Lital Hollander

Safety and efficacy of sperm washing in HIV-1-serodiscordant couples where the male is infected: results from the European CREAThE network.

Objective:To examine the safety and effectiveness of assisted reproduction using sperm washing for HIV-1-serodiscordant couples wishing to procreate where the male partner is infected. Design and methods:A retrospective multicentre study at eight centres adhering on the European network CREAThE and involving 1036 serodiscordant couples wishing to procreate. Sperm washing was used to obtain motile spermatozoa for 3390 assisted reproduction cycles (2840 intrauterine inseminations, 107 in-vitro fertilizations, 394 intra-cytoplasmic sperm injections and 49 frozen embryo transfers). An HIV test was performed in female partners at least 6 months after assisted reproduction attempt. The outcome measures recorded were number of assisted reproduction cycles, pregnancy outcome and HIV test on women post-treatment. Results:A total of 580 pregnancies were obtained from 3315 cycles. Pregnancy outcome was unknown in 47 cases. The 533 pregnancies resulted in 410 deliveries and 463 live births. The result of female HIV testing after assisted reproduction was known in 967 out of 1036 woman (7.1% lost to follow-up). All tests recorded were negative. The calculated probability of contamination was equal to zero (95% confidence interval, 0–0.09%). Conclusion:This first multicentre retrospective study of assisted reproduction following sperm washing demonstrates the method to be effective and to significantly reduce HIV-1 transmission risk to the uninfected female partner. These results support the view that assisted reproduction with sperm washing could not be denied to serodiscordant couples in developed countries and, where possible, could perhaps be integrated into a global public health initiative against HIV in developing countries.

Sperm washing, use of HAART and role of elective Caesarean section

Purpose of review Today, 50% of people living with HIV are women and most have been sexually infected. Highly active antiretroviral therapy (HAART) reduces the rates of both sexual and vertical infection, but maximum protection is achieved with sperm washing and elective Caesarean section. Recent findings Men taking HAART have lower seminal concentration of HIV, and sexual transmission may be reduced. However, a certain percentage of aviraemic men retain viral presence in semen, and unprotected intercourse to achieve fertilization must be discouraged as it carries the risk of sexual transmission of the virus. HIV-discordant couples should be informed that sperm washing can remove HIV from semen, allowing conception without the risk of infection for the seronegative female and eventually the child. In HIV-positive women, perinatal transmission of HIV can be curtailed to less than 2% by using HAART to decrease maternal viral load and offering prenatal preexposure prophylaxis of the fetus, and elective Caesarean section. Each intervention carries specific risks and benefits. The contribution of each preventive arm in achieving fetal protection can only be crudely measured and optimal obstetric management must involve discussion with the pregnant woman of the pros and cons of each strategy. Summary In HIV-positive men taking HAART, seminal viral load is decreased but not eliminated and fertilization should be achieved through sperm washing to offer maximum protection for the uninfected female. Pregnant HIV-positive women on antiretroviral medication have a reduced risk of transmitting the virus, but should still be counselled about the possibility to further limit the chances of infecting their infant through elective Caesarean section.

Safe conception for HIV-discordant couples: insemination with processed semen from the HIV-infected partner.

OBJECTIVE The objective of the study was to evaluate the safety of semen washing with intrauterine insemination (SW-IUI) for achieving pregnancy when the man is human immunodeficiency virus (HIV) infected and the woman is HIV negative. STUDY DESIGN We conducted a retrospective analysis of 635 HIV-discordant couples enrolled in a SW-IUI program and followed up 367 Italian women. We computed pregnancy, live birth, and multiple delivery rates and assessed the womens postinsemination HIV status. RESULTS The retrospective analysis included 635 couples (2113 SW-IUI cycles): 41% of the women (95% confidence interval [CI], 37-45%) had a live birth (per-cycle live birth rate 13%; 95% CI, 11-14%). HIV status after SW-IUI was negative when available but unknown for 26% of the women: missing HIV status was not associated with correlates of HIV risk. The follow-up study included 367 couples (1365 cycles): 47% of the women (95% CI, 42-52%) had a live birth (per-cycle rate 14%; 95% CI, 12-16%). Ascertainment of postinsemination HIV status was complete and confirmed no HIV transmission attributable to SW-IUI. The upper 95% confidence limit of the HIV transmission rate was 1.8 per 1000 cycles in the retrospective analysis and 2.7 per 1000 cycles in the follow-up study. CONCLUSION SW-IUI appears to be a safe and effective method for achieving pregnancy in HIV-discordant couples in which the man is HIV infected.

Safe Conception for HIV Discordant Couples through Sperm-Washing: Experience and Perceptions of Patients in Milan, Italy

Our research explored the reproductive desires of HIV-negative women and their HIV-positive partners who underwent assisted conception based on sperm-washing and intrauterine insemination in Italy. Twenty-two semi-structured interviews were conducted with former patients (6 women, 5 men and 11 couples). Desire for children, perceived risk from treatment and acceptability of the insemination technique were some of the issues explored. Participants had the treatment for a mean duration of 3.5 years, with a mean number of cycles of 5.3. They were highly motivated to conceive a biological child to bring purpose to their lives, and strongly desired options to conceive safely. Most rejected spontaneous conception. Those who successfully conceived reported a positive impact on their quality of life, fulfilling their desire to be parents and restoring their sense of “normalcy”. Participants strongly supported extending assisted conception services to all HIV negative women living with HIV positive partners who wished to become pregnant and felt that withholding such treatment was not ethically justified. They perceived assisted conception services to be a safe and effective alternative to spontaneous conception, and felt that society has a moral obligation to provide such services. Résumé Nous avons étudié les souhaits de femmes séronégatives au VIH et de leurs partenaires séropositifs qui s’étaient soumis à une procréation assistée avec lavage du sperme et insémination intra-utérine en Italie. Vingt-deux entretiens semi-structurés ont été menés avec d’anciens patients (6 femmes, 5 hommes et 11 couples). Le désir d’enfant, la perception du traitement et l’acceptabilité de la technique d’insémination figuraient parmi les questions abordées. Les participants ont suivi le traitement en moyenne pendant 3,5 ans, avec un nombre moyen de 5,3 cycles. Ils étaient très motivés pour concevoir un enfant biologique afin de donner un sens à leur vie, et demandaient des options pour procréer en toute sécurité. La plupart rejetaient la conception spontanée. Ceux qui ont conçu un enfant ont indiqué que cela avait eu des retombées positives sur leur qualité de vie, en satisfaisant leur désir d’être parents et leur redonnant un sentiment de « normalité ». Les participants soutenaient énergiquement l’élargissement des services de procréation assistée à toutes les femmes séronégatives vivant avec des partenaires séropositifs et qui souhaitaient avoir un enfant, et ils pensaient qu’il était moralement injustifié de refuser ce traitement. Ils estimaient aussi que la procréation assistée était une option sûre et efficace à la conception spontanée, et jugeaient que la société avait l’obligation morale de fournir de tels services. Resumen Nuestra investigación exploró los deseos reproductivos de mujeres VIH-negativas y sus parejas VIH-positivas, que pasaron por la concepción asistida basada en el lavado de espermatozoides e inseminación intrauterina, en Italia. Se realizaron 22 entrevistas semiestructuradas con antiguos pacientes (6 mujeres, 5 hombres y 11 parejas). Algunos de los aspectos explorados fueron: el deseo de tener hijos, el riesgo percibido del tratamiento y la aceptación de la técnica de inseminación. Los participantes recibieron el tratamiento por una duración media de 3.5 años, con un número medio de ciclos de 5.3. Estaban muy motivados a concebir un hijo biológico para darle sentido a sus vidas, y muy deseosos de tener opciones para concebir de manera segura. La mayoría rechazó la concepción espontánea. Aquéllos que lograron concebir informaron un impacto positivo en calidad de vida, realizar su deseo de ser padres y restaurar su sentido de “normalidad”. Los participantes apoyaron enfáticamente extender los servicios de concepción asistida a todas las mujeres VIH-negativas que viven con parejas VIH-positivas, que desean quedar embarazadas y opinan que la denegación de dicho tratamiento no se justifica éticamente. Percibieron los servicios de concepción asistida como una alternativa segura y eficaz a la concepción espontánea, y afirmaron que la sociedad tiene la obligación moral de proporcionar dichos servicios.

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.

Lack of clinical and scientific evidence to justify the systematic use of ICSI in HIV-serodiscordant couples wishing to conceive where the male partner is infected

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Mother-to-child HCV transmission

36.00 Copyright a2009 American 3. ICSI did not prove to be an ‘‘effective’’ treatment. The live birth rate (56.9%) in the ICSI group was similar to the cumulative live birth rate reported in IUI programs. From a public health perspective, if we integrate the cost of ICSI on the effectiveness, ICSI was less effective than IUI programs for HIV-serodiscordant couples, even when the cost of viral testing of semen is taken into account. Moreover, if we add the huge financial burden associated with MP and prematurity, ICSI then becomes a very costly treatment. In countries where health insurance companies often do not cover infertility treatment, the cost of ICSI may prohibit ART to reduce transmission risk during reproduction for many serodiscordant couples, which may in turn lead to such couples attempting to conceive through unprotected intercourse. From this aspect, we believe systematic use of ICSI in such couples carries ethical implications.

HIV-discordant couples and parenthood: how are we dealing with the risk of transmission?

1adds information about vertical transmission of hepatitis C virus (HCV), and suggests that elective caesarean delivery will reduce mother-to-child transmission of the virus. We raise some points for discussion. Gibb and colleagues report a history of drug use (78%) or blood transfusion in most of the women, whereas in an unselected population of individuals infected with HCV, the source of infection is generally difficult to identify. 2 An important selection bias might, therefore, strongly affect their results since the sociodemographic, immune, nutritional, and obstetric variables of injecting drug users are substantially different from those of non-drug using women, beyond the eventual co-infection with HIV-1. We think that more details on how women were classified as undergoing elective or emergency caesarean section, and the gestational age at birth in vaginal and caesarean deliveries should be provided. The population studied is also at increased risk of premature labour which might itself, influence the probability of transmission of bloodborne infections. 3