ART outcome in HIV-infected patients

Comparison of in vitro fertilization cycles in couples with human immunodeficiency virus type 1 infection versus noninfected couples through a retrospective matched case-control study

Objective

To compare in vitro fertilization (IVF) outcomes in couples in which at least one partner is human immunodeficiency virus (HIV) positive with that of couples in which neither partner is HIV-positive.

Design

Retrospective matched case-control study.

Setting

Fertility center at Tenon Hospital, Paris, France.

Patient(s)

A total of 179 IVF cycles in couples infected with HIV-1 and 179 IVF cycles in control couples.

Intervention(s)

Ovarian stimulation, oocytes retrieval, IVF (standard and microinjection), embryo transfer, pregnancy, and live birth follow-up.

Main Outcome Measure(s)

Live birth rate and IVF outcomes

Result(s)

The first comparison between HIV and non-HIV couples showed poorer outcomes in the HIV group (higher administered gonadotropin doses and longer stimulation periods, lower cumulative pregnancy and live birth rates, among other things). A subgroup analysis was performed in addition. No differences were found in the “men HIV” group compared with the controls. In contrast, poorer outcomes in the “women HIV” and “women and men HIV” groups were shown in terms of administered doses, duration of stimulation, and number of oocytes retrieved. For the “women HIV” group, lower cumulative clinical pregnancy and live birth rates were found.

Conclusion

The data suggested that couples with HIV-positive women have poorer medically assisted procreation outcomes than couples with non-HIV-infected women. Therefore, physicians should pay particular attention to couples with HIV-positive women.

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.

[Assisted reproductive technologies in HIV patients: Which results and which strategy in France in 2019?]

With the use of antiretroviral therapy, HIV transmission from mother to fetus and between sexual partners has been significantly reduced, successively allowing pregnancy, then assisted reproductive technologies, and targeted unprotected sex among couples living with HIV. Since first French Morlat report in 2013, natural procreation is now possible under certain conditions for these couples living with HIV and the use of assisted reproductive technologies is increasingly limited to the treatment of infertility. While the results of intrauterine insemination seem satisfactory for serodiscordant couples living with HIV, in vitro fertilization results appear to be unfavorable when the woman is infected with HIV. In vitro fertilization results appear to be comparable to those in general population when only the man is infected with HIV. It can be assumed that ovaries are impacted by the treatment and/or the HIV in infected women.

Lower endometrial receptivity in HIV-infected women receiving oocyte donation: a comorbidity of HIV infection?

STUDY QUESTION

Are the reproductive outcomes of HIV-infected donor oocyte recipient women comparable to those of non-infected women?

SUMMARY ANSWER

HIV-infected women have lower clinical pregnancy and live birth rates than non-infected women.

WHAT IS ALREADY KNOWN

The literature on the effect of HIV infection on reproductive outcome is scarce at best; the only report to date comparing oocyte donation cycles in HIV-infected women versus non-infected controls found no differences in pregnancy rates between the two groups. However, this study was performed nearly a decade ago and did not evaluate the effect of immuno-virological characteristics of oocyte recipients or the HIV antiretroviral therapy effect.

STUDY DESIGN SIZE, AND DURATION

This is a matched-cohort study including 514 oocyte donation cycles, 257 from HIV-infected women and 257 non-infected controls, performed between April 2004 and November 2014.

PARTICIPANTS/MATERIALS, SETTING, AND METHOD

Each cycle of an HIV-infected woman (n = 257) was matched with a cycle of a non-infected woman (1:1). Biochemical pregnancy, clinical pregnancy, ongoing pregnancy and live birth in the two groups were compared using a multivariate logistic regression analysis. The effect of antiretroviral treatment options on pregnancy outcomes of HIV-infected women was analyzed using a logistic regression model adjusted for time elapsed from diagnosis, and CD4 levels and viral load prior to embryo transfer.

MAIN RESULTS AND THE ROLE OF CHANCE

Cycles of HIV-infected patients receiving oocyte donation presented lower pregnancy and live birth rates than matched non-infected controls. Treatment options and infection parameters analyzed do not seem to affect the reproductive results in HIV-infected women. The variable most influencing pregnancy outcomes was the number of transferred embryos; lower pregnancy rates were obtained after single embryo transfer.

LIMITATIONS REASONS FOR CAUTION

Patients with HIV infection have specific health issues, such as infection/treatment side effects, which makes it impossible to find a matching control group of non-infected patients for these variables.

WIDER IMPLICATIONS OF THE FINDINGS

HIV-infected women receiving donated oocytes present lower pregnancy rates when compared to non-infected controls, regardless of the antiretroviral treatment followed. The complexity of the treatments (both in medication types and combinations) makes it difficult to define whether any one treatment option is better than the others in terms of pregnancy outcomes in oocyte recipients.

STUDY FUNDING/COMPETING INTERESTS

None.

TRIAL REGISTRATION NUMBER

Not applicable.

In vitro fertilization when men, women, or both partners are positive for HIV: a case-control study

PURPOSE

The aim of this study was to compare the outcomes of in vitro fertilization (IVF) for couples where one or both partners were positive for the human immunodeficiency virus (HIV) to matched control couples.

METHODS

A matched case-control retrospective study was performed. Data for 104 couples where the woman was HIV-positive; for 90 couples where the man was HIV-positive; and for 33 couples where both partners were HIV-positive were prospectively analyzed in comparison to matched controls treated in our center during the same period. The main outcomes were clinical pregnancy and live birth rates.

RESULTS

For couples involving an HIV-positive man, clinical outcomes were comparable to controls and resulted in the birth of 18 healthy babies after 90 cycles. When the woman was affected, cycle cancelation, number of retrieved oocytes, and on-going clinical pregnancy rates per transfer were statistically reduced. Implantation rates were comparable to those of non-affected controls. Seven healthy babies for 104 cycles were obtained. For a couple in which both partners were HIV-positive, only one healthy birth occurred after 33 cycles. Pregnancy rates were systematically reduced though not significantly probably due to sample size.

CONCLUSIONS

Our data suggest that IVF outcomes were similar to controls when men were HIV-positive and remain acceptable when women were HIV-positive. IVF outcomes were severely reduced in our sero-concordant couples; however, many patients had severe HIV disease previously, and therefore, these results should be reassessed in patients treated early in their disease.

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.

Effectiveness of semen washing to prevent human immunodeficiency virus (HIV) transmission and assist pregnancy in HIV-discordant couples: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of semen washing in human immunodeficiency virus (HIV)-discordant couples in which the male partner is infected.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Forty single-arm open-label studies among HIV-discordant couples that underwent intrauterine insemination (IUI) or in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) using washed semen.

INTERVENTION(S)

Semen washing followed by IUI, IVF, or IVF/ICSI.

MAIN OUTCOME MEASURE(S)

PRIMARY OUTCOME

HIV transmission to HIV-uninfected women; secondary outcomes: HIV transmission to newborns and proportion of couples achieving a clinical pregnancy.

RESULT(S)

No HIV transmission occurred in 11,585 cycles of assisted reproduction with the use of washed semen among 3,994 women. Among the subset of HIV-infected men without plasma viral suppression at the time of semen washing, no HIV seroconversions occurred among 1,023 women after 2,863 cycles of assisted reproduction with the use of washed semen. Studies that measured HIV transmission to infants reported no cases of vertical transmission. Overall, 56.3% of couples (2,357/4,184) achieved a clinical pregnancy with the use of washed semen.

CONCLUSION(S)

Semen washing appears to significantly reduce the risk of transmission in HIV-discordant couples desiring children, regardless of viral suppression in the male partner. There are no randomized controlled studies or studies from low-income countries, especially those with a large burden of HIV. Continued development of lower-cost semen washing and assisted reproduction technologies is needed. Integration of semen washing into HIV prevention interventions could help to further reduce the spread of HIV.

Lights and Shadows about the Effectiveness of IVF in HIV Infected Women: A Systematic Review

Background. HIV infected women have higher rates of infertility. Objective. The purpose of this literature review is to evaluate the effectiveness of fresh IVF/ICSI cycles in HIV infected women. Materials and Methods. A search of the PubMed database was performed to identify studies assessing fresh nondonor oocyte IVF/ICSI cycle outcomes of serodiscordant couples with an HIV infected female partner. Results and Discussion. Ten studies met the inclusion criteria. Whenever a comparison with a control group was available, with the exception of one case, ovarian stimulation cancelation rate was higher and pregnancy rate (PR) was lower in HIV infected women. However, statistically significant differences in both rates were only seen in one and two studies, respectively. A number of noncontrolled sources of bias for IVF outcome were identified. This fact, added to the small size of samples studied and heterogeneity in study design and methodology, still hampers the performance of a meta-analysis on the issue. Conclusion. Prospective matched case-control studies are necessary for the understanding of the specific effects of HIV infection on ovarian response and ART outcome.

Foetal loss and enhanced fertility observed in mice treated with Zidovudine or Nevirapine

BACKGROUND

Health concerns for HIV-infected persons on antiretroviral therapy (ART) have moved from morbidity to the challenges of long-term ART. We investigated the effect of Zidovudine or Nevirapine on reproductive capacity across two mouse generations.

METHODS

A prospective mouse study with drugs administered through one spermatogenic cycle. Mouse groups (16 males and 10 females) were given Zidovudine or Nevirapine for 56 days. Males were mated to untreated virgin females to determine dominant lethal effects. Twenty females (10 treated and 10 untreated) mated with the treated males per dose and gave birth to the F1 generation. Parental mice were withdrawn from drugs for one spermatogenic cycle and mated to the same dams to ascertain if effects are reversible. The F1 generation were exposed for another 56 days and mated to produce the F2 generation.

RESULTS

Foetal loss was indicated in the dominant lethal assay as early as four weeks into drug administration to the males. At the first mating of the parental generation to produce the F1 generation, births from 10 dams/dose when the 'father-only' was exposed to Zidovudine (10, 100 and 250 mg/kg) was 3, 2 and 1 while it was 7, 1 and 4 respectively when 'both-parents' were exposed. Similarly births from the parental generation first mating when the 'father-only' was exposed to Nevirapine (5, 50 and 150 mg/kg) was 2, 2 and 0 while it was 6, 5 and 9 respectively when 'both-parents' were exposed. However, fertility was not significantly different neither by dose nor by the parental exposure. The F1 mice mated to produce the F2 generation recorded only one birth.

CONCLUSION

The dominant lethal analysis showed foetal loss occurred when the "fathers-only" were treated while fertility was enhanced when "both-parents" were on therapy at the time of mating.

Fertility treatment options for HIV-infected individuals

Many HIV-serodiscordant couples desire children and physician-assisted techniques can help individuals achieve pregnancy while reducing the risk of seroconversion in their seronegative partner. For HIV-seropositive males, sperm washing with intrauterine insemination (SW-IUI) was introduced in Europe in the early 1990s, while in the USA in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI) has been primarily used to reduce the risk of viral transmission. When properly applied to well-selected populations, no seroconversion has been reported with either of these methods. Within the last 5 years, randomized controlled studies have demonstrated the efficacy of daily pre-exposure prophylaxis in reducing the risk of seroconversion in couples having intercourse when an HIV-seropositive male has undetectable viral loads. In both the USA and Europe, favorable reproductive outcomes have been reported for HIV-seropositive females undergoing IUI and IVF-ICSI. Herein, we review the use of various contemporary reproductive techniques available to HIV-serodiscordant couples interested in having children, including new data on cumulative clinical pregnancy rates and cumulative live-birth rates after IVF-ICSI for male serodiscordant couples. We conclude by proposing that pre-exposure prophylaxis with SW-IUI may be a safe, economical and effective alternative for achieving pregnancy in well-selected, monogamous HIV-serodiscordant couples where the male partner is seropositive.

Reproductive assistance in HIV serodiscordant couples

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Systematic review of the effectiveness and safety of assisted reproduction techniques in couples serodiscordant for human immunodeficiency virus where the man is positive

OBJECTIVE

To evaluate the effectiveness and safety of assisted reproduction techniques (ART) in human immunodeficiency virus (HIV) serodiscordant couples.

DESIGN

Systematic review of five databases of noncomparative open intervention and observational studies of serodiscordant couples undergoing ART, with study selection and data extraction performed independently and in duplicate.

SETTING

Tertiary fertility centers.

PATIENT(S)

HIV serodiscordant couples where the man is HIV positive.

INTERVENTION(S)

Intrauterine insemination (IUI), in vitro fertilization (IVF), or intracytoplasmic injection (ICSI) performed after washed semen viral testing.

MAIN OUTCOME MEASURE(S)

Pregnancy rates per cycle, cumulative pregnancy, abortion rate, and HIV seroconversion in newborns or women.

RESULT(S)

Of the 658 abstracts retrieved, 41 were selected for review, and 17 full articles were included (3,900 IUI cycles in 1,184 couples in 11 aggregated studies and 738 ICSI/IVF cycles in 579 couples across 10 studies). The IUI and ICSI results were, respectively: pregnancy rates per cycle, 18% and 38.1%; cumulative pregnancy, 50% and 52.9%; and abortion rate, 15.6% and 20.6%. No seroconversions in women or newborns were detectable at birth or after 3 to 6 months.

CONCLUSION(S)

Cumulative evidence suggests that ART is safe and effective for avoiding horizontal and vertical transmission in HIV serodiscordant couples.

Optimal management of HIV-infected women during pregnancy and delivery: an audit of compliance with recommendations

BACKGROUND

The improvement in quality of life of HIV-infected patients and a reduced risk of vertical transmission have led to an increase in the desire for pregnancy among infected women. We assessed whether local recommendations were followed by HIV-infected mothers and their reasons for noncompliance.

METHODS

Data on HIV-infected women who delivered between 2002 and 2006 in a large public university hospital in Brussels were collected and analyzed for compliance with recommendations and outcomes.

RESULTS

The evidence suggests that current recommendations were followed in two thirds of the 203 recorded deliveries, as the patients in question (n = 140) came to term with an undetectable viral load and an uninfected newborn. About half of these women delivered vaginally, and 67% had ruptured membranes for less than 4 hours and required no instrumental delivery. Among those for whom optimal conditions for delivery were not met, two newborns were infected.

CONCLUSIONS

The current recommendations were followed in only two thirds of the recorded deliveries. To improve results for the future, we have adapted our protocol both by starting antiviral therapy earlier and by assigning nurses to the patients' follow-up to try to promote better compliance to treatment during pregnancy.

Round-table multidisciplinary counselling of couples with HIV prior to assisted reproduction

Assisted reproduction is used to support couples with human immunodeficiency virus (HIV) in achieving pregnancy without compromising the health of the partner or the offspring. This complex situation requires a joint effort by experts from different medical fields over prolonged periods. In order to fulfil all requirements, a comprehensive multidisciplinary counselling approach was initiated through round-table conventions of experts together with individual couples. The aim of this novel approach was an informed sharing of responsibility in the decision-making process, and also to ensure the adherence of the couples. The experts' and the couples' experience of the multidisciplinary meetings was evaluated using structured questionnaires. A total of 34 couples were referred, 15 with the male partner HIV infected, 15 with the female partner infected, four with both partners infected. Twenty-two couples participated in the multidisciplinary counselling. Three couples withdrew after counselling. Fourteen pregnancies were achieved leading to the birth of eight children. The experts viewed the panel's composition and the decision-making process as valuable, necessary and beneficial to the couples. The responding couples considered the meetings to be clarifying and helpful and they felt respected. It is concluded that the round-table multidisciplinary meeting approach is a feasible option for HIV-affected couples with infertility.

Good efficiency of intrauterine insemination programme for serodiscordant couples with HIV-1 infected male partner: A retrospective comparative study

OBJECTIVE

Assisted reproduction techniques can minimize the risk of HIV female contamination when the male partner is HIV-infected. The aim of this study was to investigate the efficiency of sperm washing and intrauterine insemination (IUI) in these couples.

STUDY DESIGN

Retrospective comparative study. Eighty-four HIV-1 serodicordant couples underwent 294 IUI. The control group was composed of 90 couples (320 IUI cycles) with donor sperm. Spermatozoa from HIV-1 infected male partner were prepared and tested for HIV-1 according to sperm washing method. Spermatozoa from HIV-1 and donor male were frozen before IUI. IUI were performed after ovarian stimulation. Main outcomes measures were pregnancy rate per cycle and baby take-home rate per couples.

RESULTS

Although the pregnancy rate and baby take-home rate were higher in IUI with sperm washing than in IUI using donor sperm (18.0 versus 14.7 and 52.4 versus 41.1, respectively), the differences were not statistically significant. In serodiscordant couples, blood estradiol levels under ovarian stimulation and total motile sperm inseminated were a determining factor in achieving pregnancy. No female HIV-1 contamination occurred.

CONCLUSION

This study demonstrates that sperm washing and IUI are highly effective in enabling serodiscordant couples with an HIV-1 infected male partner to have a child.

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

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

Safety of sperm washing and ART outcome in 741 HIV-1-serodiscordant couples

BACKGROUND

To evaluate the safety of sperm washing and assisted reproduction technique (ART) outcome offered to serodiscordant couples with a human immunodeficiency virus-1 (HIV-1)-positive male.

METHODS

Sperm washing was performed and checked by RT-PCR on each semen sample before its fresh usage. Intrauterine insemination (IUI) or IFV/ICSI was offered according to fertility profile of each couple. Non-infected women underwent HIV testing 2 weeks before each procedure and for up to 6 months after.

RESULTS

Seven hundred and forty-one couples entered the study of a possible 2011 serodiscordant couples counselled over 4 years. Superovulation and IUI were performed in 581 couples, where the pregnancy rate per cycle and pregnancy rate per couple were 19 and 78%, respectively, with multiple pregnancy rate being 4%. One hundred and sixty couples were treated by IVF/ICSI, where pregnancy rate per cycle and per couple were 22 and 41%, respectively, with multiple pregnancy rate being 10%. All female partners were still HIV-1 negative at follow-up.

CONCLUSION

Sperm washing within a programme of reproductive counselling was proved to be safe in this large series of serodiscordant couples. The overall pregnancy rate (70.3%), independent of the procedure used (IUI or IVF/ICSI), justifies the effort of the medical team in setting up and implementing dedicated centres and of the individual patient in seeking a safe pregnancy.