Synchronous sperm retrieval and sperm washing in an intracytoplasmic sperm injection cycle in an azoospermic man who was positive for human immunodeficiency virus

People living with HIV and procreation: 30 years of progress from prohibition to freedom?

The emergence of human immunodeficiency virus (HIV) infection in the 1980s drastically changed the prospects of conceiving a child for the man or woman infected with the virus. Advances in treatment then made it possible to envisage pregnancy while decreasing the risk of transmission to the child when the mother was infected. For couples where one partner was HIV-positive and who desired a child, recourse to medical help, notably medically assisted procreation, was discouraged, and very few centres offered such assistance in the 1980s and 1990s. Improved knowledge of viral excretion in the genital tracts, together with more effective treatment, made it possible to envisage medically assisted procreation for these couples, allowing them to have a child while at the same time likely reducing the risk of transmitting HIV to their partner. Several programmes have demonstrated their effectiveness in this domain. Owing to continually increasing knowledge over the past decade, natural conception can now be proposed. Couples where one or both partners are HIV-positive may opt for medically assisted procreation or natural reproduction. Specialists in reproductive medicine and HIV specialists need to provide couples with objective information allowing them to achieve near-optimal conditions that minimize HIV transmission risk. Couples will then be able to choose freely the mode of procreation most appropriate for them.

Intracytoplasmic sperm injection with microsurgically retrieved spermatozoa in azoospermic men infected with human immunodeficiency virus 1 or hepatitis C virus: the EP43 AZONECO ANRS study

OBJECTIVE

To evaluate the viral contamination of sperm obtained after testicular sperm extraction (TESE) and microsurgical epididymal sperm aspiration (MESA) in men with azoospermia and human immunodeficiency virus (HIV) or hepatitis C virus infection.

DESIGN

Prospective study.

SETTING

Fertility clinic, and reproductive technology and virology laboratories.

PATIENT(S)

Six men with azoospermia: two HIV-1 infected with undetectable blood viral load and four HCV infected with detectable blood viral load.

INTERVENTION(S)

Processing by gradients density centrifugation and washing of surgically recovered sperm (TESE and MESA); virological analysis; in vitro fertilization with intracytoplasmic sperm injection (ICSI).

MAIN OUTCOME MEASURE(S)

Detection of HIV-1 RNA or HCV RNA in gradient supernatants, testis tissues and final processed spermatozoa, and of HIV-1 DNA in testis tissues.

RESULT(S)

Gradient supernatants and testis tissues tested HCV RNA positive in all cases while processed spermatozoa always tested negative. Gradient supernatants, testis tissues, and processed spermatozoa tested HIV-1 RNA negative. HIV-1 DNA was detectable in one testis tissue. All female partners tested HCV or HIV negative after ICSI.

CONCLUSION(S)

Density gradient and washing suppressed virus detection in final suspensions of testicular and epididymal spermatozoa. ICSI after MESA or TESE appears to be feasible and could be offered in azoospermic men infected by HCV or HIV.

Reproductive assistance in HIV serodiscordant couples

BACKGROUND

Three quarters of individuals infected with human immunodeficiency virus (HIV) are in their reproductive years and may consider pregnancy planning. Techniques have been developed which can minimize the risk of HIV transmission in these couples, and the current literature on this topic is reviewed here.

METHODS

We reviewed the literature for the following topics: risk of HIV transmission, effects of HIV infection on fertility, reproductive assistance in industrialized and low-income countries, pre-exposure chemoprophylaxis (PrEP) and timed intercourse in HIV-discordant couples for both male and female positivity. Relevant publications were identified through searches of the EMBASE Medline and PubMed databases, the Google-indexed scientific literature and periodic specialized magazines from the on-line Library Service of the University of Milan, Italy.

RESULTS

In serodiscordant couples in which the man is positive, the primary method used to prevent HIV transmission is 'sperm washing', followed by IUI or IVF. Data show that sperm washing in HIV-positive men has not produced seroconversion in women or their offspring; however, the evidence is limited. Recently, increasing evidence describing PrEP for HIV prevention has been published and PrEP could be an alternative to ART for fertile couples. Usually HIV-infected women undergo self-insemination around the time of ovulation. Few studies have been published on IVF outcome in HIV-infected women.

CONCLUSIONS

Assisted reproduction programmes should be integrated into global public health services against HIV. For HIV serodiscordant couples with infected men, sperm washing should be the first choice. However, timed intercourse and PrEP for HIV prevention has been reported. Recent data highlight the possible impairment of fertility in HIV-infected women. Efforts to design a multicentric study should be strengthened.

Fertility choices and management for HIV-positive women

PURPOSE OF REVIEW

It is becoming increasingly important to address the issue of reproductive counselling and management of HIV-infected individuals during their reproductive years. Sexual and reproductive health-related needs and aspirations are similar to those of uninfected individuals but some differences require specific attention, which are discussed in this review.

RECENT FINDINGS

Hormonal contraception should be used with caution in women on antiretroviral treatment. Its impact on both HIV infectivity and disease progression is still controversial. An intrauterine device can be considered for pregnancy prevention and pregnancy termination should be offered in safe conditions. HIV-infected women have a lower spontaneous fertility rate, which may persist after assisted reproduction. Data on safety of antiretroviral treatment during conception are reassuring. No clear association can be found between exposure to antiretrovirals and fetal abnormalities. Secondary prevention remains crucial and condom use remains a key method.

SUMMARY

Different topics related to fertility choices among HIV-infected patients should be addressed. Family planning methods and termination of pregnancy have specific aspects among infected individuals. When needed, medically assisted reproduction may be required and antiretroviral treatment should be adapted before conception. Secondary prevention has a key role in reducing newly acquired infections.

Endemic Venezuelan equine encephalitis in the Americas: hidden under the dengue umbrella

Venezuelan equine encephalitis (VEE) is an emerging infectious disease in Latin America. Outbreaks have been recorded for decades in countries with enzootic circulation, and the recent implementation of surveillance systems has allowed the detection of additional human cases in countries and areas with previously unknown VEE activity. Clinically, VEE is indistinguishable from dengue and other arboviral diseases and confirmatory diagnosis requires the use of specialized laboratory tests that are difficult to afford in resource-limited regions. Thus, the disease burden of endemic VEE in developing countries remains largely unknown, but recent surveillance suggests that it may represent up to 10% of the dengue burden in neotropical cities, or tens-of-thousands of cases per year throughout Latin America. The potential emergence of epizootic viruses from enzootic progenitors further highlights the need to strengthen surveillance activities, identify mosquito vectors and reservoirs and develop effective strategies to control the disease. In this article, we provide an overview of the current status of endemic VEE that results from spillover of the enzootic cycles, and we discuss public health measures for disease control as well as future avenues for VEE research.

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.

First report of the absence of viral load in testicular sperm samples obtained from men with hepatitis C and HIV after washing and their subsequent use

Human immunodeficiency virus and hepatitis C infections are sexually transmitted diseases that require sperm samples to be pretreated to eliminate the viral presence before their safe use in assisted reproduction treatments. In this report we describe our experience with sperm washing protocols applied to sperm cells from testicular biopsies as well as the results obtained in subsequent assisted reproduction treatments on seropositive males that are also azoospermic.

[Assisted reproductive care in serodiscordant couples whose man is infected with HIV]

Serodiscordant couples whose man is infected by human immunodeficiency virus have actually induced sterility by condom use. Since 2001, in France, assisted reproduction in serodiscordant couples has been facilitated thanks to the decree of 10th May 2001. In spite of the immense social and scientific advances in Assisted Reproductive Techniques, in such couples, limitation of care remains in certain cases. This study reviews current practices in France and other countries. Limits due to present reproductive and virological methods or legal conditions are underlined. In agreement with current scientific knowledge we suggest new modalities of reproductive care in serodiscordant couples with HIV infected men.

HIV and reproductive care—a review of current practice

In developed countries, antiretroviral treatment has increased life quality and expectancy of HIV-infected individuals and led to a drop in mother-to-child transmission (MCT) risk to below 1%. Fertility has been shown to be reduced in both men and women with HIV. As a result of these factors, the demand for reproductive care in this population is rising. In discordant couples where the man is positive, sperm washing significantly reduces viral transmission risk to the uninfected female partner over unprotected intercourse. Positive women do not necessarily need specialised fertility treatment but should be monitored closely during pregnancy to minimise MCT risk.