Assessing the reproductive performance of men co-infected with HIV-1 and hepatitis C undergoing assisted reproduction

Effectiveness of semen washing to prevent human immunodeficiency virus (HIV) transmission and assist pregnancy in HIV-discordant couples: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of semen washing in human immunodeficiency virus (HIV)-discordant couples in which the male partner is infected.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Forty single-arm open-label studies among HIV-discordant couples that underwent intrauterine insemination (IUI) or in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) using washed semen.

INTERVENTION(S)

Semen washing followed by IUI, IVF, or IVF/ICSI.

MAIN OUTCOME MEASURE(S)

PRIMARY OUTCOME

HIV transmission to HIV-uninfected women; secondary outcomes: HIV transmission to newborns and proportion of couples achieving a clinical pregnancy.

RESULT(S)

No HIV transmission occurred in 11,585 cycles of assisted reproduction with the use of washed semen among 3,994 women. Among the subset of HIV-infected men without plasma viral suppression at the time of semen washing, no HIV seroconversions occurred among 1,023 women after 2,863 cycles of assisted reproduction with the use of washed semen. Studies that measured HIV transmission to infants reported no cases of vertical transmission. Overall, 56.3% of couples (2,357/4,184) achieved a clinical pregnancy with the use of washed semen.

CONCLUSION(S)

Semen washing appears to significantly reduce the risk of transmission in HIV-discordant couples desiring children, regardless of viral suppression in the male partner. There are no randomized controlled studies or studies from low-income countries, especially those with a large burden of HIV. Continued development of lower-cost semen washing and assisted reproduction technologies is needed. Integration of semen washing into HIV prevention interventions could help to further reduce the spread of HIV.

Viral Hepatitis and Assisted Reproduction

Infertility treatment in couples where one or both parents are infected with hepatitis raises many concerns about transmission of the infection to the baby, laboratory technicians, and medical staff, and contamination of other gametes/embryos that are from virus-free parents in the same laboratory. Exposure to the other partner is only a risk when the couple's hepatitis status is discordant. The management of infertility, in association with HBV or HCV, has sparked debates about the potential risk of spread of infection to virus-free individuals, embryos, and/or semen. This risk can only be minimized or eliminated by the use of SOPs for safety in fertility clinics and by the use of proper initial detection and segregation of potentially hazardous materials. HBV may interfere with the development of embryos and even result in abortion and other adverse outcomes. Although sexual transmission of HCV is very low, in subfertile or infertile couples sperm washing should be used to treat HCV-positive semen before ART. Testing for HBsAg and HCV should be offered to high-risk infertile couples seeking fertility therapy to reduce the potential risk of transmission to an uninfected partner, baby, staff members, and disease-free gametes and embryos in the same laboratory. Testing for HIV, HBsAg, and HCV status should be performed on the couple prior to cryopreservation of semen or embryos.

Systematic review of the effectiveness and safety of assisted reproduction techniques in couples serodiscordant for human immunodeficiency virus where the man is positive

OBJECTIVE

To evaluate the effectiveness and safety of assisted reproduction techniques (ART) in human immunodeficiency virus (HIV) serodiscordant couples.

DESIGN

Systematic review of five databases of noncomparative open intervention and observational studies of serodiscordant couples undergoing ART, with study selection and data extraction performed independently and in duplicate.

SETTING

Tertiary fertility centers.

PATIENT(S)

HIV serodiscordant couples where the man is HIV positive.

INTERVENTION(S)

Intrauterine insemination (IUI), in vitro fertilization (IVF), or intracytoplasmic injection (ICSI) performed after washed semen viral testing.

MAIN OUTCOME MEASURE(S)

Pregnancy rates per cycle, cumulative pregnancy, abortion rate, and HIV seroconversion in newborns or women.

RESULT(S)

Of the 658 abstracts retrieved, 41 were selected for review, and 17 full articles were included (3,900 IUI cycles in 1,184 couples in 11 aggregated studies and 738 ICSI/IVF cycles in 579 couples across 10 studies). The IUI and ICSI results were, respectively: pregnancy rates per cycle, 18% and 38.1%; cumulative pregnancy, 50% and 52.9%; and abortion rate, 15.6% and 20.6%. No seroconversions in women or newborns were detectable at birth or after 3 to 6 months.

CONCLUSION(S)

Cumulative evidence suggests that ART is safe and effective for avoiding horizontal and vertical transmission in HIV serodiscordant couples.

Reproductive assistance for infected couples with bloodborne viruses

During the past 15 years Assisted Reproduction has been facing a new demand from patients requiring ART: couples at risk of partner to partner, and mother to child transmission of viral infections, mainly HIV-1, HCV and HIV-HCV co-infected partners. The general conditions and life expectancy of many patients with HIV infection are very good, and three-quarters of these individuals are in their reproductive years. For these reasons, a large number of young couples are expected to make future plans to have children. This desire is not easy to realize for serodiscordant couples, if we consider that, in order to avoid HIV virus transmission, it is necessary to encourage the condom use in vaginal and anal contacts. On the other hand infertile discordant HCV couples need to be included in protocols of controlled assisted reproduction procedures to avoid any risk of HCV transmission to the partner. In this paper we consider assisted reproduction in discordant couples for HIV or HCV-positive men.