Assisted conception in HIV discordant couples: evaluation of semen processing techniques in reducing HIV viral load

[Interaction of herpesviruses with mature human spermatozoa in the model system in vitro]

The DNA of human herpesviruses (HHV), including the herpes simplex virus (HSV) and cytomegalovirus (CMV), is often identified in ejaculates of patients with urogenital diseases and infertility. At least a part of viral DNA is associated with cell fraction of ejaculate. However, it remains unclear how the semen is infected by the virus. It can be located in gametes or be capable of infecting mature germ cells, including motile sperm cells. In order to resolve this issue, interactions of the CMV and HSV with human sperm cells were studied using an original optimized model of the herpesviral infection of male gametes in vitro. The analysis of the immunofluorescent staining of gametes for viral antigens has shown that CMV infected 2% gametes, while HSV infected 17.26 ± 2.58% gametes. The fraction of progressively motile sperm cells contained 13.99 ± 4.64% infected cells. Localization of HSV was studied by the confocal microscopy. Sometimes, viral gB protein was found on sperm cell membrane. In addition, optical scanning of other cells has shown the intracellular localization of the viral proteins. In the majority of spermatozoa, the viral proteins were observed in the head and neck. In some cells, they were located in the middle piece or, rarely, in the equatorial segment. In general, after in vitro infection HSV antigens were located in the same areas of the sperm cells as in ejaculates from infected patients. According to DNA-DNA hybridization in situ, gametes containing HSV DNA accounted for 16.94 ± 5.28%, which is consistent with the results obtained in the immunofluorescence assay. It can be concluded that mature male gametes are infected by HHV in the genital tract, where the virus binds to the sperm cell membrane and enters the cell. Interaction of HHV with progressively motile sperm cells implies a vertical viral transmission upon fertilization and points to the necessity of testing ejaculate for herpesviruses infections.

Rapid dissemination of SIV follows multisite entry after rectal inoculation

Receptive ano-rectal intercourse is a major cause of HIV infection in men having sex with men and in heterosexuals. Current knowledge of the mechanisms of entry and dissemination during HIV rectal transmission is scarce and does not allow the development of preventive strategies. We investigated the early steps of rectal infection in rhesus macaques inoculated with the pathogenic isolate SIVmac251 and necropsied four hours to nine days later. All macaques were positive for SIV. Control macaques inoculated with heat-inactivated virus were consistently negative for SIV. SIV DNA was detected in the rectum as early as four hours post infection by nested PCR for gag in many laser-microdissected samples of lymphoid aggregates and lamina propria but never in follicle-associated epithelium. Scarce SIV antigen positive cells were observed by immunohistofluorescence in the rectum, among intraepithelial and lamina propria cells as well as in clusters in lymphoid aggregates, four hours post infection and onwards. These cells were T cells and non-T cells that were not epithelial cells, CD68⁺ macrophages, DC-SIGN⁺ cells or fascin⁺ dendritic cells. DC-SIGN⁺ cells carried infectious virus. Detection of Env singly spliced mRNA in the mucosa by nested RT-PCR indicated ongoing viral replication. Strikingly, four hours post infection colic lymph nodes were also infected in all macaques as either SIV DNA or infectious virus was recovered. Rapid SIV entry and dissemination is consistent with trans-epithelial transport. Virions appear to cross the follicle-associated epithelium, and also the digestive epithelium. Viral replication could however be more efficient in lymphoid aggregates. The initial sequence of events differs from both vaginal and oral infections, which implies that prevention strategies for rectal transmission will have to be specific. Microbicides will need to protect both digestive and follicle-associated epithelia. Vaccines will need to induce immunity in lymph nodes as well as in the rectum.

HIV infection of the male genital tract--consequences for sexual transmission and reproduction

Despite semen being the main vector of human immunodeficiency virus (HIV) dissemination worldwide, the origin of the virus in this bodily fluid remains unclear. It was recently shown that several organs of the male genital tract (MGT) are infected by HIV/simian immunodeficiency virus (SIV) and likely to contribute to semen viral load during the primary and chronic stages of the infection. These findings are important in helping answer the following questions: (i) does the MGT constitute a viral reservoir responsible for the persistence of virus release into the semen of a subset of HIV-infected men under antiretroviral therapy, who otherwise show an undetectable blood viral load? (ii) What is the aetiology of the semen abnormalities observed in asymptomatic HIV-infected men? (iii) What is the exact nature of the interactions between the spermatozoa, their testicular progenitors and HIV, an important issue in the context of assisted reproductive techniques proposed for HIV-seropositive (HIV+) men? Answers to these questions are crucial for the design of new therapeutic strategies aimed at eradicating the virus from the genital tract of HIV+ men--thus reducing its sexual transmission--and for improving the care of serodiscordant couples wishing to have children. This review summarizes the most recent literature on HIV infection of the male genital tract, discusses the above issues in light of the latest findings and highlights future directions of research.

Technical note: effect of density gradient centrifugation with trypsin on the in vivo fertilising capability of bovine spermatozoa

The present study investigated the effect of a novel density gradient centrifugation (DGC) treatment using recombinant trypsin on the in vivo fertilising capability of bovine spermatozoa compared with a standard method. In Trial 1, semen collected from Boran and Ankole (Bos indicus) bulls was treated either with a silane-coated silica particle colloid formulated for humans with a recombinant trypsin or processed using a standard method (dilution in an egg yolk-based diluent). Semen processed by the two methods was used to artificially inseminate (AI) superovulated cattle. Day 7 embryos were flushed and assessed for fertilisation rates and embryo quality. Trial 2 used a trypsinised silane-coated silica particle colloid formulated specifically for bovine semen. Trial 1 resulted in significantly higher fertilisation rates using the trypsinised human DGC treatment than cows inseminated using the standard method (75.2% v. 67%, respectively; P < 0.01), but the numbers of transferable-quality Day 7 embryos did not differ between the two groups (P > 0.05). Results for Trial 2 indicated that cows inseminated with the trypsinised bovine DGC treatment had significantly increased fertilisation rates compared with the standard method (88.4% v. 63.1%, respectively; P < 0.01) and had significantly higher numbers of transferable-quality embryos (70.3% v. 51.8%, respectively; P < 0.01). In summary, bovine sperm treatment before AI by DGC and recombinant trypsin increases fertilisation rates and can result in more transferable-quality embryos compared with standard methods.

[Assisted reproductive techniques in the context of HIV: the infectiologist's point of view]

Assisted reproductive techniques (ART) in the context of HIV has been possible in France out of research studies since 2001 for couples with one or both partners HIV infected. Couples should fulfil general criteria allowing access to ART and also specific criteria related to the HIV infection and adherence to measures for reduction of viral transmission either to their partner and the child expected. This management is multidisciplinary and brings together gynecologists, obstetricians, reproduction biologists, psychologists or specialized psychiatrists, HIV and hepatitis specialists, virologists and their teams. The patient's assessment should be comprehensive to allow decisions and to answer to the couples' queries in a reasonable delay. The infectious diseases specialist role is multiple: to inform patients according to the HIV disposition for individuals and for the couple, to remind HIV infected women that there are conditions required to reduce the risk of mother-to-child transmission of HIV and that the risk remains even if it is very low with specific treatment. For infected men the processing of semen will require at least two tests. The specialist will evaluate the HIV infection progression, the necessity for antiretroviral therapy initiation or modification. Sometimes therapeutic management avoids exclusion of the couple from ART program for immunovirological parameters. Then according to these evaluations the infectious diseases specialist would share his conclusions with the ART specialists allowing them to adapt their decisions of care to the couple fertility situation without fear or constraints related to HIV.

Reproduction and fertility in human immunodeficiency virus type-1 infection

Human immunodeficiency virus type-1 (HIV-1) affects mostly men and women in their reproductive years. For those who have access to highly active antiretroviral therapy (HAART), the course of HIV-1 infection has shifted from a lethal to a chronic disease. As a result of this, many patients with HIV-1 consider having offspring, as do other patients of reproductive age with chronic illnesses. This article summarizes the current knowledge on the presence of HIV in the male and female genital tract, the effects of HIV-1 infection and HAART on male and female fertility and the results of various assisted reproduction techniques (ART) in HIV-1-infected men and women who wish to have offspring.

Prevailing discourses among AIDS care professionals about childbearing by couples with HIV in Taiwan

The aim of this study was to analyze the dynamics of ideology, power and language in the dominant discourses about childbearing by couples with HIV that were expressed by AIDS care professionals in Taiwan. Critical discourse analysis of the interview texts with 11 AIDS care professionals identified three prevailing discourses on childbearing by couples with HIV/AIDS: pro-children, conditional pro-choice and pro-rights. The pro-children and conditional pro-choice were the predominant discourses. The two discourses both medicalized childbearing among couples with HIV/AIDS by identifying medical authorities as the proper persons to decide which reproductive choices people with HIV/AIDS should make under what conditions. Even though the pro-rights discourse embodied an ideology of individualism, empowerment and autonomy, it was weak and relatively rare in the other two discourses.

Development and evaluation of a qualitative reverse-transcriptase nested polymerase chain reaction protocol for same-day viral validation of human immunodeficiency virus type 1 ribonucleic acid in processed semen

OBJECTIVE

To develop a method for same-day validation of processed semen in the setting of assisted reproductive techniques (ART) with patients who are seropositive for human immunodeficiency virus, type 1 (HIV-1).

DESIGN

Laboratory experiments.

SETTING

University hospital.

PATIENT(S)

Volunteers who are HIV-1 seronegative and seropositive.

INTERVENTION(S)

Evaluation of the sensitivity of a reverse-transcriptase (RT)-nested polymerase chain reaction (PCR) in HIV-1 RNA-positive blood plasma, in artificially infected blood plasma and semen, and in 85 semen samples of 29 HIV-1-seropositive volunteers. Semen was submitted to gradient separation, followed by swim-up.

MAIN OUTCOME MEASURE(S)

Qualitative detection of HIV-1 RNA in blood plasma and in different parts of semen preparation by using RT-nested PCR, PCR inhibition control by dilution of samples, and an internal control.

RESULT(S)

The detection limit of our PCR was 20 HIV-1 RNA copies per milliliter. Among seropositive patients, RNA was detected in 25% of fresh semen, 36.5% of seminal plasma, 27.5% of gradient supernatants, and 7.1% of final preparations before the migration-sedimentation stage. Positive final preparations were observed in patients who had blood viral loads of >/=20,000 HIV-1 RNA copies per milliliter. Inhibition was present in 17.6% of seminal plasma and in 20% gradient supernatants and in 2 final preparations among 69 tested. Among 25 preparations tested after the migration-sedimentation stage, 2 were positive (1 patient; 70,000 HIV-1 RNA copies per milliliter).

CONCLUSION(S)

The RT-nested PCR detects low viral load and allows the validation of semen preparations of HIV-1-seropositive patients for ART on the day of sampling. For this purpose, the validation is performed on spermatozoa that are obtained after gradient separation before swim-up. Inhibition of the PCR must be controlled by using an internal control that is well-designed to explore the detection limit of the method.

Use of a novel washing method combining multiple density gradients and trypsin for removing human immunodeficiency virus-1 and hepatitis C virus from semen

OBJECTIVE

To determine the effectiveness of a novel treatment designed to remove human immunodeficiency virus (HIV) -1 and hepatitis C virus (HCV) from spiked semen and to evaluate sperm motility and viability after treatment.

DESIGN

A prospective clinical laboratory-based study.

SETTING

The human studies were conducted in academic and national research environments. The bovine study was conducted in an accredited research facility.

PATIENT(S)

Healthy volunteers provided the semen samples used in the human studies; abattoir-derived material was used for the bovine embryo production study.

INTERVENTIONS(S)

None.

MAIN OUTCOME MEASURE(S)

Cytopathic, reverse transcriptase-polymerase chain reaction, and branched DNA assays were used to test the efficacy of the procedure for inactivating or removing viruses from spiked semen; standard semen evaluation criteria were used to assess the effects of the procedures on sperm motility and viability.

RESULT(S)

Trypsin exposure significantly reduced the infectivity of HIV-1. The triple density gradient treatment, with or without trypsin, had no detrimental affect on fresh or cryopreserved/thawed sperm 2-48 hours after treatment. The treatment of semen spiked with HIV-1 or HCV indicated that the procedure was effective for reducing viral copies to undetectable levels or below levels of clinical relevance.

CONCLUSION(S)

The procedure was effective for significantly inactivating or reducing HIV-1 and HCV in spiked semen without adversely affecting sperm quality.

Evaluation of risks of viral transmission to recipients of bovine embryos arising from fertilisation with virus-infected semen

This scientific review was prompted by recent legislation to curtail the use of semen from potentially virus-infected bulls to produce embryos for import into the European Union. From studies in laboratory animals, humans and horses, it is apparent that viruses may sometimes attach to, or be integrated into, spermatozoa, although in domestic livestock, including cattle, this seems to be a rare phenomenon, and carriage of virus through the zona pellucida into the oocyte by fertilising sperm has never been described in these species. Four specific viruses; enzootic bovine leukosis (EBLV), bovine herpesvirus-1 (BoHV-1), bovine viral diarrhoea virus (BVDV) and bluetongue virus (BTV), all of which tend to cause subclinical infections in cattle, but which can occur in bovine semen, are examined with regard to the risks that use of infected semen might lead to production of infected embryos. With regard to in vivo-derived embryos, when internationally approved embryo processing protocols are used, the risks from EBLV- and BTV-infected semen are negligible, and the same is almost certainly true for semen infected with BoHV-1 if the embryos are also treated with trypsin. For BVDV, there is insufficient data on how the virus is carried in semen and how different BVDV strains can interact with sperm, oocytes and embryos. There is a potential, at least, that in vivo-derived embryos resulting from infected semen might carry BVDV, although field studies so far suggest that this is very unlikely. With regard to in vitro-produced embryos, use of semen infected with any of the four viruses, with the probable exception of EBLV, will often lead to contaminated embryos, and virus removal from these embryos is difficult even when the internationally approved embryo processing protocols are used. However, it has never been demonstrated that such embryos have resulted in transmission of infection to recipients or offspring.

[Male genital tract infection: the point of view of the virologist]

Attention to viral infection of the male genital tract has been renewed over the last 15 years as a result of the prolific ongoing research on AIDS. Epidemiological studies of the virus in sperm and male genital tract contributes to the understanding of STD physiopathology and helps assessing their impact on male fertility. Recent advances in this field have allowed to offer Assisted reproductive techniques to couples with chronic viral infection, under strict and specific protocols. This paper presents an overview of these recent developments.

Separation of human immunodeficiency virus type 1 from motile sperm by the double tube gradient method versus other methods

OBJECTIVE

To compare a new sperm-processing device, utilizing a double tube and gradient, with other commonly used sperm-processing methods for their abilities to exclude human immunodeficiency virus type 1 (HIV-1) from the motile sperm fraction while retaining maximum sperm yield.

DESIGN

Laboratory experiments.

SETTING

Academic research environment.

PATIENT(S)

Healthy HIV-1 seronegative men between the ages of 25 and 55.

INTERVENTION(S)

Semen samples were spiked with HIV-1 (MN HIV-1 strain; range of concentrations: 10(-1)-10(6) TCID(50)) and subjected to one of the following sperm-processing methods: double sperm tube with discontinuous gradient of sperm separation medium formed inside (double tube gradient), conventional single tube gradient, swim-up or single tube gradient followed by swim-up (gradient/swim-up), which is the method currently used to minimize HIV-1 in semen used for assisted reproductive technology (ART) procedures. For the gradient techniques, Percoll, ISolate, and PureSperm sperm separation media were compared for efficacy of HIV-1 removal. The amount of HIV-1 remaining in the motile sperm pellet after processing was measured by reverse transcription-polymerase chain reaction (RT-PCR), NucliSens assay, or quantitative HIV-1 culture. A hemacytometer was used to microscopically assess motile sperm count.

MAIN OUTCOME MEASURE(S)

HIV-1 RNA copy number, decrease in HIV-1 TCID(50), motile sperm yield.

RESULT(S)

The double tube gradient technique was significantly better than all other methods in the removal of HIV-1 from the motile sperm fraction, and produced significantly higher sperm yields in comparison with the gradient/swim-up method.

CONCLUSION(S)

The double tube gradient technique is a relatively simple and effective method that reduces the risk of infection by HIV-1 while producing good sperm recovery.

HIV and gamete interactions

With the development of combination therapies and their use for the treatment of the human immunodeficiency virus (HIV), the health and life expectancy of HIV-positive patients has improved significantly. As a result, HIV-discordant couples are looking to a future that involves starting a family. However, the potential risks of exposing HIV-infected sperm to oocytes are still being assessed. This article outlines the clinical detection of HIV in semen samples, the relationships between HIV and semen parameters, and HIV-sperm and oocyte interactions. It also considers the implications of introducing exogenous genetic material into an oocyte via intracytoplasmic sperm injection (ICSI) and the possible implications of this for assisted reproduction.

Assisted reproductive technology for men and women infected with human immunodeficiency virus type 1

In 2001, the World Health Organization reported 4.3 million new human immunodeficiency virus (HIV) infections in adults globally, 41% of which were in women. During the year 2000, 27% of newly diagnosed HIV infections in the United States occurred in women. In developed countries, the perception of HIV infection has changed from an acute, lethal infection to a chronic illness; the introduction of highly active antiretroviral therapy has decreased morbidity and mortality, and new drug therapies have dramatically decreased perinatal transmission. In view of these advances, some HIV-infected individuals are considering reproduction. Following the lead of organizations in other developed countries, the American College of Obstetricians and Gynecologists has recently endorsed the use of reproductive technology in HIV-infected patients. Which patients should be offered assisted reproduction and what the optimal methods are of decreasing heterosexual and perinatal HIV transmission must be determined.

Assisted reproduction in HIV-1-serodifferent couples: the need for viral validation of processed semen

BACKGROUND

Many HIV-infected men and women have a strong desire for a child. Assisted reproductive technologies (ART) are an option for HIV-serodifferent couples to reduce the risk of HIV transmission from an infected man to the woman. Potential HIV contamination of selected spermatozoa after semen processing is an important issue in this context.

METHODS

HIV in processed semen obtained in our laboratory since 1995 were analysed. HIV RNA and DNA detection was performed in the selected spermatozoa of 125 men. HIV RNA was analysed in blood and semen plasma as well as HIV DNA in non-sperm cells.

RESULTS

HIV RNA and DNA were detected in the selected spermatozoa of eight and two men (6.4% and 1.6%), respectively. HIV RNA was detected with a median load of 5 copies/10(6) spermatozoa. Six of the eight men were untreated, one was taking nucleoside analogue therapy and one was on highly active antiretroviral treatment (HAART). HIV RNA detection was more likely to be positive in selected spermatozoa of men with high seminal plasma viral load. HIV RNA was detected in 26% and 11% of selected spermatozoa fractions when the seminal plasma load was > 10,000 copies/ml and 20-10,000 copies/ml, respectively, but in none when the seminal plasma tested negative.

CONCLUSION

Selected spermatozoa may be positive for HIV RNA detection even in treated patients. Viral validation of processed semen is necessary in ART programmes for serodifferent couples, particularly in men with only partially or poorly controlled HIV infection.

Viruses in the mammalian male genital tract and their effects on the reproductive system

This review describes the various viruses identified in the semen and reproductive tracts of mammals (including humans), their distribution in tissues and fluids, their possible cell targets, and the functional consequences of their infectivity on the reproductive and endocrine systems. The consequences of these viral infections on the reproductive tract and semen can be extremely serious in terms of organ integrity, development of pathological and cancerous processes, and transmission of diseases. Furthermore, of essential importance is the fact that viral infection of the testicular cells may result not only in changes in testicular function, a serious risk for the fertility and general health of the individual (such as a fall in testosteronemia leading to cachexia), but also in the possible transmission of virus-induced mutations to subsequent generations. In addition to providing an exhaustive account of the data available in these domains, this review focuses attention on the fact that the interface between endocrinology and virology has so far been poorly explored, particularly when major health, social and economical problems are posed. Our conclusions highlight the research strategies that need to be developed. Progress in all these domains is essential for the development of new treatment strategies to eradicate viruses and to correct the virus-induced dysfunction of the endocrine system.

Human immunodeficiency virus and assisted reproduction: reconsidering evidence, reframing ethics

OBJECTIVE

To review the advances in the treatment of human immunodeficiency virus (HIV) infection and revisit the medical, ethical, and legal issues surrounding infertility management in HIV-infected couples.

DESIGN

Analytic review.

RESULTS(S)

HIV infection continues to be a serious public health and reproductive issue. However, present policies which allow for the categorical exclusion of HIV-infected individuals from infertility services should be reconsidered in light of improvements in the prognosis of infected individuals and a dramatic decrease in the risk of vertical transmission. An analysis of the ethical cogency of the arguments against the provision of services does not substantiate the exclusion of HIV-infected individuals; rather, the principle of justice requires that HIV-infected women be treated the same way as a woman who might have an increased risk of conceiving a child with a disability or a may have a decreased life expectancy due to a chronic illness such as diabetes. Ethical disagreement notwithstanding, with the precedents recently established by the Americans with Disabilities Act (ADA), discrimination based on HIV status would also likely be unlawful under most circumstances.

CONCLUSIONS(S)

With advances in the treatment of HIV infection, contextualized counseling and a respect for patients' decisions regarding infertility treatment should be adopted as public policy. It is neither ethically nor legally justifiable to categorically exclude individuals from infertility services on the basis of HIV infection.