- Email: [email protected]
Fertility management of HIV-discordant couples
Current Obstetrics & Gynaecology (2003) 13, 307--313
c 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0957-5847(03)00045-3
Fertility management of HIV-discordant couples Carole Gilling-Smith Consultant Gynaecologist, Director of the Assisted Conception Unit, Chelsea & Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
KEYWORDS HIV; semen; sperm washing; insemination; fertility; discordant
Summary Couples in which the man is HIV-1 positive and the women is HIV-1 negative have limited optionsifthey wishto reproduce safely.Timed unprotected intercourse carries a 0.1--4% risk of transmitting the virus through semen to the female partner. Sperm washing is a risk-reduction treatment option in which semen is centrifuged to separate live sperm, which does not carry HIV, from seminal plasma and non-germinal cells which may carry the virus, irrespective of the man’s viralload,CD4 count or antiretroviral therapy. Absence of detectable HIV should be verif|ed using a polymerase chain reaction nucleic-acid-based sequence amplif|cation assay before the washed sperm is used in treatment.In couples with no fertilityissues, the processed semen is inseminated into the female partner at the time of ovulation during a natural cycle. If a couple have additional fertility issues, sperm washing can be combined with ovulation induction, invitro fertilization or intracytoplasmic sperm injection. Pregnancy rate per insemination is12% based on published reports of over 2000 inseminations.To date, there have been no seroconversionsin either mother orchild following use ofcorrectlyprocessed sperm.
c 2003 Elsevier Science Ltd. All rights reserved.
INTRODUCTION In 1983, human immunodef|ciency virus-1 (HIV-1) was f|rst reported as the causative factor in the development of acquired immunodef|ciency syndrome (AIDS). By the end of 2002, 42 million people worldwide were reported to be living with HIV, of which 3 million were children. Ninety-f|ve percent of these live in the developing world where lack of resources for treatment and prevention of viral spread fuel the epidemic. Here HIV progression to AIDS and death is inevitable and planning for a family is not an option. In the UK, 54 000 people have been infected with HIV of whom over 19 000 have died of AIDS. The majority of infected patients have HIV-1. HIV-2, a second variant, is conf|ned to patients with West African origins or contacts. Developed countries such as the UK have seen dramatic changes in the life quality and expectancy of HIV-infected patients since 1996 when highly active antiretroviral treatment (HAART) became widely available. This, in turn, has led to the reclassif|cation of HIV as a chronic disease. Following diagnosis, patients are monitored in specialized genito-urinary clinics where regular CD4 count and viral load measurements are taken. HAART is started or modif|ed when viral load rises (4 10 000 copies/ml) and/or CD4 count falls (o 400.106/ l). With such close monitoring and effective therapy, opportunistic infections or progression to AIDS is becoming increasingly rare.Given these developments, it is now Correspondence to: CG-S.Tel.: +44(0) 208 746 8922; E-mail: [email protected]
accepted that couples in whom one or both partners are infected should be given the opportunity to have children.The main limitation is ensuring that the uninfected partner or future child is not put at risk of viral infection through horizontal or vertical transmission.
CHANGING EPIDEMIOLOGYOF HIV IN THE UK The exact number of infected couples in the UKwishing to conceive is unknown. However, the medical profession needs to take note of the following statistics: since 1996, the number of newly acquired infections has continued to rise, and since 1999, the rate of heterosexually acquired infections has overtaken that of homosexually acquired infections. In 2002, 2199 new infections reported were acquired through heterosexual intercourse as opposed to1195 through homosexual (male) intercourse. Finally, over 75% of infected patients are in the reproductive age group. It is clear from these f|gures that the UK has an increasing heterosexual population of HIVinfected patients of reproductive age, of which a signif|cant number are likely to request help with conception. We therefore have a responsibility to address their needs if the spread of HIV is to be halted.
REPRODUCTIVE OPTIONS FOR HIV-DISCORDANT COUPLES In HIV-serodiscordant couples in which the man is HIV positive and the woman is HIV negative (referred to as
308
discordant couples in the subsequent text), unprotected intercourse carries the risk of HIV transmission to the uninfected partner through sperm. An uninfected mother cannot transmit virus to her offspring. However, should she become infected through intercourse, the vertical transmission risk can be as high as 30% if appropriate measures are not taken, although this is reduced to less than 2% if she takes antiretroviral medication during pregnancy, has an elective bloodless Caesarean section and avoids breastfeeding.
Transmission of HIV in semen The risk of HIV transmission during unprotected vaginal intercourse in HIV-1-discordant couples where the man is positive is diff|cult to measure. The principal variables known to affect transmission risk are stage of disease (viral load, CD4 count, presence of AIDS def|ning symptoms), use of HAART, source of HIV infection, stability and length of the relationship, practice of anal intercourse, presence of genital tract lesions or infections, circumcision in the male partner, time of the menstrual cycle (maximum risk during menstruation) and the frequency of intercourse. A Cochrane review has calculated the incidence of seroconversion in discordant couples who never use condoms to be 6.68 seroconversions/100 person-years compared with 1.14 seroconversions/100 person-years in couples who always use condoms. A more useful f|gure for couples wishing to conceive is the risk per act of unprotected intercourse which is estimated to be 0.1-- 0.2% in couples who are in a stable monogamous relationship, not abusing intravenous drugs or participating in any other form of high-risk activity. A critical factor influencing this risk is the viral load in semen, which unfortunately correlates poorly with serum viral load. Although serum HIV-1 levels in plasma are generally higher than those in semen, virus has been detected in men with undetectable plasma viral levels, and several studies suggest separate compartments for HIV-1 in serum and semen.
The risks of unprotected intercourse Discordant couples wishing to conceive must be made aware of the risk of unprotected intercourse. A single act of intercourse is suff|cient to infect the female partner, and serum viral load or use of HAART are not reliable measures in assessing the extent of risk. In a series of 92 HIV-negative women with HIV-positive partners using carefully timed, but unprotected intercourse to conceive, there were four seroconversions. Although these were restricted to couples in whom the use of condoms outside the fertile window was inconsistent, this study indicates that the risk of unprotected intercourse timed to the fertile period carries an unacceptable risk (4%) of infecting the female partner and, in consequence,
CURRENT OBSTETRICS & GYNAECOLOGY
the child. This option should no longer be advised given that other safer options are available. If HIV-serodiscordant couples are to conceive safely, they are restricted to the following two options: 1. Insemination using donor sperm. Although this removes the risk of viral transmission as sperm donors are screened for HIV, it also removes the option of genetic parenting from the infected male. This is not an easy decision to take when faced with chronic illness. 2. Sperm washing. The female partner is inseminated with the infected partner’s sperm, washed free of HIV. If neither is acceptable to the couple, adoption is an alternative route to explore, although the HIV status of the prospective father is likely to render this process very diff|cult.
RISKS WITH SPERM WASHING Scientif|c evaluation The concept of inseminating HIV-negative women with sperm washed free of HIV was f|rst proposed by Semprini et al.1 and he published his f|rst series of cases in 1992. The literature available at this time indicated that, within semen, HIV was present as free virus in seminal fluid and as cell-associated virus in non-spermatozoa cells (NSC), but that spermatozoa themselves were free of HIV. The issue of whether spermatozoa themselves can be infected with virus has been intensely investigated but remains controversial. Our centre evaluated this along with the effectiveness of sperm washing prior to starting a clinical programme. Semen samples from11HIV-1-positive men were separated into spermatozoa, NSC and plasma fractions using the same differential centrifuge gradient as that previously described in clinical spermwashing programmes. The f|nal spermatozoa pellet obtained after centrifugation and two further washes was resuspended in fresh medium and left for 20 min to allow motile sperm to ‘swim-up’ to the supernatant. Control samples were taken from HIV-negative donors and processed in the same way. The level of viral RNA, proviral DNA and expression of HIV receptors CD4, CCR5 and CXCR4 in the separated compartments were then measured, and HIV viral RNA and proviral DNA were only found in seminal plasma and NSC. Spermatozoa did not express signif|cant levels of CD4, CCR5 or CXCR4, which measure infectivity, implying that they are unlikely to be a major target for HIV infection. After processing, the sperm count was reduced compared with the unprocessed ejaculate by up to one log, in line with previous reports. The weakness of this study, and potential risks in the clinical programme, relate to the detection limit
FERTILITY MANAGEMENTOF HIV-DISCORDANTCOUPLES
of the HIV assay used. The PCR nucleic-acid-based sequence amplif|cation (NASBA) assay is the only commercial assay available which can reliably extract RNA from sperm. However, the lower limit of detection of this assay is 25 HIV-1copies per million sperm.Therefore, HIV-1 could theoretically be present, but not detectable, postwashing. For this reason, sperm washing should be regarded as a risk reduction not risk-free option until suff|cient clinical cases have been reported to conf|rm its safety and reliability.
Clinical evaluation In terms of clinical outcome, sperm washing has a good track record to date . In Europe, more than 3000 cases of treatment using sperm processed as described above have been published resulting in the birth of over 300 healthy HIV-negative children. Compared with the published 4% risk of unprotected timed intercourse, sperm washing is undeniably safer. In statistical terms, over 8000 inseminations would have to be published before its safety could be reported to be comparable to that of donor insemination. The process of auditing outcome to reach this target number is ongoing through the collaboration of European centres, including our own, offering a sperm-washing service. These centres have adopted the policy of testing for HIV prior to use of washed sperm as a quality-control measure of the eff|cacy and safety of the processing. It is debatable whether the inoculum of HIV in a sample of sperm, which has been washed but has detectable viral load, is suff|cient to infect the female partner. In the USA, a single case report of a women becoming infected through insemination with inappropriately processed sperm from an HIVpositive man led to a ban on the use of washed sperm by the Centres for Disease Control.The lesson to be learnt from this is that centres wishing to establish a programme must process sperm and test for HIV according to published protocols.This will ensure that the service is covered medico-legally should the female partner become infected. Couples are also reassured that every effort is being made to minimize the risk of infection. If testing cannot be done on the day of insemination, a sample should be washed, tested and frozen prior to use.
MANAGEMENTOF COUPLES REQUESTING SPERM WSHING At present, sperm washing is only offered in a few centres in the UK and Europe. For a centre to offer treatment, it needs to have an established fertility service and assisted conception programme which, in addition, can offer pre-conceptual counselling specif|c to the needs of these couples, and facilities for processing and subsequently testing infected sperm within a separate laboratory or laboratory area. Figure 1 summarizes the
309
steps involved in managing discordant couples wishing to conceive through sperm washing.
Pre-conceptual counselling The aims of counselling couples who are considering sperm washing are to allow them to consider all the reproductive options available to them, talk through the specif|c risks associated with sperm washing, and discuss the possibility of treatment failure. They need to understand that, as opposed to unprotected intercourse, treatment reduces the risk of HIV transmission signif|cantly but not completely.They need to consider the implications should the female partner become infected through treatment, both to herself, to their relationship and to the child if pregnancy results. HIV medication, long-term outcome and vertical transmission risk should be covered briefly. It is important that the long-term health, possible disability or death of the father is also explored and that the couple try to put in place a support network in the form of relatives or friends should the mother become a single parent.
Welfare of the child The clinic needs to make a ‘welfare of the child assessment’ prior to offering treatment to couples.This should be done during counselling and subsequent work-up. Couples need to show that they are in a committed and stable relationship, have planned for the future and that neither is involved in any high-risk activity that could put any resulting child at risk of acquiring HIV, such as unprotected sex or intravenous drug abuse. They should also agree not to have unprotected intercourse throughout the treatment programme and during pregnancy.
Sexual health screen Both partners should have a full sexual health screen to exclude the possibility of the female partner also being infected and to provide the opportunity of treating any genital lesions or infections before treatment, which could increase the risk of viral transmission. The female partner should be screened for HIV-1, hepatitis B and C, syphilis serology and rubella immunity, and have cervical and high vaginal swabs taken for chlamydia and gonorrhoea. The male partner should also have genital swabs. In the majority of cases, the referring physician will have provided information on the male partner’s HIV status (viral load, CD4 count and medication) and Hep B and C status. If not, this information should be requested and verif|ed up to date.
Fertility evaluation The majority of couples wishing to proceed with spermwashing treatment will not have tested their potential
310
CURRENT OBSTETRICS & GYNAECOLOGY
HIV-discordant couple referred by genito-urinary physician
Pre-conceptual counselling
Male and female sexual health screen
Male and female fertility screen
• • •
Bilateral tubal damage/blockage Failed IUI x 6 FSH > 12 IU/l
SPERM WASHING + IVF
Results reviewed Treatment planned
• • • •
Normal semen analysis Normal FSH Ovulatory progesterone One or both tubes
•
Abnormal semen analysis
SPERM WASHING + ICSI
SPERM WASHING + IUI
HIV testing of female partner for 1year after treatment
Figure 1 Flow chart for the management of HIV-discordant couples.
fertility but, unlike most couples attending infertility clinics, are voluntarily infertile and unlikely to have fertility issues. Nevertheless, a non-invasive fertility screen should be done in both partners to exclude any factors which would reduce the chances of natural-cycle-timed insemination being successful.The female partner should have an assessment of ovarian reserve (baseline pelvic scan and follicle stimulating hormone, luteinizing hormone and oestradiol measured 2--5 days after onset of menstruation), a mid-luteal progesterone and a non-invasive test of tubal patency (hysterosalpingogram or HyCoSy), and the male partner should have a detailed semen analysis to assess count, motility and morphology. Provided the fertility tests reveal a normal endocrine prof|le (early follicular phase follicle stimulating hormone o 12 U/ml), spontaneous ovulation (mid-luteal progesterone 430 ng/ml), at least one patent tube and a normal semen analysis (count 4 20.106/ml, o80% abnormal forms and 450% motility by World Health Organization criteria), the couple should be offered up to six cycles of natural cycle intra-uterine insemination with washed sperm. In women with proven anovulation, insemination is performed in conjunction with ovulation induction using either clomiphene (f|rst line) or gonadotrophins (second line).When both fallopian tubes are damaged or blocked,
in-vitro fertilization (IVF) using washed sperm should be advised. If the semen analysis parameters are suboptimal for either intra-uterine insemination or IVF, intracytoplasmic sperm injection (ICSI) with washed sperm should be performed. ICSI has been suggested as the safest method of reducing viral transmission risk in serodiscordant couples as each oocyte is exposed to only one sperm as opposed to several million in the case of insemination or IVF. A recent series of 55 cases of ICSI using unwashed sperm in discordant couples reported no seroconversions in either uninfected partner or child. These are small numbers and safety remains in question. Aside from general concerns on the long-term outcome of children born through ICSI, one concern is that ICSI could introduce HIV into the oocyte by the virus attaching itself to the acrosome membrane. At present, there is no justif|cation for offering ICSI in preference to conventional sperm washing with insemination unless a male fertility factor is identif|ed.
Consent A specif|c consent form should be signed by both partners before sperm washing treatment to the effect that sperm washing is a risk-reduction (not risk-elimination)
FERTILITY MANAGEMENTOF HIV-DISCORDANTCOUPLES
technique with no absolute guarantee of protecting the female partner from HIV. This is an essential document which protects the service from medico-legal action should transmission occur.
Ultrasound monitoring As in conventional intra-uterine insemination programmes, follicle tracking is used from day 8 or 9 of the cycle to ensure correct timing of insemination. Once the lead follicle reaches 17 mm in diameter, human chorionic gonadotrophin (HCG) 5000 IU is given by subcutaneous injection (typically at 24.00 h) to allow insemination during working hours to be carried out 40 h later when the oocyte is released and in the fallopian tube.
Figure 2
The stages of sperm washing.
311
Semen processing A sperm specimen should be produced about 30 h after the HCG injection, following an optimal time of 2--3 days abstinence from ejaculation. The sample is centrifuged for 20 min in a 40 -- 80% colloidal, silica density gradient to separate the semen into its different cellular components (Fig. 2).The clean sperm pellet is pushed to the bottom of the tube, leaving infected NSC and seminal plasma in the supernatant. The sperm pellet is carefully removed, resuspended in fresh medium and centrifuged twice more before a f|nal swim-up is prepared. It is mandatory that an aliquot of washed sperm be tested for detectable HIV RNA using a NASBA (or equivalent) assay. Provided the test is negative, intra-uterine insemination of the female partner is carried out. A pregnancy test is performed 2 weeks later. The risk of the sample having
312
detectable HIV is 5-- 6% based on data from Marina et al. (1998) in which 5.6% (six of 107 semen samples) had detectable levels of HIV RNA on PCR after washing, and our own series in which detectable virus was present in 4.2% (six of 142) of samples post-wash. If it is not technically feasible to test a fresh washed sample for HIVon the day of treatment, a sample should be washed, tested and frozen for future use. One explanation for the presence of virus after washing is that the virus can become intraspermal in men with more advanced disease and cannot be eliminated with washing. It is detectable because PCR involves sperm lysis. Another explanation is that washing does not remove all the seminal plasma. A limit is imposed on the number of washes as sperm damage during repeated centrifuging leads to loss of the sperm quality and quantity needed to achieve fertilization.
RESULTS IN THE UK Our programme, established 3 years ago, has treated 53 HIV serodiscordant couples and resulted in the birth of 15 healthy children. Thirty-eight couples have had 94 cycles of intra-uterine insemination and 30 couples have had 42 cycles of either IVF or ICSI. The ongoing pregnancy/live birth rate is 10.8% (11/94) for intra-uterine insemination and 23.8% (10/42) for IVF/ICSI, f|gures that are consistent with previous reports.The pregnancy rate for intra-uterine insemination using washed sperm is comparable with that using donor sperm, and IVF and ICSI rates are similar to those using conventional methods to process sperm when controlled for female partner’s age. We ensure that all women receiving treatment with washed sperm have regular HIV testing for up to 1 year after treatment as a means of monitoring the effectiveness of the processing.To date, there have been no seroconversions in uninfected partner or child.
CURRENT OBSTETRICS & GYNAECOLOGY
The second is the possibility of transmitting a mutated drug-resistant form of HIV virus to the female partner. Both reinforce the importance of ensuring long-term follow-up of all children born through sperm washing.
FUNDING ISSUES At present, the majority of patients that have undergone sperm-washing treatment have to self-fund their treatment. Over the last 3 years, only a small number (14% of all patients undergoing sperm-washing treatment in a recent audit of UK genito-urinary clinics) have secured NHS funding on the basis that the treatment is for risk reduction not fertility. We now advise all patients to approach their Primary Care Trusts to be considered for funding on this basis. We believe that the results of our programme, and that of our colleagues in Europe, are suff|cient evidence that sperm washing is a cost-effective treatment which, in the long term, will signif|cantly reduce the transmission rate of HIV to uninfected women trying to conceive.
CONCLUSION The demand for risk-reduction fertility treatment in HIV-discordant couples is likely to rise. Timed unprotected intercourse carries an unacceptable risk to the uninfected female partner and is not recommended. Sperm washing should be offered but only carried out in dedicated units able to process semen according to strict laboratory criteria and to test washed sperm for HIV before treatment. In addition, these centres need to provide pre-conceptual counselling of risks involved and monitor the HIV status of the female partner post-treatment. All children born through sperm washing should be monitored over the long term to ensure that sperm exposure to HAART does not have any long-term harmful consequences.
EFFECTOF HAARTON SPERM Little is known of the effect of HIV or HAARTon semen parameters, although data are emerging to suggest that some antiretrovirals may adversely affect sperm motility through an effect on mitochondrial function. A study of sperm parameters in 250 non-vasectomized HIV-seropositive men and 38 fertile controls would suggest that sperm count, volume and motility are reduced in HIVpositive men irrespective of use of HAART. Our present advice is that the decision to start or stop medication should not be based on concern for fertility but rest solely on viral load and CD4 count parameters, as there are insuff|cient data at present to advise otherwise. There are two concerns for patients conceiving when on HAART. The f|rst is whether there could be any longterm harmful effects of the medication on the offspring.
Practice Points *
*
*
Discordant couples trying to conceive safely have only two optionsFsperm washing or donor insemination.The risk of infecting the female partner if timed unprotected intercourse is considered has been shown to be unacceptable (4%) All couples considering sperm washing should receive pre-conceptual counselling to ensure that they understand that the procedure signif|cantly reduces the risk of viral transmission through sperm but cannot be guaranteed to be risk free All processed samples should be tested for HIV prior to being used in treatment
FERTILITY MANAGEMENTOF HIV-DISCORDANTCOUPLES
REFERENCES [1] Semprini AE, Levi-Setti P, Bozzo M et al. Insemination of HIVnegative women with processed semen of HIV-positive partners. Lancet 1992; 340: 1317--1319. [2] Marina S, Marina F, Alcolea R et al. Pregnancy following intracytoplasmic sperm injection from an HIV-1 seropositive man. Hum Reprod 1998; 13: 3247--3249.
FURTHER READING BHIVA. Guidelines for the management of HIV infection in pregnant women and the prevention of mother-to-child transmission. HIV Med 2001; 2: 314--334.
313
Gilling-Smith C. Assisted reproduction in HIV discordant couples. AIDS Reader 2001; 10: 581--587. Gilling-Smith C, Smith JR, Semprini A. Infertility and HIV: time to treat. BMJ 2001; 322: 566--567. Gilling-Smith C, Almeida PA. HIV, hepatitis B & hepatitis C and infertility: Reducing Risk Educational Bulletin sponsored by the Practice & Policy Committee of the BFS. Hum Fert 2003 (in press). Kim LU, Johnson MR, Barton S et al. Evaluation of sperm washing as a potential method of reducing HIV transmission in HIV-discordant couples wishing to have children. AIDS 1999; 13: 645--651. Mandlebrot L, Heard I, Henrion-Geant E, Henrion R. Natural conception in HIV-negative women with HIV-infected partners [letter] Lancet 1997; 349: 850--851.
c 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0957-5847(03)00045-3
Fertility management of HIV-discordant couples Carole Gilling-Smith Consultant Gynaecologist, Director of the Assisted Conception Unit, Chelsea & Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
KEYWORDS HIV; semen; sperm washing; insemination; fertility; discordant
Summary Couples in which the man is HIV-1 positive and the women is HIV-1 negative have limited optionsifthey wishto reproduce safely.Timed unprotected intercourse carries a 0.1--4% risk of transmitting the virus through semen to the female partner. Sperm washing is a risk-reduction treatment option in which semen is centrifuged to separate live sperm, which does not carry HIV, from seminal plasma and non-germinal cells which may carry the virus, irrespective of the man’s viralload,CD4 count or antiretroviral therapy. Absence of detectable HIV should be verif|ed using a polymerase chain reaction nucleic-acid-based sequence amplif|cation assay before the washed sperm is used in treatment.In couples with no fertilityissues, the processed semen is inseminated into the female partner at the time of ovulation during a natural cycle. If a couple have additional fertility issues, sperm washing can be combined with ovulation induction, invitro fertilization or intracytoplasmic sperm injection. Pregnancy rate per insemination is12% based on published reports of over 2000 inseminations.To date, there have been no seroconversionsin either mother orchild following use ofcorrectlyprocessed sperm.
c 2003 Elsevier Science Ltd. All rights reserved.
INTRODUCTION In 1983, human immunodef|ciency virus-1 (HIV-1) was f|rst reported as the causative factor in the development of acquired immunodef|ciency syndrome (AIDS). By the end of 2002, 42 million people worldwide were reported to be living with HIV, of which 3 million were children. Ninety-f|ve percent of these live in the developing world where lack of resources for treatment and prevention of viral spread fuel the epidemic. Here HIV progression to AIDS and death is inevitable and planning for a family is not an option. In the UK, 54 000 people have been infected with HIV of whom over 19 000 have died of AIDS. The majority of infected patients have HIV-1. HIV-2, a second variant, is conf|ned to patients with West African origins or contacts. Developed countries such as the UK have seen dramatic changes in the life quality and expectancy of HIV-infected patients since 1996 when highly active antiretroviral treatment (HAART) became widely available. This, in turn, has led to the reclassif|cation of HIV as a chronic disease. Following diagnosis, patients are monitored in specialized genito-urinary clinics where regular CD4 count and viral load measurements are taken. HAART is started or modif|ed when viral load rises (4 10 000 copies/ml) and/or CD4 count falls (o 400.106/ l). With such close monitoring and effective therapy, opportunistic infections or progression to AIDS is becoming increasingly rare.Given these developments, it is now Correspondence to: CG-S.Tel.: +44(0) 208 746 8922; E-mail: [email protected]
accepted that couples in whom one or both partners are infected should be given the opportunity to have children.The main limitation is ensuring that the uninfected partner or future child is not put at risk of viral infection through horizontal or vertical transmission.
CHANGING EPIDEMIOLOGYOF HIV IN THE UK The exact number of infected couples in the UKwishing to conceive is unknown. However, the medical profession needs to take note of the following statistics: since 1996, the number of newly acquired infections has continued to rise, and since 1999, the rate of heterosexually acquired infections has overtaken that of homosexually acquired infections. In 2002, 2199 new infections reported were acquired through heterosexual intercourse as opposed to1195 through homosexual (male) intercourse. Finally, over 75% of infected patients are in the reproductive age group. It is clear from these f|gures that the UK has an increasing heterosexual population of HIVinfected patients of reproductive age, of which a signif|cant number are likely to request help with conception. We therefore have a responsibility to address their needs if the spread of HIV is to be halted.
REPRODUCTIVE OPTIONS FOR HIV-DISCORDANT COUPLES In HIV-serodiscordant couples in which the man is HIV positive and the woman is HIV negative (referred to as
308
discordant couples in the subsequent text), unprotected intercourse carries the risk of HIV transmission to the uninfected partner through sperm. An uninfected mother cannot transmit virus to her offspring. However, should she become infected through intercourse, the vertical transmission risk can be as high as 30% if appropriate measures are not taken, although this is reduced to less than 2% if she takes antiretroviral medication during pregnancy, has an elective bloodless Caesarean section and avoids breastfeeding.
Transmission of HIV in semen The risk of HIV transmission during unprotected vaginal intercourse in HIV-1-discordant couples where the man is positive is diff|cult to measure. The principal variables known to affect transmission risk are stage of disease (viral load, CD4 count, presence of AIDS def|ning symptoms), use of HAART, source of HIV infection, stability and length of the relationship, practice of anal intercourse, presence of genital tract lesions or infections, circumcision in the male partner, time of the menstrual cycle (maximum risk during menstruation) and the frequency of intercourse. A Cochrane review has calculated the incidence of seroconversion in discordant couples who never use condoms to be 6.68 seroconversions/100 person-years compared with 1.14 seroconversions/100 person-years in couples who always use condoms. A more useful f|gure for couples wishing to conceive is the risk per act of unprotected intercourse which is estimated to be 0.1-- 0.2% in couples who are in a stable monogamous relationship, not abusing intravenous drugs or participating in any other form of high-risk activity. A critical factor influencing this risk is the viral load in semen, which unfortunately correlates poorly with serum viral load. Although serum HIV-1 levels in plasma are generally higher than those in semen, virus has been detected in men with undetectable plasma viral levels, and several studies suggest separate compartments for HIV-1 in serum and semen.
The risks of unprotected intercourse Discordant couples wishing to conceive must be made aware of the risk of unprotected intercourse. A single act of intercourse is suff|cient to infect the female partner, and serum viral load or use of HAART are not reliable measures in assessing the extent of risk. In a series of 92 HIV-negative women with HIV-positive partners using carefully timed, but unprotected intercourse to conceive, there were four seroconversions. Although these were restricted to couples in whom the use of condoms outside the fertile window was inconsistent, this study indicates that the risk of unprotected intercourse timed to the fertile period carries an unacceptable risk (4%) of infecting the female partner and, in consequence,
CURRENT OBSTETRICS & GYNAECOLOGY
the child. This option should no longer be advised given that other safer options are available. If HIV-serodiscordant couples are to conceive safely, they are restricted to the following two options: 1. Insemination using donor sperm. Although this removes the risk of viral transmission as sperm donors are screened for HIV, it also removes the option of genetic parenting from the infected male. This is not an easy decision to take when faced with chronic illness. 2. Sperm washing. The female partner is inseminated with the infected partner’s sperm, washed free of HIV. If neither is acceptable to the couple, adoption is an alternative route to explore, although the HIV status of the prospective father is likely to render this process very diff|cult.
RISKS WITH SPERM WASHING Scientif|c evaluation The concept of inseminating HIV-negative women with sperm washed free of HIV was f|rst proposed by Semprini et al.1 and he published his f|rst series of cases in 1992. The literature available at this time indicated that, within semen, HIV was present as free virus in seminal fluid and as cell-associated virus in non-spermatozoa cells (NSC), but that spermatozoa themselves were free of HIV. The issue of whether spermatozoa themselves can be infected with virus has been intensely investigated but remains controversial. Our centre evaluated this along with the effectiveness of sperm washing prior to starting a clinical programme. Semen samples from11HIV-1-positive men were separated into spermatozoa, NSC and plasma fractions using the same differential centrifuge gradient as that previously described in clinical spermwashing programmes. The f|nal spermatozoa pellet obtained after centrifugation and two further washes was resuspended in fresh medium and left for 20 min to allow motile sperm to ‘swim-up’ to the supernatant. Control samples were taken from HIV-negative donors and processed in the same way. The level of viral RNA, proviral DNA and expression of HIV receptors CD4, CCR5 and CXCR4 in the separated compartments were then measured, and HIV viral RNA and proviral DNA were only found in seminal plasma and NSC. Spermatozoa did not express signif|cant levels of CD4, CCR5 or CXCR4, which measure infectivity, implying that they are unlikely to be a major target for HIV infection. After processing, the sperm count was reduced compared with the unprocessed ejaculate by up to one log, in line with previous reports. The weakness of this study, and potential risks in the clinical programme, relate to the detection limit
FERTILITY MANAGEMENTOF HIV-DISCORDANTCOUPLES
of the HIV assay used. The PCR nucleic-acid-based sequence amplif|cation (NASBA) assay is the only commercial assay available which can reliably extract RNA from sperm. However, the lower limit of detection of this assay is 25 HIV-1copies per million sperm.Therefore, HIV-1 could theoretically be present, but not detectable, postwashing. For this reason, sperm washing should be regarded as a risk reduction not risk-free option until suff|cient clinical cases have been reported to conf|rm its safety and reliability.
Clinical evaluation In terms of clinical outcome, sperm washing has a good track record to date . In Europe, more than 3000 cases of treatment using sperm processed as described above have been published resulting in the birth of over 300 healthy HIV-negative children. Compared with the published 4% risk of unprotected timed intercourse, sperm washing is undeniably safer. In statistical terms, over 8000 inseminations would have to be published before its safety could be reported to be comparable to that of donor insemination. The process of auditing outcome to reach this target number is ongoing through the collaboration of European centres, including our own, offering a sperm-washing service. These centres have adopted the policy of testing for HIV prior to use of washed sperm as a quality-control measure of the eff|cacy and safety of the processing. It is debatable whether the inoculum of HIV in a sample of sperm, which has been washed but has detectable viral load, is suff|cient to infect the female partner. In the USA, a single case report of a women becoming infected through insemination with inappropriately processed sperm from an HIVpositive man led to a ban on the use of washed sperm by the Centres for Disease Control.The lesson to be learnt from this is that centres wishing to establish a programme must process sperm and test for HIV according to published protocols.This will ensure that the service is covered medico-legally should the female partner become infected. Couples are also reassured that every effort is being made to minimize the risk of infection. If testing cannot be done on the day of insemination, a sample should be washed, tested and frozen prior to use.
MANAGEMENTOF COUPLES REQUESTING SPERM WSHING At present, sperm washing is only offered in a few centres in the UK and Europe. For a centre to offer treatment, it needs to have an established fertility service and assisted conception programme which, in addition, can offer pre-conceptual counselling specif|c to the needs of these couples, and facilities for processing and subsequently testing infected sperm within a separate laboratory or laboratory area. Figure 1 summarizes the
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steps involved in managing discordant couples wishing to conceive through sperm washing.
Pre-conceptual counselling The aims of counselling couples who are considering sperm washing are to allow them to consider all the reproductive options available to them, talk through the specif|c risks associated with sperm washing, and discuss the possibility of treatment failure. They need to understand that, as opposed to unprotected intercourse, treatment reduces the risk of HIV transmission signif|cantly but not completely.They need to consider the implications should the female partner become infected through treatment, both to herself, to their relationship and to the child if pregnancy results. HIV medication, long-term outcome and vertical transmission risk should be covered briefly. It is important that the long-term health, possible disability or death of the father is also explored and that the couple try to put in place a support network in the form of relatives or friends should the mother become a single parent.
Welfare of the child The clinic needs to make a ‘welfare of the child assessment’ prior to offering treatment to couples.This should be done during counselling and subsequent work-up. Couples need to show that they are in a committed and stable relationship, have planned for the future and that neither is involved in any high-risk activity that could put any resulting child at risk of acquiring HIV, such as unprotected sex or intravenous drug abuse. They should also agree not to have unprotected intercourse throughout the treatment programme and during pregnancy.
Sexual health screen Both partners should have a full sexual health screen to exclude the possibility of the female partner also being infected and to provide the opportunity of treating any genital lesions or infections before treatment, which could increase the risk of viral transmission. The female partner should be screened for HIV-1, hepatitis B and C, syphilis serology and rubella immunity, and have cervical and high vaginal swabs taken for chlamydia and gonorrhoea. The male partner should also have genital swabs. In the majority of cases, the referring physician will have provided information on the male partner’s HIV status (viral load, CD4 count and medication) and Hep B and C status. If not, this information should be requested and verif|ed up to date.
Fertility evaluation The majority of couples wishing to proceed with spermwashing treatment will not have tested their potential
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CURRENT OBSTETRICS & GYNAECOLOGY
HIV-discordant couple referred by genito-urinary physician
Pre-conceptual counselling
Male and female sexual health screen
Male and female fertility screen
• • •
Bilateral tubal damage/blockage Failed IUI x 6 FSH > 12 IU/l
SPERM WASHING + IVF
Results reviewed Treatment planned
• • • •
Normal semen analysis Normal FSH Ovulatory progesterone One or both tubes
•
Abnormal semen analysis
SPERM WASHING + ICSI
SPERM WASHING + IUI
HIV testing of female partner for 1year after treatment
Figure 1 Flow chart for the management of HIV-discordant couples.
fertility but, unlike most couples attending infertility clinics, are voluntarily infertile and unlikely to have fertility issues. Nevertheless, a non-invasive fertility screen should be done in both partners to exclude any factors which would reduce the chances of natural-cycle-timed insemination being successful.The female partner should have an assessment of ovarian reserve (baseline pelvic scan and follicle stimulating hormone, luteinizing hormone and oestradiol measured 2--5 days after onset of menstruation), a mid-luteal progesterone and a non-invasive test of tubal patency (hysterosalpingogram or HyCoSy), and the male partner should have a detailed semen analysis to assess count, motility and morphology. Provided the fertility tests reveal a normal endocrine prof|le (early follicular phase follicle stimulating hormone o 12 U/ml), spontaneous ovulation (mid-luteal progesterone 430 ng/ml), at least one patent tube and a normal semen analysis (count 4 20.106/ml, o80% abnormal forms and 450% motility by World Health Organization criteria), the couple should be offered up to six cycles of natural cycle intra-uterine insemination with washed sperm. In women with proven anovulation, insemination is performed in conjunction with ovulation induction using either clomiphene (f|rst line) or gonadotrophins (second line).When both fallopian tubes are damaged or blocked,
in-vitro fertilization (IVF) using washed sperm should be advised. If the semen analysis parameters are suboptimal for either intra-uterine insemination or IVF, intracytoplasmic sperm injection (ICSI) with washed sperm should be performed. ICSI has been suggested as the safest method of reducing viral transmission risk in serodiscordant couples as each oocyte is exposed to only one sperm as opposed to several million in the case of insemination or IVF. A recent series of 55 cases of ICSI using unwashed sperm in discordant couples reported no seroconversions in either uninfected partner or child. These are small numbers and safety remains in question. Aside from general concerns on the long-term outcome of children born through ICSI, one concern is that ICSI could introduce HIV into the oocyte by the virus attaching itself to the acrosome membrane. At present, there is no justif|cation for offering ICSI in preference to conventional sperm washing with insemination unless a male fertility factor is identif|ed.
Consent A specif|c consent form should be signed by both partners before sperm washing treatment to the effect that sperm washing is a risk-reduction (not risk-elimination)
FERTILITY MANAGEMENTOF HIV-DISCORDANTCOUPLES
technique with no absolute guarantee of protecting the female partner from HIV. This is an essential document which protects the service from medico-legal action should transmission occur.
Ultrasound monitoring As in conventional intra-uterine insemination programmes, follicle tracking is used from day 8 or 9 of the cycle to ensure correct timing of insemination. Once the lead follicle reaches 17 mm in diameter, human chorionic gonadotrophin (HCG) 5000 IU is given by subcutaneous injection (typically at 24.00 h) to allow insemination during working hours to be carried out 40 h later when the oocyte is released and in the fallopian tube.
Figure 2
The stages of sperm washing.
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Semen processing A sperm specimen should be produced about 30 h after the HCG injection, following an optimal time of 2--3 days abstinence from ejaculation. The sample is centrifuged for 20 min in a 40 -- 80% colloidal, silica density gradient to separate the semen into its different cellular components (Fig. 2).The clean sperm pellet is pushed to the bottom of the tube, leaving infected NSC and seminal plasma in the supernatant. The sperm pellet is carefully removed, resuspended in fresh medium and centrifuged twice more before a f|nal swim-up is prepared. It is mandatory that an aliquot of washed sperm be tested for detectable HIV RNA using a NASBA (or equivalent) assay. Provided the test is negative, intra-uterine insemination of the female partner is carried out. A pregnancy test is performed 2 weeks later. The risk of the sample having
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detectable HIV is 5-- 6% based on data from Marina et al. (1998) in which 5.6% (six of 107 semen samples) had detectable levels of HIV RNA on PCR after washing, and our own series in which detectable virus was present in 4.2% (six of 142) of samples post-wash. If it is not technically feasible to test a fresh washed sample for HIVon the day of treatment, a sample should be washed, tested and frozen for future use. One explanation for the presence of virus after washing is that the virus can become intraspermal in men with more advanced disease and cannot be eliminated with washing. It is detectable because PCR involves sperm lysis. Another explanation is that washing does not remove all the seminal plasma. A limit is imposed on the number of washes as sperm damage during repeated centrifuging leads to loss of the sperm quality and quantity needed to achieve fertilization.
RESULTS IN THE UK Our programme, established 3 years ago, has treated 53 HIV serodiscordant couples and resulted in the birth of 15 healthy children. Thirty-eight couples have had 94 cycles of intra-uterine insemination and 30 couples have had 42 cycles of either IVF or ICSI. The ongoing pregnancy/live birth rate is 10.8% (11/94) for intra-uterine insemination and 23.8% (10/42) for IVF/ICSI, f|gures that are consistent with previous reports.The pregnancy rate for intra-uterine insemination using washed sperm is comparable with that using donor sperm, and IVF and ICSI rates are similar to those using conventional methods to process sperm when controlled for female partner’s age. We ensure that all women receiving treatment with washed sperm have regular HIV testing for up to 1 year after treatment as a means of monitoring the effectiveness of the processing.To date, there have been no seroconversions in uninfected partner or child.
CURRENT OBSTETRICS & GYNAECOLOGY
The second is the possibility of transmitting a mutated drug-resistant form of HIV virus to the female partner. Both reinforce the importance of ensuring long-term follow-up of all children born through sperm washing.
FUNDING ISSUES At present, the majority of patients that have undergone sperm-washing treatment have to self-fund their treatment. Over the last 3 years, only a small number (14% of all patients undergoing sperm-washing treatment in a recent audit of UK genito-urinary clinics) have secured NHS funding on the basis that the treatment is for risk reduction not fertility. We now advise all patients to approach their Primary Care Trusts to be considered for funding on this basis. We believe that the results of our programme, and that of our colleagues in Europe, are suff|cient evidence that sperm washing is a cost-effective treatment which, in the long term, will signif|cantly reduce the transmission rate of HIV to uninfected women trying to conceive.
CONCLUSION The demand for risk-reduction fertility treatment in HIV-discordant couples is likely to rise. Timed unprotected intercourse carries an unacceptable risk to the uninfected female partner and is not recommended. Sperm washing should be offered but only carried out in dedicated units able to process semen according to strict laboratory criteria and to test washed sperm for HIV before treatment. In addition, these centres need to provide pre-conceptual counselling of risks involved and monitor the HIV status of the female partner post-treatment. All children born through sperm washing should be monitored over the long term to ensure that sperm exposure to HAART does not have any long-term harmful consequences.
EFFECTOF HAARTON SPERM Little is known of the effect of HIV or HAARTon semen parameters, although data are emerging to suggest that some antiretrovirals may adversely affect sperm motility through an effect on mitochondrial function. A study of sperm parameters in 250 non-vasectomized HIV-seropositive men and 38 fertile controls would suggest that sperm count, volume and motility are reduced in HIVpositive men irrespective of use of HAART. Our present advice is that the decision to start or stop medication should not be based on concern for fertility but rest solely on viral load and CD4 count parameters, as there are insuff|cient data at present to advise otherwise. There are two concerns for patients conceiving when on HAART. The f|rst is whether there could be any longterm harmful effects of the medication on the offspring.
Practice Points *
*
*
Discordant couples trying to conceive safely have only two optionsFsperm washing or donor insemination.The risk of infecting the female partner if timed unprotected intercourse is considered has been shown to be unacceptable (4%) All couples considering sperm washing should receive pre-conceptual counselling to ensure that they understand that the procedure signif|cantly reduces the risk of viral transmission through sperm but cannot be guaranteed to be risk free All processed samples should be tested for HIV prior to being used in treatment
FERTILITY MANAGEMENTOF HIV-DISCORDANTCOUPLES
REFERENCES [1] Semprini AE, Levi-Setti P, Bozzo M et al. Insemination of HIVnegative women with processed semen of HIV-positive partners. Lancet 1992; 340: 1317--1319. [2] Marina S, Marina F, Alcolea R et al. Pregnancy following intracytoplasmic sperm injection from an HIV-1 seropositive man. Hum Reprod 1998; 13: 3247--3249.
FURTHER READING BHIVA. Guidelines for the management of HIV infection in pregnant women and the prevention of mother-to-child transmission. HIV Med 2001; 2: 314--334.
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Gilling-Smith C. Assisted reproduction in HIV discordant couples. AIDS Reader 2001; 10: 581--587. Gilling-Smith C, Smith JR, Semprini A. Infertility and HIV: time to treat. BMJ 2001; 322: 566--567. Gilling-Smith C, Almeida PA. HIV, hepatitis B & hepatitis C and infertility: Reducing Risk Educational Bulletin sponsored by the Practice & Policy Committee of the BFS. Hum Fert 2003 (in press). Kim LU, Johnson MR, Barton S et al. Evaluation of sperm washing as a potential method of reducing HIV transmission in HIV-discordant couples wishing to have children. AIDS 1999; 13: 645--651. Mandlebrot L, Heard I, Henrion-Geant E, Henrion R. Natural conception in HIV-negative women with HIV-infected partners [letter] Lancet 1997; 349: 850--851.