HIV and Reproductive Care


• CD4+ lymphocytes >200/mm3 at least twice in the four months prior to treatment;


• stable viral load; and •


infection by an quantifiable, amplifiable strain of HIV-1.


Each couple was interviewed by a psychologist at inclusion and thereafter whenever necessary. Female fertility was assessed by standard procedures.


In clinical practice it is important to screen HIV-discordant couples to determine infertility factors due to the high prevalence of subfertility factors. One of the most important factors is genital tract infection in both males and females. The exact mechanisms involved in male-to-female transmission of HIV-1 are as yet undefined, but circumstantial evidence indicates that genital tract infections may act as facilitating factors. In sub-Saharan and Latin American countries, where heterosexual transfer of the virus is the leading cause of infection, there is also a high prevalence of genital infection carriers. The presence of a sexually transmitted pathogen recruits inflammatory cells in both the male and female genital tract. This may increase the number of HIV-1-infected cells in the semen or vaginal fluid of the seropositive subject, leading to a higher risk of infection for the seronegative partner. Conversely, when genital tract infection is present in the seronegative partner, the uninfected inflammatory cells may become a specific target for the virus.


The ART laboratory used for the procedure was considered to be a ‘viral risk’ area. It was separated from laboratory facilities used for couples negative for HIV and hepatitis B and C. The ART laboratory complied with standard recommended safety precautions. Specific precautions were implemented against the risk of HIV and hepatitis B and C contamination, as recommended by the French decree of 10 May 2001.45


technique of choice in serodiscordant couples with an HIV-positive male partner when no other infertility problems are involved. When the female partner was suffering from infertility factors, the male partner had fewer than 1x106 total motile cells in the final fraction after sperm washing or both partners had a combination of subfertility conditions, IVF/ICSI was performed. The pregnancy rate per embryo transfer was in agreement with similar smaller HIV series37


and larger non-HIV series.48 Other markers of outcome were


as good in these couples treated after sperm washing as in other infertility series of comparable age: fertilisation rate was 65% by IVF and 88% by ICSI.38


The problem with ICSI in serodiscordant couples is the high multiple pregnancy rate and possible obstetric and neonatal complications associated with these pregnancies (14% for Garrido38 Pena).48


and 57.1% for


The possible additional costs determined by pre-natal and neonatal care in multiple pregnancies should be considered.49–51 In the authors’ experience, the multiple pregnancy rate by IVF/ICSI was 10%, reflecting the special care in superovulation induction and embryo transfer. In 2002, at the Luigi Sacco Biomedical Institute, more than 4,000 IUIs were performed in serodiscordant couples and 1,000 fertilisation in vitro and embryo transfer (FIVET)/ ICSI cycles without HIV-1 transmission to the female partners with an adequate follow up.


Reproductive Assistance in an HIV-discordant Couple with an HIV-positive Female Some preliminary studies suggest that HIV-infected women may have a decreased fertility rate52


and a higher frequency of


menstruation disturbances associated with low CD4 cell counts53 and upper genital tract infections.54


Ovarian resistance to In addition, severe ovarian


dysfunction, such as premature ovarian failure or ovarian resistance to stimulation, has also been described.55,56


The potentially infected gametes and embryos were handled separately. A special biosafety cabinet workstation was used for all tasks that involved handling of sperm, oocytes and embryos.


In the Department of Obstetrics and Gynecology at the Luigi Sacco Biomedical Institute, the IUI pregnancy rate per cycle is 19% and per couple is 78%. Here, the pregnancy rate per couple was higher than the average 57% overall pregnancy rate by IUI in serodiscordant couples summarised by Sauer in 2005.47


These results could be


explained by the routine adoption of ovulation induction with low doses of recombinant fluorescence in situ hybridisation (FISH) and timing of ovulation with recombinant luteinising hormone (LH), according to Marina.40


It could also be due to the standard usage of


fresh sperm after realtime PCR or due to a good selection of cases, with an average of four attempts per couple. In addition, other centres used frozen semen.37


There is a negative impact on the


number of available motile sperm after freezing, as already reported,43


which has a resultant impact on pregnancy rate per IUI.


At the centre at the Luigi Sacco Biomedical Institute more than 3,000 IUIs have been performed. This large number of cases, with safe pregnancy after sperm washing and the consistent biological results that have been published, has led the authors to consider the efficiency of sperm washing to be high.47


The efficiency of IUI, its safe outcome after sperm washing with swim-up and its relatively low cost make this first-level procedure the


EUROPEAN OBSTETRICS & GYNAECOLOGY


hyperstimulation may add to this effect because a greater number of units of gonadotrophins were needed to adequately stimulate these patients. This resistance may reflect an underlying subclinical (normal menses) and subanalytical (comparable basal FISH values) hypogonadism. Superovulation may be considered a functional stress test on the ovary.


Very few data are available on the presence of viral material in the cumulus oophorus complex of infected women. Baccetti26


exposed


unfertilised human oocytes partly surrounded by follicular cells to low doses of HIV-1 and found that they remained negative for the presence of HIV-1 DNA. This suggests the resistance of oocytes to HIV-1 penetration, possibly as a result of the absence of specific receptors for the virus, as assessed by immunocytochemistry. Bertrand57


was unable to detect the presence of HIV-1 genetic material in the follicular fluid or flush fluids of patients with undetectable plasma viral loads. Nevertheless, in one of his patients with a low but detectable load, HIV-1 RNA was detected in one follicular fluid and one flush.


A paper from Martinet58 evaluates the ovarian response to IVF


stimulation of HIV-positive patients compared with control patients. No significant difference was observed between HIV-positive patients and matched negative controls in terms of ovarian response to stimulation. The pregnancy rate calculated per transfer was 14%, which is lower than that obtained by Ohl (23.9%)59 results of Terriou and colleagues (16.1%).60


but similar to the The latter authors


21


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