5. Conclusion

syndrome with greater prevalence of thyroid autoimmunity (14–27% at initial diagnosis) and thyroid peroxidase AAbs [127, 128]. At least 10% women with Addison's disease manifest AAbs to 21- or 17-hydroxylase and autoimmune oophoritis [129]. Thyroid peroxidase antibodies (TPO Abs) are also prevalent in PCOS cases. Thus, these along with HSP90β could be

In women with endometriosis, use of biomarkers including CA-125 for diagnosis of endometriosis was prohibited [130, 131]. However as per recent guidelines, use of biomarkers has been recommended for both diagnosis and disease monitoring [132] and is still a researchable area. Anti-endometrial antibodies exist but their sensitivity and accuracy varies from 0 to 100%

Endometriosis management guidelines are valid for women with mild to moderate disease and do not recommend hormonal therapy for managing ovulation to improve fertility rate [135]. Despite reduction in ovarian function, one time laparoscopic operation to remove endometriosis and improve pregnancy rates is often recommended [136, 137]. Adjunctive hormonal therapy is prohibited pre- or post-surgery to improve pregnancy rates [138]. Intra uterine insemination along with controlled ovarian stimulation is recommended 6 months postsurgery since it shows similar pregnancy rates as that of women with unexplained infertility [139]. ART can also be recommended especially in cases of tubal factor or male factor infertility as controlled ovarian stimulation does not increase chances of recurrence of endometriosis

POI seems to be an end-stage disease in women with an autoimmune disorder since it is detected at a late stage when the ovary has been substantially ravaged with little scope for fertility management. Thus treatment options for fertility management of women with POI are limited. Counseling for early marriage and pregnancy to complete the family is applicable only in case of early diagnosis or known familial origin. Other options include egg donation and IVF-ICSI or surrogacy. The women are administered corticosteroids in case of known autoimmune disease diagnosis and advised IVF-ICSI when AAb titers fall. However, this is not an option since it entails risk of osteoporosis and iatrogenic Cushing's syndrome [119]. In most cases, adoption is the only option along with psychological counseling and cardiovascular and

Additionally, there should be efforts to increase awareness among reproductive endocrinologists to recommend testing for undiagnosed autoimmune disease to couples on a case basis

Presence of AAbs is hallmark of autoimmune disease with no clarity on their role in disease pathogenesis and ensuing AI. With few exceptions these are not organ-specific indicating them

3.1. Treatment modalities and management of autoimmune infertility

after IVF/ICSI [140–143] however, it may not always be effective [144, 145].

bone health management of hypoestrogenism effects [146].

before embarking on ART-IVF [147].

4. Future research

included in an antibody detection panel.

[131, 133, 134].

46 Autoantibodies and Cytokines

The very lack of any organ-specific biomarker till date along with the preponderance of NAbs indicates that warped self-tolerance would lead to AI. AAbs in females alone appear to be significant in AI. Fertility studies need to be undertaken to gauge effect of such AAbs identified thus far and immunodominant epitopes gleaned could prove useful to design a pan autoimmune disease diagnostic peptide array to manage AI. Global immunosuppressant therapy and IVF-ICSI are the only current hope for such couples.
