Hepatitis B surface antigen in oocytes and embryos may not result in vertical transmission to offspring of hepatitis B virus carriers

Exploring the impact of hepatitis B immunoglobulin and antiviral interventions to reduce vertical transmission of hepatitis B virus

Hepatitis B virus (HBV) infection is a major public health burden. In HBV endemic regions, high prevalence is also correlated with the infections acquired in infancy through perinatal transmission or early childhood exposure to HBV, the so-called mother-to-child transmission (MTCT). Children who are infected with HBV at a young age are at higher risk of developing chronic HBV infection than those infected as adults, which may lead to worse clinical outcome. To reduce the incidence of HBV MTCT, several interventions for the infants or the mothers, or both, are already carried out. This review explores the newest information and approaches available in literature regarding HBV MTCT prevalence and its challenges, especially in high HBV endemic countries. This covers HBV screening in pregnant women, prenatal intervention, infant immunoprophylaxis, and post-vaccination serological testing for children.

Hepatitis B virus in oocytes and embryos: pregnancy outcomes and children's health

Objective

To investigate whether the presence of hepatitis B virus (HBV) in oocytes and embryos affects pregnancy outcomes for in vitro fertilization and embryo transfer (ET) as well as is related to the vertical transmission of HBV to children.

Design

Retrospective cohort study.

Setting

A university-affiliated fertility center.

Patients

This study included 167 couples with at least 1 hepatitis B surface antigen-seropositive partner. These couples underwent in vitro fertilization-ET, and the discarded oocytes and embryos had been tested for HBV. Couples with HBV-positive oocytes or embryos were categorized as the positive group, whereas those couples with HBV-negative oocytes and embryos served as the negative group.

Interventions

None.

Main Outcome Measures

Pregnancy outcomes and the rate of children's HBV infection.

Results

The pregnancy outcomes of fresh and frozen ETs were not associated with the presence of HBV in the oocytes and embryos. Of the 106 infants born, 1 child whose mother tested positive for hepatitis B surface antigen but had negative oocytes and embryos was infected with HBV. Additionally, 26.09% of children who had been administered passive immunization and active vaccinations did not reach protective levels of anti-HBV antibodies (hepatitis B surface antibodies) and became nonresponders. The negative rate of children's hepatitis B surface antibody was associated with the presence of HBV in oocytes and embryos (odds ratio, 3.01; 95% confidence interval, 1.04-9.25).

Conclusions

The presence of HBV in oocytes and embryos did not affect pregnancy outcomes or result in the vertical transmission of HBV to the offspring of HBV carriers. Follow-up is needed for HBV-vaccinated children with an HBV-infected parent. Booster vaccinations are necessary for continued protection.

Hepatitis B virus infection, infertility, and assisted reproduction

BACKGROUND: Hepatitis B virus (HBV) is one of the most widespread viruses worldwide and a major cause of hepatitis, cirrhosis, and hepatocellular carcinoma. Previous studies have revealed the impacts of HBV infection on fertility. An increasing number of infertile couples with chronic hepatitis B (CHB) virus infection choose assisted reproductive technology (ART) to meet their fertility needs. Despite the high prevalence of HBV, the effects of HBV infection on assisted reproduction treatment remain limited and contradictory. OBJECTIVE: The aim of this study was to provide a comprehensive overview of the effect of HBV infection on fertility and discuss its effects on pregnancy outcomes, vertical transmission, pregnancy complications, and viral activity during ART treatment. METHODS: We conducted a literature search in PubMed for studies on HBV infection and ART published from 1996 to 2022. RESULTS: HBV infection negatively affected fertility in both males and females. Existing research shows that HBV infection may increase the risk of pregnancy complications in couples undergoing assisted reproduction treatment. The impact of HBV infection on the pregnancy outcomes of ART is still controversial. Current evidence does not support that ART increases the risk of vertical transmission of HBV, while relevant studies are limited. With the development of ART, the risk of HBV reactivation (HBVr) is increasing, especially due to the wide application of immunosuppressive therapy. CONCLUSIONS: Regular HBV infection screening and HBVr risk stratification and management are essential to prevent HBVr during ART. The determination of optimal strategy and timing of prophylactic anti-HBV therapy during ART still needs further investigation.

Vertical Transmission of Hepatitis B Virus-An Update

Hepatitis B virus (HBV) infection is a major public health problem in the world. Approximately 296 million people are chronically infected. In endemic areas, vertical transmission is a common route of transmission. There are several strategies for the prevention of HBV vertical transmission, such as antiviral treatment during the third trimester of pregnancy and immunoprophylaxis to newborns that includes the administration of hepatitis B immune globulin (HBIG) and an HBV vaccine. Despite this, immunoprophylaxis failure can occur in up to 30% of infants born to HBeAg-positive mothers and/or with high viral load. Therefore, management and prevention of HBV vertical transmission is of paramount significance. In this article, we provided a review of the epidemiology, mechanisms of pathogenesis and risk factors of vertical transmission, as well as the strategies implemented to prevent the infection.

Impact of in vitro fertilization-embryo transfer on mother-to-infant transmission in women with chronic HBV infection

BACKGROUND AND AIMS

In vitro fertilization-embryo transfer (IVF-ET) may increase the risk of mother-to-child transmission (MTCT) of hepatitis B virus (HBV). The purpose of this study was to investigate the impact and safety of IVF-ET on MTCT in women with chronic HBV infection (CHB).

METHODS

The data of 298 women who got pregnant by IVF-ET and their 375 children were collected retrospectively. Mothers were divided into the CHB group (n = 224) and the control group (HBsAg negative, n = 74). After birth, newborns were routinely vaccinated with the hepatitis B vaccine, and infants in the CHB group were injected with hepatitis B immunoglobulin within 2 h after birth. Demographic information, clinical data and laboratory test results were collected. The primary outcome measures were the MTCT rate of HBV, and the secondary outcome measures were the safety of the mother and infant.

RESULTS

There was no case of HBV MTCT in all 282 newborns born in the CHB group and 93 neonates born in the control group. Of the two groups, the birth weight (3056.74 ± 601.65 vs. 2926.24 ± 704.86, P = .083), length (49.22 ± 1.97 vs. 48.74 ± 3.09, P = .167), 5-min Apgar score (9.97 ± 0.21 vs. 9.90 ± 0.51, P = .212), days of pregnancy (265.70 ± 12.73 vs. 262.02 ± 17.50, P = .064) and neonatal malformation rate (0.71% vs. 0, P = 1.000) were similar. Two cases of neonatal malformation occurred in the CHB group. The incidences of pregnancy and childbirth complications were similar between the two groups.

CONCLUSION

IVF-ET does not increase the risk of MTCT in women with chronic HBV infection, and it is safe for mothers and infants.

Asian Pacific association for the study of liver (APASL) guidelines: hepatitis B virus in pregnancy

Hepatitis B virus (HBV) infection still remains a major public health issue in the Asia-Pacific region. Most of the burden of HBV-related disease results from infections acquired in infancy through perinatal or early childhood exposure to HBV in Asia-Pacific. Hepatitis B during pregnancy presents unique management issues for both the mother and fetus. These APASL guidelines provide a comprehensive review and recommendations based on available evidence in the literature, for the management of females with HBV infection through every stage of pregnancy and postpartum. These also address the concerns, management challenges, and required follow-up of children born to hepatitis B-positive mothers.

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.

Viruses in the reproductive tract: On their way to the germ line?

Studies of vertebrate genomes have indicated that all species contain in their chromosomes stretches of DNA with sequence similarity to viral genomes. How such 'endogenous' viral elements (EVEs) ended up in host genomes is usually explained in general terms such as 'they entered the germ line at some point during evolution'. This seems a correct statement, but is also rather imprecise. The vast number of endogenous viral sequences suggest that common routes to the 'germ line' may exist, as relying on chance alone may not easily explain the abundance of EVEs in modern mammalian genomes. An increasing number of virus types have been detected in human semen and a growing number of studies have reported on viral infections that cause male infertility or subfertility and on viral infections that threaten in vitro fertilisation practices. Thus, it is timely to survey the pathway(s) that viruses can use to gain access to the human germ line. Embryo transfer and semen quality studies in livestock form another source of relevant information because virus infection during reproduction is clearly unwanted, as is the case for the human situation. In this review, studies on viruses in the male and female reproductive tract and in the early embryo will be discussed to propose a plausible viral route to the mammalian germ line.

Managing and preventing blood-borne viral infection transmission in assisted reproduction: a Canadian Fertility and Andrology Society clinical practice guideline

Fertility care providers have an obligation to provide safe and effective care to patients. When a user of assisted reproductive technology (ART) is living with a blood-borne viral infection (BBVI: HIV, hepatitis C or hepatitis B), physicians and ART laboratory personnel need to know the requirements for providing quality care. Recent developments in the treatment of BBVI and understanding of transmission have changed these requirements. This guideline from the Canadian Fertility and Andrology Society (CFAS) provides comprehensive, evidence-based guidelines for reducing horizontal transmission and cross-contamination in the ART setting.

Assisted reproduction in hepatitis carrier couples

Chronic Hepatitis B virus (HBV) infection is endemic worldwide, and the prevalence is especially high in the Asia-Pacific regions. Despite its high prevalence, the literature regarding the impact of HBV infection on subfertility and fertility treatment remains limited and conflicting. Latest studies do not suggest any detrimental effect of HBV infection on the outcome of IVF/ICSI treatment in women having chronic HBV infection. There is evidence that HBV exists in ovarian tissue including oocyte and follicular fluid, and therefore has the potential risk of transmission to the embryo, which can explain the finding of vertical transmission despite immunoprophylaxis. Most recently, we have observed the evidence of HBV viral replication in female HBV carriers undergoing IVF/ICSI treatment. This raises the question of whether antiviral medication should be administered during ovarian stimulation in IVF/ICSI treatment cycles for women with chronic HBV infection to help reduce the chance of vertical transmission.

Ovarian HBV replication following ovulation induction in female hepatitis B carriers undergoing IVF treatment: A prospective observational study

Hepatitis B virus (HBV) can be found in ovarian tissues. This study compared HBV DNA levels in follicular fluid collected during oocyte retrieval with paired serum samples in HBV carriers after ovarian stimulation during IVF treatment for infertility. Sixty-four HBV carrier women referred to the Assisted Reproductive Units of two Hong Kong hospitals were recruited. At oocyte retrieval, the follicular fluid aspirated from the first follicle was collected for study. In 22 women, the first follicular fluid sample from both ovaries was similarly collected and studied. These women were also tested for liver function test and HBeAg. In 28 (43.8%) women, HBV DNA was detected in follicular fluid and the level correlated with serum levels (Spearman's correlation P < .001). There was concordant detection of HBV DNA in both ovaries, and the levels were significantly correlated (Spearman's correlation P = .029). In 40% of women with FF HBV DNA, the follicular fluid:serum ratio was >1.0, suggesting stimulation of HBV replication. These women also had significantly different liver function test results. Increased HBV replication exists in 40% of women with HBV DNA detected in follicular undergoing ovarian stimulation during IVF treatment.

Assisted conception does not increase the risk for mother-to-child transmission of hepatitis B virus, compared with natural conception: a prospective cohort study

OBJECTIVE

To determine whether assisted conception increases the risk for mother-to-child transmission of hepatitis B virus (HBV) infection compared with natural conception.

DESIGN

Prospective cohort study.

SETTING

Research laboratory.

PATIENT(S)

A total of 305 children, 176 born with assisted conception and 129 born with natural conception, were born to a total of 251 hepatitis B surface antigen- (HBsAg-) positive women.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The seropositive rates of HBsAg in children at birth and HBV infection rates at 9-15 months of age.

RESULT(S)

Overall, 7.5% (23/305) of children were HBsAg-positive at birth. The rate of HBsAg-positive children at birth did not significantly differ between children in the assisted conception group compared with those in the natural conception group (6.3% [11/176] vs. 9.3% [12/129]). Multivariate logistic regression analysis showed that conception method is not related to the rate of HBsAg-positive children at birth. All children who were positive for HBsAg at birth and were followed up for 9-15 months became negative for HBsAg after hepatitis B immunization.

CONCLUSION(S)

Assisted conception does not increase the risk for mother-to-child transmission of HBV compared with natural conception.

Effects of maternal body mass index on pregnancy outcome after 8570 artificial insemination cycles with donor's sperm

Increased body mass index (BMI) might have an adverse effect on pregnancy. However, the influence of BMI on the pregnancy outcomes after artificial insemination with donor's sperm (AID) had been rarely reported. This study aimed to investigate the correlation between BMI and AID. The pregnancy outcome of 8570 AID cycles was retrospectively analyzed. BMI was categorized as underweight (<18.5 kg/m²; group A), normal weight (18.5-23.9 kg/m²; group B), overweight (24-27.9 kg/m²; group C), and obese (≥28 kg/m²; group D). The results showed that cumulative pregnancy rate and cumulative live birth rate in groups A, B, C and D tended to decrease as BMI increased; however, abortion rate, and ectopic pregnancy rate in groups A, B, C, and D exhibited a gradual increase in the tendency. Cesarean delivery rate also increased as BMI increased. Birth defect rate in the group D were significantly higher than that in the group A. Interestingly, the pregnancy rate was gradually decreased with increasing age in groups A, B, and C, but this was not observed in the group D. The findings suggested that BMI can affect the pregnancy outcomes after AID; it is important to achieve a normal BMI prior to AID treatments.

Mechanisms and Prevention of Vertical Transmission in Chronic Viral Hepatitis

Vertical transmission (VT) is the primary route of transmission of viral hepatitis in children. The rate of VT ranges from 1-28% with hepatitis B virus (HBV) and 3-15% with hepatitis C virus (HCV). VT for both viruses can occur during the intrauterine or peripartum period. VT of HBV primarily occurs by intrauterine transmission (IUT). Hepatitis B surface antigen is unable to cross the placenta and, therefore, relies on processes like transplacental leakage, placental infection, cellular transmission by peripheral blood mononuclear cells, and germline transmission. HCV can also infect the fetus by IUT. Both viruses also have the potential for transmission during delivery, when there is increase chance of maternal-fetal blood exposure. HBV and HCV share some common risk factors for VT, including maternal viral load, human immunodeficiency virus co-infection and neonatal sex. Prevention of VT differs greatly between HBV and HCV. There are several alternatives for prevention of HBV VT, including antiviral medications during the third trimester of pregnancy and HBV vaccine, as well as hepatitis B immunoglobulin administration to infants post-partum. In contrast, there are no preventative interventions available for HCV. Despite these differences, the key to prevention with both viruses is screening women prior to and during pregnancy.

Guidelines for risk reduction when handling gametes from infectious patients seeking assisted reproductive technologies

According to the Americans with Disabilities Act (1990), couples with blood-borne viruses that lead to infectious disease cannot be denied fertility treatment as long as the direct threat to the health and safety of others can be reduced or eliminated by a modification of policies or procedures. Three types of infectious patients are commonly discussed in the context of fertility treatment: those with human immunodeficiency virus (HIV), hepatitis C or hepatitis B. Seventy-five per cent of hepatitis C or HIV positive men and women are in their reproductive years, and these couples look to assisted reproductive techniques for risk reduction in conceiving a pregnancy. In many cases, only one partner is infected. Legal and ethical questions about treatment of infectious patients aside, the question most asked by clinical embryologists and andrologists is: "What are the laboratory protocols for working with gametes and embryos from patients with infectious disease?" The serostatus of each patient is the key that informs appropriate treatments. This guidance document describes protocols for handling gametes from seroconcordant and serodiscordant couples with infectious disease. With minor modifications, infectious patients with stable disease status and undetectable or low viral load can be accommodated in the IVF laboratory.