Subfertility among HIV-affected couples in a safer conception cohort in South Africa

Molecular mechanisms underpinning the protection against antiretroviral drug-induced sperm-endocrine aberrations and testicular toxicity: A review

The introduction of highly active antiretroviral therapy (HAART) has revolutionized the treatment of HIV/AIDS worldwide. The HAART approach is the combination of two or more antiretroviral drugs of different classes and are responsible for patient's survival and declining death rates from HIV/AIDS and AIDS-related events. However, the severe and persistent reproductive side effect toxicity of HAART regimens is of great concern to patients within the reproductive age. Till date, the underlying pathophysiology of the HAART-induced reproductive toxicity remains unraveled. Nevertheless, preclinical studies show that oxidative stress and inflammation may be involved in HAART-induced sperm-endocrine deficit and reproductive aberrations. Studies are emerging demonstrating the efficacy of plant-based and non-plant products against the molecular alterations and testicular toxicity of HAART. The testicular mechanisms of mitigation by these products are associated with enhancement of testicular steroidogenesis, spermatogenesis, inhibition of oxidative stress and inflammation. This review presents the toxic effects of HAART on spermatogenesis, reproductive hormones and testis integrity. It also provides insights on the molecular mechanisms underlying the mitigation of HAART testicular toxicity by plant-based and non-plant agents. However, effect of repurposing clinical drugs to combat HAART toxicity is unknown, and more mechanistic studies are evidently needed. Altogether, plant-based and non-plant products are potential agents for prevention of rampant endocrine dysfunction and testicular toxicity of HAART.

Social impacts experienced by women with HIV and infertility in sub-Saharan Africa: A scoping review

BACKGROUND

In Sub-Saharan Africa (SSA), HIV (Human Immunodeficiency Virus) prevalence among reproductive-aged women remains high, and infertility among these women is common. The social consequences for these women are yet to be explored. This scoping review summarises the social consequences of living with HIV and infertility for SSA women.

METHODS

This scoping review of published peer-reviewed literature focused on the intersection of infertility and living with HIV among women in SSA. We followed the PRISMA guidelines for scoping reviews. We searched PubMed, Web of Science and SCOPUS and included all original research reports which met the inclusion criteria; women in Sub-Saharan Africa, living with HIV, and infertility.

RESULTS

Fourteen papers met the inclusion criteria. Both HIV diagnosis and infertility were reported as stigmatising experiences for women who desire to have children. The stigma of infertility had a greater negative impact on women than that of an HIV diagnosis. Familial, community support, and medical intervention were perceived vital to ensure women feel de-stigmatised and in control of their future, even without children.

CONCLUSION

This is the first review demonstrating the social consequences of HIV and infertility on SSA women. Further research and interventions are needed to reduce the social consequences of infertility within SSA.

Semen Washing and Intrauterine Insemination for Reducing the Risk of Human Immunodeficiency Virus Transmission in Serodiscordant Couples: A Cross-sectional Study

Background

Antiretroviral therapy has helped human immunodeficiency virus (HIV)-infected people live an enhanced quality of life and attempt for a pregnancy, without placing their partner at risk. Although periconceptional pre-exposure prophylaxis for the uninfected partner and consistent antiretroviral therapy for the HIV-infected partner are important to prevent HIV transmission, semen washing could be a great option to further reduce the semen viral load.

Aim

The aim of this study were as follows: to determine if semen washing with intrauterine insemination provides an added safety net to HIV-serodiscordant couples when the male partner is HIV-infected and virally suppressed and to determine if the U = U concept (undetectable = untransmittable) holds true in virally suppressed HIV-infected males.

Settings and Design

This was an observational study conducted in seropositive HIV men under treatment with highly active antiretroviral therapy (HAART) in collaboration with Metropolis Laboratory, a CAP recognised private Healthcare Laboratory in Mumbai, India.

Materials and Methods

Blood and semen samples were collected from a total of 110 adult HIV-1-infected males virally suppressed on HAART. These samples were processed to assess the viral load in plasma as well as raw and processed semen fractions.

Statistical Analysis Used

Descriptive statistics were used to analyse the data.

Results

Only men with plasma viral loads < 1000 copies were selected in our study. Out of the 110 HIV-infected individuals, 102 (92.73%) patients had undetectable (<20 copies/ml) plasma viral load while 8 (7.27%) patients had a detectable (>20 copies/ml) viral load, who were excluded from the study. In the virally suppressed 102 men, the raw semen samples of 100 men showed an undetectable viral load, while 2 samples showed detectable contamination, even though their plasma samples from the blood showed a viral load of <20 copies/ml. The semen was then separated into the sperm and the seminal plasma samples. The seminal plasma had <20 copies/ml in 95 samples (93.14%) but a detectable viral load in 7 (6.86%) samples. After subjecting all the 102 processed (post-wash) sperm samples to quantitative analysis, an undetectable viral load of <20 copies/ml was found in all the samples. Thus, the raw sample (prewashed),seminal plasma and processed (postwash) samples were evaluated. The post-wash sperm sample showing zero contamination was frozen for intrauterine insemination (IUI) in the uninfected female partner.

Conclusions

Semen washing with IUI should be advocated as a safe, efficacious way to increase the safety net and to further reduce the minimal risk of HIV transmission in serodiscordant couples in addition to the U = U concept.

Decrease of condom use in heterosexual couples and its impact on pregnancy rates: the Swiss HIV Cohort Study (SHCS)

Introduction

Following the ‘Swiss statement’ in 2008 it became an option to omit the use of condoms in serodiscordant couples and to conceive naturally. We analysed its impact on condom use and pregnancy events.

Methods

In all, 3023 women (aged 18–49 years) participating in the Swiss HIV Cohort Study were included. Observation time was divided into pre‐ and post‐Swiss statement phases (July 2005–December 2008 and January 2009–December 2019). We used descriptive statistics, Poisson interrupted time series analysis for pregnancy incidence, and logistic regression to identify predictors of live births, spontaneous and induced abortions.

Results

Condomless sex in sexually active women increased from 25% in 2005 to 75% in 2019, while pregnancy incidence did not. Women after 2008 experienced higher spontaneous abortion rates (12.1% vs. 17.2%, p = 0.02) while induced abortion and live birth rates did not change significantly. Spontaneous abortions were more common in older women [adjusted odds ratio (aOR) = 1.4, 95% CI: 1.2–1.7, p < 0.001], in women consuming alcohol (aOR = 2.8, 95% CI: 1.9–4.1, p < 0.001) and in those with non‐suppressed viral load (aOR = 0.2, 95% CI: 0.1–0.4, p ≤ 0.001). Induced abortions were more likely in women with depression (aOR = 3.4, 95% CI: 1.8–6.3, p < 0.001) and non‐suppressed viral load (aOR = 0.3, 95% CI: 0.2–0.7, p = 0.003).

Conclusions

The publication of the Swiss statement resulted in more condomless sex in heterosexual women, but this did not result in a higher incidence of pregnancy. Maternal age and spontaneous abortion rates increased over time, while induced abortion rates were not significantly affected. Women living with HIV in Switzerland have an unmet need regarding family planning counselling.

Long-Term Administration of Abacavir and Etravirine Impairs Semen Quality and Alters Redox System and Bone Metabolism in Growing Male Wistar Rats

Highly active antiretroviral therapy (HAART) is used in HIV-infected patients. Alongside the prolongation of patients' life, adverse side effects associated with long-term therapy are becoming an increasing problem. Therefore, optimizing of HAART is extremely important. The study is aimed at evaluating the toxicity of abacavir and etravirine in monotherapy on the reproductive system, liver, kidneys, and bones in young, sexually mature, male rats. Thirty-six 8-week-old male Wistar rats randomized into three 12-animal groups received either normal saline (control), abacavir 60 mg/kg (AB group), or etravirine 40 mg/kg (ET group) once daily for 16 weeks. Semen morphology, oxide-redox state parameters (MDA, SOD, catalase, GPx, glutathione, GSH/GSSG ratio) in tissue homogenates (testes, liver, kidneys), and serum samples were studied. In bones, microcomputed tomography and a four-point bending test were performed. Total sperm count, sperm concentration, motility, and sperm morphology did not differ significantly in AB or ET groups compared to the control. In the flow cytometry of semen, an increased percentage of cells with denatured DNA was noticed for both tested drugs. However, no significant changes of oxide-redox state in testicular homogenates were found, except of increased SOD activity in the AB-receiving group. Additionally, ET significantly altered catalase and GPx in the liver and SOD activity in kidneys. Abacavir decreased catalase in the liver and GSH levels in kidneys. AB caused significant changes to bone microarchitecture (bone volume fraction, trabecular number, connectivity density, total porosity) and increased Young's modulus. Etravirine had a greater impact on macrometric parameters of bones (tibial index, mid-tibial diameter, femur length). After 4 weeks in the ET group, a lower 1,25-dihydroxyvitamin D₃ serum concentration was found. The results showed that abacavir and etravirine disturb oxidative stress. An increase in the percentage of sperms with chromatin damage suggests decreased fertility in rats receiving the studied drugs. Both drugs affected bone formation in growing rats. Additionally, etravirine disturbed vitamin D metabolism.

Association between bacterial vaginosis and fecundability in Kenyan women planning pregnancies: a prospective preconception cohort study

STUDY QUESTION

Is bacterial vaginosis (BV) associated with fecundability?

SUMMARY ANSWER

Women with BV may be at increased risk for sub-fecundity.

WHAT IS KNOWN ALREADY

While BV has been associated with poor IVF outcomes, the association between vaginal microbiota disruption and non-medically assisted conception has not been thoroughly explored.

STUDY DESIGN, SIZE, DURATION

Kenyan women with fertility intent were enrolled in prospective cohort that included monthly preconception visits with vaginal fluid specimen collection and pregnancy testing. Four hundred fifty-eight women attempting pregnancy for ≤3 menstrual cycles at enrollment were eligible for this fecundability analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

At monthly preconception visits, participants reported the first day of last menstrual period and sexual behavior, underwent pregnancy testing and provided vaginal specimens. Discrete time proportional probabilities models were used to estimate fecundability ratios (FRs) and 95% CI in menstrual cycles with and without BV (Nugent score ≥ 7) at the visit prior to each pregnancy test. We also assessed the association between persistent BV (BV at two consecutive visits) and fecundability.

MAIN RESULTS AND THE ROLE OF CHANCE

Participants contributed 1376 menstrual cycles; 18.5% (n = 255) resulted in pregnancy. After adjusting for age, frequency of condomless sex and study site, BV at the visit prior to pregnancy testing was associated with a 17% lower fecundability (adjusted FR (aFR) 0.83, 95% CI 0.6-1.1). Persistent BV was associated with a 43% reduction in fecundability compared to cycles characterized by optimal vaginal health (aFR 0.57, 95% CI 0.4-0.8).

LIMITATIONS, REASONS FOR CAUTION

Detection of vaginal microbiota disruption using Gram stain and a point-of-care test for elevated sialidase identified a non-optimal vaginal environment, but these non-specific methods may miss important relationships that could be identified by characterizing individual vaginal bacteria and bacterial communities using molecular methods. In addition, results may be subject to residual confounding by condomless sex as this was reported for the prior month rather than for the fertile window during each cycle.

WIDER IMPLICATIONS OF THE FINDINGS

Given the high global prevalence of BV and infertility, an association between BV and reduced fecundability could have important implications for a large number of women who wish to conceive. Multi-omics approaches to studying the vaginal microbiota may provide key insights into this association and identify potential targets for intervention.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a National Institutes of Health grant (NICHD R01 HD087346-R.S.M.). R.S.M. received additional support for mentoring (NICHD K24 HD88229). E.M.L. was supported by pre- and post-doctoral fellowships (NIAID T32 AI07140, NICHD F32 HD100202). Data collection and management were made possible using REDCap electronic data capture tools hosted at the University of Washington's Institute of Translational Health Science supported by grants from NCATS/NIH (UL1 TR002319). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. R.S.M. receives research funding, paid to the University of Washington, from Hologic Corporation, and has received honoraria for consulting from Lupin Pharmaceuticals. L.E.M. receives research funding, paid to the University of Washington, from Hologic Corporation, and has received honoraria for service on scientific advisory boards from Hologic and Nabriva Therapeutics.

TRIAL REGISTRATION NUMBER

N/A.

Genitourinary Infections Related to Circumcision and the Potential Impact on Male Infertility

Male circumcision (MC) is one of the oldest surgical procedures still completed today. Medical indications for MC include phimosis, recurrent balanitis, cosmesis, and infection prevention. In this review, we mainly focus on the role of MC in the prevention of human immunodeficiency virus, human papillomavirus, herpes simplex virus, gonorrhea, chlamydia, chancroid, and syphilis, and the subsequent impact of these genitourinary infections on male fertility. Overall, many compelling data support that MC may play an essential role in both genitourinary infection prevention and male fertility.

Fertility among women living with HIV in western Ethiopia and : a cross-sectional study

OBJECTIVE

This study aimed to examine fertility (live births) in the last 3 years and its associated factors among women living with HIV (WLHIV) in western Ethiopia .

DESIGN

Participants were recruited into a cross-sectional survey using systematic sampling.

SETTINGS

Four healthcare facilities in western Ethiopia were included.

PARTICIPANTS

Eligible participants were WLHIV of reproductive age (15-49 years) from western Ethiopia who found out about their HIV-positive status more than 3 years ago (N=866).

PRIMARY OUTCOME MEASURES

The fertility (live births) of HIV-positive women in the last 3 years was surveyed using face-to-face interviews (March-June 2018). Logistic regression analyses were conducted to examine factors influencing fertility in the last 3 years.

RESULTS

A total of 108 (12.5%) HIV-positive women gave birth to 121 live children in the last 3 years. Of these births, 18.2% were reported as mistimed at conception, while 26.4% were reported as unwanted. Of the live births, 8.3% ended in death. Of the 76 (62.8%) children with known HIV status born to HIV-positive women in the last 3 years, 7.9% were HIV-positive. In terms of predictors of fertility, women aged 15-24 years (adjusted OR (AOR) 2.72; 95% CI 1.14 to 6.49) and 25-34 years (AOR 4.34; 95% CI 2.61 to 7.21) had increased odds of fertility compared with women aged 35-49 years. Women using antiretroviral therapy (ART) for less than 5 years were more likely to have given birth in the last 3 years compared with those using ART for 10 years or more (AOR 2.96; 95% CI 1.19 to 7.36), even after controlling for age.

CONCLUSIONS

WLHIV in Ethiopia are having children and so it is imperative that safe conception strategies are readily available as well as support to reduce HIV-related risks for children born to these mothers. Strengthening reproductive health services for HIV-positive women in order to achieve their family planning goals is therefore important.