Letter to the editor |
Choice of ART programme for serodiscordant couples with an HIV infected male partner
1 CECOS Midi-Pyrénées, Research Group on Human Fertility (EA 3694), University Hospital Paule de Viguier and 2 Department of Virology, University Hospital Purpan, Toulouse, France
3 To whom correspondence should be addressed at: CECOS Midi-Pyrénées, Research Group on Human Fertility (EA 3694), University Hospital Paule de Viguier, TSA 70034, 31059 Toulouse Cedex 9, France. E-mail: bujan.l{at}chu-toulouse.fr
Sir,
Mencaglia et al. (2005)
report in a recent issue of Human Reproduction the results of an ICSI programme in serodiscordant couples where the male partner is infected with human immunodeficiency virus (HIV) and/or hepatitis C virus. In their conclusions, they affirm that ICSI is the method of choice to reduce the risk of viral transmission to the partner, whatever the fertility status of the couple.
The debate on HIV presence on spermatozoa is probably not definitively closed. However, while the presence of galactosyl-alkyl-acylglycerol (Brogi et al., 1995), a molecule structurally related to galactosylceramide which is an alternative receptor for HIV, has been reported on sperm membranes, this receptor requires an HIV co-receptor in order to penetrate and infect the cell. There have been several publications on the lack of HIV receptor expression on spermatozoa (Kim et al., 1999) and on the absence of HIV particles or genomes in spermatozoa fractions obtained after two techniques of sperm washing (Quayle et al., 1998; Kim et al., 1999; Pasquier et al., 2000; Bujan et al., 2002, 2004a). Although two studies have shown the presence of HIV nucleic acid after sperm preparation (Marina et al., 1998; Meseguer et al., 2002), we have demonstrated that the use of two successive preparation methods (i.e. sperm density gradient and swim-up methods) effectively yielded spermatozoa fractions with systematically undetectable HIV DNA and RNA (Pasquier et al., 2000; Bujan et al., 2004a) in more than 800 semen preparations to date, whatever the seminal viral load (Bujan et al., 2002). Moreover, although this was not mentioned by Mencaglia et al., several publications on intrauterine insemination (IUI) programmes in serodiscordant couples with an HIV-infected male partner have reported no case of female contamination (Semprini et al., 1992; Marina et al., 1998; Semprini et al., 1998; Gilling-Smith, 2000; Ohl et al., 2003; Bujan et al., 2004b). There is no clear evidence that ICSI is safer than IUI where HIV transmission risk is concerned. Furthermore, we have reported the results of 213 IUI cycles in such couples. The pregnancy rate per couple was 66%, and the percentage of couples with a child was 50% (Bujan et al., 2004b). These rates are comparable to the results of ICSI reported by Mencaglia et al.
In our opinion, there is no justification for systematic use of ICSI methods in these couples who are naturally fertile. In serodiscordant couples with HIV-positive men, compulsory condom use in order to avoid female contamination induces artificial sterility. The physician is then asked to help these couples to have a child, without contamination of the partner. Insemination, using spermatozoa prepared with both successive methods, is a very efficient assisted reproduction technique (ART) to help these fertile patients. ICSI does not increase the pregnancy rate per couple in fertile couples, and in addition, it exposes them to the side effects of this method: physical (treatment, ovarian puncture, anaesthesia, etc.) and emotional stress. Moreover, the cost of ICSI should be taken into account, particularly in countries with an inadequate health care insurance system. This point is particularly important because when a couple has no access to an ART programme, they may try to conceive naturally with exposure to HIV-transmission risk (Mandelbrot et al., 1997). We believe, in the light of present scientific knowledge, that patients should be informed about all available possibilities of reducing the risk of HIV transmission and that the choice of ART method should be related only to the fertility status of both partners.
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