Hum. Reprod. Advance Access originally published online on July 3, 2007
Human Reproduction 2007 22(10):2793-2794; doi:10.1093/humrep/dem197
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Letters to the Editor |
Establishing the safety profile of sperm washing followed by ART for the treatment of HIV discordant couples wishing to conceive
1 Facoltà di Medicina e Chirurgia, Università Statale di Milano, Via Festa del Perdono 7, 20121 Milano, Italy; 2 Research Group on Human Fertility, University Toulouse III Paul Sabatier, EA 3694, France 3 CECOS Midi-Pyrénées, Hôpital Paule de Viguier, 330 avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse Cedex 9, France 4 Fertility Clinic, Department of Obstetrics and Gynaecology, Erasme Hospital and Laboratory for Research in Human Reproduction, Medicine Faculty, Free University Brussels, Belgium 5 Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, 369 Fulham Road, London, UK 6 APHP, Hôpital Cochin—Université Paris Descartes, Unité de Médecine de la Reproduction Service de Gynécologie-obstétrique, Paris, France 7 ESMAN Medical Consulting, Milan Via Carlo Crivelli 20, 20122 Milan, Italy 8 Centre d'AMP de Strasbourg, Service de Gynécologie-Obstétrique, CMCO-SIHCUS, 19 rue Louis Pasteur, BP 120, 67303 Schiltigheim, France 9 Infectious Diseases, Department of Medicine, Kantonsspital, St Gallen, Switzerland
10 Correspondence address. Via Carlo Crivelli 20, 20122 Milan, Italy. Tel: +39 02 58 43 07 03; Fax: +39 02 365 18 194; E-mail: semprini{at}esman.it
We read with interest the ample clinical series of HIV discordant couples undergoing sperm washing and ART, reported by Savasi et al. (2007)
in your March issue. The title and abstract of the article indicate it focuses on the safety of the sperm washing procedure which, according to the authors was investigated by serological follow-up of treated women at three and six months after each cycle. Yet, the results section only contains a general reference to the three months follow-up, and only for women who underwent intrauterine insemination (IUI), consisting in the general statement, that all tests performed were negative.
It is regretable that the authors have chosen not to support the ambitious safety statement reported in the article abstract, of complete serological follow-up, with actual serological follow-up results. Similarly, no mention is made to the rate of the loss to follow-up or, if really none of the three and six months serologies were missing, to the system employed by the authors to ensure such complete post-treatment follow-up. It would be so remarkable that we would be delighted to know how PCR testing were made available to 100% of HIV negative women after the end of the treatment period and how obtaining perfect compliance with post-treatment follow-up was achieved.
Since its development in 1989 in Italy (Semprini et al., 1992), sperm washing and IUI have been employed as a risk reduction method in HIV discordant couples wishing to conceive. In vitro testing following sperm washing showed that the method reduced the HIV titre in washed semen by >1000 fold (Anderson et al., 1992). However, HIV heterosexual transmission is a relatively rare event, in the order of 1 to 500–1000 acts of unprotected intercourse (Gray et al., 2001) and probably much lower for patients with undetectable viral load. Hence, such determination of safety requires not only a careful description of the follow-up methods and the eventual numbers lost to follow-up but needs a sufficiently large sample that has been evaluated between 3000 and 30 000 cycles (Englert et al., 2004). The results section of this article should in our eyes be cautious before claiming to have reached this ambitious goal. Moreover, the authors declare that sperm washing was provided only to couples where the man was aviraemic. The risk of HIV transmission has been shown to correlate with blood viraemia levels. Gray et al. (2001) showed lack of HIV transmission through unprotected intercourse in couples in which the man's viral load was <1500 copies/ml. It is unclear how a patient population in which the risk of the event of transmission is minimal can be used to indicate the safety of the intervention. In addition, the authors supply no indication or explanation of how and whether the difference in risk was foreseen and dealt with in their population and sum their results to those of other groups who reported the outcome of sperm washing in populations at different degree of transmission risk.
The evidence of low risk of HIV transmission from aviraemic men, gave way to the debate on whether these couples could be offered timed unprotected intercourse (Vernazza et al., 2006). The authors of the present article affirm this option to be unacceptable. However, they seem to see no problem in abandoning couples in whom the men have unsuppressed viraemia to this forced choice. Indeed, almost two-thirds of couples who requested this procedure were excluded before treatment and positive blood viraemia was an exclusion criterion. The authors affirm that such exclusions were motivated by the desire to protect the woman. In any form of clinical treatment, choosing the patients who are most likely to have a positive outcome, while denying treatment to those in actual need, is likely to protect the medical establishment, rather than patients.
When sperm washing and ART were introduced in Italy in 1989, no exclusion criteria were posed, apart from the willingness to practice unprotected intercourse for the duration of the program. Until 1997, when highly active antiretroviral treatment (HAART) was introduced, over 1100 sperm washing and insemination cycles have been performed, with a rate of serological follow up at six months of 92.9% with no case of HIV transmission (Bujan et al., 2007).
If sperm washing is to fulfil its role as a public health measure aiming to reduce the risk of HIV transmission to seronegative female partners of HIV positive men wishing to conceive, its application should be allowed and even encouraged in those couples who are actually at risk of transmission.
References
Anderson DJ, Politch JA, Oneta M, et al. Efficacy of conventional semen processing techniques in separation of motile sperm from HIV-1 and HIV-1 host cells. 48th annual Meeting of the. American Fertility Society (1992) 107. Abstracts P 213.
Bujan L, Hollander L, Coudert M, Gilling Smith C, Vucetich A, Guibert J, Vernazza P, Ohl J, Weigel M, Englert Y, Semprini AE. Safety and efficacy of sperm washing in HIV-1 serodiscordant couples where the male is infected: results from the European CREAThE Network. (2007) for the CREAThE network AIDS.
Gray RH, Wawer MJ, Brookmeyer R, Sewankambo NK, Serwadda D, Wabwire-Mangen F, Lutalo T, Li X, van Cott T. Quinn TC. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet (2001) 357:1149–1153.[CrossRef][Web of Science][Medline]
Englert Y, Lesage B, Van Vooren JP, Liesnard C, Place I, Vannin AS, Emiliani S, Delbaere A. Medically assisted reproduction in presence of chronic viral diseases. Hum Reprod Update (2004) 10:149–162.
Savasi S, Ferrazzi E, Lanzani C, Oneta M, Parrilla B, Persico T. Safety of sperm washing and ART outcome in 741 HIV-1-serodiscordant couples. Hum Reprod (2007) 22:772–777.
Semprini AE, Levi-Setti PE, Bozzo M, Ravizza M, Taglioretti A, Sulpizio P, Albani E, Oneta M, Pardi G. Insemination of HIV-negative women with processed semen of HIV-positive partners. Lancet (1992) 340:1317–1319.[CrossRef][Web of Science][Medline]
Vernazza PL, Hollander L, Semprini AE, Anderson DJ, Duerr A. HIV-discordant couples and parenthood: how are we dealing with the risk of transmission? AIDS (2006) 20:63.
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