Impaired ovarian stimulation during in vitro fertilization in women who are seropositive for hepatitis C virus and seronegative for human immunodeficiency virus

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.

Melatonin and its mechanism of action in the female reproductive system and related malignancies

Melatonin (N-acetyl-5-methoxytryptamine), the main product of pineal gland in vertebrates, is well known for its multifunctional role which has great influences on the reproductive system. Recent studies documented that melatonin is a powerful free radical scavenger that affects the reproductive system function and female infertility by MT1 and MT2 receptors. Furthermore, cancer researches indicate the influence of melatonin on the modulation of tumor cell signaling pathways resulting in growth inhibitor of the both in vivo/in vitro models. Cancer adjuvant therapy can also benefit from melatonin through therapeutic impact and decreasing the side effects of radiation and chemotherapy. This article reviews the scientific evidence about the influence of melatonin and its mechanism of action on the fertility potential, physiological alteration, and anticancer efficacy, during experimental and clinical studies.

The effects of human immunodeficiency virus, human papillomavirus, herpes simplex virus-1 and -2, human herpesvirus-6 and -8, cytomegalovirus, and hepatitis B and C virus on female fertility and pregnancy

Female infertility may be defined as a woman of reproductive age being unable to become pregnant after a year of regular unprotected sexual intercourse. Social, genetic, endocrine, physiological, and psychological factors as well as lifestyle habits (i.e., smoking and alcohol consumption), either alone or in combination with male factors, are major causes. However, approximately 15-30% of cases of female infertility remain unexplained. Numerous investigations have also indicated that microbiomes play an important role in human reproduction. All parts of the female reproductive system may be influenced by infectious and pathological agents, especially viruses, and these may interfere with reproductive function and so are risk factors for infertility, although in many cases an exact role is unclear. We present an overview of the impact of common viral infections on female reproduction, searching Medline, PubMed, Scopus, and Google scholar databases for potentially relevant studies of viruses known to have a potential effect. Human immunodeficiency virus (HIV), herpes simplex virus (HSV) and human herpesvirus (HHV) increase infertility rates whilst human papillomavirus (HPV), cytomegalovirus (CMV), and hepatitis B and C virus (HBV, HCV) infections mostly lead to higher abortion and miscarriage rates. Moreover, HPV infection is linked to increased tubal infertility, endometriosis, and pelvic inflammatory disease. HPV was the most frequently observed infection and with lower pregnancy rate and foetal death in women undergoing IVF treatments. Assisted reproductive treatment could be a safe and effective approach for HIV and HBV infected women.

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.

Other Extrahepatic Manifestations of Hepatitis C Virus Infection (Pulmonary, Idiopathic Thrombocytopenic Purpura, Nondiabetes Endocrine Disorders)

Extrahepatic manifestations of hepatitis C virus (HCV) infection are a rare but serious condition. This article summarizes the current literature on the association between HCV and endocrine and pulmonary manifestations, as well as idiopathic thrombocytopenic purpura (ITP). HCV may directly infect extrahepatic tissues and interact with the immune system predisposing for obstructive and interstitial lung disease, ITP, autoimmune thyroiditis, infertility, growth hormone and adrenal deficiencies, osteoporosis, and potentially lung and thyroid cancers. However, in many cases, the current evidence is divergent and cannot sufficiently confirm a true association, which emphasizes the need for future targeted projects in this field.

In vitro fertilization for women infected by hepatitis C virus: a matched case-control study and a systematic literature review

PURPOSE

The aim of this study was to investigate whether infection of women by the hepatitis C virus (HCV) reduces the chance of conceiving after in vitro fertilization (IVF).

METHODS

We performed a retrospective blind matched case-control study where IVF outcomes for the first 37 cycles of HCV sero-positive women were compared to those of 107 cycles of an uninfected control group. Our results were included in a systematic literature review.

RESULTS

Out of five eligible studies, ours included, three observed an impact of HCV infection, though at various levels including response to stimulation, fertilization, implantation, and pregnancy rates. Two studies differentiated results for patients with confirmed active viral replication. Matching criteria and populations studied varied between studies.

CONCLUSIONS

More and larger studies with well-defined groups are needed to clarify the eventual impact of the HCV on IVF outcomes. Data concerning the infectious status of a patient as well as her health state should be systematically recorded. A multi-disciplinary approach as well as a thorough knowledge of the patient's general health state might prove useful in the management and counseling of these patients in terms of success in conceiving.

Use of antimüllerian hormone to predict the menopausal transition in HIV-infected women

BACKGROUND

HIV infection has been associated with early menopausal onset, which may have adverse long-term health consequences. Antimüllerian hormone, a biomarker of ovarian reserve and gonadal aging, is reduced in HIV-infected women.

OBJECTIVE

We sought to assess the relationship of antimüllerian hormone to age of menopause onset in HIV-infected women.

STUDY DESIGN

We used antimüllerian hormone levels measured in plasma in 2461 HIV-infected participants from the Women's Interagency HIV Study to model the age at final menstrual period. Multivariable normal mixture models for censored data were used to identify factors associated with age at final menstrual period.

RESULTS

Higher antimüllerian hormone at age 40 years was associated with later age at final menstrual period, even after multivariable adjustment for smoking, CD4 cell count, plasma HIV RNA, hepatitis C infection, and history of clinical AIDS. Each doubling of antimüllerian hormone was associated with a 1.5-year increase in the age at final menstrual period. Median age at final menstrual period ranged from 45 years for those in the 10th percentile of antimüllerian hormone to 52 years for those in the 90th percentile. Other factors independently associated with earlier age at final menstrual period included smoking, hepatitis C infection, higher HIV RNA levels, and history of clinical AIDS.

CONCLUSION

Antimüllerian hormone is highly predictive of age at final menstrual period in HIV-infected women. Measuring antimüllerian hormone in HIV-infected women may enable clinicians to predict risk of early menopause, and potentially implement individualized treatment plans to prevent menopause-related comorbidities and to aid in interpretation of symptoms.

Women infected with human immunodeficiency virus type 1 have poorer assisted reproduction outcomes: a case-control study

OBJECTIVE

To compare the efficacy of assisted reproductive technology (ART) in women infected with human immunodeficiency virus type 1 (HIV-1) versus HIV-negative controls.

DESIGN

Retrospective case-control study.

SETTING

University hospital ART unit.

PATIENT(S)

Eighty-two women infected with HIV-1 and 82 women as seronegative controls.

INTERVENTION(S)

Ovarian stimulation, oocytes retrieval, standard in vitro fertilization (IVF) or intracytoplasmic sperm injection, embryo transfer.

MAIN OUTCOME MEASURE(S)

Clinical pregnancies and live-birth rates.

RESULT(S)

After oocyte retrieval, all women infected with HIV-1 infected were matched 1:1 to HIV-negative controls according to the following criteria: date of ART attempt, age, parity, main cause of infertility, ART technique, and rank of attempt. Only the first IVF cycle during the study period was considered for each couple. We found no statistically significant differences between the two groups for ovarian stimulation data, fertilization rate, or average number of embryos transferred. The clinical pregnancy rate per transfer was statistically significantly lower for the cases compared with the controls (12% vs. 32%), as were the implantation rate (10% vs. 21%) and the live-birth rate (7% vs. 19%).

CONCLUSION(S)

In one of the largest studies to pair six factors that influence the results of ART, HIV infection in women was associated with poorer outcomes after ART. These results suggest that women with controlled HIV-1-infection should be counseled not to delay ART in cases of self-insemination failure or other causes of infertility. Fertility preservation by vitrification of oocytes in women whose pregnancy should be delayed may be an important future consideration.

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.

Coxsackievirus B3 infection reduces female mouse fertility

Previously we demonstrated coxsackievirus B3 (CVB3) infection during early gestation as a cause of pregnancy loss. Here, we investigated the impacts of CVB3 infection on female mouse fertility. Coxsackievirus-adenovirus receptor (CAR) expression and CVB3 replication in the ovary were evaluated by immunohistochemistry or reverse transcription-polymerase chain reaction (RT-PCR). CAR was highly expressed in granulosa cells (GCs) and CVB3 replicated in the ovary. Histological analysis showed a significant increase in the number of atretic follicles in the ovaries of CVB3-infected mice (CVBM). Estrous cycle evaluation demonstrated that a higher number of CVBM were in proestrus compared to mock mice (CVBM vs. mock; 61.5%, 28.5%, respectively). Estradiol concentration in GC culture supernatant and serum were measured by an enzyme-linked immunosorbent assay. Baseline and stimulated levels of estradiol in GC were decreased in CVBM, consistent with significantly reduced serum levels in these animals. In addition, aromatase transcript levels in GCs from CVBM were also decreased by 40% relative to the mock. Bone mineral density evaluated by micro-computed tomography was significantly decreased in the CVBM. Moreover, the fertility rate was also significantly decreased for the CVBM compared to the mock (CVBM vs. mock; 20%, 94.7%, respectively). This study suggests that CVB3 infection could interfere with reproduction by disturbing ovarian function and cyclic changes of the uterus.

Hepatitis B virus infection reduces fertilization ability during in vitro fertilization and embryo transfer

Whether hepatitis B virus (HBV) infection impairs human infertility is unclear. The present retrospective case-controlled study investigated the impact of HBV on sperm parameters, ovarian stimulation, and outcomes of in vitro fertilization (IVF) and embryo transfer. A total of 224 couples with at least one partner being HBsAg-seropositive undergoing their first IVF and embryo transfer cycle were identified, which included 77 couples with female partners being HBsAg-seropositive, 136 couples with male partners being HBsAg-seropositive, and 11 couples with both partners being HBsAg-seropositive. A total of 448 both HBsAg-seronegative couples served as controls. The percentage of normal sperm morphology was significantly lower in HBsAg-seropositive male partners than that in HBsAg-seronegative male partners (11.9 ± 9.4% vs. 19.0 ± 11.9%, P < 0.01). The duration of infertility was significantly prolonged in HBV-seropositive patients compared with HBV-seronegative patients (4.9 vs. 4.1 years, P < 0.01). Couples with female partners being HBsAg-seropositive had significantly lower top-quality embryo rate than control group (22.4% vs. 31.6%, P < 0.01). In addition, the fertilization rates in groups with male or female partners being HBsAg-seropositive were both significantly lower than the matched controls (80.2% vs. 82.8%, P < 0.05; 76.6% vs. 84.3%, P < 0.01, respectively). HBV infection was also found to be associated negatively with fertilization rate by logistic regression analysis (odds ratios: 0.410, 95% confidence interval: 0.186-0.906, P < 0.05). However, there was no significant difference in clinical pregnancy rates between HBsAg-seropositive and HBsAg-seronegative group. These results suggest that chronic HBV infection is likely to represent a significant cause of infertility.

Melatonin modulates the expression of BCL-xl and improve the development of vitrified embryos obtained by IVF in mice

PURPOSE

Antioxidant and anti-apoptotic effects of melatonin on development of in vitro fertilization (IVF)/vitrified two-cell mouse embryos were evaluated in this study.

METHODS

The IVF two-cell embryos were vitrified by cryotop, and were cultured in KSOM medium in different concentrations of melatonin (10(-6), 10(-9), 10(-12) M) and without melatonin. The blastocyst cell number, apoptotic cells and glutathione (GSH) level were evaluated by differential, TUNEL and cell tracker blue staining, respectively. The expression of Bax and Bcl-xl genes was evaluated by qPCR. The expression of melatonin receptors (Mtnr1a and Mtnr1b) in mouse 2-cell embryos and blastocysts was evaluated by RT-PCR.

RESULTS

Melatonin increased the rate of cleavage and blastulation at 10(-12) M concentration (p < 0.05). The number of trophectoderm and inner cell mass showed a significant increase (p < 0.05) in 10(-9) M melatonin. The 10(-9) M and 10(-12) M melatonin treatments significantly reduced (p < 0.05) the apoptotic index. The significant increase in the expression of Bcl-xl observed at 10(-9) M concentration however, reduced expression of Bax was not statistically significant. The levels of GSH in 10(-9) and 10(-12) M groups were significantly improved relative to the control group (p < 0.05). The Mtnr1a was expressed in 2-cell embryos and blastocysts in all groups, but the expression of Mntr1b was not detected.

CONCLUSION

Melatonin may have a special role against oxidative stress in protection of IVF/vitrified embryos.

Oocyte destruction is activated during viral infection

Viral infection has been associated with a starvation-like state in Drosophila melanogaster. Because starvation and inhibiting TOR kinase activity in vivo result in blocked oocyte production, we hypothesized that viral infection would also result in compromised oogenesis. Wild-type flies were injected with flock house virus (FHV) and survival and embryo production were monitored. Infected flies had a dose-responsive loss of fecundity that corresponded to a global reduction in Akt/TOR signaling. Highly penetrant egg chamber destruction mid-way through oogenesis was noted and FHV coat protein was detected within developing egg chambers. As seen with in vivo TOR inhibition, oogenesis was partially rescued in loss of function discs large and merlin mutants. As expected, mutants in genes known to be involved in virus internalization and trafficking [Clathrin heavy chain (chc) and synaptotagmin] survive longer during infection. However, oogenesis was rescued only in chc mutants. This suggests that viral response mechanisms that control fly survival and egg chamber survival are separable. The genetic and signaling requirements for oocyte destruction delineated here represent a novel host-virus interaction with implications for the control of both fly and virus populations.

[Alterations of ovarian reserve tests in Human Immunodeficiency Virus (HIV)-infected women]

OBJECTIVES

Little is known about the impact of highly active antiretroviral therapy or HIV infection itself on the ovarian function. The aim of this study was to evaluate ovarian function in HIV-infected women in comparison with normal values from non-HIV infected women.

PATIENTS AND METHODS

This is a prospective pilot study using markers of ovarian function: the antral follicular count (AFC) defined between cycle days 7 and 10 and follicle-stimulating hormone (FSH), inhibin B and antimüllerian hormone (AMH) for early follicular phase hormonal assessments. A descriptive analysis according to age was performed.

RESULTS

Results from 78 HIV positive women are presented. AFC shows a high rate of abnormal values (63 %) occurring surprisingly early. The hormonal markers are concordant with a 36, 57 and 23 % abnormal rate for FSH, inhibin B and AMH respectively.

DISCUSSION AND CONCLUSION

In our series, HIV seropositivity was associated with stigmas of premature ovarian insufficiency. This may explain impaired fertility but also suggests premature menopause in this population that should therefore be monitored early for such changes.