Valeria Savasi

The incidence of complications after caesarean section in 156 HIV-positive women

ObjectiveTo investigate the risks of post-operative complications in HIV-positive mothers who undergo a caesarean section (CS) because the delivery cannot be safely accomplished by the vaginal route or to protect the infant from viral infection. DesignIn a multicentre study, we reviewed the incidence, and type of post-operative complications in 156 HIV-positive women who underwent a CS. These results were compared with those observed in an equal number of HIV-uninfected women who matched for the indication requiring a caesarean delivery, the stage of labour, the integrity or rupture of membranes, and the use of antibiotic prophylaxis. SettingSeven teaching hospitals providing obstetrical care for mothers infected with HIV. ResultsWe found that six HIV-infected mothers suffered a major complication (two cases of pneumonia, one pleural effusion, two severe anaemia, and one sepsis) compared with only one HIV-negative woman who required blood transfusion after surgery. Minor complications like post-operative fever, endometritis, wound, and urinary tract infections were significantly more frequent in HIV-positive women than controls. Multivariate analysis revealed that in HIV-infected women the only factor associated with a significant increase in the rate of complications was a CD4 lymphocyte count <200±106/l. ConclusionsThe results of our study indicate that HIV-positive mothers are at an increased risk of post-operative complications when delivered by CS. The risk of post-operative complications is higher in HIV-infected women who are severely immunodepressed.

Hepatitis B or hepatitis C coinfection in HIV-infected pregnant women in Europe

The aim of the study was to investigate the prevalence of and risk factors for hepatitis C or B virus (HCV or HBV) coinfection among HIV‐infected pregnant women, and to investigate their immunological and virological characteristics and antiretroviral therapy use.

Reproductive experience of HIV-infected women living in Europe

BACKGROUND The aim of this study was to describe the experience of pregnant and non-pregnant HIV-infected women regarding fertility and childbearing, with a view to inform policies and practices to improve reproductive outcome. METHODS A cross-sectional survey collected information on socio-demographic and basic reproductive characteristics of HIV-infected women in Europe. A total of 403 women participated; 121 were pregnant. RESULTS The median age was 29 years and 84% (228) of women were born in Europe. Overall 68% (275 of 403) had been pregnant at some time. At the time of the survey, 59% (n = 160) of women had no HIV symptoms; severe symptoms were more frequent among non-pregnant than pregnant respondents (36% (65 of 181) versus 5% (4 of 88)). Of the women, 80% reported being in a long-standing relationship; 39% (74 of 190) reported that they became infected by their current partner and, overall, heterosexual infection was reported as the mode of acquisition in 55% (190 of 344). Maternal well-being, no previous live birth and having an uninfected partner were strongly associated with the likelihood of being pregnant. To assess the problems relating to fertility, pregnant and non-pregnant women were considered separately. Overall, 46% of pregnant women reported not using condoms to protect against infection during pregnancy. Of the 60 pregnant women who planned their pregnancies, 10 reported the need for assistance in conceiving: five monitored their ovulation period and five became pregnant through in vitro fertilization. Of 34 non-pregnant women currently trying for a baby, 15 (44%) had done so for more than 18 months. Overall 25 (27%) of 94 women who planned to become pregnant needed reproductive care. CONCLUSIONS Our results suggest that these days knowledge of HIV infection neither influences the desire for children nor the decisions regarding pregnancy in HIV-infected women living in Europe.

Two-dimensional HyCoSy with contrast tuned imaging technology and a second-generation contrast media for the assessment of tubal patency in an infertility program

OBJECTIVE To compare the efficiency of hysterosalpingo-contrast-sonography performed with air and saline (Hydro-HyCoSy) with HyCoSy performed with contrast media (SonoVue) and contrast-tuned imaging technology (CnTI-SonoVue-HyCoSy) considering hysterosalpingography (HSG) and laparoscopy (LPS) as reference tests and to evaluate the learning curve of this procedure. DESIGN Retrospective study. SETTING Reproductive unit of a university hospital. PATIENT(S) Forty-two infertile female patients. INTERVENTION(S) HyCoSy were performed with a 2.4-mm intrauterine catheter. Patients underwent HSG or LPS as controls. MAIN OUTCOME MEASURE(S) Mean age, sensitivity, specificity, positive and negative predictive value, kappa value, and diagnostic accuracy were evaluated for statistical analysis. RESULT(S) Sensitivity, specificity, and positive and negative predictive values of Hydro-HyCoSy were 91%, 71%, 55%, and 95%, respectively, while for CnTI-SonoVue-HyCoSy they were 87%, 84%, 69%, and 94%. The diagnostic accuracy of Hydro-HyCoSy and of CnTI-SonoVue-HyCoSy were 77% and 85%, with a Cohens kappa of 0.52 and 0.66, respectively. CnTI-SonoVue-HyCoSy does not require a learning curve period. CONCLUSION(S) CnTI-SonoVue-HyCoSy is more accurate than Hydro-HyCoSy for the assessment of fallopian tubes. The very high normal predictive value of Hydro-HyCoSy suggests that this procedure could be performed as a screening examination, whereas CnTI-SonoVue-HyCoSy could be used as a second-step technique.

Treatment of viral hepatitis in pregnancy

Viral hepatitis can be caused by the hepatitis A, B, C, D and E viruses. In the Western world, hepatitis A, B or C do not seem to influence the course of pregnancy, whereas hepatitis E infection, when contracted during the second or third trimester, seems to have a higher risk of developing into a fulminant hepatitis. Mother-to-infant transmission of hepatitis A seems to be very uncommon. The majority of HBsAg-positive and HBeAg-positive mothers can transmit the disease vertically. The timing of transmission is predominantly peripartum, and newborns of HBsAg-positive mothers should receive hepatitis B immunoglobulins within 12 h of birth, with HBV vaccine at birth and 1 and 6 months later. Hepatitis C is more often a chronic disease. Vertical transmission of hepatitis C is considered to be relatively rare but high viraemia or coinfection with HIV can increase this risk. There is currently no treatment to prevent this vertical transmission and pregnancies among HCV-positive mothers should not be discouraged. Infants should be tested for anti-HCV at 1 year and followed for the development of hepatitis. Breast feeding does not seem to play an important role in the transmission of hepatitis B and C.

Should HCV discordant couples with a seropositive male partner be treated with assisted reproduction techniques (ART)

OBJECTIVE The debate on HCV discordant couples requiring assisted reproduction is still open today, and specific guidelines have not yet been established on whether or not physicians should treat HCV discordant couples who require ART. We studied the results of our reproductive assistance with sperm washing in HCV discordant couples, all treated in a single center, including the serological status of mothers and babies, and the outcome of the pregnancies. STUDY DESIGN Prospective study conducted between January 2008 and December 2010 in our Reproductive Center in Sacco Hospital, University of Milan. Thirty-five HCV serodiscordant infertile couples with an HCV viremic positive male partner were enrolled. All of them completed the immuno-virological and fertility triage, and were treated according to our clinical protocols. RESULTS Forty-seven superovulation and IUI and 38 second-level ART procedures are reported. The pregnancy rates for IUI and ICSI are similar to those reported by the Italian ART register. All the 85 sperm samples were treated with sperm washing technique to reduce HCV in semen and the possible risk of transmission. We did not observe any preterm delivery or negative perinatal outcome. No mothers or babies are infected by HCV. CONCLUSION This is the biggest prospective study conducted in a single center involving HCV discordant infertile couples in an ART program. Although sexual transmission of HCV is very low, in subfertile or infertile couples sperm washing should be used to treat HCV positive semen before ART. We suggest that it is not necessary to perform nested PCR to detect HCV RNA in the final swim-up. Since the presence of HCV in semen implies a possible risk of nosocomial contamination, safety regulations must be strictly applied in assisted reproduction laboratories.

Hepatitis C virus RNA detection in different semen fractions of HCV/HIV-1 co-infected men by nested PCR

OBJECTIVE The aim was to evaluate, by nested PCR, the prevalence of hepatitis C virus (HCV) RNA in seminal plasma in different semen fractions of HCV/HIV-1 co-infected men. STUDY DESIGN This study enrolled 16 HCV/HIV-1 infected men. A total of 16 seminal samples and 16 blood samples were tested for the presence of HCV-RNA. HCV-RNA in blood plasma was quantified by Amplicor HCV Monitor Test version 2.0 and HCV-RNA detection in seminal plasma, non-spermatozoa cells (NSCs), spermatozoa pellet and swim-up was investigated by nested PCR. RESULTS Thirteen blood plasma samples were positive for HCV-RNA. HCV-RNA was detectable in seminal plasma and in non-sperm cells, but not detectable in spermatozoa samples, neither before nor after swim-up. One of the two patients whose seminal plasma tested positive at nested PCR had undetectable HCV virus in blood plasma. CONCLUSIONS HCV-RNA can be found in seminal plasma and non-sperm cells but not in spermatozoa before and after swim-up. We observed HCV-RNA in the semen of an aviremic man. According to these findings we suggest that sperm washing should be performed for each semen sample of HCV patients before assisted reproduction techniques.

Reproductive assistance in HIV-1 discordant couples.

Purpose of review The total number of people living with HIV has reached 39.5 million. In developed countries, the major risk for HIV transmission is by heterosexual intercourse. The general condition and life expectancy of many patients with HIV infection is very good, and three-quarter of these individuals are in their reproductive years. For these reasons a large number of young couples are expected to make future plans to have children. Assisted reproduction in HIV-1 discordant couples has become important for clinicians in preventing HIV-1 transmission. Recent findings The main theme covered in this article is epidemiology of HIV-1 in the world, the biology of the virus present in the sperm, the recently published guidelines from the American Society for Reproductive Medicine and ethics recommendations concerning assisted reproduction in people infected by virus, and all clinical aspects and scientific data published that have been modified to allow assisted reproduction in HIV-serodiscordant couples. Summary To evaluate in clinical practice the safety of HIV-1 assisted reproduction with sperm washing and the outcome of assisted reproductive technologies offered to HIV-1 serodiscordant couples counselled for the prevention of HIV transmission.

First trimester placental markers in oocyte donation pregnancies.

INTRODUCTION This study investigates the hypothesis that placenta works differently in oocyte donation (OD) compared to spontaneous pregnancies. To verify this hypothesis we examine the first trimester maternal serum levels of free β-hCG and pregnancy-associated plasma protein-A (PAPP-A). Then we evaluated for potential differences of Down syndrome screening between OD pregnancies, in vitro fertilization/intracytoplasmic sperm injection pregnancies with autologous oocytes (IVF/ICSI) and spontaneous pregnancies. METHODS We analyze 13624 spontaneously conceived pregnancies (Controls), 171 oocyte donation pregnancies (OD IVF/ICSI) and 76 IVF pregnancies with autologous oocytes (Autologous IVF/ICSI). Furthermore, we collect a cohort of 802 spontaneously conceived age-matched pregnancies, in order to evaluate how older uteri contribute to explain the changes in markers concentrations (Age-matched controls We compare the multiples of the median (MoM) of free β-hCG and PAPP-A and nuchal translucency. RESULTS Free β-hCG levels are significantly higher both in OD IVF/ICSI pregnancies (1.44 ± 1.06 MoM) and Autologous IVF/ICSI (1.48 ± 1.02 MoM) compared to Controls (1.15 ± 0.84 MoM; p < 0.05) and Age-matched Controls (1.18 ± 0.98 MoM; p < 0.05). PAPP-A levels do not significantly differ among the four groups. Significantly lower nuchal translucency is detected in Controls (1.41 ± 0.36 mm) compared to OD IVF/ICSI (1.46 ± 0.44 mm; p < 0.05), in Autologous IVF/ICSI (1.51 ± 0.34 mm; p < 0.05) and Age-matched Controls (1.44 ± 0.42 mm; p < 0.05). DISCUSSION Oocyte donation pregnancies (OD IVF/ICSI) are significantly related to altered maternal serum placenta marker levels. These alterations might be due to the IVF technique.

Reproductive Assistance for Infected Couples with Bloodborne Viruses

During the past 15 years Assisted Reproduction has been facing a new demand from patients requiring ART: couples at risk of partner to partner, and mother to child transmission of viral infections, mainly HIV-1, HCV and HIV-HCV co-infected partners. The general conditions and life expectancy of many patients with HIV infection are very good, and three-quarters of these individuals are in their reproductive years. For these reasons, a large number of young couples are expected to make future plans to have children. This desire is not easy to realize for serodiscordant couples, if we consider that, in order to avoid HIV virus transmission, it is necessary to encourage the condom use in vaginal and anal contacts. On the other hand infertile discordant HCV couples need to be included in protocols of controlled assisted reproduction procedures to avoid any risk of HCV transmission to the partner. In this paper we consider assisted reproduction in discordant couples for HIV or HCV-positive men.