Decreased pregnancy rate after in-vitro fertilization in HIV-infected women receiving HAART

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.

Assisted reproductive technology outcomes in women with a chronic viral disease

OBJECTIVE

The aim of this study was to evaluate the cumulative live birth rate in women undergoing in-vitro fertilization/intracytoplasmic-sperm-injection (IVF/ICSI) according to the type of chronic viral infection [HIV, hepatitis-B virus (HBV) and hepatitis-C virus (HCV)].

DESIGN

A cohort study.

SETTING

A tertiary-care university hospital.

PARTICIPANTS

Women with a chronic viral illness HIV, HBV or HCV- were followed until four IVF/ICSI cycles had been completed, until delivery or until discontinuation of the treatment before the completion of four cycles.

MAIN OUTCOME MEASURES

The primary outcome was the cumulative live birth rate after up to four IVF/ICSI cycles.

RESULTS

A total of 235 women were allocated to the HIV-infected group (n = 101), the HBV-infected group (n = 114) and the HCV-infected group (n = 20). The cumulative live birth rate after four cycles was significantly lower in the HIV-infected women than in those with HBV [39.1%, 95% confidence interval (95% CI): 17.7-60.9 versus 52.8%, 95% CI: 41.6-65.5, respectively; P = 0.004]. Regarding the obstetrical outcomes, the mean birth weight was lower in the HIV-infected women than in those with HBV or HCV. Multivariate analysis indicated that the age, the anti-Müllerian hormone and the number of cycles performed were significantly associated with the chances of a live birth.

CONCLUSION

HIV-infected women had lower cumulative live birth rate than women with chronic hepatitis, and this was due to less favourable ovarian reserve parameters. These findings underscore the need to better inform practitioners and patients regarding fertility issues and the importance of early fertility assessment. However, larger studies are necessary to gain more in-depth knowledge of the direct impact of HIV on live birth rates.

HIV and amenorrhea: a meta-analysis

OBJECTIVE

There is conflicting literature to support a link between HIV and amenorrhea. Here, we conduct a meta-analysis to summarize the results from landmark studies in this area and shed light on this important clinical association.

METHODS

Using a search of Ovid Medline and Embase, a total of 322 articles were screened for controlled matched observational studies of amenorrhea in premenopausal women living with HIV (WLWH). For inclusion, amenorrhea was defined as absence of menses for 3 months or longer. The meta-analysis used a random-effects model with an I2 calculated to assess heterogeneity.

RESULTS

Six studies from 1996 to 2010 were included in our analysis for a total of 8925 women (6570 WLWH). There was a significant association between HIV status and amenorrhea (OR 1.68, P value 0.0001) without evidence of heterogeneity (I2: 0.0%). In the majority of studies, there was no significant difference in substance use, smoking, or socioeconomic status between WLWH and controls. Additionally, in the majority of studies, amenorrhea in the setting of low BMI was significantly more frequent in WLWH than controls.

CONCLUSION

This meta-analysis provides a large population assessment of amenorrhea in HIV to suggest increased prevalence of menstrual disturbances in WLWH. It lends evidence suggestive that this relation is independent of substance use and socioeconomic status, but may be related to low BMI. Our findings reinforce the importance of routine assessment of reproductive health and time of last menstrual period as part of the health assessment of women, especially those living with HIV.

[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.

Nucleoside reverse transcriptase inhibitor-induced rat oocyte dysfunction and low fertility mediated by autophagy

Low fertility is one of the most common side effects caused by nucleoside reverse transcriptase inhibitors (NRTIs), whereas the molecular mechanism underlying this process were largely unclear. This study was conducted to investigate whether autophagy plays a role in NRTIs-induced oocyte dysfunction and low fertility in female rat. Both in vivo and in vitro experiments were conducted. For the in vivo experiment, female adult Sprague-Dawley rats were subjected to zidovudine (AZT) and lamivudine (3TC) intragastric treatment for 3, 6, 9, and 12 weeks; a control was also set. Oocytes were collected for maturation evaluation, in vitro fertilization and mitochondrial function assays, and apoptosis and autophagy analysis. For the in vitro experiment, oocytes were collected and assigned to the control, 3-methyladenine (3-MA, an effective autophagy inhibitor), AZT, AZT+3-MA, 3TC, and 3TC+3-MA groups. The oocytes were cultured with the abovementioned drugs for 24, 48, and 72 h and then, subjected to the same assays as in the in vivo study. The results showed a significant time-dependent decrease in oocyte maturation-related maker levels, oocyte cleavage rate, blastocyst formation rate, mitochondrial DNA copy number and adenosine triphosphate level, and apoptosis, and a significant increase in the reactive oxygen species levels (all P-values < 0.05), in both the in vivo and the in vitro experiments. These changes, except for the changes in the oocyte maturation-related markers, were partially attenuated by 3-MA. In conclusion, we demonstrated that NRTIs can cause rat oocyte dysfunction and low fertility, and this damage was, at least partially, mediated by autophagy.

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.

Natural conception in HIV-serodiscordant couples with the infected partner in suppressive antiretroviral therapy: A prospective cohort study

The potential of antiretroviral treatment (ART) to prevent the sexual transmission of HIV has increased the number of serodiscordant couples who are considering natural conception. We aim to describe the results of a protocol for reproductive counseling aimed at HIV serodiscordant couples who desire natural conception, in which the infected partner, the index case, is receiving suppressive antiretroviral treatment.A prospective cohort included all HIV serodiscordant couples attended a counseling program in the period 2002 to 2013 who opted for natural conception and met the following criteria: index case on ART with persistent plasma viral suppression for at least the previous 6 months, ART compliance over 95%, preserved immune status, undetectable HIV viral and proviral load in semen in male index cases, and absence of genitourinary infections and fertility problems in both members of the couple.Of the 161 HIV serodiscordant couples included, 133 with male index cases, 66% achieved at least 1 pregnancy, 18% a second one, and 5% a third pregnancy. A total of 144 natural pregnancies occurred and 107 babies were born. The pregnancy rate was 1.9 for each 100 acts of vaginal intercourse, and the mean time to conception was 6.1 months, both independently of the sex of the index case. No case of sexual or vertical HIV transmission occurred.In the absence of fertility problems and under controlled conditions, natural conception might be a safe and effective reproductive method for those HIV serodiscordant couples who choose this reproductive option.

People living with HIV and procreation: 30 years of progress from prohibition to freedom?

The emergence of human immunodeficiency virus (HIV) infection in the 1980s drastically changed the prospects of conceiving a child for the man or woman infected with the virus. Advances in treatment then made it possible to envisage pregnancy while decreasing the risk of transmission to the child when the mother was infected. For couples where one partner was HIV-positive and who desired a child, recourse to medical help, notably medically assisted procreation, was discouraged, and very few centres offered such assistance in the 1980s and 1990s. Improved knowledge of viral excretion in the genital tracts, together with more effective treatment, made it possible to envisage medically assisted procreation for these couples, allowing them to have a child while at the same time likely reducing the risk of transmitting HIV to their partner. Several programmes have demonstrated their effectiveness in this domain. Owing to continually increasing knowledge over the past decade, natural conception can now be proposed. Couples where one or both partners are HIV-positive may opt for medically assisted procreation or natural reproduction. Specialists in reproductive medicine and HIV specialists need to provide couples with objective information allowing them to achieve near-optimal conditions that minimize HIV transmission risk. Couples will then be able to choose freely the mode of procreation most appropriate for them.

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.

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.

Perception of sexuality and fertility in women living with HIV: a questionnaire study from two Nordic countries

INTRODUCTION

As the human immunodeficiency virus (HIV)-positive population ages, issues concerning sexuality and fertility, among others, are becoming relevant. HIV is still surrounded by stigma and taboos, and there have been few studies conducted in industrialized settings concerning these questions. We therefore wanted to investigate the perception of sexuality and fertility in women living with HIV (WLWH) in an industrialized setting, using a questionnaire.

METHODS

WLWH were recruited at their regular outpatient clinic visits, at the major Departments of Infectious Diseases in Denmark and Finland, from January 2012 to October 2013. A questionnaire was developed, study participants were informed of the nature of study and, if they agreed to participate and signed a consent form, they filled in the questionnaire. Demographic information on the participants was obtained from patient files (in Finland) or from a national HIV cohort (in Denmark). Statistical analysis was performed using STATA, version 11.

RESULTS

In total, 560 women were included in the study. The median age was 44 years. The majority were of white European origin, with fully suppressed HIV viral load, CD4 cell count >350 µL and mild or no symptoms of their HIV infection. A total of 62% were sexually active, stating condom use as their sole form of contraception. Of the sexually inactive women, one-third were in steady relationships. Eighty percent reported prior pregnancies, of which the majority had one or more children. Most children were born prior to the women's HIV diagnosis and the mode of conception was predominantly natural. One-quarter of the participating women desired pregnancy, while more than half did not. The remaining quarter either stated that they already had the desired number of children or chose not to answer the question. Fourteen percent stated that their HIV diagnosis ended their wish for children; of these women, the median time of diagnosis was between 1995 and 1996. Pregnancy had been attempted unsuccessfully in one-quarter of study participants. The final question inquired what the risk of mother-to-child transmission was, with all precautions taken. Fifteen percent estimated the risk to be above two percent.

CONCLUSIONS

In conclusion, the majority of WLWH in industrialized settings in Denmark and Finland have few HIV-related symptoms, are sexually active and have a strong desire for children.

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.

[Consensus statement on monitoring of HIV: pregnancy, birth, and prevention of mother-to-child transmission]

OBJECTIVE

The main objective in the management of HIV-infected pregnant women is prevention of mother-to-child transmission; therefore, it is essential to provide universal antiretroviral treatment, regardless of CD4 count. All pregnant women must receive adequate information and undergo HIV serology testing at the first visit.

METHODS

We assembled a panel of experts appointed by the Secretariat of the National AIDS Plan (SPNS) and the other participating Scientific Societies, which included internal medicine physicians with expertise in the field of HIV infection, gynecologists, pediatricians and psychologists. Four panel members acted as coordinators. Scientific information was reviewed in publications and conference reports up to November 2012. In keeping with the criteria of the Infectious Diseases Society of America, 2levels of evidence were applied to support the proposed recommendations: the strength of the recommendation according to expert opinion (A, B, C), and the level of empirical evidence (I, II, III). This approach has already been used in previous documents from SPNS.

RESULTS AND CONCLUSIONS

The aim of this paper was to review current scientific knowledge, and, accordingly, develop a set of recommendations regarding antiretroviral therapy (ART), regarding the health of the mother, and from the perspective of minimizing mother-to-child transmission (MTCT), also taking into account the rest of the health care of pregnant women with HIV infection. We also discuss and evaluate other strategies to reduce the MTCT (elective Cesarean, child's treatment…), and different aspects of the topic (ARV regimens, their toxicity, monitoring during pregnancy and postpartum, etc.).

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.

Fertility choices and management for HIV-positive women

PURPOSE OF REVIEW

It is becoming increasingly important to address the issue of reproductive counselling and management of HIV-infected individuals during their reproductive years. Sexual and reproductive health-related needs and aspirations are similar to those of uninfected individuals but some differences require specific attention, which are discussed in this review.

RECENT FINDINGS

Hormonal contraception should be used with caution in women on antiretroviral treatment. Its impact on both HIV infectivity and disease progression is still controversial. An intrauterine device can be considered for pregnancy prevention and pregnancy termination should be offered in safe conditions. HIV-infected women have a lower spontaneous fertility rate, which may persist after assisted reproduction. Data on safety of antiretroviral treatment during conception are reassuring. No clear association can be found between exposure to antiretrovirals and fetal abnormalities. Secondary prevention remains crucial and condom use remains a key method.

SUMMARY

Different topics related to fertility choices among HIV-infected patients should be addressed. Family planning methods and termination of pregnancy have specific aspects among infected individuals. When needed, medically assisted reproduction may be required and antiretroviral treatment should be adapted before conception. Secondary prevention has a key role in reducing newly acquired infections.

Evaluating safer conception options for HIV-serodiscordant couples (HIV-infected female/HIV-uninfected male): a closer look at vaginal insemination

HIV serodiscordant couples represent at least half of all HIV-affected couples worldwide. Many of these couples have childbearing desires. Safer methods of conception may allow for pregnancy while minimizing the risk of sexual transmission of HIV. In serodiscordant partnerships with an HIV-infected female and HIV-uninfected male, vaginal insemination of a partner's semen during the fertile period coupled with 100% condom use may be the safest method of conception.

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

Human immunodeficiency virus serodiscordant couples on highly active antiretroviral therapies with undetectable viral load: conception by unprotected sexual intercourse or by assisted reproduction techniques?

Until recently, only assisted reproduction was proposed to serodiscordant couples wishing to conceive. Nevertheless, recent publications have proposed unprotected sexual intercourse, targeting fertile days, for couples where antiretroviral treatment has lowered blood viral load to an undetectable level. Available data and the arguments for and against conception by safe sex versus the use of a strategy of unprotected sexual intercourse targeting fertile days are reviewed and analyzed. Although the rate of transmission of human immunodeficiency virus in serodiscordant couples in precise conditions (such as an undetectable viral load on treatment by highly active antiretroviral therapies and sexual intercourse limited to the fertile days) is very low, not zero, here we stress the various factors which can increase the risk of seroconversion in this particular population. In this context, it seems less cautious to abandon the recommendations of safe sex in serodiscordant couples desiring a child. The recourse to medically assisted procreation is advised, as long as evidence from further studies does not show that unprotected sexual intercourse, targeted to fertile days, does not have unexpected harmful consequences.

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.

Mitochondrial DNA Depletion in Oocytes of HIV-Infected Antiretroviral-Treated Infertile Women

Background

HIV-infected women under highly active antiretroviral therapy (HAART) undergoing in vitro fertilization (IVF) have a lower pregnancy rate than non-infected controls, which depends on oocyte-related factors. We hypothesized that mitochondrial toxicity caused by antiretrovirals could be the underlying mechanism of such disturbance.

Methods

We have studied 16 and 19 frozen-thawed oocytes obtained after oocyte retrieval IVF cycles from 8 and 14 infertile HIV-infected and uninfected women, respectively, matched by age. At inclusion, HIV-positive women had been infected for >13 years and had received HAART for >9 years, including at least one nucleoside reverse transcriptase inhibitor. All of them had undetectable HIV viral load and a good immunological status. Mitochondrial DNA (mtDNA) content was determined by quantitative real-time PCR in each individual oocyte.

Results

HIV-infected infertile women on HAART showed significant oocyte mtDNA depletion when compared with uninfected controls (32% mtDNA decrease, P<0.05). This oocyte mtDNA depletion was even greater on those HIV-infected women who failed to become pregnant when compared with controls (39% mtDNA decrease, P=0.03). No significant correlation was found between mtDNA oocyte content and cumulative doses of antiretrovirals or the immunological status of HIV patients.

Conclusions

Oocytes from infertile HIV-infected HAART-treated women show decreased mtDNA content, and this could explain their poor reproductive outcome.

Infertility Treatment for HIV-Positive Women

Thanks to antiretroviral combination therapy, HIV-infected individuals live longer, healthier lives and may wish to have children. Women with HIV can attempt to conceive naturally or through simple self-insemination to minimize the risk of horizontal HIV transmission. Assisted reproduction technology is necessary in couples with infertility, which can either be independent of HIV infection and its treatment or be associated with it. This article summarizes the latest evidence regarding the desire for a child in HIV-positive women and how HIV infection and its treatment may impact female fertility. Current data regarding access to and outcomes of assisted conception programs in HIV-positive women wishing to conceive in both high- and low-income countries is also reviewed.

Désir d'enfant et infections virales: hépatites C et B et virus de l'immunodéficience humaine

The French law (arrêté du 10 mai 2001) allows Assisted Reproductive Techniques (ART) in case of infection with human immunodeficiency virus, hepatitis C virus or hepatitis B virus. Our six years' experience is positive even if pluridisciplinary care needs specific equipment and human forces. Couples express high motivation. The wish to become a parent leads to a better care of the infection. ART results are excellent in case of male contamination, not as good when the female partner is infected but still encouraging. No contamination of the partner or the offspring occurred after ART. Data are already collected in France in this context. A European register should be constituted in an early future.

Fertility assessment in non-infertile HIV-infected women and their partners

The objective of the study was to assess the fertility of non-infertile couples seeking pregnancy in whom the woman was HIV infected. Therefore, a cross-sectional study was conducted between January 1998 and March 2005. A standardized fertility assessment was performed in all the included couples. A total of 130 women and 121 men were evaluated. Their median age was 34 years (range 22-43). Only 7.2% of the women were severely immunocompromised. The majority of women had regular cycles. Only one woman had an active sexually transmitted disease at the time of evaluation. A tubal occlusion on hysterosalpingogram was present in 27.8% of the women with no proven fertility. In 50.5% of the women, hepatitis C virus co-infection was present. One-third of the male partners (38/121) was infected with HIV. Abnormal semen parameters were observed in 83.4% of HIV-infected and 41.7% of HIV-uninfected partners (OR = 7; 95% CI = 2.1-23). It is concluded that the great majority of the HIV-infected women seeking pregnancy had a good infection status. Because in many of the couples, the women presented unexplained tubal occlusions and the men presented semen alterations, a hysterosalpingography and semen analysis should be part of the preconceptional investigations.

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.

Natural Pregnancies in HIV-Serodiscordant Couples Receiving Successful Antiretroviral Therapy

Increasing numbers of HIV-serodiscordant heterosexual couples are concerned about the chances for pregnancy. We reviewed all natural pregnancies attained by HIV-serodiscordant couples seen in 3 clinics in Spain, in which the infected partner had undetectable plasma viremia while receiving highly active antiretroviral therapy (HAART). In the case of HIV-infected mothers, only those with undetectable viremia during pregnancy and at delivery were chosen. A total of 62 HIV-serodiscordant couples, 22 HIV-infected women (mean CD4 count of 522 cells/microL, 55% hepatitis C virus [HCV]-seropositive) and 40 HIV-infected men (mean CD4 count of 629 cells/microL, 75% HCV-seropositive), were recorded. Overall, 76 natural pregnancies occurred, and 68 children were born. There were 9 fetal deaths, 1 twin pregnancy, 6 couples with 2 consecutive babies, and 4 couples with 3 consecutive newborns. There were no cases of HIV seroconversion in uninfected sexual partners. One case of vertical HIV transmission occurred, however. Serodiscordant couples attaining natural pregnancy are exposed to a negligible risk of sexual transmission of HIV when the infected partner presents with complete suppression of plasma viremia while receiving HAART.