 Reyleigh effect d << WL Reyleigh - Debye d ~ WL Mie phenomenon d >> WL

58 Antisperm Antibodies Motility Preparation Immunobea d rapidly time SpermMAR good non SVl S. Volume ml 10 µ l Shelf life 1 month 1 year Sensitivity- specificity Price ~ X 2 Better

59 Disturbances due to A. S. A. Sperm Cytotoxicity Sperm Maturation Sperm Motility Sperm- Oocyte interactions Sperm fusion to Ovum Zygote Development Implantation Embryonic Growth (Recurrent Spontaneous Abortion)

60 Presence of ASA should be evaluated if: 1. Report of Sperm Clump/ Agglutination in the Semen Analysis 2. High Count of Round Cells are proven to be WBCs 3. Low Motility, especially with a Hx of Trauma 4. Idiopathic/ Unexplained Infertility 5. Recurrent Spontaneous Abortion

61 اسپرم: نسبت به ايمني Not All Or None است نسبی تيتر آنتی بادی Concentration Ig Class ايزوتايپ آن ا Affinity ميل اتصال فردی محل اتصال Epitope Location

62 :ASA درمان اختلالات و نازايي هاي ناشي از كاهش توليد (با ايمونوساپرسورها) (Elution) پاك كردن ASA متصل ART

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66 Questions?