Screening to reduce transmission of sexually transmitted diseases in semen used for artificial insemination

Revisiting selected ethical aspects of current clinical in vitro fertilization (IVF) practice

Ethical considerations are central to all medicine though, likely, nowhere more essential than in the practice of reproductive endocrinology and infertility. Through in vitro fertilization (IVF), this is the only field in medicine involved in creating human life. IVF has, indeed, so far led to close to 10 million births worldwide. Yet, relating to substantial changes in clinical practice of IVF, the medical literature has remained surprisingly quiet over the last two decades. Major changes especially since 2010, however, call for an updated commentary. Three key changes deserve special notice: Starting out as a strictly medical service, IVF in recent years, in efforts to expand female reproductive lifespans in a process given the term “planned” oocyte cryopreservation, increasingly became more socially motivated. The IVF field also increasingly underwent industrialization and commoditization by outside financial interests. Finally, at least partially driven by industrialization and commoditization, so-called add-ons, the term describing mostly unvalidated tests and procedures added to IVF since 2010, have been held responsible for worldwide declines in fresh, non-donor live birthrates after IVF, to levels not seen since the mid-1990s. We here, therefore, do not offer a review of bioethical considerations regarding IVF as a fertility treatment, but attempt to point out ethical issues that arose because of major recent changes in clinical IVF practice.

Screening for sexually transmitted infection pathogens in semen samples

The transmission of sexually transmitted infection (STI) pathogens from an infected donor to the recipient of a semen donation in assisted conception may result not only in acute infection but also in long-term reproductive complications or adverse outcomes of pregnancy, including infection of the offspring. Screening for bacterial STI pathogens, Chlamydia trachomatis and Neisseria gonorrhoeae is strongly recommended because these pathogens can cause serious reproductive complications in the recipients of semen donations and infection in their offspring. Screening for these pathogens should be performed using the most sensitive methods, such as nucleic acid amplified tests. False-negative results due to inhibitory substances in the semen sample should be monitored using amplification controls. Where specimen transport is not a problem and culture facilities are available, N gonorrhoeae can also be detected by culture. Laboratories performing screening should subscribe to proficiency programs and have strict quality controls. Although Trichomonas vaginalis, group B streptococcus and genital mycoplasmas have been associated with adverse outcomes of pregnancy, the frequent finding of these organisms in healthy individuals brings into question the validity of mandatory inclusion of these organisms in the screening panel. Although viral STI pathogens and Treponema pallidum - the causative agent of syphilis - may be detected in semen, their presence may be more sensitively detected through antibody testing of the donor. Screening donors for HIV, hepatitis B and syphilis by serology is uniformly recommended in all of the guidelines, but the value of screening either donors or semen samples for cytomegalovirus, herpes simplex viruses and human papilloma viruses is less clear.

Managing multiple masculinities in donor insemination: doctors configuring infertile men and sperm donors in Taiwan

This article investigates how doctors configured infertile men and sperm donors in the development of donor insemination (DI) in Taiwan. In the initial stage (1950s-1970s) doctors adjusted clinical procedures to repair the deformed gender identities of infertile men. To expand DI in the late 1970s and early 1980s, doctors stressed the positive eugenics of DI by spotlighting the high intelligence of donors, playing down biological patrilineage and re-emphasising the contribution of men of higher rank in society. In the mid-1980s, when donors came to be seen as potential carriers of fatal diseases like acquired immune deficiency syndrome, doctors managed to associate risky donors with socially stigmatised men, and therefore perpetuate the conventional hierarchy of masculinities. As the intracytoplasmic sperm injection emerged in the early 1990s doctors quickly presented infertile men as universally longing for biological fatherhood and hence devalued DI in an attempt to augment paternal masculinity. These diverse configuration activities come together to create a socio-technical network of DI that most of the time perpetuates the reigning gender order, rather than destabilising it. I argue the importance of incorporating various types of participants in analysis to understand the changing dynamics of multiple masculinities along with the development of DI.

Frequency of postinsemination infections as reported by donor semen recipients

Over an 18-year period, 47 women claimed to have acquired an infection after insemination with donor semen. This translates to an infection rate of less than 1 per 10,000 inseminations.

Novel gamete storage

The aim of this review is to outline recent advances in gamete storage that are beneficial for rescuing endangered species or for the breeding of companion animals. Much more information is available on the technical resolutions and practical applications of sperm cryopreservation in various species than of female gametes, reproductive tissues or organs. Mammalian sperm cryopreservation often works relatively efficiently; however, the ability of female gametes to be cryopreserved and still be viable for fertilisation is also essential for rescuing endangered species. For a proper evaluation of gamete cryopreservation possibilities in a given species, it is essential to understand the basic mechanism affecting the survival of cryopreserved cells, the technical and physical limitations, the available techniques and the new avenues to resolve the specific problems in that species. This paper is aimed to provide some help for this process. The limited length of this paper resulted in the omission of information on many important areas, including most data on teleosts, amphibian and insect cryopreservation.

Rapid quantification of semen hepatitis B virus DNA by real-time polymerase chain reaction

AIM: To examine the sensitivity and accuracy of real-time polymerase chain reaction (PCR) for the quantification of hepatitis B virus (HBV) DNA in semen.

METHODS: Hepatitis B viral DNA was isolated from HBV carriers’ semen and sera using phenol extraction method and QIAamp DNA blood mini kit (Qiagen, Germany). HBV DNA was detected by conventional PCR and quantified by TaqMan technology-based real-time PCR (quantitative polymerase chain reaction (qPCR)). The detection threshold was 200 copies of HBV DNA for conventional PCR and 10 copies of HBV DNA for real time PCR per reaction.

RESULTS: Both methods of phenol extraction and QIAamp DNA blood mini kit were suitable for isolating HBV DNA from semen. The value of the detection thresholds was 500 copies of HBV DNA per mL in the semen. The viral loads were 7.5 × 10⁷ and 1.67 × 10⁷ copies of HBV DNA per mL in two HBV infected patients’ sera, while 2.14 × 10⁵ and 3.02 × 10⁵ copies of HBV DNA per mL in the semen.

CONCLUSION: Real-time PCR is a more sensitive and accurate method to detect and quantify HBV DNA in the semen.

Real-time sperm separation system: a review of Wang tubes and related technologies

This paper discusses real-time sperm separation technology and the use of Wang tubes for isolating high-quality and fertile sperm. Several methods have been developed and used to prepare a better sperm specimen, including the conventional swim-up technique, Percoll discontinuous density gradient, Sephadex gel filtration, centrifugation, migration-sedimentation, albumin column, and Sperm-prep. However, none of these methods has the ability to isolate from the original ejaculum a large number of highly motile, morphologically normal, and normal-chromatin sperm, while retaining in an adequate volume of physiological medium, free of less-motile and nonmotile sperm, and free of microorganisms, cell debris, seminal plasma, leukocytes, and foreign bodies. These methods should be classified as incomplete techniques of sperm separation and are of only limited effectiveness in infertility treatment. They may also cause irreparable damage to the mother or fetus. Real-time sperm separation technology is based on the observations that nonpathological spermatozoa do not transfer organisms, that the motility pattern and swim-up capacity of pathological sperm are limited or disturbed, and that the movement of sperm differs from the passive motion of nonciliated microorganisms and the random active motion of ciliated microorganisms in terms of velocity and direction. Real-time sperm separation technology encompasses the Wang tube system, which has two main functions: to isolate organisms-free, normal-chromatin, morphologically normal, and highly motile spermatozoa that are suitable for use in infertility treatment, and to prevent sex-linked inherited diseases. The results of these evaluations indicate that real-time sperm separation technology is the most effective and precise method of isolating and decontaminating sperm to date.

Detection of Chlamydia trachomatis in semen of artificial insemination donors by the polymerase chain reaction

OBJECTIVE

To assess the feasibility of detecting Chlamydia trachomatis in cryopreserved donor semen by a specific, direct polymerase chain reaction (PCR).

DESIGN

Cryopreserved donor semen was tested for the presence of C. trachomatis by a specific PCR, directly applied to semen without prior DNA purification.

SETTING

Tertiary care fertility center in a teaching hospital and university-based laboratory for molecular pathology.

PARTICIPANTS

Cryopreserved semen from 30 donors was investigated. These semen samples had previously given negative results in cell culture for C. trachomatis. Two different ejaculates of each donor, cryopreserved with an interval of 2 years, were retrospectively analyzed.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

The presence of C. trachomatis as demonstrated by PCR.

RESULTS

In 3 of 30 donors C. trachomatis was detected in both ejaculates, whereas in 2 additional donors only one of the two samples tested positive. Additional samples from 2 positive donors, together with samples from 3 negative donors, were studied more extensively, to test the reproducibility and reliability of PCR results. All ejaculates of the donors, previously positive for C. trachomatis by PCR, indeed appeared to be positive, whereas the samples of the negative donors remained negative.

CONCLUSIONS

The direct PCR is a reliable, sensitive, and valuable method for detection of C. trachomatis in semen. The incidence of contamination of donor semen with C. trachomatis in the donor population in this study stresses the need for rigorous screening of donor semen before artificial insemination, preferably using a sensitive method such as the PCR.

Cryosurvival of Trichomonas vaginalis during cryopreservation of human semen

Despite a 90% cryosurvival of Trichomonas vaginalis in their growth medium trypticase yeast maltose (TYM) with DMSO, none of these parasites have previously been observed to survive during cryopreservation of infected human semen with glycerol (Andrologia 18, 323 (1986)). This could have been due to the failure of the culture method used to detect low numbers of survivors. The prospects of possible transmission of T. vaginalis by artificial insemination with cryobanked (-196 degrees C) semen prompted an investigation of the cryosurvival of this parasite in the presence of semen with the cryoprotectant glycerol, using a more sensitive culture method for viability evaluation. Semen and seminal fluid from the same 23 ejaculates, as well as culture medium, were inoculated with small clinical numbers of T. vaginalis and evaluated as to their survival before and after cryopreservation. Results indicated: (i) The highest cryosurvival of T. vaginalis (4.5%) was in cryobanked (glycerolated) semen, (ii) semen, as well as glycerol, shows cryoprotective action, and (iii) glycerol reduced survival of parasites in semen, seminal fluid, and TYM medium during exposure prior to freezing. Clinical information on infectivity of small numbers of T. vaginalis and the data presented here suggests that these organisms could be transmitted by artificial insemination with infected cryobanked human semen.

Donor insemination--a look to the future

In this article we have reviewed many aspects of donor insemination. The deficiencies in the screening of semen donors especially for sexually-transmitted diseases has been discussed and importance of a rational protocol for recruitment and screening of potential donors has been emphasized. Factors influencing the success and outcome of donor insemination have been reviewed with particular emphasis on providing prognostic guidelines to potential donor insemination couples as to the success and outcome of the treatment. The importance of accurate timing of inseminations in determining the success of donor insemination has also been discussed. However, as has been highlighted throughout this review, there is a lack of specific prospective controlled trials, which are clearly necessary to answer specific important questions. Also emphasized has been the need of these trials to answer such basic questions as the influence of accurate timing on conception rates in specific groups of insemination recipients.

Artificial insemination with donor semen: the necessity of frequent donor screening

Artificial insemination with donor semen has become a well established alternative for couples with untreatable male factor infertility. Because of the widespread use of donor insemination, and the increasing awareness and prevalence of sexually transmitted diseases, the American Fertility Society recently redrafted procedural guidelines for the use of donor screening for insemination. Our series of donor screenings is reported to emphasize the necessity of donor evaluations at frequent intervals. From June 1986 through August 1987, 48 healthy male volunteers presented as potential semen donors for our donor program. Each was evaluated with a careful medical history, physical examination and 2 semen analyses for evidence of sexually transmitted disease. On initial evaluation, no donor presented with a positive human immunodeficiency virus antibody, abnormal karyotype, elevated serum glutamic oxaloacetic transaminase, rapid plasma reagent, or positive cultures for Chlamydia or Mycoplasma. One potential donor was excluded because of a positive hepatitis B-core antibody and 1 because of a positive IgM test for cytomegalovirus. At initial examination 3 potential donors had a positive culture for Ureaplasma; all 3 were treated with 3 weeks of tetracycline, and repeat cultures were all negative. Routine followup screening was performed on all donors at 3-month intervals for all sexually transmitted diseases. During this 14-month period cultures converted to positive for Ureaplasma in 4 donors. Furthermore, 1 donor at 6 months contracted gonorrhea. He was treated but no longer used as a donor. Since initiation of the outlined protocol more than 800 inseminations have been performed using fresh semen with no case of sexually transmitted diseases reported from our recipients. We conclude that careful sexual history, and frequent donor and semen evaluation are necessary for prevention of diseases that might be transmitted sexually. If these precautions are strictly observed use of donor semen is safe and effective.

Cryopreservation of human semen

A review is given of the techniques for the cryopreservation of human semen, including the preparation of cryoprotective media, the use of ampoules, straws, and pellets, and freezing and thawing techniques. The use of cryopreserved semen for therapeutic artificial insemination by donor is described. The advantages of cryopreserved semen over fresh donor semen mostly lie in the ability to exclude infections before use and the extra convenience, in spite of the lower success rate and increased cost. The recovery of sperm motility on thawing is described, as are other methods for assessing the degree of damage to the spermatozoa by the freezing procedure. The success rates reported by large semen banks are summarized.

Artificial insemination with fresh donor semen

A review is given of the use of fresh donor semen for therapeutic artificial insemination. This includes a section on the legal, ethical, and psychological aspects as seen from the point of view of various cultures. Topics covered are the indications for donor insemination, the selection of donors, and the techniques in common use. The success rate is described together with the sex ratio of the neonates. Short mention is made of short-term office semen preservation and the obsolete technique of mixed husband-donor insemination.

Current management of a donor insemination program

Substantial evidence now exists to show that considerable maternal-fetal morbidity may result from microbiologic transmitted diseases that can be transmitted through artificial insemination by donor. In the present decade it has become increasingly clear that the use of fresh semen is potentially hazardous and its use has been discouraged by both the CDC and AFS. To minimize this risk, donor insemination programs should establish their own guidelines to thoroughly evaluate potential semen donors via history, physical examination, and laboratory evaluation before the use of donor semen after cryopreservation and quarantine. The management of a donor insemination program in the future requires uniform procedures for rigorous genetic and microbiologic screening before the selection and use of semen donors for artificial insemination.

Screening donors for sexually transmitted disease in donor insemination clinics in the UK. A survey

A survey conducted amongst the 40 donor insemination centres in the UK registered by the Royal College of Obstetricians and Gynaecologists (RCOG) showed that most of the clinics had no structured policy for control of common (non-HIV) sexually transmitted diseases within their programmes.

Transmission of sexually transmitted diseases by donor semen

Therapeutic insemination by donor (TID) is being used with increasing frequency. Because many diseases, some of which are lethal, can be transmitted through semen, the American Fertility Society established guidelines for use of donor sperm. They limit TID to cases of male infertility or hereditary/genetic disorders. Donor selection requires good health and absence of genetic abnormalities; criteria for semen including normal sperm motility, concentration, and normal morphology, and blood screening for infectious agents. Human immunodeficiency virus (HIV) testing should be performed initially in donors for fresh semen inseminations. If positive, the assay is verified with a Western blot test; if negative, the donor should be screened at 6-month intervals. Frozen samples should not be used until the 180 day reevaluation of the donor. Many studies show higher pregnancy rates using fresh rather than frozen semen samples for insemination. New methods of cryopreservation minimize the deleterious effects of freezing. If these effects, namely decreased sperm motility and impaired penetration ability, are eliminated, pregnancy rates can be expected to rise. Frozen semen is preferable because it allows time for sexually transmitted diseases to manifest themselves and for specimens from those donors to be rejected prior to use.

Culture of cytomegalovirus from frozen-thawed semen

Twenty-four donors in a TID program were tested for previous exposure to CMV. Four (16.7%) donors were seropositive for CMV. One donor's semen was culture-positive for CMV following cryopreservation and storage at -196 degrees C for up to 9 months. Culture reports for blinded specimens from the same ejaculate were all in agreement. Days to viral detection following inoculation of test cells were similar for specimens from the same ejaculate. Seminal quality was not adversely affected during the period of viral shedding. This appears to be the first report of survival of this previously reported cold labile virus in frozen-thawed semen.

Cryopreservation of human spermatozoa. II. Postthaw chronology of motility and of zona-free hamster ova penetration

Postthaw dynamics of motility maintenance and ability to penetrate zona-free hamster ova were examined with human sperm. Ten semen samples were each divided into two equal volumes; one was cryopreserved while the other half remained untreated. Frozen samples were thawed, and initial evaluations for motility and hamster egg penetration were made on both untreated and frozen-thawed samples. The time difference between the initial evaluations for the two treatment groups was approximately 30 minutes as a result of the time required to freeze and thaw aliquots. Subsequent evaluations were made 6, 12, 24, and 48 hours later. Over all times both the motility and fertilizability of cryopreserved spermatozoa were significantly reduced (P less than 0.05) when compared with those of untreated sperm. The pattern of motility loss over time was similar between untreated and frozen-thawed sperm (P greater than 0.10). Conversely, differences between untreated and frozen-thawed sperm in fertilizability patterns were dramatic (P less than 0.05). This was evidenced by penetration rates for cryopreserved sperm highest at 0 hour and decreasing over time, whereas penetration by untreated spermatozoa was lowest at 0 hour, increasing to a maximum at 24 hours. These observations may be important in the development of laboratory protocols for freezing and clinical protocols for using frozen-thawed sperm.

Cryopreservation of human spermatozoa. I. Effects of holding procedure and seeding on motility, fertilizability, and acrosome reaction

Three experiments were conducted to evaluate effects of holding semen at +5.0 degrees C for 30 minutes or -5.0 degrees C for 10 minutes and ice crystal induction (seeding) on frozen-thawed human spermatozoa. In experiment 1, spermatozoa were frozen, and postthaw motility was evaluated immediately (0 hour) and 24 hours later. At both 0 and 24 hours, nonfrozen control samples had higher motility than all other treatment groups. At 0 hour postthaw, motility was higher in samples held at -5.0 degrees C for 10 minutes with no significant effect of seeding. At 24 hours, samples held at -5.0 degrees C for 10 minutes and seeded, but not samples held at -5.0 degrees C and not seeded, had higher motility than samples held at +5.0 degrees C. In experiment 2, semen samples were frozen, and fertilizability was evaluated in a zona-free hamster egg penetration assay. Seeded samples had a higher frequency of sperm penetration than either nonfrozen or nonseeded samples. In experiment 3, nonfrozen controls and frozen treatment groups were evaluated for the frequency of survival and acrosomal integrity. Seeded samples had higher frequencies of survival and loss of acrosomal integrity than nonseeded samples. All frozen-thawed samples had a lower frequency of survival and a higher frequency of loss of acrosomal integrity than nonfrozen controls. Although altered patterns of fertilizability and acrosomal integrity are induced, collectively these data suggest that incorporating a holding temperature of -5.0 degrees C for 10 minutes and seeding may result in a superior protocol for freezing human spermatozoa.