This is a follow-up article to Part 1 of this series, Autoimmune Infertility which was published in the March 2011 Autoimmunity edition of NDNR. This was one of our most popular articles on our blog and many people were requesting more updated information. As such I have compiled the latest research in this field to date. As this is an ever-evolving and very new field of medicine, more updates will likely be posted in the future.
Women with autoimmunity experience greater rates of infertility than average(1). Although long underestimated, the immune system plays a significant role in both normal and abnormal reproduction. Autoimmunity has been well-investigated for its role in recurrent pregnancy loss and implantation failure(2). In recent years immunologic endocrinology, the interaction between immune system and hormones, has also become a topic of interest.
Immunology and Infertility
The immune system must be in a specific state for fertility and pregnancy to occur. Firstly, pregnancy is a TH2 dominant state. In patients who remain TH1 dominant, there is an increased association with pregnancy loss and miscarriage(3). T regulatory cells also play an important role in fertility, and it has been found that patients who have a higher level of serum T regulatory cells have better fertility outcomes(4). Low levels of T regulatory cells have also been implicated in infertility related to endometriosis(5), unexplained infertility(6), and miscarriage(7). Low T regulatory cells are also found in a wide variety of autoimmune disorders(8). Other cellular and molecular factors that affect fertility such as natural killer cells and antiphospholipid antibodies were covered in the first part of this series.
Immunologic processes can not only directly affect implantation and fertility, but they can also indirectly affect fertility through interfering with the endocrine system. There is a good deal of “crosstalk” between the hormonal system and the immune system. Reproductive processes depend on the interactions between cytokines and lymphokines, and hormones(9). When the female immune system is altered in function, as in autoimmune disease, the endocrine system can become affected, and fertility can be compromised. It is important to consider that autoimmune antibodies can develop sub-clinically many years before an actual symptomatic autoimmune disease is diagnosed, and during such time they may affect fertility(10).
It is quite clear that the immune system and endocrine system are connected. For example thyroid autoimmunity can result in hypothyroidism. Hypothyroidism can cause hyperprolactinemia which then may suppress ovulation. Thyroid antibodies have also been associated with endocrine disorders such as polycystic ovarian syndrome(11), and also with premature ovarian insufficiency(12) As another example of the link between the immune system on the endocrine system; SLE, Celiac disease, Endometriosis(13), and Type 1 diabetes have all been associated with hyperprolactinemia(14). Interestingly, extrapituitary immune sites can secrete prolactin, and this too has been associated with autoimmune disease. There is also evidence that there may be a silent form of autoimmune hypophysitis that can cause mild degrees of hormonal deficiencies(15). Such glandular autoimmunity may also involve the adrenals, ovaries, and even pancreas(16), all of which may have effects on reproduction.
The ovary itself has been described is an immunological hotspot(17). Immune dysfunction can adversely affect female fertility by prematurely diminishing ovarian reserve and increasing the speed of oocyte loss(18). Autoimmunity may also specifically impact androgen levels. It is well known that premature ovarian insufficiency(POI), a condition that affects 10% of all women, is associated with low levels of androgens(19). The adrenal glands produce 50% of all of the androgens, and 100% of the DHEA. Androgens are crucial for the early growing follicle maturation stages and when androgen levels are low, the follicles are held back from development.
An immune derived androgen-producing factor that acts on the adrenal glands and which may be functionally altered in patients with POI(20) may exist. A recent study found that in women with normal fertility, those with autoimmune activation tended to have higher levels of testosterone than controls(21), suggesting that a functional autoimmune androgen-producing factor (APF) may mediate the production of androgens. It was also found that women with POI had lower levels of testosterone than control women in the presence of the same immune activation, suggesting that this autoimmune regulatory function was altered.
In polycystic ovary syndrome, the most common reproductive disorder in women, this immunologic component may be important. Increased autoimmune activation through APF may be involved in the etiology of some androgenic phenotypes of PCOS(22). This information suggests that more research needs to be done on a possible ovarian-adrenal autoimmune system which could be involved in both POI and PCOS. It is important to note that functional autoantibodies can be either suppressive or enhancing.
Women with PCOS also have an increased incidence of a variety of serologic autoimmune markers, most especially Hashimoto’s thyroiditis(23). Polymorphisms related to inflammatory mediators IL-1 and Il6 are also more prevalent in PCOS, and CRP and IL18 levels are increased. It is difficult to determine however, if adjustments for obesity may remove these specific associations.
Diffuse immunological activity and effects on reproduction
Women with recurrent miscarriages and unexplained infertility often have a diffusely activated immune system. This can include thyroid autoimmunity, TH2 dominance, elevated antibodies such as ANA, anticardiolipin and others(24). As a variety of autoimmune diseases such as type 1 diabetes, Hashimoto’s and Grave’s thyroiditis, Addison’s disease, autoimmune thyroiditis, multiple sclerosis, rheumatoid arthritis are associated with infertility, it appears that a diffusely activated state can disrupt reproduction through some of the mechanisms previously detailed.
The intestine contains the largest amount of lymphoid tissue in the entire body. The GALT (Gut Associated Lymphoid Tissue). The GALT lies directly underneath the intestinal epithelial cells, and is populated mostly by B and T cells in various stages of development. Many environmental components such as foods, microbes, and environmental toxins pass through the intestine, and as such, the body must maintain a strong defense at the mucosal boundary. The tight junctions between the intestinal epithelial cells ideally create an impermeable barrier to the contents of the intestinal lumen.
The intestinal lining tight junctions keep antigens such as microbes and food particles from being “seen” by the immune system. Zonulin is the only known protein, discovered through the work of Alessio Fasano(25), that is involved in the regulation of the tight junctions. If excessive zonulin is released and the tight junctions become “leaky”, the contents of the bowel are exposed directly to the GALT immune cells residing just below. In genetically susceptible individuals, this causes a miscommunication between the innate and adaptive immune systems, which can perpetuate autoimmunity(26) and disrupt the natural immune processes required for reproduction.
Let’s take a step back and talk about the different causes of autoimmunity according to current theory.
- Molecular mimicry(27). This is the concept that autoimmune diseases can develop when an immune cell reacts to an antigen similar to “self”. The immune system then goes on to attack its own tissues. An example of this is found in the link between proteus infections and rheumatoid arthritis(28).
- Tissue damage. This occurs when a virus or a heavy metal, for example enter the body and damage a tissue. The immune system then attacks the damaged tissue, and autoimmunity can develop. This is called “bystander effect”(29)
- Malfunction during the development of the immune cells. During development, T cells must learn “tolerance” to self. If development is disrupted, tolerance can also be affected. Also, the suppressive effects of the T regulatory cells on autoimmunity can be lost if their development is altered. Examples of triggers that can disrupt T cell development include environmental toxins, pathogens, and free radical damage(30).
It is thought that a genetic susceptibility to autoimmunity must be present for one of the above triggers to create pathology.
Association of Autoimmune Pathology with Leaky Gut
Intestinal permeability changes the above traditional theories of autoimmunity from a condition that once started is self-moderated, to one that can perhaps be reversed by preventing the interplay of genetics and environment . A permeable intestinal barrier allows microbes, toxins and food substances direct access to the GALT, triggering immune response and/or disrupting immune cell development (31). There has been an association between autoimmune diseases such as type 1 diabetes and elevated levels of zonulin, implying that the leaky gut may play a significant role in the autoimmune process.
When it comes to fertility, the gut and endocrine autoimmunity, we can also consider the action of the toll-like receptors, which are significantly expressed in the immune rich GALT beneath the intestinal lining. Toll-like receptors have been proposed as a possible link between the immune, hormonal and metabolic systems(32). As part of the innate immune system, these receptors control responses to invading microbes. The toll-like receptors produce an instant inflammatory response which has been demonstrated in cells of the hypothalamus, pituitary, thyroid, and pancreas(32).
So, if we look at autoimmune infertility as a process of widespread inflammation that may be disrupting reproductive endocrinology, or the process of implantation, it makes sense to address it at both the level of the trigger of the process, and also at the level of improving the immunological parameters that will reduce the functional effect of the autoimmunity on fertility.
Much of the testing for autoimmune infertility was covered in part 1 of this article. Microbial stool analysis for patients with autoimmunity, is helpful to identify pathogenic organisms such as bacteria or yeast. If an organism is identified, a herbal compound determined by sensitivities can be used in order to kill the pathogen.
I often recommend a variation on the autoimmune paleo, elimination or hypoallergenic diet for autoimmune fertility patients to reduce inflammatory responses of the GALT. Grains (particularly gluten/gliadin which is known to increase the expression of zonulin(33), dairy, soy, sugar and legumes are eliminated. Other potentially allergenic or inflammatory foods such as egg whites, nuts, and nightshades are eliminated and then tested through re-introduction. In some patients, sprouted legumes may also be reintroduced if well tolerated. Nutrient-dense foods are encouraged. Home-made fermented foods are recommended such as sauerkraut, or kombucha.
Reinnoculation with probiotics is necessary. Strain selection is important. Antiinflammatory strains include Bifidobacterium infantis(34) , Lactobacillus rhamnosis(35), Lacrobacillus caseii(36). Some strains(37) have been shown to bind to Hashimoto’s thyroiditis antibodies so it is possible that if the gut barrier is disrupted that these could compete with natural antigens for the binding of anti TPO and anti TG. In addition, gut healing nutraceuticals may be used including L-glutamine, N-acetylglucosamine, mucilaginous herbs and so on.
A variety of supplements were discussed in part one of this article and as such it is important to detail new points since that time.
- Vitamin D may improve the integrity of the tight junctions(38), benefit patients with thyroid autoimmunity(39), and enhance T regulatory cell function(40). 5000IU per day is the recommended dose.
- Glutathione – glutathione is required for T regulatory cell function(41). As oral glutathione is poorly correlated with increased intracellular glutathione, N-Acetyl Cysteine, Biologically active whey, or S-Acetyl Glutathione may be used to reduce the impact of autoimmunity.
- Dietary polyphenols: EGCG(42), grapeseed(43) extract and pinebark(44) extract can be used to influence TH1:Th2 ratios to promote healthy reproduction. EGCG can protect the lymphocytes while in development and reduce the triggering of autoimmunity(45).
- 5-MTHF. T regulatory cells express a high level of folic acid receptor on their cell surfaces. Folic acid is a survival factor for T regs(46). Dosage may be individual and dependent on genetic SNPS found on testing.
- Omega 3 Fish oil enhances the development of Fox P3 Tregs in vivo(47).
- If prolactin is elevated, consider Vitex agnus castus.
- In patients with POI, androgenic therapy such as DHEA or herbs such as Epimedium, Tribulus or Panax ginseg may be beneficial.
- Strain specific probiotic supplementation as outlined above may be helpful.
A 34 year old woman, Lisa arrived at the clinic with unexplained infertility. She had been trying to conceive for 3 years. She had experienced 3 chemical pregnancies during that time, and had attempted medicated IUI cycles with both Clomid and Femara. 2 of the chemical pregnancies were conceived naturally and 1 with IUI. Lisa experienced frequent gastrointestinal bloating and was fairly constipated. She would occasionally experience achy joints, Raynaud’s syndrome, difficulty sleeping, and poor energy. Her temperature was quite good in the luteal phase, rising to 37 degrees Celcius.
Her cycles were occasionally irregular, ranging from 28-35 days, but tended to be 29 days. Her androgen panel was normal and she showed no androgenic signs clinically. Her FSH and AMH were normal, and her ultrasound was unremarkable. Upon ordering her bloodwork, she was positive for Antithyroid peroxidase antibodies at 554 kiU/L and had a homozygous MTHFR C677T mutation.
Lisa’s TSH was at 1.5 miU/ml, her Free T3 and Free T4 were at the upper ends of the range. She also had elevated levels of total serum IgG (1876 mg/dL), and ANA (1:160 speckled), and her hs-CRP was borderline at 1.0 mg/L. Family history revealed that her mother had psoriatic arthritis and her brother also had psoriasis.
As such, a comprehensive digestive stool analysis was ordered. It was revealed that Lisa was positive for 2 opportunistic bacterial strains which were sensitive to berberine, and a deficiency of lactobacilli.
Lisa was initiated on a diet free of grains, dairy, eggs, corn and soy and high in vegetables, protein, fatty fish, and olive oil. A berberine compound was prescribed for a period of 4 weeks along with anti-inflammatory probiotic strains and a digestive enzyme which were continued throughout treatment. This was followed by gut healing nutrients L-glutamine and NAG. Our patient experienced a resolution of her GI symptoms during this time, and an increase in energy.
She was then initiated on 200mg of EGCG tid, 200mg pine bark tid, 2mg MTHF, selenium 200mcg qd and 1300mg EPA/800mg DHA qd. N-Acetyl Cysteine was provided at a dosage of 1200mg per day and Vitamin D at 5000IU per day.
After 5 months on this protocol, she became pregnant. Her thyroid function was monitored throughout pregnancy to ensure that it remained below 2.5 miU/ml which it did, despite raising up towards the top of this range. 9 months later she delivered her beautiful baby girl.
Autoimmune processes can have a profound effect on healthy reproduction, an aspect of fertility care which has long been underestimated. A healthy immune system can not only promote implantation and prevent miscarriage, but it also is a key component to the dynamic interactions within the hormonal system in the body.
- Cervera R, Balasch J. Bidirectional effects on autoimmunity and reproduction. Hum Reprod Update. 2008 Jul-Aug;14(4):359-66. doi: 10.1093/humupd/dmn013. Epub 2008 May 22.
- McCulloch F. Autoimmune Infertility. NDNR March 2011.
- Garzia E, Clauser R, Persani L, Borgato S, Bulfamante G, Avagliano L, Quadrelli F, Marconi AM. Prolactin and proinflammatory cytokine expression at the fetomaternal interface in first trimester miscarriage. Fertil Steril. 2013 Jul;100(1)
- Zhou J, Wang Z, Zhao X, Wang J, Sun H, Hu Y. An increase of Treg cells in the peripheral blood is associated with a better in vitro fertilization treatment outcome. Am J Reprod Immunol. 2012 Aug;68(2):100-6.
- Chen S, Zhang J, Huang C, Lu W, Liang Y, Wan X. Expression of the T regulatory cell transcription factor FoxP3 in peri-implantation phase endometrium in infertile women with endometriosis. Reprod Biol Endocrinol. 2012 Apr 27
- Jasper MJ, Tremellen KP, Robertson SA. Primary unexplained infertility is associated with reduced expression of the T-regulatory cell transcription factor Foxp3 in endometrial tissue. Mol Hum Reprod.
- 2006 Winger EE, Reed JL. Low circulating CD4(+) CD25(+) Foxp3(+) T regulatory cell levels predict miscarriage risk in newly pregnant women with a history of failure. Am J Reprod Immunol. 2011 Oct;66(4):320-8. doi: 10.1111/j.1600-0897.2011.00992.x. Epub 2011 Feb 14.
- Dejaco C, Duftner C, Grubeck-Loebenstein B, Schirmer M. Imbalance of regulatory T cells in human autoimmune diseases. Immunology. 2006 Mar;117(3):289-300.
- Sen A, Kushnir VA, Barad DH, Gleicher N. Endocrine autoimmune diseases and female infertility. Nat Rev Endocrinol. 2013 Nov 5.
- Carp, H. J., Selmi, C. & Shoenfeld, Y . The autoimmune bases of infertility and pregnancy loss. J. Autoimmun. 38, J266–J274 (2012).
- Kachuei M, Jafari F, Kachuei A, Keshteli AH. Prevalence of autoimmune thyroiditis in patients with polycystic ovary syndrome. Arch Gynecol Obstet. 2012 Mar;285(3):853-6. doi: 10.1007/s00404-011-2040-5. Epub 2011 Aug 25.
- Luborsky J, Llanes B, Davies S, Binor Z, Radwanska E, Pong R. Ovarian autoimmunity: greater frequency of autoantibodies in premature menopause and unexplained infertility than in the general population. Clin Immunol. 1999 Mar;90(3):368-74.
- Gómez R, Abad A, Delgado F, Tamarit S, Simón C, Pellicer A. Effects of hyperprolactinemia treatment with the dopamine agonist quinagolide on endometriotic lesions in patients with endometriosis-associated hyperprolactinemia. Fertil Steril. 2011 Mar 1;95(3):882-8
- De Bellis, A., Bizzarro, A., Pivonello, R., Lombardi, G. & Bellastella, A. Prolactin and autoimmunity. Pituitary 8, 25–30 (2005).
- Orbach, H. & Shoenfeld, Y . Hyperprolactinemia and autoimmune diseases. Autoimmun. Rev. 6,
- Codner E, Merino PM, Tena-Sempere M. Female reproduction and type 1 diabetes: from mechanisms to clinical findings. Hum Reprod Update. 2012 Sep-Oct;18(5):568-85.
- de Graaff, L. C., De Bellis, A., Bellastella, A. & Hokken-Koelega, A. C. Antipituitary antibodies in Dutch patients with idiopathic hypopituitarism. Horm. Res. 71, 22–27 (2009)
- Albertini, D. F . Searching for answers to the riddle of ovarian aging. J. Assist. Reprod. Genet. 29, 577–578 (2012)
- Janse F, Tanahatoe SJ, Eijkemans MJ, Fauser BC. Testosterone concentrations, using different assays, in different types of ovarian insufficiency: a systematic review and meta-analysis. Hum Reprod Update. 2012 Jul;18(4):405-19.
- Sen A, Kushnir VA, Barad DH, Gleicher N. Endocrine autoimmune diseases and female infertility. Nat Rev Endocrinol. 2013 Nov 5.
- Gleicher N, Weghofer A, Kushnir VA, Shohat-Tal A, Lazzaroni E, Lee HJ, Barad DH. Is androgen production in association with immune system activation potential evidence for existence of a functional adrenal/ovarian autoimmune system in women? Reprod Biol Endocrinol. 2013 Jun 27;11:58
- Gleicher, N. et al. Is Gleicher, N. et al. Is androgen production in association with immune system activation potential evidence for existence of a functional adrenal/ovarian autoimmune system in women? Reprod. Biol. Endocrinol. 11, 58 (2013).
- Kachuei, M., Jafari, F ., Kachei, A. & Keshteli, A. H. Prevalence of autoimmune thyroiditis in patients with polycystic ovary syndrome. Arch. Gynecol. Obstet. 285, 853–856 (2012).
- McCulloch, F. Autoimmune Infertility. NDNR March 2011.
- Fasano A (2001) Intestinal zonulin: open sesame! Gut 49:159–162
- Fasano A. Leaky gut and autoimmune diseases. Clin Rev Allergy Immunol. 2012 Feb;42(1):71-8.
- Christen U, von Herrath MG (2004) Induction, acceleration or prevention of autoimmunity by molecular mimicry. Mol Immunol 40:1113
- Ebringer A, Rahid T. Rheumatoid arthritis is an autoimmune disease triggered by Proteus urinary tract infection. Clin Dev Immunol. 2006;13(1):41-48.
- Haring JS, Pewe LL, Perlman S. Bystander CD8 T cell-mediated demyelination after viral infection of the central nervous system. J Immunol. 2002 Aug 1;169(3):1550-5.
- Jorissen A, Plum LM, Rink L, Haase H. Impact of lead and mercuric ions on the interleukin-2-dependent proliferation and survival of T cells. Arch Toxicol. 2013 Feb;87(2):249-58.
- Fasano A, Shea-Donohue T. Mechanisms of disease: the role of intestinal barrier function in the pathogenesis of gastrointestinal autoimmune diseases. Nat Clin Pract Gastroenterol Hepatol. 2005 Sep;2(9):416-22.
- Kanczkowski, W., Ziegler, C. G., Zacharowski, K. & Bornstein, S. R. Toll-like receptors in endocrine disease and diabetes. Neuroimmunomodulation 15, 54–60 (2008).
- Drago, Sandro, et al. “Gliadin, zonulin and gut permeability: Effects on celiac and non-celiac intestinal mucosa and intestinal cell lines.” Scandinavian journal of gastroenterology 41.4 (2006): 408-419.
- Groeger D, O’Mahony L, Murphy EF, Bourke JF, Dinan TG, Kiely B, Shanahan F, Quigley EM. Bifidobacterium infantis 35624 modulates host inflammatory processes beyond the gut. Gut Microbes. 2013 Jul-Aug;4(4):325-39.
- Timothy D. Wallace, Shannon Bradley, Nicole D. Buckley, and Julia M. Green-Johnson. Interactions of Lactic Acid Bacteria with Human Intestinal Epithelial Cells: Effects on Cytokine Production. Journal of Food Production. November 2003. Vol 66, p 466-472
- Schiffer C, Lalanne AI, Cassard L, Mancardi DA, Malbec O, Bruhns P, Dif F, Daëron M. A strain of Lactobacillus casei inhibits the effector phase of immune inflammation. J Immunol. 2011 Sep 1;187(5):2646-55.
- Kiseleva EP, Mikhailopulo KI, Sviridov OV, Novik GI, Knirel YA, Szwajcer Dey E. The role of components of Bifidobacterium and Lactobacillus in pathogenesis and serologic diagnosis of autoimmune thyroid diseases. Benef Microbes. 2011 Jun;2(2):139-54.
- Kong J, Zhang Z, Musch MW, et al. Novel role of the vitamin D receptor in maintaining the integrity of the intestinal mucosal barrier. Am J Physiol Gastro Liver Physiol. 2008;294:G208-G216.
- Tamer G, Arik S, Tamer I, Coksert D. Relative vitamin D insufficiency in Hashimoto’s thyroiditis. Thyroid. 2011;21(8):891-896.
- Prietl B, Pilz S, Wolf M, Tomaschitz A, Obermayer-Pietsch B, Graninger W, Pieber TR. Vitamin D supplementation and regulatory T cells in apparently healthy subjects: vitamin D treatment for autoimmune diseases? Isr Med Assoc J. 2010 Mar;12(3):136-9.
- Dröge, Wulf, and Raoul Breitkreutz. “Glutathione and immune function.”Proceedings of the Nutrition Society 59.04 (2000): 595-600.
- Byun JK, Yoon BY, Jhun JY, Oh HJ, Kim EK, Min JK, Cho ML. Epigallocatechin-3-gallate ameliorates both obesity and autoinflammatory arthritis aggravated by obesity by altering the balance among CD4(+) T-cell subsets. Immunol Lett. 2014 Jan-Feb;157(1-2):51-9.
- Ahmad SF, Zoheir KM, Abdel-Hamied HE, Ashour AE, Bakheet SA, Attia SM, Abd-Allah AR. Grape seed proanthocyanidin extract has potent anti-arthritic effects on collagen-induced arthritis by modifying the T cell balance. Int Immunopharmacol. 2013 Sep;17(1):79-87.
- Cho KJ et al. Inhibition mechanisms of bioflavonoids extracted from the bark of Pinus maritime on the expression of pro inflammatory cytokines. Ann NY Acad Sci. 2001;(928)141-56.
- Wu D, Wang J, Pae M, Meydani SN. Green tea EGCG, T cells, and T cell-mediated autoimmune diseases. Mol Aspects Med. 2012 Feb;33(1):107-18.
- Kunisawa J, Hashimoto E, Ishikawa I, Kiyono H. A pivotal role of vitamin B9 in the maintenance of regulatory T cells in vitro and in vivo. PLoS One. 2012;7(2)
- Han SC, Kang GJ, Ko YJ, Kang HK, Moon SW, Ann YS, Yoo ES. Fermented fish oil suppresses T helper 1/2 cell response in a mouse model of atopic dermatitis via generation of CD4+CD25+Foxp3+ T cells. BMC Immunol. 2012 Aug 9;13:44.