here - eshre

More documents

Recommendations

Info

When only the female is HIV+ve:the issues for consideration• Protection for the man against sexuallytransmitted infection, and to the infant fromvertical transmission• Antiretrovirals during pregnancy• Measures to reduce the risk of verticaltransmission• Frequency of unprotected intercourse• Self-insemination in the ovulation windowshould be explained• Re-evaluate after six months of unsuccessfulattemptsinfected parent and the risk of viral transmission to boththe uninfected partner or offspring.However, despite such concerns, the fact is that indeveloped countries HIV infection has now become achronic but manageable disease; highly active antiretroviraltherapy (HAART) has substantially increased lifeexpectancy and quality of life for both children and adultsinfected with HIV. 1 Thus, in the context of mother-to-childtransmission (MTCT), a combination of prophylacticantiretroviral therapy during pregnancy and labour, deliveryby elective Caesarean section and avoidance of breastfeedingcan reduce the risk of MTCT to less than 2%. 2 Thebalance in fertility treatment decisions in HIV infection hasthus shifted considerably, such that treatment has nowbecome both feasible and appropriate.Reproductive counselling for HIV-infected couplesReproductive assistance to HIV discordant couples can havea significant impact on the prevention of viral, sexual andMTC transmission. Most HIV-infected people are youngand fertile, and both men and women are willing to have achild at sometime in their lives. 3 The marked increase in lifeexpectancy as a result of antiretroviral therapy has removedmost of the ethical difficulties in helping people with HIVbecome parents, and specific information and assistance cannow be offered to protect the uninfected partner or childfrom infection.4,5,6When only the woman is infected, self-insemination withthe partner’s semen completely eliminates the risk of sexualinfection. Semen analysis to evaluate semen quality and torule out genital infection might be indicated, and completeinfertility screening should be provided if pregnancy doesnot occur within six months - preliminary observationsindicate that HIV-positive women might have an added riskof subfertility. 7When only the man is HIV-positive, the possibility ofspontaneous conception carries a risk of sexuallytransmitted HIV to the uninfected female through infectedsemen. This risk is difficult to quantify, but might besignificantly higher than a theoretical 1/1000 risk per singleact of penetrative intercourse; a small trial on naturalconception reported four cases of seroconversion in the 94healthy women enrolled and advised to have unprotectedintercourse at the time of ovulation with their HIV-positivepartners. 8Different reports have discussed the ‘efficiency’ of sexualtransmission from male to female and a mathematicalmodel has been proposed. 9,10,11 Wilson et al put thecumulative annual risk of female-to-male HIV transmissionat 0.0022 and male-to-female at 0.0043 with an average of100 acts of sexual intercourse per year. 12 A recent review of11 cohorts reporting on 5021 heterosexual couples and 461HIV transmissions found no transmission in patientstreated with antiretrovirals and with a viral load below 400copies/ml. 13The very low risk of HIV transmission to the negativepartner and to the baby if HIV-positive individuals haveundetectable viraemia with HAART now lies behind anincreasing interest in natural conception. 14 Naturalconception has also been chosen by some couples followingassisted reproduction programmes. Indeed, in one Italianstudy up to one-third of couples did not start theirinsemination procedures and a further third withdrew fromthe programme after a number of failed attempts; half ofthese couples tried natural conception with unprotected sexand without medical control. 15Although some expert advice has claimed that the risk ofsexual transmission is negligible when the HIV-infectedpartner is receiving antiretroviral therapy (with excellentadherence, undetectable viral load and no STDs), 16 themathematical model noted above would suggest thatabandoning condom use could quadruple the number ofcontaminations and thereby have a significant effect interms of public health. The general perception of HIVtransmission by sexual intercourse is extremely low in thispopulation, and protected sexual intercourse remains themost important means of prevention.Anecdotal reports also suggest that periconceptional preexposureprophylaxis with oral antiretroviral therapy isalready in limited use; if effective in reducing heterosexualHIV transmission, this too might be an option fordiscordant couples wanting to conceive spontaneously. 17Long-term treatment with antiretrovirals can reduce viralAUGUSTO SEMPRINI:‘COUPLES IN WHOM ONEOR BOTH PARTNERSARE HIV INFECTEDSHOULD HAVE ACCESSTO THE SAME FERTILITYADVICE AND TREATMENTAS NON-INFECTEDCOUPLES.’32 Focus on Reproduction January 2012
eplication in blood and semen, butsome infected men maintain substantialviral concentrations in their semen, evenin the presence of undetectable bloodplasma viral load with antiretroviraltreatment. 18 Certain studies have shownthat HIV-RNA may be amplified insemen when undetectable in plasma in2–8% of patients on HAART,suggesting that the genital tract mayrepresent a separate reservoir for viralreplication. 19,20 Genital tract infectionsaccount for a significant number ofepisodes of HIV genital shedding andtheir eradication is followed by areduction in the HIV concentration ingenital fluids. 21Screening for genital tract infection,for semen and ovulatory quality and fortubal patency should be performedbefore treatment to select the mostappropriate reproductive technologyand to minimise the number oftreatment cycles. Some observationshave suggested an increased prevalenceof infertility factors in couples with HIV, which canprolong the time (and number of attempts) to achievefertilisation; this may increase the risk of sexualtransmission, or make conception impossible, as in the caseof severe dyspermia or tubal disease. In the latter cases,such couples are exposed to a risk of infection without thechance of conception.Reproductive techniques in HIV-infected couplesSpermatozoa tested for the absence of HIV contaminationcan be used for fertilisation by IUI or IVF/ICSI in HIVdiscordantcouples with male infection. The technology,used in conjunction with semen washing, should minimisepotential damage to the healthy female while providing agood fertility rate.Semen washing was developed more than 15 years agoand consists of a three-step method to remove infectedseminal leukocytes and wash the spermatozoa free ofseminal plasma. 22 Other pioneering centres in Europe havestarted their own sperm washing programmes, which hasnow culminated in a European network of units providingassisted conception to HIV-discordant couples. These andother centres are now linked in CREAThE, a network ofclinics covering Italy, Spain, UK, Germany, Russia,Switzerland, France, Belgium and Israel to optimisetreatment and monitor outcomes.A systematic review of 658 abstracts (of which only 41were selected for analysis) and 17 full articles has just beenpublished. 23 The review included 3900 IUI cycles in 1184couples in 11 studies, and 738 ICSI/IVF cycles in 579couples across ten studies. The IUI and ICSI results were,respectively: pregnancy rates per cycle 18% and 38.1%;The risk of viral transmission from an HIV +ve male to his uninfected partner and futurechild can be virtually removed by ART with washed sperm. Sperm washing is based onthe observation that the HIV virus cannot attach itself to spermatozoa, but can be foundin the fluid and cells surrounding spermatozoa. Sperm washing allows the separation oflive sperm from the surrounding fluid and cells in a three-step process: 1, a spermatozoamigration on density gradient; 2, repeated washing of the migrated pellet; and 3, aspermatozoa swim up.cumulative pregnancy 50% and 52.9%; and abortion rate15.6% and 20.6%. No seroconversions in women ornewborns were detectable at birth or after 3-6 months.HIV-infected women have additional special needs insexual and reproductive health, including information andservices to protect their own health as well as to reduce therisk of mother-to-child HIV transmission. The number ofspecialists ready to offer these services to HIV-positivewomen with fertility problems has been increasing since1993. 24 And today there is a general willingness to treatHIV-infected women with ART, given the low risk of HIVvertical transmission.A reduced pregnancy rate after IVF has been observed inHIV-infected women when the patient’s own oocytes wereused. However, no significant reduction in pregnancy ratewas found when donated oocytes were used. It has beensuggested that subclinical hypogonadism mediated byimmunosuppression may explain these observations. It isalways important to optimise the woman’s HIVimmunological status before considering ART. The mostrecent studies report clinical pregnancy rates per cyclevarying from 11-21% in HIV-1-infected women after IVFor ICSI, compared with 26% in matched controls. Thepaucity of data reported on IVF and ICSI cycles in HIV-1-infected women do not allow any further conclusion. 25It is now well accepted that couples in whom one or bothpartners are HIV infected should have access to the samefertility advice and treatment as non-infected individuals toallow them to conceive, and to do so with the minimum ofrisk to their partners or children.Reproductive counselling to individuals with HIV mightFocus on Reproduction January 2012 33
Page 1 and 2: Focus onREPRODUCTIONEuropean Societ
Page 3 and 4: EXECUTIVE COMMITTEEChairmanAnna Vei
Page 5 and 6: a small island located on the Bosph
Page 7 and 8: Paul Devroey bows out from the VUBP
Page 9 and 10: Almost one in five women having IVF
Page 11 and 12: since the world’s first hMG babyr
Page 13 and 14: ESHRE NEWS// THE BEST OF ESHRE AND
Page 15 and 16: Men need fertility preservation too
Page 17 and 18: SPECIAL INTEREST GROUPS// EMBRYOLOG
Page 19 and 20: a progressive disease of the retina
Page 21 and 22: EARLY PREGNANCY //An audience respo
Page 23 and 24: PSYCHOLOGY AND COUNSELLING //New gu
Page 25 and 26: BASIC REPRODUCTIVE SCIENCE //ESHRE
Page 27 and 28: COVER STORYThe urgent needfor new s
Page 29 and 30: laboratories almost impossible and
Page 31: GETTY IMAGESFEATUREAntiretroviral t
Page 36: The European Society of Human Repro

here - eshre

Create successful ePaper yourself

Delete template?

Save as template?