Detection of HIV and HCV RNA in semen from Brazilian coinfected men using multiplex PCR before and after semen washing

The negative impact of most relevant infections on fertility and assisted reproduction technology

Infections may act with variable impact on the physiopathology of the reproductive organs, determining infertility or reducing the outcomes of assisted reproduction technology. The aim of this narrative review is to describe the existing evidence regarding the pathogens with a supposed or recognized role in reproductive medicine. Viral hepatitis, as well as HIV, can reduce sperm quality. Syphilis carries a risk of erectile dysfunction and increased endometrial thickness. Chlamydia is the main cause of pelvic inflammatory disease. In relation to Mycoplasma and Ureaplasma spp., only few species seem to show a correlation with infertility and poor in-vitro fertilization outcomes. There is evidence of a role for bacterial vaginosis in early pregnancy loss. HPV infection in males seems to determine infertility. Herpesviruses are more a risk for fetuses than for fertility itself. Zika virus is responsible for altered early embryo development and waiting to conceive is recommended in suspected or confirmed cases. The impact of SARS-CoV-2 is yet to be elucidated. Rubella and toxoplasmosis can provoke important congenital defects and therefore screening is mandatory before conception; a vaccine for Rubella is recommended. Further and well-designed studies are still needed to better elucidate the role of some infectious agents, to improve fertility and its treatments.

ESHRE guideline: medically assisted reproduction in patients with a viral infection/disease

STUDY QUESTION

What is the recommended management for medically assisted reproduction (MAR) in patients with a viral infection or disease, based on the best available evidence in the literature?

SUMMARY ANSWER

The ESHRE guideline on MAR in patients with a viral infection/disease makes 78 recommendations on prevention of horizontal and vertical transmission before, during and after MAR, and the impact on its outcomes, and these also include recommendations regarding laboratory safety on the processing and storage of gametes and embryos testing positive for viral infections.

WHAT IS KNOWN ALREADY

The development of new and improved anti-viral medications has resulted in improved life expectancy and quality of life for patients with viral infections/diseases. Patients of reproductive age are increasingly exploring their options for family creation.

STUDY DESIGN SIZE DURATION

The guideline was developed according to the structured methodology for the development of ESHRE guidelines. After the formulation of nine key questions for six viruses (hepatitis B virus, hepatitis C virus, human immunodeficiency virus, human papilloma virus, human T-lymphotropic virus I/II and Zika virus) by a group of experts, literature searches and assessments were performed. Papers published up to 2 November 2020 and written in English were included in the review. Evidence was analyzed by female, male or couple testing positive for the virus.

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. There were 61 key questions to be answered by the guideline development group (GDG), of which 12 were answered as narrative questions and 49 as PICO (Patient, Intervention, Comparison, Outcome) questions. A stakeholder review was organized after the finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

This guideline aims to help providers meet a growing demand for guidance on the management of patients with a viral infection/disease presenting in the fertility clinic.The guideline makes 78 recommendations on prevention of viral transmission before and during MAR, and interventions to reduce/avoid vertical transmission to the newborn. Preferred MAR treatments and interventions are described together with the effect of viral infections on outcomes. The GDG formulated 44 evidence-based recommendations-of which 37 were formulated as strong recommendations and 7 as weak-33 good practice points (GPP) and one research only recommendation. Of the evidence-based recommendations, none were supported by high-quality evidence, two by moderate-quality evidence, 15 by low-quality evidence and 27 by very low-quality evidence. To support future research in the field of MAR in patients with a viral infection/disease, a list of research recommendations is provided.

LIMITATIONS REASONS FOR CAUTION

Most interventions included are not well-studied in patients with a viral infection/disease. For a large proportion of interventions, evidence was very limited and of very low quality. More evidence is required for these interventions, especially in the field of human papilloma virus (HPV). Such future studies may require the current recommendations to be revised.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in MAR for patients with a viral infection/disease, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in the field.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive any financial incentives, all work was provided voluntarily. A.D. reports research fees from Ferring and Merck, consulting fees from Ferring, outside the submitted work. C.P. reports speakers fees from Merck and MSD outside the submitted work. K.T. reports speakers fees from Cooper Surgical and Ferring and consultancy fees as member of the advisory board BioTeam of Ferring, outside the submitted work. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at  www.eshre.eu/guidelines.).

Reproductive considerations in the setting of chronic viral illness

Special considerations must be taken when patients with human immunodeficiency virus (HIV), hepatitis B, or hepatitis C desire to become pregnant. Patients with chronic viral illnesses desire to have children at rates similar to the general population, and options are available to decrease both vertical transmission and viral transmission between partners. Preconception counseling or consultation with fertility specialists is imperative in patients with HIV, hepatitis B, and hepatitis C so that reproductive goals can be addressed and optimized. In couples in which one partner has HIV, the use of highly active antiretroviral therapy or preexposure prophylaxis can significantly reduce the risk of transmission between serodiscordant partners. The use of density gradient sperm-washing techniques and intrauterine insemination or in vitro fertilization results in an apparent lack of transmission of HIV between partners when the male partner is HIV-positive. Vertical transmission of HIV from mother to child can be reduced by use of highly active antiretroviral therapy regimens throughout pregnancy or by cesarean delivery in the setting of high maternal viral load. Transmission of hepatitis B between partners can be eliminated by vaccinating the uninfected partner. Vertical transmission from a hepatitis B-infected mother to a child can be reduced by vaccinating neonates with the standard hepatitis B vaccine series as well as hepatitis B immune globulin. Recent data have shown the antiviral medication tenofovir to be an effective way to reduce vertical transmission in the setting of high maternal viral load or the presence of hepatitis B e antigen. There are multiple antiviral medications available to treat chronic hepatitis C, although access to these medications often is limited by cost. Similar to HIV-positive patients, in settings in which the male partner is infected with hepatitis C, density gradient sperm washing can be used before intrauterine insemination or in vitro fertilization to reduce transmission of hepatitis C between partners. No safe and effective method exists to reduce vertical transmission of hepatitis C once a woman becomes pregnant, highlighting the importance of treatment of hepatitis C before pregnancy.

Uso da técnica de swim-up para a remoção do Vírus da Artrite Encefalite Caprina do sêmen de reprodutores infectados

Neste estudo, 67 ejaculados foram avaliados, antes e depois da técnica de swim-up,em relação à qualidade seminal e à presença do CAEV. Das 67 amostras testadas por PCRn, antes do swim-up,47 (70,15%) foram positivas para o DNA pró-viral. No entanto, quatro amostras adicionais foram positivas ao RT-nested PCR após o swim-up, o que permite dizer que, pelo menos, 76,12% (51/67) delas estavam infectadas antes da lavagem. Todavia, em 23,88% (16/67) das amostras não foi detectada a presença do CAEV. Após a aplicação da técnica de swim-up, constatou-se, pela PCRn e RT-nested PCR, que houve uma redução significativa (χ²= 9,078; p<0,001) da presença do CAEV nas amostras seminais, pois 28 de 51 amostras positivas resultaram livres do vírus (54,90%), tanto para DNA pró-viral quanto para o vírus livre. Em relação à motilidade individual progressiva (MIP) e vigor espermático obtidos antes e depois da técnica de swim-up,observou-se uma diminuição significativa em suas médias, sendo o MIP de 86,42% para 71,49%, já o vigor espermático de 4,16 para 3,93. Conclui-se que a eliminação do CAEV no sêmen é de caráter intermitente, e que a associação da PCRn e RT-nested PCR é uma opção segura para a certificação sanitária individual das amostras seminais quanto à presença ou ausência do CAEV. Finalmente, a técnica de swim-uppromove uma redução na infectividade de amostras de sêmen contaminadas, e, além disso, é possível promover a recuperação de espermatozoides viáveis.

Development and evaluation of a new detection tool-visual DNA microarray for simultaneous and specific detection of human immunodeficiency virus type-1 and hepatitis C virus

Human immunodeficiency virus type-1 (HIV-1) and hepatitis C virus (HCV) are transfusion-transmitted human pathogens that have a major impact on blood safety and public health. Based on multiplex asymmetrical PCR and coupled with gold labelled silver stain (GLSS), we developed the visual DNA microarray for sensitive and specific detection of these two viruses. Capturing probes of 5'-end-amino-modified oligonucleotides were immobilized on glass surface to bind the complement biotinylated target DNA. The Au-streptavidin probe was introduced to the microarray for specific binding to biotin. Black images of microarray spots which result from the precipitation of silver onto Au-streptavidin probes, were visualized by naked eyes. In order to improve the efficiency of microarray hybridization, triplex asymmetrical PCR of HIV-1, HCV and Human enterovirus 71 (EV-71, used as positive control) were performed to prepare abundant biotinylated single-stranded target DNA. The sensitivity of visual DNA microarray (10(3) copies/ml) was higher than conventional PCR (10(4) copies/ml) and was identical to FQ-PCR (10(3) copies/ml). Total 152 blood samples containing the two viruses were tested using the DNA microarray and fluorescence quantitative real-time PCR (FQ-PCR). The results were identical (P > 0.05). So this system has high sensitivity and may have potential in clinical applications.