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This workshop had four main objectives: (A) Trying to look at the preeclampsia (PE) problem “from the Space Shuttle”: why preeclampsia has emerged in humans (a specific human reproductive feature among 4300 mammal species)? (B) Epidemiology : there are major geographical differences concerning early onset PE and late onset PE throughout the world. (C) Vascular : The very promising use of pravastatin in the treatment of the vascular maternal syndrome (based on the metabolism of carbon monoxide (CO), the role of inositol phosphate glycans P-type (IPG-P), a major role in comprehending the insulin resistance phenotype in preeclampsia. (D) Immunology : the specialty of these workshops since their start in 1998; our understanding of the role of the immune system and the regulation of the deep implantation of the human trophoblast (and the obligatory compromises between the fetal/placental unit and the mother) have reached a kind of “maturity,” following the pivotal studies exploring the biology of repetitive sperm exposure in the female genital tract. The meeting of people who never meet each other in the course of their normal professional lives (obstetricians, evolutionists, geneticists, immunologists, fundamentalist vascular biologists, epidemiologists, anthropologists, neonatologists, etc.) permitted some fruitful reflections to be made again this year. [ABSTRACT FROM AUTHOR]

Regulatory T cells (Tregs) play crucial roles in both fetal and tumor development. We recently showed that immunosurveillance by pre-existing CD44highCD62Llow activated/memory Tregs (amTregs) specific for self-Ags protects emergent tumor cells in mice. This Treg response of a memory type is more rapid than and dominates the antitumor response of tumor-specific effector T cells. In this study, we report striking similarities between the early Treg responses to embryo and tumor implantation. Tregs are rapidly recruited to uterus-draining lymph nodes and activated in the first days after embryo implantation in both syngeneic and allogeneic matings; express the markers of the amTreg subset; and are at least in part self-Ag specific, as seen in tumor emergence. Unlike in the tumor emergence setting, however, for which preimmunization against tumor Ags is sufficient for complete tumor eradication even in the presence of Tregs, Treg depletion is additionally required for high frequencies of fetus loss after preimmunization against paternal tissue Ags. Thus, amTregs play a major role in protecting embryos in both naive and preimmune settings. This role and the ensuing therapeutic potential are further highlighted by showing that Treg stimulation, directly by low-dose IL-2 or indirectly by Fms-related tyrosine kinase 3 ligand, led to normal pregnancy rates in a spontaneous abortion-prone model. [ABSTRACT FROM AUTHOR]

Abstract: G-CSF in individual follicular fluids correlates with the potential of the corresponding embryo to result in a live birth after transfer in IVF. To evaluate the requirements for routine follicular fluid G-CSF quantification, we compared follicular fluid G-CSF measurements made with two multiplexed microbead assays purchased from Bio-Rad Laboratories and R&D Systems, and a commercial G-CSF ELISA (R&D Systems). Individual follicular fluids (n =139) associated with transferred embryos were analysed to determine cytokine profile and the fate of each transferred embryo was recorded. The effect of multiplexing as well as comparison of the respective performances of the microbead assay with a flow cytometry assay was explored. Multivariable logistic regression analysis was performed and receiver operating characteristic (ROC) analysis was used to determine the performance and sensitivity/specificity of each method for individual follicular fluids. Covariate factors known to influence IVF outcome such as age, serum oestradiol and embryo score were systematically integrated in each analysis. The quantification of follicular fluid G-CSF using microbead assay methodologies, but not ELISA, yielded results showing the utility of follicular fluid G-CSF as a biomarker predictive of a successful delivery (Auroc: 0.77 [0.68–0.84] (p =0.003) and 0.75 [0.66–0.82] (p =0.004) for Bio-Rad and R&D Systems microbead assays respectively), whereas follicular fluid G-CSF values quantified by ELISA were not predictive (Auroc:0.61 [0.52–0.70] p =0.84). Microbead assay and flow cytometry appeared similarly efficient for quantifying follicular fluid G-CSF and multiplex versus single-plex assays did not influence the reliability of quantification. [ABSTRACT FROM AUTHOR]

Several reports have described an association between the presence of soluble human leukocyte antigen G (sHLA-G) in human embryo culture supernatants (ES) and implantation success. However, not all studies agree with these findings. To further document this debate, a multicentre blinded study was performed to investigate, on a large number of IVF ES and ICSI ES, whether sHLA-G is a useful criterion for embryo selection before transfer. A total of 1405 ES from 355 patients were collected from three assisted reproductive technique (ART) centres and evaluated for their sHLA-G content in a single laboratory, using a chemiluminescence enzyme-linked immunosorbent assay. In only one centre was a significant association between sHLA-G-positive ES and successful implantation established (P = 0.0379), whereas no such association was observed in the other centres. It was found that the percentages and concentrations of sHLA-G-positive ES varied between centres, depending on culture media and ART conditions. The percentage of sHLA-G-positive ES was significantly higher in IVF ES than ICSI ES (P < 0.001 and P < 0.01 for two centres). These data demonstrate that substantial variations of sHLA-G content in ES occur between different ART centres, highlighting the influence of several technical parameters that differ from one centre to another. [ABSTRACT FROM AUTHOR]

Problem An important subset of implantation defects/early abortion seems to be linked with a deregulation of the interleukin (IL)-12/IL-15/IL-18 system as well as tumor necrosis factor (TNF)- and natural killer (NK)-controlled/mediated networks at the decidual placental interface, both in case of deficient or excess expression. The presence of TNF in high amounts in the pre/peri-implantation uterus and its pivotal role during pregnancy are difficult to reconcile with its abortive effects in ongoing pregnancy. We therefore searched for regulators of the IL-12/IL-18 family of cytokines as well as for antagonist(s) of TNF with potentially selective effects on implantation. Method of study We first used Swiss mice to verify the presence in the murine reproductive tract of ‘new members’ of the IL-12 family of cytokines, IL-23 and IL-27, as well as of tumor necrosis factor-like WEAK inducer of apoptosis (TWEAK), described as acting with TNF as Yin and Yang of innate immunity in murine placenta/ decidua at days 0–12.5. We then compared expression by RT-PCR in the CBA × DBA/2, and CBA × BALB/c murine mating combinations. Finally, we performed in vivo neutralization experiments of TWEAK and IL-27. Results Immunohistochemistry (IHC) studies showed that IL-23, IL-27, and TWEAK were expressed at the interface. For RT-PCR, IL-23 expression peaked at day 9.5 in the non-aborting mating combination, a peak absent in the aborting one, and thus difficult to explain except by invoking a feed back on EB13 (Epstein–Barr virus-induced gene 3 cytokine). Most important, an immediate post-mating IL-27 hyper expression was seen in the CBA × DBA/2 mating compared to CBA × BALB/c one. The difference in expression resurged and was statistically very significant by days 6.5–9.5, compatible with an early activation of inflammation on day 0.5 which would then peak again in the ‘resorption window’ where takes place the early NK/mph activation described by Baines et al. A significant TWEAK expression was present in both strains from days 0.5 to 4.5 peaking in both cases in the first days when it is known that intra uterine TNF also reaches high levels as a component of post-mating inflammation. However, it was lower from day 1.5 in the abortion-prone CBA × DBA/2 mating combination, and almost absent by days 6.5–9.5 when compared to the non-aborting CBA × BALB/c mating combination. In both mating combinations, neutralization of TWEAK-enhanced resorption rates, but surprisingly so did IL-27 neutralization. Conclusion TWEAK is likely offering protection against the deleterious effects of TNF in implantation explaining embryo survival in a TNF-rich environment, and equal number of implants in both strains. However, there is a clear difference of protection in abortion-prone mating peaking in the abortion/resorption window but starting early, and therefore possible links with the prevention of abortion in CBA × DBA/2 matings by interfering with complement activation as recently described by Girardi et al. are discussed, as well as consequences for our current view of feto-maternal ‘seed and soil’ interplay. The apparently paradoxical effects of IL-27 neutralization are also discussed. [ABSTRACT FROM AUTHOR]

Problem To evaluate the influence of ovarian steroids on IL-18, IL-15 and angiopoietin-2 mRNA expression in the endometrium in the mid luteal phase. Method of study We quantified IL-18/GAPDH, IL-18 BP/GAPDH, IL-15/GAPDH and angiopoietin-2/GAPDH in the endometrium by quantitative polymerase chain reaction on day 21 of the cycle. We first compared cytokines expression over two natural cycles ( n = 15) then between natural and oestrogen–progestin replacement treatment ( n = 18). Results Endometrial IL-18, IL-18 BP, IL-15 and angiopoietin-2 mRNA expression did not change over two natural cycles. Addition of exogenous hormones significantly decreased IL-18 and IL-18 BP mRNA expression but not influence IL-15 or angiopoietin-2 ratios. This was also observed with immunohistochemistry. Conclusion Exogenous oestro-progestative hormones influence endometrial IL-18 system expression involved in angiogenesis and in the uterine natural killer (uNK) cell activation pathway during the implantation process. [ABSTRACT FROM AUTHOR]

Objective: To document in the endometrium the correlation among the interleukin (IL)-12, -15, and -18 mRNA and the correlation between cytokine levels, vascular status, and endometrial natural killer (NK) cell count in the context of recurrent implantation failure. Design: A pilot study. Setting: Department of Reproductive Immunology. Patient(s): Women who failed to become pregnant after repeated IVF-embryo transfer and fertile control subjects. Intervention(s): Ultrasonic evaluation and endometrial biopsy in luteal phase. Main outcome measure(s): Uterine artery Doppler, count of uterine CD56 bright cells/field, and quantification by real-time polymerase chain reaction (PCR) to monitor IL-12 family (IL-12p40, IL-12p35, EBI3, IL-23), the IL-18 system (IL-18, IL-18R, IL18BP), and the IL-15 mRNA ratio. Result(s): The uterine artery Doppler and the CD56 bright cell counts were significantly different in fertile and infertile patients. The mean uterine artery pulsatility index correlated significantly negatively with the IL-18/actin ratio suggesting a defect of the cytokine-dependent vascular remodeling pathway. The number of uterine CD56 bright cells was significantly correlated with the IL-15/actin and IL-18/IL-18BP ratios. Thus, IL-18 and IL-15 seems to be involved in the local recruitment and the activation of uterine natural killer (uNK) cells. IL-18 was itself correlated with IL-15 and IL-12, suggesting a local control of uNK cells activation. Conclusion(s): The assessment of the tripod IL-12/-15/-18 shows distinct immune-related mechanisms that are involved in the broader context of inadequate uterine receptivity. [Copyright &y& Elsevier]

: ObjectiveTo assess intrauterine levels of leukemia inhibitory factor (LIF) by uterine flushing at the time of egg retrieval and to confirm that the procedure has no detrimental effect on pregnancy rates.: DesignProspective study.: SettingAssisted reproductive unit of a university hospital.: Patient(s)Uterine flushing was performed in 148 IVF patients. The first 100 patients were compared with a matched control group.: Intervention(s)Uterine flushing at the time of egg retrieval.: Main outcome measure(s)IVF-ET results, pregnancy rates, and intrauterine LIF levels.: Result(s)Pregnancy rates were not different in the group of patients with (27%) or without uterine flushing (28%). Leukemia inhibitory factor was detected in 60 patients (46%). Pregnancy rates did not differ between patients’ detectable LIF and those in whom LIF was undetectable. Mean levels of LIF were 30.1 ± 49.3 pg/mL and 28.6 ± 51.2 pg/mL in pregnant and nonpregnant patients respectively.: Conclusion(s)The flushing procedure at the time of egg retrieval did not adversely affect pregnancy rates. Leukemia inhibitory factor was detected in 46% of patients at the time of egg retrieval, but no correlation were observed with better pregnancy rates in patients with detectable LIF. Mean LIF levels did not differ in pregnant and nonpregnant women. Access to endoluminal secretions of the endometrium during IVF-ET may represent a new research in human implantation. [Copyright &y& Elsevier]

Although previous cross-sectional studies suggested significantly dysregulated immune response in alexithymia, there is a lack of longitudinal studies. We sought to determine the reliability of the reported relationship between alexithymia and decreased immune response in a longitudinal study. Thirty-eight healthy women who had participated in a cross-sectional study were recontacted 1-year later. Of this sample, 26 were finally included: 13 females who had been found to be alexithymic, and 13 females who were classified as non-alexithymic under the 20-item Toronto Alexithymia Scale during the first phase of the study. A year later, they were still healthy women without any psychiatric disorders, their ages now ranging from 19 to 28 years old. Lymphocyte subset counts (CD4, CD8), in vitro production of interleukin 1β (IL-1β), IL-2, IL-4, and IL-10 by phytohemagglutinin stimulated peripheral blood lymphocytes, as well as serum cortisol levels, were compared between women with and without alexithymia. One-year later, alexithymic women still had significantly lowered in vitro production of IL-2 and IL-4, with lowered IL-2/IL-10 ratio and a reduced percentage of CD4. This is the first ever published study assessing cytokine production during a follow-up of alexithymics . Although our results should be interpreted with caution due the small sample size, they suggest a sustained reduction in both major type 1 and type 2 cytokines while the former seems to be more affected. The potential long-term health impact, if any, is still to be determined., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Guilbaud, Perrin, Curt, Chaouat, Dugré-Le Bigre, Strebler, Touitou and Corcos.)

Objectives: To investigate in singleton multiparous pregnancies the effect of having a new father for an index pregnancy on new-borns' birthweights and intrauterine growth restriction., Design: 20 year-observational cohort study (2001-2020)., Settings: Centre Hospitalier Universitaire Hospitalier Sud Reunion's maternity (French overseas department, Indian Ocean)., Main Outcomes and Measures: Comparing the 811 multiparas (cases) who had a new partner with the 49,712 who did not (controls), there were no differences concerning maternal age, education, ovulation induction/IVF, previous miscarriages, exams during pregnancies, pre-pregnancy BMI, gestational diabetes, and chronic hypertension. Cases had more previous pregnancies than controls (gravidity 4.2 vs 2.8, p < 0.001), volunteer abortions (OR1.93, p < 0.001), in vitro fecundations (OR 4.34, p < 0.001), were more likely to be unmarried (OR 2.94, p < 0.001) smoker (OR 2.2, p < 0.0001) and consuming alcohol during pregnancy (OR 2.35, p = 0.001). Cases had a much higher risk of preeclampsia than controls (OR 3.94, p < 0.001), especially early-onset preeclampsia (< 34 weeks) with an OR 4.1 (p < 0.001). Controlling for confounding factors (preeclampsia, smoking, alcohol use, early prematurity < 33 weeks, maternal ethnicity), primipaternity was an independent factor for small for gestational age newborns (OR 1.48, p < 0.001)., Conclusions: It has been known for decades that primiparas have lighter babies than multiparas. Primipaternity represents also a risk for lower birth weights. Human birthweight seems to be linked with a "couple habituation" (to paternal genes) which may be not fully established in the first pregnancy of the couple., (Copyright © 2021. Published by Elsevier B.V.)

Problem: Continuous failures to achieve a pregnancy despite effective embryo transfers is extremely distressing for couples. In consequence, many adjuvant therapies to IVF have been proposed to achieve an "ideal" immune environment. We here focus on Intralipid® therapy (IL) reported to have immunosuppressive properties on NK cells., Method of Study: 94 patients exhibited an immune profile of endometrial over-immune activation and an history of repeated implantation failures despite multiple embryos transfers (RIF). They received a slow perfusion of Intralipid®. We here report the live birth rate following the procedure at the next embryo transfer. To get new insight on its mechanism of action, a second immune profiling had been performed under Intralipid® before the embryo transfer., Results: The live birth rate of the RIF cohort treated with Intralipid® reached 54% (51/94) at the next embryo transfer. In patients successfully pregnant under Intralipid® who benefitted of a test of sensibility before the embryo transfer, we observed a significant decrease of the three biomarkers used to diagnose the over-immune endometrial activation (CD56 cells; IL-18/TWEAK, IL-14/FN-14)., Conclusions: Double blind placebo versus Intralipid® studies should be conducted. Intralipid® may be an option to explore in RIF patients who exhibit an over-immune activation of uNK cells., (Copyright © 2018. Published by Elsevier B.V.)

The authors delineate seven quantum leap forward and, or revolutions having occurred during the 20th century in the understanding of the physiopathology of preeclampsia. First the discovery of the inflatable arm band permitting to measure blood pressure in 1896. Second, the discovery that eclamptic (convulsions), and later "pre"eclamptic (proteinuria) women presented hypertension in 1897 and confirmed in 1903, discovery of the hypertensive disorders of pregnancy. Third, the eight major textbooks published all along the 20th century by delineating risk factors of preeclampsia with the concept of "preeclampsia, disease of primigravidae". Fourth, the discovery in the 1970's that human trophoblast implantation was far deeper than in other mammalian species. Fifth, and a major step forward, description at the end of the 1980's that the maternal syndrome in preeclampsia (glomeruloendotheliosis, HELLP syndrome, eclampsia) could be unified in a global endothelial cell inflammation. Sixth, the epidemiological descriptions in the 1970-1990's that indeed preeclampsia was a disease of first pregnancies at the level of a couple ("primipaternity concept"), leading to an explosion in immunological research in the last decade, beginning in 1998. Seventh and finally, in the search for the "factor X" explaining the vascular inflammation in preeclamptic women (inositol phospho glycans P-type were described in 2000, while soluble Flt-1 and S-endoglins have been clearly predicted since 1997). The majority of the seeds or findings have been grounded or realized in the 20th century. Indeed, for preeclampsia, the 20th century has been le "Siècle des Lumières" (the Enlightments)., (Copyright © 2018 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Introduction: Corticotherapy is the leading medication worldwide for patients with history of repeated implantation failures (RIF) after IVF/ICSI. Nevertheless, we still do not know its local mechanism of action, hence its precise indication. Our objective is to document the impact of prednisone on the endometrial expression of immune biomarkers (CD56 cells count, IL-18/TWEAK, IL-15/Fn-14 mRNA ratio) at the time of uterine receptivity in a RIF population., Materials and Method: An endometrial biopsy was realized in the mid luteal phase for immune profiling: IL-15/Fn-14 and IL-18/TWEAK mRNA ratios were determined by quantitative RT-PCR and CD56 mobilization per IHC. Fifty-five patients with a RIF history were diagnosed to have local over-immune activation [high IL-18/TWEAK mRNA ratio, and/or high IL-15/Fn-14 mRNA ratio] likely to impair the implantation process. They underwent a second immune profiling with supplementation of prednisone. A paired comparison of the immune profile before and under prednisone was performed in the subset of patients subsequently pregnant under prednisone., Finding: In 54.5% of the cases, both immune biomarkers were normalized and in 16.5%, only one was normalized under prednisone. In 29% we observed a paradoxical increase of both immune biomarkers. The IL-18/TWEAK mRNA ratio reflecting the Th-1/Th-2 local equilibrium was significantly reduced (0.29 versus 0.10, p = .004), through very significant increase of TWEAK expression, in patients who were subsequently pregnant under prednisone., Conclusion: Testing the response to prednisone in a RIF context may be very useful. Less than half of RIF patients with immune deregulation may be prednisone responders and would benefit from its administration., (Copyright © 2018. Published by Elsevier B.V.)

Eclampsia (together with epilepsy) being the first disease ever written down since the beginning of writings in mankind 5000 years ago, we will make a brief presentation of the different major steps in comprehension of Pre-eclampsia. 1) 1840. Rayer, description of proteinuria in eclampsia, 2) 1897 Vaquez, discovery of gestational hypertension in eclamptic women, 3) In the 1970's, description of the "double" trophoblastic invasion existing only in humans (Brosens & Pijnenborg,), 4) between the 1970's and the 1990's, description of preeclampsia being a couple disease. The "paternity problem" (and therefore irruption of immunology), 5) at the end of the 1980's, a major step forward: Preeclampsia being a global endothelial cell disease (glomeruloendotheliosis, hepatic or cerebral endotheliosis, HELLP, eclampsia), inflammation (J.Roberts.C Redman, R Taylor), 6) End of the 1990's: Consensus for a distinction between early onset preeclampsia EOP and late onset LOP (34 weeks gestation), EOP being rather a problem of implantation of the trophoblast (and the placenta), LOP being rather a pre-existing maternal problem (obesity, diabetes, coagulopathies etc…). LOP is predominant everywhere on this planet, but enormously predominant in developed countries: 90% of cases. This feature is very different in countries where women have their first child very young (88% of world births), where the fatal EOP (early onset) occurs in more than 30% of cases. 7) What could be the common factor which could explain the maternal global endotheliosis in EOP and LOP? Discussion about the inositol phospho glycans P type., (Copyright © 2017. Published by Elsevier B.V.)

The classic Medawar paradigm sees viviparity in vertebrates as a "problem". Established in 1953, it was then largely determined by a self-non-self view of the immune system. However, there are alternative models of the immune system, such as the danger model. For these models, pregnancy is neither a problem nor a danger. Supporting this view, we recall that placenta or placental-like-dependent(1) (allo) pregnancy has existed for eons. In fact, it appeared as far back as the time of aquatic colony invertebrates, such as some of the Bryozoa.(2) Since then, convergent evolution has seen placentation appear in a large variety of phyla. These placentae did not seem to cause "immunological problems", even in vertebrates possessing a graft rejection potential. The reappearance of placentae in marsupial and eutherian mammals found placentae confronted with a highly developed adaptive immune system. Two strategies were developed, therefore: short-term only placentation (marsupials) or specialised control of T cell-mediated immunity (Tregs). The problem is likely to be most acute in cases of deep invasive placentation. As an alternative to a restricted view of the Medawar paradigm for preeclampsia, an integrated model putting both inflammation and Tregs into perspective is proposed, somehow embedding the questioning of the initial Medawar paradigm., (Copyright © 2015. Published by Elsevier Ireland Ltd.)

The proposition "This house agrees that the proper study of man is woman" was debated. For those negating the proposition, the alternative was that "animal models are useful in understanding the human feto-maternal relationship." Evidence for the proposition emphasized molecular and structural differences between the human and animal placenta and placentation. Evidence against the proposition and in favor of the alternative focused on functional and structural homologies, emphasizing that different molecules could be used in humans to achieve similar functional effects seen in animal (e.g., mouse) models. It was agreed that one always needed to test the validity of animal data by studying humans. The advantages and limitations of animal models were discussed., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

This paper depicts an overview of debates that have taken place during the 14 years of the International Workshops on Reproductive Immunology/Immunological Tolerance and Immunology of Preeclampsia. This 8th event in 2012 (Reunion island, overseas department of France in the Indian Ocean) witnessed a consensus among immunologists on the key role of regulatory T-cells in the orchestration of trophoblastic invasion at the maternal-fetal interface, while they represent some 10% of the immunological cellular repertoire at the site of implantation (NK cells representing 70%). On the vascular side, the upregulation of carbon monoxide CO, metabolite of heme oxygenase-1 (HO-1; by inhibiting soluble Flt-1, SFlt-1, and soluble endoglin, SEng, release), explains the very promising protective and potentially therapeutic effect of pravastatin in preeclampsia and the paradoxical strong protective effect of cigarette smoking on preeclampsia. Finally, there was, through a study performed on Mauritius island a great interest in the inositol phosphoglycans P-type (IPG-P) as a reliable, cheap, and predictive urinary test in preeclamptic women (a few weeks before the clinical onset of the disease). Besides the interest of a specific test, IPG-P may also partially explain the global endothelial cell disease encountered in preeclampsia. Furthermore, the Appendix of this paper lists the programs of all the workshops that have taken place since 1998., (Copyright © 2013. Published by Elsevier Ireland Ltd.)

In this short remembrance paper, I survey (what I believe are) key events in the evolution of the concepts of preeclampsia from the first workshop in 1998 to the 2012 one, and from Tahiti to Reunion island, via Mauritius and Tioman Island., (Copyright © 2013. Published by Elsevier Ireland Ltd.)

This review summarises an invited talk presented at the 2012 ESRI/ASRI meeting in Hamburg, concerning current views of inflammation in pregnancy, which is timely given that the effects of a local injury in the uterus acts to favour implantation. Recalling that inflammation can be good (it is useful and necessary for implantation), bad (in implantation failure, RSA) and ugly (at the extreme, endometriosis is associated with pain and infertility) leads to consideration of its status in pregnancy. Its role in implantation and the fact that pregnancy maintains some aspects of inflammation throughout, leads to revision of not only concepts of immunosuppression and the Th1/Th2 paradigm, but also the feto-maternal relationship as seen since Medawar's hypotheses were advanced. This is examined from an evolutionary perspective, which should lead to further review of our perception of uterine NK cells, and the emergence of Treg cells to control some aspects of adaptive immunity, which appeared long after placentation., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

The objective was to examine if IVF/ICSI repeated implantation failures (IF) or recurrent miscarriages (RM) could be related to preconceptional endometrial deregulations. IF was defined as the absence of pregnancy despite the transfer of at least ten IVF/ICSI good quality embryos, and RM as having at least three unexplained miscarriages. Fertile controls (FC) were women who had given birth at least once. Endometrial biopsy was performed in the mild luteal phase of a non-conceptual cycle (five women were selected in each group). Affymetrix chips (GeneChip Human Genome U133 Plus2.0 Array) were used for hybridization. Data were normalized by the gcRMA method, and raw p values adjusted by the Bonferroni procedure (1%). Differential expression of selected genes was analysed using real-time PCR. Gene networks and biological functions were explored using the Ingenuity Pathways Analysis software. Endometrial gene expression profiles at the time of uterine receptivity differ dramatically in the endometrium among FC, RM, and IF patients. Compared to FC, 2126 and 2477 genes are differentially expressed in IF and RM groups, respectively, and 2363 between IF and RM. In both conditions, differential gene expression referred mainly to DNA transcription and expression. Other main cellular functions deregulated in IF conditions correspond to cell morphology, cellular development, cell cycle, and cellular assembly, while in RM conditions, deregulated cellular functions relate to cell signalling (degradation of cyclic AMP and calcium metabolism) and cellular maintenance. In both conditions, there is an over-representation of deregulations related to the haematological system. In the IF condition, cell-mediated immune response and nervous system development and function are highly deregulated, while in RM patients, main deregulations are in organ and tissue development, humoral immune response, and muscular system development and function. Extensive endometrial deregulations are present before conception in patients who experienced IF or RM with both distinct and common deregulation., (Copyright © 2011 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.)

Hypertensive disorders of pregnancy (HDP) represent 10% of human births globally and the major complication preeclampsia has a 3-5% prevalence. The etiology of HDP remains uncertain; however, major advances have been made over the last 25 years. The Seventh International Workshop on Reproductive Immunology, Immunological Tolerance and Immunology of Preeclampsia 2010 celebrated its 12th Anniversary in Tioman Island in 2010. Over this period, these seven workshops have contributed extensively to immunological, epidemiological, anthropological, and even vascular debates. The defect of trophoblastic invasion encountered in preeclampsia, intra-uterine growth restriction, and to some extent preterm labor, was understood only at the end of the 1970s. On the other hand, clinical and epidemiological findings at the end of the 20th century permitted us to apprehend that "preeclampsia, the disease of primiparae" may well be a disease of first pregnancy for a couple. Among the important advances, reproductive immunology is certainly the topic where knowledge has exploded in the last decade. This paper relates some major steps in the comprehension of this disease and provides a review of epidemiological studies on the "primipaternity paradigm". It focuses on the relevance of new developments and new concepts in immunology. At the beginning of the 21st century we are possibly closer than ever to understanding the etiology of this obstetrical enigma and also the pathophysiology of global endothelial inflammation in preeclamptic women. In this quest, reproductive immunology will certainly emerge as one of the main players., (Copyright © 2011. Published by Elsevier Ireland Ltd.)

In the introduction, we briefly recall old but classic evidence that there is no tolerance to paternal alloantigens in a first pregnancy. Therefore, we performed small- and large-scale microarrays in CBA × DBA/2 and CBA × BALB/c combinations, recently described as a murine model for preeclampsia. Our results are in line with other data suggesting a very early deregulation of local immune vascular events rather than a break of immune tolerance. Other data presented at the Tioman 2010 Preeclampsia Workshop supporting this hypothesis are briefly summarised, as well as indications and caveats from a recent human microarray on implantation failure and recurrent pregnancy loss., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

In this review, we will detail the concept of tolerance and its history in reproductive immunology. We will then consider whether it applies to the foetal-maternal relationship and discuss the mechanisms involved in non-rejection of the foeto-placental unit.

This paper reports a summary of our comparative analysis of the uterine expression of interleukin-23 (IL-23), IL-27 and TWEAK in the CBA/J femalexDBA/2 male mouse mating combination, a model of immune-mediated early pregnancy loss. Compared with the MHC-identical CBA/JxBALB/c mating combination, which yields successful pregnancies, immunohistochemistry and qPCR in uterine tissue showed an immediate post-mating IL-27 hyper-expression after mating with DBA/2 males. Intra-uterine TWEAK expression was present in females mated with DBA/2 or Balb/c males from days 0.5 to 4.5 post-coitum (pc), peaking on day 0.5 pc together with uterine TNFalpha. In uteri of DBA/2 mated mice, TWEAK declined to almost undetectable levels on days 6.5-9.5 pc, a steeper drop than in BALB/c mated mice where TWEAK remained detectable. In both mating combinations, neutralisation of TWEAK by antibodies increased resorption rates, but surprisingly, so did IL-27 neutralisation. The complement regulator mannan binding lectin-A (MBL-A), but not MBL-C, was present on day 4.5 pc especially after mating with DBA/2 males. High levels of MBL are present in the uterine luminal fluid of sterile women, and possible functions for TWEAK and MBL in human implantation are indicated by their protein and mRNA expression in uterine biopsies from infertile and fertile individuals. Consistent with the results in mice, increased MBL expression is linked with pregnancy failure. Serum and uterine VEGF and VEGF receptor levels are also different between fertile and sterile patients. The implications of these findings for utilising the CBA/JxDBA/2 mating combination as an early onset model of preeclampsia are discussed.

The introduction to this review discusses briefly why immunology, perceived as difficult by assisted reproduction technology clinicians, need nevertheless be envisaged as a central actor in the reproduction process, and how the maternal immune system, initially perceived as a threat to the fetoplacental unit, is in fact utterly necessary for successful pregnancy. The key cells in such a process are uterine natural killer cells, which can act as friend or foe to the fetus, but are now known to play a key role in local vasculogenesis. As an ultimate consequence in cases of dysfunction/dysregulation, these factors result in implantation failure, abortion or pre-eclampsia.

Introduction: Uterine receptivity was assessed simultaneously by measurement of vasoactive cytokines possibly involved in development of spiral arteries and by assessment of endometrial and uterine arterial blood flow. The objective was to explore the relationship between cytokine-related dysregulation and endometrial vascularisation in women with repeated implantation failures after in vitro fertilisation embryo transfer (IVF-ET)., Materials and Methods: We studied 40 women with recurrent IVF/ICSI-ET failures, despite replacement of more than 10 embryos of 'good quality', and 8 fertile controls. Three-dimensional ultrasound with power angiography was performed to record the sub-endometrial vascular flow index (VFI) and uterine artery pulsatility index prior to endometrial biopsy at day 21-23 of a monitored natural cycle. Endometrial IL-18, IL-18BP and IL-15 mRNA expression was assessed by real-time PCR, and the number of CD56(+) cells determined by immunochemistry., Results: IL-18 and IL-15 mRNA expression was significantly different between the two groups. The range of variation in vascular imaging data was increased in the implantation failure (IF) group. The mRNA ratio for IL-15, but not the other cytokines, correlated with sub-endometrial vascular flow (r=0.65; p<0.001). This ratio correlated also with the mean number of CD56(+) cells per high-power field (r=0.41; p=0.005). Both IL-18 and IL-18BP mRNA expression was significantly negatively correlated with mean uterine artery pulsatility index (r=-0.37 and -0.43; p=0.02 and 0.01, respectively)., Conclusion: Comprehensive ultrasonographic indicators appear to be related to various mechanisms, including insufficient or excessive uterine NK cell recruitment and inadequate endothelial vascular remodelling. New molecular tools may be useful in providing greater precision of uterine receptivity than ultrasonic indicators alone.

Developed countries represent 20% of the population in the world, but only 12% of human births annually, while 98% of medical publications are issued from these areas. What we can read on preeclampsia is correct, but only for 12% of human pregnancies! In addition, reproductive patterns in the developed world, but only for the last three decades, are different from elsewhere and during the first 70 years of the 20th century. A major difference is in the number of children in families but also, and mainly, in the ages at first pregnancies in primiparae (approaching now 30 years in many developed countries). This is probably why current epidemiological data seem different than that of the 20th century. The purpose of this article is to analyse to what extent the 'primipaternity model' may give clues for the comprehension of epidemiological descriptions past and present--and, indeed, it works in many respects. However, it is evident also that a proportion of preeclampsia cases cannot be explained by paternity patterns, and vascular disease predisposition in women (diabetes, obesity, thrombophilias, etc.) evidently comes into play. For these latter, maternal age is also strongly associated with these complications. Here, we reflect on what can be respective parts of the disease in preeclamptic couples, and on preeclampsia as a marker of subjects susceptible to vascular disease.

In this review, we put the discovery of 'suppressor T cells' in pregnancy in an historical perspective, and then highlight some of the data that precluded the resurrection of the phenomenon in the last years. We then review the evidence for the existence of Tregs in murine and human pregnancy. We then emit our opinion on some data presented in a murine abortion system. We review the evidence linking the cyclic recruitment of Tregs in the uterus with preparation for pregnancy, and how this, via endocrine signals, might affect autoimmunity.

Problem: Cytokines are obviously very important in an established pregnancy, but what about human embryo implantation?, Methods: Literature review., Results: We first discuss the necessity and limits of animal models, and then review the few cytokines which have been demonstrated by knock-out methods to be absolutely necessary for embryo implantation using in animal models. We then review what is known or discussed about the role of other cytokines as deduced from quantitative and/or qualitative dysregulation in animals and in humans., Conclusions: Cytokines are indeed involved in implantation as they are in ongoing pregnancy and delivery. Relevance to infertility and recurrent pregnancy loss is discussed.

The enunciation of the T helper 1/T helper 2 (Th1/Th2) paradigm in pregnancy has represented a major step forward in our understanding of physiological and pathologic materno-foetal relationship. However, recent developments in studies of the implantation process and in the emergence of the uterine vascular bed and its control by natural killer cells and cytokines suggest that one must go beyond this hitherto useful scheme. In this review, we replace the emergence of the paradigm in its historical context and then emphasises what it does explain and what it no longer account for. A final reappraisal of the paradigm is suggested.

In a brief introduction, this review states why the presence of immune cells at the interface poses problems for an immunologist (Medawar paradigm). Different types of placentation are then discussed, and the various interactions with leukocytes, the extreme being with the equids where a certain degree of 'attack' is often seen. The limits of animal models when dealing with the human situation are emphasized. It is then stated why the various phases of pregnancy are different, and an analysis made of the cellular movements at the implantation, peri-implantation, immediate post-implantation and resorption windows in rodents. Details of the cellular components involved are given, as are hints for the human situation. The Th1/Th2 paradigm is described, with clinical examples, and its limits. Thus, the newly appraised dual role of natural killer (NK) cells is discussed, with examples in rodents and in humans (pre-eclampsia, implantation failure, abortion systems). Clinical data on the IL-12/IL-18/NK tripod and implantation failure in humans are detailed.

Problem: Cytokines are involved in implantation success and failure. We envisage that they could be similarly involved in pre-eclampsia (PE)., Materials and Methods: First, we review the primipaternity and primiparity concepts and then why natural killer (NK) cells are involved in implantation. We stress that the common event in all PE is vascular remodelling., Results and Conclusion: We conclude that PE could involve cytokine and/or NK dysfunctions, and propose a working hypothesis.

This review introduces the field of cytokines and implantation and then recalls the specialized role of the uterus and the notion of the 'implantation window'. The role of inflammatory and angiogenic cytokines is presented, as well as the involvement of cytokines such as -interferons in corpus luteum maintenance in non-chorionic gonadotrophin-producing species. -Interferons are reviewed, before dealing with the more in depth analysis of cytokine networks in the pre- and peri-implantation uterus. The emerging involvement of cytokines in controlling uterine vascularization angiogenesis is reviewed, with emphasis on NK activating factors.

Background: During healthy pregnancy, T helper (Th) 1-type and inflammatory-type responses are down-regulated, and Th2-type and proinflammatory-type responses predominate. In Plasmodium falciparum-infected females, these responses induce enhanced production of tumor necrosis factor- alpha and interferon- gamma., Methods: To assess the respective implication of monocytes and T cells in this placental immunomodulation, we cocultured cells from delivering females living in an area where malaria is endemic. Monocytes and T cells from both peripheral and intervillous blood were crossed in in vitro cultures, to compare the proliferative response to several antigens. Moreover, monocyte cell-surface molecules were quantified by flow cytometry., Results: Coculture results confirmed placental immunomodulation and suggested that the most affected cells are not the intervillous monocytes, which are as able to present the antigen as the peripheral monocytes, but the intervillous T cells. Monocyte staining showed significant increases in human leukocyte antigen D-related, CD54, CD80, and CD86 surface markers in intervillous blood, compared with peripheral blood, which suggests a relative activation of monocytes in the placenta., Conclusion: A state of T cell deactivation and monocyte activation is present at delivery. The T cell deactivation in reaction to purified protein derivative could be explained by the presence of local T cell immunoregulatory factors.

Problem: In the human, lymphocyte alloimmunization immunotherapy (IT) has been proposed as a treatment for recurrent spontaneous abortion (RSA). This treatment has been the subject of debate for a long period of time. Recently, it has been proposed to extend such a treatment for implantation failure in humans, and I was asked to express my opinion on this topic., Methods: I reviewed the evolution and theories and current paradigms in Reproductive Immunology and rationales proposed for IT. New discoveries show the complexity of implantation as a step by step developmental event, in mice and humans, and as such led me to re-examine paradigms currently evoked for extension of IT to implantation. Such a re-examination obviously leads me to re-question the basis of IT for RSA itself., Conclusions: I conclude that the Th1/Th2 paradigm, evoked as the current basis for IT, and as useful as it has been to explain pregnancy, is no longer sufficient. It is especially insufficient to explain the process of implantation, which involves inflammatory molecules and cannot fit in such a scheme. It ensues that alloimmunization has no scientific rationale for the treatment of human implantation as a whole, and should not be applied broadly at such a stage of pregnancy. Furthermore, its use in RSA should be re-examined.

Problem: The aim of the present study was to define the expression of CXCR4 and CCR5 on non-cultured non-stimulated primary human trophoblast cells (TCs) immediately after their immunopurification., Method of Study: We have evaluated by flow cytometric analysis and immunofluorescence, highly purified primary TCs prepared from first trimester (8.2 +/- 0.3 weeks, n = 15) and term (Caesarean section, n = 10) placentae for the cell surface and intracellular expression of CXCR4 and CCR5., Results: There was a high level of individual variability for CXCR4 and CCR5 expression between trophoblast batches. In first trimester and term placentae TCs, we found a greater number of TCs preparations expressing intracellular CXCR4 than CCR5 (P < 0.05). Both receptors were predominantly localized in the intracellular compartment of TCs, whatever if isolated from first trimester or term placentae., Conclusions: The functional consequences of the predominance of CXCR4 expression and of cellular addressing are briefly discussed.