Letter to the editor |
Use of washed sperm for assisted reproduction in HIV-positive males without checking viral absence. A risky business?
Andrology and Semen Bank, Instituto Valenciano de Infertilidad, Plaza de la Policia Local 3, 46015 Spain
1 To whom correspondence should be addressed. E-mail: nicolas.garrido{at}ivi.es
Sir,
We read with interest the manuscript by Mencaglia et al. (2005)
, where they described their experience in the treatment of human immunodeficiency virus serodifferent couples when the male was infected, and surprisingly we noticed that no test to confirm viral absence in the washed sperm sample was performed.
This is (to our knowledge), the second paper available in the literature using the same procedures (see Pena et al., 2003), and they argued, as Pena did, that no method is currently available to detect HIV in a single sperm, that sensitivity of the available laboratory assays is 200–800 copies/ml, and also that polymerase inhibitors interfering with PCR reactions exist, thus provoking false negatives.
We are against these affirmations, and firmly believe that nowadays it is possible to detect even a single copy of HIV virus in washed sperm by nested PCR, as we previously published (Meseguer et al., 2002). Moreover, we can avoid false negatives by implementing the adequate positive controls (adding viral sequences to aliquots of the samples before they are tested). Polymerase inhibitors were never present after wash, and the failure rate of the assay was zero.
We agree with the suggestion that both gamete manipulation and assisted reproduction procedures themselves probably reduce the transmission risks—the former by the elimination of seminal plasma and round cells, the latter by simply exposing the women to very few potentially infected sperm and diminishing the number of exposures needed to achieve pregnancy (obviously, via sexual intercourse, repeated exposures to more sperm cells could be needed before achieving pregnancy).
Nevertheless, technically we can ensure the absence of virus, reducing the transmission risk to a theoretical zero. Also, we can be sure that no sperm present the virus, when a sample is washed, since one-half of the resulting sample is analysed, and then we can extrapolate the result to the half sample frozen for the ICSI procedures. Then there is no need to test the single sperm that is going to be injected, in the same way that collecting a sample of peripheral blood and testing it is enough to determine whether or not a person carries HIV, and in consequence it is not necessary to test the whole blood in an individual.
Also, we must take into account the costs associated with these tests. They imply <10% of the treatment fees, and even less when more than one treatment is needed, since frozen sperm from a single wash can be employed several times.
To date, ~5–10% of the samples still present HIV load after wash. For patient, children, and staff safety, we consider this should be treated accordingly.
As they stated, we recommended in our paper sperm wash and ICSI as a safe method to treat serodiscordant couples, but they neglected to add the need for a viral test before the ICSI which we clearly stated in our work (Garrido et al., 2004).
Finally, no seroconversion occurred, as in Pena’s paper, just in <200 cycles altogether, and this still does not demonstrate that these procedures display a risk of transmission lower than that of sexual contact (whose transmission rate is between 1/1000 and 1/3000).
If our goal is the achievement of excellence in assisted reproduction and the extreme reduction of any associated risk, then undoubtedly, testing is safer than not doing so.
References
Garrido N, Meseguer M, Bellver J, Remohi J, Simon C and Pellicer A (2004) Report of the results of a 2 year programme of sperm wash and ICSI treatment for human immunodeficiency virus and hepatitis C virus serodiscordant couples. Hum Reprod 19,2581–2586.
Mencaglia L, Falcone P, Lentini GM, Consigli S, Pisoni M, Lofiego V, Guidetti R, Piomboni P and De Leo V (2005) ICSI for treatment of human immunodeficiency virus and hepatitis C virus-serodiscordant couples with infected male partner. Hum Reprod 20,2242–2246.
Meseguer M, Garrido N, Gimeno C, Remohí J, Simón C and Pellicer A (2002) Comparison of polymerase chain reaction-dependent methods for determining the presence of human immunodeficiency virus and hepatitis C virus in washed sperm. Fertil Steril 78,1199–1202.[CrossRef][ISI][Medline]
Pena JE, Thornton MH and Sauer MV (2003) Assessing the clinical utility of in vitro fertilization with intracytoplasmic sperm injection in human immunodeficiency virus type 1 serodiscordant couples: report of 113 consecutive cycles. Fertil Steril 80,356–362.[CrossRef][ISI][Medline]
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