Reproductive considerations in the setting of chronic viral illness

Update on known and emergent viruses affecting human male genital tract and fertility

Many viruses infect the male genital tract with harmful consequences at individual and population levels. In fact, viral infections may induce damage to different organs of the male genital tract (MGT), therefore compromising male fertility. The oxidative stress, induced during viral-mediated local and systemic inflammation, is responsible for testicular damage, compromising germinal and endocrine cell functions. A reduction in sperm count, motility, number of normal sperm and an increase in DNA fragmentation are all common findings in the course of viral infections that, however, generally regress after infection clearance. In some cases, however, viral shedding persists for a long time leading to unexpected sexual transmission, even after the disappearance of the viral load from the blood.The recent outbreak of Zika and Ebola Virus evidenced how the MGT could represent a reservoir of dangerous emergent viruses and how new modalities of surveillance of survivors are strongly needed to limit viral transmission among the general population.Here we reviewed the evidence concerning the presence of relevant viruses, including emergent and re-emergent, on the male genital tract, their route of entry, their adverse effects on male fertility and the pattern of viral shedding in the semen.We also described laboratory strategies to reduce the risk of horizontal or vertical cross-infection in serodiscordant couples undergoing assisted reproductive technologies.

Epidemiology of hepatitis B virus infection among preconception couples in South China: a cross-sectional study

OBJECTIVES

Hepatitis B virus (HBV) infection is a global public health threat, and couples of reproductive age comprise a key population in aiming to reduce both the vertical and horizontal transmission of HBV. We aimed to update knowledge on the seroepidemiology status of HBV in Guangdong, China among a large number of couples planning conception, and to identify high-risk subgroups.

DESIGN

A cross-sectional study was performed in Guangdong, China from 2014 to 2017.

SETTING

The data were collected from 641 642 couples (1 283 284 individuals) participating in the National Free Preconception Health Examination Project in Guangdong, China from 1 January 2014 to 31 December 2017. For each participant, sociodemographic data were obtained and a serum sample was tested for HBV infection status.

RESULTS

161 204 individuals (12.56%) were positive for hepatitis B surface antigen (HBsAg+), and 47 318 (3.69%) were positive for both HBsAg and hepatitis B e antigen (HBsAg+ and HBeAg+). There was a higher prevalence of HBsAg+ (12.77% vs 9.42%, p<0.05) and HBsAg+ and HBeAg+ (3.77% vs 2.45%, p<0.05) among the participants with a Guangdong household registration than a non-Guangdong household registration. Similarly, the prevalence of HBsAg (13.26% vs 11.72%, p<0.05) and HBsAg+ and HBeAg+ (4.31% vs 2.94%, p<0.05) was higher among participants not living in the Pearl River Delta than those living in the Pearl River Delta. At the couple level, 12 446 couples (1.94%) were both positive; in 51 849 (8.08%), only the wife was positive; in 84 463 (13.16%), only the husband was positive. Moreover, HBsAg+ prevalence was lowest in couples where both individuals were vaccinated (18.63%) and highest in couples where neither the wife or husband was vaccinated (24.46%).

CONCLUSION

There was a relatively high HBsAg+ prevalence in married couples in this high-epidemic region and urgent prevention strategies are required, such as ensuring access to health services for those not living in the Pearl River Delta, and expanding vaccine programmes to high-risk adults.

Hepatitis B and C in Pregnancy and Children: A Canadian Perspective

In 2016, the World Health Organization released a plan to eliminate viral hepatitis as a public health threat by 2030. For Canada to achieve the recommended decreases in HBV- and HCV-related new diagnoses and deaths, an increase in services is urgently required. Identifying those at risk of, or who have acquired HBV and HCV, remains a challenge, especially with the emergence of new priority populations such as pregnant persons and children. Importantly, prenatal, and pediatric care are times when individuals are often already engaged with the healthcare system, leading to the potential for opportunistic or co-localized care and interventions. At present, Canada may not be maximizing all available virologic tools that could lead to increases in prevention, identification, improved management, or even cure. Here, we describe the continuum of care that includes preconception, prenatal, postpartum, and pediatric stages; and identify current global and Canadian recommendations, findings, and opportunities for improvement.

The negative impact of most relevant infections on fertility and assisted reproduction technology

Infections may act with variable impact on the physiopathology of the reproductive organs, determining infertility or reducing the outcomes of assisted reproduction technology. The aim of this narrative review is to describe the existing evidence regarding the pathogens with a supposed or recognized role in reproductive medicine. Viral hepatitis, as well as HIV, can reduce sperm quality. Syphilis carries a risk of erectile dysfunction and increased endometrial thickness. Chlamydia is the main cause of pelvic inflammatory disease. In relation to Mycoplasma and Ureaplasma spp., only few species seem to show a correlation with infertility and poor in-vitro fertilization outcomes. There is evidence of a role for bacterial vaginosis in early pregnancy loss. HPV infection in males seems to determine infertility. Herpesviruses are more a risk for fetuses than for fertility itself. Zika virus is responsible for altered early embryo development and waiting to conceive is recommended in suspected or confirmed cases. The impact of SARS-CoV-2 is yet to be elucidated. Rubella and toxoplasmosis can provoke important congenital defects and therefore screening is mandatory before conception; a vaccine for Rubella is recommended. Further and well-designed studies are still needed to better elucidate the role of some infectious agents, to improve fertility and its treatments.

The probable destructive mechanisms behind COVID-19 on male reproduction system and fertility

PURPOSE

The present study aims to summarize the current understanding of probable mechanisms and claims of adverse effects of SARS-CoV-2 on male fertility potential.

METHODS

Our search was including original articles, reviews, guidelines, letters to the editor, comments on guidelines, and editorials, regarding the male reproductive system. We used the words SARS-CoV-2, coronavirus, severe acute respiratory syndrome coronavirus 2, "2019 ncov," testis, sperm, male factor infertility, fertility treatment, semen, assisted reproductive technology (ART), sexual transmission, and ACE2.

RESULTS

Data showed coronavirus affects men more than women because of more expression of 2019 nCoV receptors (ACE2 and TMPRSS2) in testicular cells. Also, "Bioinformatics Analysis" suggests that sperm production may be damaged, since "Pseudo Time Analysis" has shown disruption in spermatogenesis. "Gene Ontology" (GO) showed an increase in viral reproduction and a decrease in sperm production-related terms. Recently, SARS-COV-2 mRNA and protein were detected in the semen of patients that had recovered from SARS-CoV-2 infection. Therefore, the probable disruption of blood-testis barrier (BTB) in febrile diseases is suspected in the acute phase of the disease enabling viral entry into the testes. Not only is spermatogenesis disturbed, but also disturbs gonadotropin, androgens, and testosterone secretion during SARS-CoV-2 infection. No sexual transmission has been reported yet; however, detection of the virus in semen still makes the sexual transmission an open question.

CONCLUSION

There is a concern that male fertility may be disturbed after the SARS-CoV-2 infection. Therefore, follow-up of the reproductive functions and male fertility may be necessary in recovered cases, especially in aged men.

Infectious Hepatitis in Pregnancy

Infectious hepatitis in pregnancy is clinically significant in both the acute and chronic phases. Here, we review the perinatal implications of chronic hepatitis B and C and acute hepatitis A and E. Familiarity with screening, transmission, diagnosis, and management of infectious hepatitis is of ongoing importance during obstetric care, as these diseases are endemic in much of the world. Pregnancy and interpregnancy care provide opportunities to prevent infection and transmission of hepatitis.

Assisted reproductive technology outcomes in women with a chronic viral disease

OBJECTIVE

The aim of this study was to evaluate the cumulative live birth rate in women undergoing in-vitro fertilization/intracytoplasmic-sperm-injection (IVF/ICSI) according to the type of chronic viral infection [HIV, hepatitis-B virus (HBV) and hepatitis-C virus (HCV)].

DESIGN

A cohort study.

SETTING

A tertiary-care university hospital.

PARTICIPANTS

Women with a chronic viral illness HIV, HBV or HCV- were followed until four IVF/ICSI cycles had been completed, until delivery or until discontinuation of the treatment before the completion of four cycles.

MAIN OUTCOME MEASURES

The primary outcome was the cumulative live birth rate after up to four IVF/ICSI cycles.

RESULTS

A total of 235 women were allocated to the HIV-infected group (n = 101), the HBV-infected group (n = 114) and the HCV-infected group (n = 20). The cumulative live birth rate after four cycles was significantly lower in the HIV-infected women than in those with HBV [39.1%, 95% confidence interval (95% CI): 17.7-60.9 versus 52.8%, 95% CI: 41.6-65.5, respectively; P = 0.004]. Regarding the obstetrical outcomes, the mean birth weight was lower in the HIV-infected women than in those with HBV or HCV. Multivariate analysis indicated that the age, the anti-Müllerian hormone and the number of cycles performed were significantly associated with the chances of a live birth.

CONCLUSION

HIV-infected women had lower cumulative live birth rate than women with chronic hepatitis, and this was due to less favourable ovarian reserve parameters. These findings underscore the need to better inform practitioners and patients regarding fertility issues and the importance of early fertility assessment. However, larger studies are necessary to gain more in-depth knowledge of the direct impact of HIV on live birth rates.

HIV, HPV and Chlamydia trachomatis: impacts on male fertility

Sexually transmitted diseases (STDs) are pathologies that have viruses, bacteria, protozoa and fungi as infectious agents, affecting millions of people worldwide and causing physical and psychological consequences for the carrier. Some of these infections such as HIV, HPV and Chlamydia trachomatis may present an asymptomatic phase, making the diagnosis difficult, which is often only performed when the couple looks for infertility treatment after not achieving spontaneous pregnancy. Infertility affects 15% of couples, 50% of cases are male-related, and it is estimated that STDs, which interfere with the physiology of the male reproductive system and may impair semen in parameters such as motility, concentration, morphology and number, cause 15% of male infertility cases. Since STDs treatments are increasing the expectation and quality of life of infected patients, discussing issues such as sexuality and reproduction is of great importance in clarifying unknown facts. This paper aims to discuss how the infectious processes associated with HIV, HPV and Chlamydia trachomatis can interfere with semen quality causing male infertility without apparent cause.

Indian National Association for the Study of the Liver-Federation of Obstetric and Gynaecological Societies of India Position Statement on Management of Liver Diseases in Pregnancy

Liver diseases occurring during pregnancy can be serious and can progress rapidly, affecting outcomes for both the mother and fetus. They are a common cause of concern to an obstetrician and an important reason for referral to a hepatologist, gastroenterologist, or physician. Liver diseases during pregnancy can be divided into disorders unique to pregnancy, those coincidental with pregnancy, and preexisting liver diseases exacerbated by pregnancy. A rapid differential diagnosis between liver diseases related or unrelated to pregnancy is required so that specialist and urgent management of these conditions can be carried out. Specific Indian guidelines for the management of these patients are lacking. The Indian National Association for the Study of the Liver (INASL) in association with the Federation of Obstetric and Gynaecological Societies of India (FOGSI) had set up a taskforce for development of consensus guidelines for management of patients with liver diseases during pregnancy, relevant to India. For development of these guidelines, a two-day roundtable meeting was held on 26-27 May 2018 in New Delhi, to discuss, debate, and finalize the consensus statements. Only those statements that were unanimously approved by most members of the taskforce were accepted. The primary objective of this review is to present the consensus statements approved jointly by the INASL and FOGSI for diagnosing and managing pregnant women with liver diseases. This article provides an overview of liver diseases occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and the recommended treatment options.

The association between inter-twin birth weight discordance and hepatitis C: The United States 2011-2015 twin birth registration data

BACKGROUND

Twins with discordant growth have increased risks of perinatal mortality and morbidity. Previous studies have identified a number of risk factors for inter-twin birth weight discordance, yet no study has examined the effect of maternal hepatitis C infection.

METHODS

We used the twin birth records extracted from the 2011 to 2015 United States birth records created by the Centers for Disease Control and Prevention. The outcome variable of this study was inter-twin birth weight discordance, defined as [(birth weight of larger twin-birth weight of smaller twin) / birth weight of larger twin]. The independent association of hepatitis C infection with birth weight discordance was examined using the gamma regression or log binomial regression, adjusted by potential confounders.

RESULTS

Of the 270,256 twin pairs included in the final analysis, 850 (0.31%) had positive hepatitis C. Compared to mothers without hepatitis C, mothers with hepatitis C positive tended to have higher risk of birth weight discordance, but with no statistical significance. After adjustment for potential confounding factors, hepatitis C positive became a significant risk factor for birth weight discordance >25% (relative risk 1.14, 95% confidence interval 1.02-1.29). Sensitivity analyses (by treating birth weight discordance as a continuous outcome or dichotomizing into by different cutoffs) yielded similar results, with relative risks ranging from 1.07 to 1.12 (all P<0.05).

CONCLUSION

Maternal hepatitis C positive is associated with inter-twin birth weight discordance, an important adverse infant outcome in twin pregnancies, although the effect size is small.

Hepatitis C and pregnancy outcomes: a systematic review protocol

INTRODUCTION

Many women living with hepatitis C (HCV) are of childbearing age. While the risk of vertical HCV transmission has been well established, the impact of HCV on pregnancy outcomes are equivocal, with some studies reporting risks of preterm birth, low gestational weight, gestational diabetes and hypertension, while other studies report no such risks. With the shift of the HCV treatment landscape to more effective, tolerable and shorter medications, understanding pregnancy outcomes of women living with HCV are an important consideration in order to provide a baseline from which to consider the usefulness and safety of HCV treatment for this population. The objective of this systematic review will be to investigate pregnancy outcomes associated with maternal HCV infection.

METHODS AND ANALYSIS

This systematic review will incorporate articles relevant to pregnancy outcomes among women living with HCV (eg, gestational diabetes and caesarean delivery). Articles will be retrieved from academic databases including MEDLINE, EMBASE, CINAHL, clinicaltrial.gov and the Cochrane Library and hand searching of conference proceedings and reference lists. A database search will not be restricted by date, and conference abstract will be restricted to the past 2 years. The Newcastle-Ottawa Quality Assessment Scale will be used to assess the quality of the retrieved studies. Data will be extracted and scored independently by two authors. A narrative account will synthesise the findings to answer the objectives of this review.

ETHICS AND DISSEMINATION

This systematic review will synthesise the literature on the pregnancy outcomes of women living with HCV. Results from this review will be disseminated to clinical audiences, community groups and policy-makers, and may support clinicians and decision-makers in developing guidelines to promote best outcomes for this population.

Premature ovarian senescence and a high miscarriage rate impair fertility in women with HCV

BACKGROUND & AIMS

Premenopausal women who are HCV positive (HCV+) have failing ovarian function, which is likely to impact their fertility. Thus, we investigated the reproductive history, risk of infertility, and pregnancy outcomes in women of childbearing age who were HCV+.

METHODS

Three different groups were studied: (1) Clinical cohort: 100 women who were HCV+ and also had chronic liver disease (CLD), age matched with 50 women who were HBV+ with CLD and with 100 healthy women; all women were consecutively observed in three gastroenterology units in hospitals in Italy; (2) 1,998 women who were HCV+ and enrolled in the Italian Platform for the Study of Viral Hepatitis Therapies (PITER); (3) 6,085 women, who were mono-infected with HCV, and 20,415 women, who were HCV-, from a large de-identified insurance database from the USA.

MEASUREMENTS

total fertility rate (TFR) defined as the average number of children that a woman would bear during her lifetime. To define the reproductive stage of each participant, levels of anti-Müllerian hormone (AMH) and 17β-estradiol were measured.

RESULTS

Clinical cohort: women who were either HCV+ or HBV+ had similar CLD severity and age at first pregnancy. Based on a multivariate analysis, women who were HCV+ had a higher risk of miscarriage than those who were HBV+ (odds ratio [OR] 6,905; 95% CI 1.771-26.926). Among women who were HCV+, incidence of miscarriage was correlated with median AMH level (1.0 ng/ml). Achieving a sustained virologic response (SVR) after antiviral treatment reduced the risk of miscarriage (OR 0.255; 95% CI 0.090-0.723). In the PITER-HCV cohort, miscarriage occurred in 42.0% of women (44.6% had multiple miscarriages). TFR for women who were HCV+ and between 15 and 49 years of age was 0.7 vs. 1.37 of Italian population of the same age range. In the US cohort: compared with women who were HCV-, women who were HCV+ positive were significantly more likely to have infertility (OR 2.439; 95% CI 2.130-2.794), premature birth (OR 1.34; 95% CI 1.060-1.690), gestational diabetes (OR 1.24; 95% CI 1.020-1.510), and pre-eclampsia (OR 1.206; 95% CI 0.935-1.556), and were less likely to have a live birth (OR 0.754; 95% CI 0.622-0.913).

CONCLUSIONS

Ovarian senescence in women of childbearing age who are HCV+ is associated with a lower chance of live birth, greater risk of infertility, gestational diabetes, pre-eclampsia and miscarriage. Such risks could be positively influenced by successful HCV cure.

LAY SUMMARY

Most new cases of HCV infection are among people who inject drugs, many of whom are young women in their childbearing years. Women of reproductive age who are HCV+ display markers of ovarian senescence. This is associated with an increased burden in terms of infertility and adverse pregnancy outcomes, including stillbirth, miscarriage, fewer live births, and gestational diabetes. Early viral suppression with therapy is likely to mitigate these risks.

A Review of HIV Pre-Exposure Prophylaxis: The Female Perspective

When taken consistently, pre-exposure prophylaxis (PrEP) against human immunodeficiency virus (HIV) with once daily tenofovir disoproxil fumarate-emtricitabine (TDF-FTC) has been shown to safely reduce the incidence of HIV infection in high-risk individuals by more than 90%. Yet, according to the Centers for Disease Control and Prevention, there were about 2.1 million new cases of HIV reported worldwide in 2015. Undoubtedly, there is significant room for improvement to prevent the transmission of HIV. Research to date has been heavily focused on the high-risk men who have sex with men (MSM) population, yet, many women worldwide remain at high risk of HIV transmission. PrEP offers women a protection method that is discrete, does not require partner consent, and may be compatible with both contraception or conception as desired. However, women often remain under-represented in HIV prevention literature and are reported to have lower real-world uptake in comparison to men. Furthermore, clinical trials that do focus on the female population demonstrate mixed efficacy results that highlight the adherence challenges in this population. It is essential to identify factors that contribute to PrEP non-adherence as well as barriers to preventative treatment. This review will discuss the clinical evidence behind PrEP in women, current barriers to use afflicting this population, pharmacotherapy considerations for the female patient, alternative and future agents, and the current real-world application of PrEP.