Letter to the editor |
Reply: Choice of ART programme for serodiscordant couples with an HIV-infected male partner
1 Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Siena and 2 Centro di Chirurgia Ambulatoriale SrL, Florence, Italy
3 To whom correspondence should be addressed at: Obstetrics and Reproductive Medicine, University of Siena, Policlinico S. Maria alle Scotte, Siena, Italy. E-mail: piomboni{at}unisi.it
Sir,
We thank Prof Bujan, Dr Daudin and Prof Pasquier for their interest in the study published by our group in Human Reproduction (Mencaglia et al., 2005
). Their main criticism concerns our choice of ICSI as the optimal method to avoid viral transmission in serodiscordant couples with human immunodeficiency virus (HIV)- and hepatitis C virus (HCV)-infected males without severe fertility impairment.
The principal aim of our procedure was to minimize the risk of viral infection in couples wishing to achieve pregnancy, and ICSI clearly reduces near to zero the risk of horizontal and vertical transmission.
Nevertheless, results from Bujan’s group are impressive in their efficacy in quite a large sample [213 intrauterine insemination (IUI) cycles], their high pregnancy rate (66%) and the absence of cases of HIV transmission. In their opinion, IUI based on high-quality procedures of sperm preparation before insemination (sperm-density gradient + swim-up methods) is the optimal choice for serodiscordant couples with HIV-infected men. However, it is known from different reports that sperm washing does not ensure absolute absence of viral genome in semen because of viral presence inside sperm cells (Dussaix et al., 1993; Baccetti et al., 1994). This could be why even the most sensitive diagnostic methods have been unable to definitively exclude viral presence in sperm cells after meticulous washing procedures (Pena et al., 2003). The risk of HIV transmission therefore exists, as reported in various studies (Araneta et al., 1995; Matz et al., 1998; Englert et al., 2001, 2004). Thus, their confidence in the safety and reliability of IUI is based only on their experience and on the absence of recorded cases of viral transmission, not on certainty about the absence of HIV in semen. It is important to stress that approximately 5–10% of the samples still had HIV load after washing. Furthermore, standardized sperm washing for infected male patients severely decreases the number of cells recovered, and even if the patient was normospermic (this is not very usual in HIV-infected males), at the end of treatment, the number of recovered sperm could be insufficient to perform IUI.
Our experience with ICSI confirms its safety, which is due to the fact that:
- fertilization of the oocyte occurs outside the body of the seronegative woman, without exposing her to many sperm;
- the oocyte is fertilized by only one sperm (i.e. the oocyte does not come into contact with many sperm, some of which could contain viruses), so even with a false-negative semen test, ICSI quantitatively decreases the chances of HIV transmission, which makes it more reliable.
Since January 2004, we have offered serodiscordant couples excellence in assisted reproduction by performing sensitive PCR tests in sperm samples before ICSI. This is done in a fraction of semen, while another fraction of the same sample is cryopreserved until the results of molecular analysis are obtained. This procedure decreases the number of sperm available for fertilization, making IUI unreliable.
The negative psychological and economic aspects of ICSI are justified by the high reliability of contamination prophylaxis. For economic reasons, IUI with washed semen could be offered to serodiscordant couples who do not have access to a good healthcare system, but in our opinion, when possible, sperm wash with ICSI is safer method to treat these couples.
References
Araneta MR, Mascola L, Eller A, O’Neil L, Ginsberg MM, Bursaw M, Marik J, Friedman S, Sims CA and Rekart ML (1995) HIV transmission through donor artificial insemination. JAMA 273,854–858.[Abstract]
Baccetti B, Benedetto A, Burrini AG, Collodel G, Ceccarini EC, Crisa N, Di Caro A, Estenoz M, Garbuglia AR, Massacesi A et al. (1994) HIV-particles in spermatozoa of patients with AIDS and their transfer into the oocyte. J Cell Biol 127,903–914.[Abstract]
Dussaix E, Guetard D, Dauguet C, De Almeida M, Auer J, Ellrodt A, Montaigner L and Aroux M (1993) Spermatozoa as potential carriers of HIV. Res Virol 144,187–195.[CrossRef][ISI][Medline]
Englert Y, Van Vooren JP, Place I, Liesnard C, Laruelle C and Dellbaere A (2001) ART in HIV-infected couples. Hum Reprod 16,1309–1315.
Englert Y, Lesage B, Van Vooren JP, Liesnard C, Place I, Vannin AS, Emiliani S and Delbaere A (2004) Medically assisted reproduction in the presence of chronic viral diseases. Hum Reprod Update 10,149–162.
Matz B, Kupfer B, Ko Y, Walger P, Vetter H, Eberle J and Gurtler L (1998) HIV-1 infection by artificial insemination. Lancet 351,728.[CrossRef][ISI][Medline]
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.
Pena JE, Thornton II 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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