A decade of the sperm-washing programme: where are we now?

Since 1999, we have treated HIV-positive men with sperm washing as part of a risk-reduction programme with a year-on-year increase in total infectious cycles performed to over 200 in 2008. Four hundred and thirty nine cycles of IUI, 114 cycles of IVF and 117 cycles of ICSI have been performed in HIV positive men over the decade and of the 259 couples treated, a pregnancy rate and ongoing pregnancy rate per couple of 45.4% and 36.3% have been achieved with over 100 children born with no seroconversions. We outline the continued importance of such risk-reduction measures with 9.7% of samples from men with 'stable' disease on anti-retroviral treatment and undetectable viral load demonstrating detectable viral particles in seminal fluid and discuss measures to improve outcome in this patient group.

A decade of sperm washing: clinical correlates of successful insemination outcome.

BACKGROUND: Since 1999, we have treated HIV-positive men with sperm washing as part of a risk-reduction programme. METHODS: Retrospective analysis of the sperm-washing database from the treatment of 245 couples with 439 cycles of intrauterine insemination assessed the effects of patient factors (age, maternal FSH, rank of attempt), markers of HIV-disease [time since diagnosis, CD4 count, viral load (VL), use of highly active antiretroviral therapy (HAART)], cycle factors (natural versus stimulated, number of follicles, fresh versus frozen sperm) and sperm parameters on clinical (CPR) and ongoing pregnancy rate (OPR). RESULTS: Overall 111-245 (45.4%) couples achieved a clinical pregnancy (CPR: 13.5% and OPR: 9.6% per insemination) with no seroconversions. The mean duration since HIV diagnosis was 5.8 years, 73% of men were on antiretroviral therapy, there was an undetectable VL in 64% and the median CD4 was 409 cells/mm(3). A significantly decreased OPR and a non-significantly increased miscarriage rate (MR) was observed after the female age of 40. Similarly, there was a significant increased OPR and decreased MR for women with a mean cycle maternal FSH of <6.4 IU/l. There was no effect of VL, CD4 count, use of HAART or time since diagnosis on the outcome. Nor was there a difference in the OPR according to paternal age, rank of attempt, cycle regime or number of follicles. Semen volume, sperm concentration, total count and progressive motility and post-wash concentration, progressive motility and total motile count inseminated were significantly higher in successful cycles. The use of frozen sperm had a significant negative impact on outcome. CONCLUSIONS: This study of the potential safe and successful reproductive options available to HIV-positive men demonstrates that maternal age and semen quality, rather than HIV factors, remain the most important determinants of cycle success.

A decade of the United Kingdom sperm-washing program: untangling the transatlantic divide.

Fertility assistance to HIV-positive men is now accepted practice in many parts of the world. We analyze the legislative, ethical, and clinical factors that explain the differences across continents with the aim of opening up the debate within the United States on whether clinics can justify denying HIV-infected men the opportunity of parenting through a now well-established risk reduction method with a proved safety record.

Infertility treatment for HIV-positive women.

Thanks to antiretroviral combination therapy, HIV-infected individuals live longer, healthier lives and may wish to have children. Women with HIV can attempt to conceive naturally or through simple self-insemination to minimize the risk of horizontal HIV transmission. Assisted reproduction technology is necessary in couples with infertility, which can either be independent of HIV infection and its treatment or be associated with it. This article summarizes the latest evidence regarding the desire for a child in HIV-positive women and how HIV infection and its treatment may impact female fertility. Current data regarding access to and outcomes of assisted conception programs in HIV-positive women wishing to conceive in both high- and low-income countries is also reviewed.

Sperm DNA fragmentation in subfertile men: the effect on the outcome of intracytoplasmic sperm injection and correlation with sperm variables.

OBJECTIVE: To present the first UK data on sperm DNA fragmentation levels in subfertile men and fertile controls, the correlation with semen variables, and to assess the effect on the outcome of intracytoplasmic sperm injection (ICSI). PATIENTS, SUBJECTS AND METHODS: In all, 56 subfertile men undergoing ICSI (28 with positive and 28 with a negative outcome for paternity) and 10 control fertile semen donors were recruited. The sperm DNA fragmentation index (DFI) was assessed on raw pre-preparation samples using the sperm chromatin structure assay. A mean of 5212 sperm were analysed per sample and DFI data are presented by fertility status, ICSI outcome and correlated with semen variables (assessed using World Health Organisation criteria). RESULTS: Total DFI was significantly higher in subfertile men than in fertile controls (mean and median of 22.8% and 17.0% vs 8.4% and 5.0%; P < 0.001), as was the proportion of both moderate DFI (16.4% and 13.0% vs 6.4% and 4.0%; P = 0.001) and high DFI (6.2% and 6.1 vs 2.0% and 1.0%; P = 0.01). This difference remained significant when the control men were compared only with the subfertile men with successful paternity. There was no significant difference in DFI in the subfertile men when analysed by ICSI outcome (mean and median of 24.5% and 17.0% vs 22.3% and 21.0% for successful and unsuccessful cycles, respectively; P = 0.94). There was a positive statistically significant correlation (r = 0.37; P = 0.02) between the DFI and sperm morphology. CONCLUSIONS: This study confirms a relationship between male subfertility and sperm DFI; we discuss the correct role for genetic testing of sperm in the evaluation of subfertile men. Although DNA fragmentation data might help to decide a suitable treatment, once it is decided to proceed with ICSI, DFI levels have no effect on the outcome.

Safety and efficacy of sperm washing in HIV-1-serodiscordant couples where the male is infected: results from the European CREAThE network.

OBJECTIVE: To examine the safety and effectiveness of assisted reproduction using sperm washing for HIV-1-serodiscordant couples wishing to procreate where the male partner is infected. DESIGN AND METHODS: A retrospective multicentre study at eight centres adhering on the European network CREAThE and involving 1036 serodiscordant couples wishing to procreate. Sperm washing was used to obtain motile spermatozoa for 3390 assisted reproduction cycles (2840 intrauterine inseminations, 107 in-vitro fertilizations, 394 intra-cytoplasmic sperm injections and 49 frozen embryo transfers). An HIV test was performed in female partners at least 6 months after assisted reproduction attempt. The outcome measures recorded were number of assisted reproduction cycles, pregnancy outcome and HIV test on women post-treatment. RESULTS: A total of 580 pregnancies were obtained from 3315 cycles. Pregnancy outcome was unknown in 47 cases. The 533 pregnancies resulted in 410 deliveries and 463 live births. The result of female HIV testing after assisted reproduction was known in 967 out of 1036 woman (7.1% lost to follow-up). All tests recorded were negative. The calculated probability of contamination was equal to zero (95% confidence interval, 0-0.09%). CONCLUSION: This first multicentre retrospective study of assisted reproduction following sperm washing demonstrates the method to be effective and to significantly reduce HIV-1 transmission risk to the uninfected female partner. These results support the view that assisted reproduction with sperm washing could not be denied to serodiscordant couples in developed countries and, where possible, could perhaps be integrated into a global public health initiative against HIV in developing countries.

HIV infection and subfertility.

With the improvements in life expectancy and quality of life for HIV-infected individuals in the developed world, and the increasing rates of HIV transmission among heterosexuals, reproductive issues are becoming increasingly important. We discuss the management of conception and pregnancy in HIV-infected couples. Couples where one or both partners are HIV infected may also experience subfertility and in this article we review the methods available to treat subfertility in this population and the current guidelines for the use of these techniques. HIV-infected couples can enjoy normal, healthy lives and should have access to the same investigation and treatment as their HIV-negative counterparts. Current inequities in the treatment available must be addressed.

Multicenter quality control of the detection of HIV-1 genome in semen before medically assisted procreation.

Couples in whom the man is HIV-1-positive may use medically assisted procreation in order to conceive a child without contaminating the female partner. But, before medically assisted procreation, the semen has to be processed to exclude HIV and tested for HIV nucleic acid before and after processing. The performance was evaluated of the technical protocols used to detect and quantify HIV-1 in 11 centers providing medically assisted procreation for couples with HIV-1 infected men by testing panels of seminal plasma and cells containing HIV-1 RNA and/or DNA. The performance of these tests varied due to the different assays used. False positive results were obtained in 14-19% of cases. The sensitivity for RNA detection in seminal plasma was 500-1,000 RNA copies/ml, over 500 RNA copies/10(6) cells in semen cells, and for DNA detection in semen cells 50-500 DNA copies/10(6) cells. The use of silica-based extraction seemed to increase the assay performance, whereas the use of internal controls to detect PCR inhibitor did not. This first quality control highlights the need for technical improvements of the assays to detect and quantify HIV in semen fractions and for regular evaluation of their performance.

Human immunodeficiency virus infection and fertility care in the United Kingdom: demand and supply.

OBJECTIVE: To collect data on the demand and provision of fertility care in HIV-infected couples in the United Kingdom and data on the etiology of subfertility in this population. DESIGN: A postal questionnaire survey and audit of causes of infertility in HIV-infected women. SETTING: Seventy-four Human Embryology and Fertilisation Authority-registered assisted conception units (ACUs) and 294 genitourinary medicine (GUM) clinics in the United Kingdom were sent questionnaires. PATIENT(S): Sixty-five HIV-infected women attending the Research Clinic at the Chelsea and Westminster ACU. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Number of ACUs treating HIV-infected patients and number of GUM clinics receiving requests for referral, as well as the etiology of subfertility in HIV-infected women attending our clinic. RESULT(S): Response rates from ACUs and GUM clinics were 93% and 63%, respectively. Fourteen ACUs (20%) were treating HIV-infected men; of these, seven (10%) performed sperm washing, but only two (3%) tested sperm for HIV after processing, before use. Nine units (13%) treated HIV-infected women, but only three ACUs (4%) had separate laboratories for handling potentially infected gametes or embryos. Of the 15,211 patients registered in 81 GUM clinics, 4% of the men and 16% of the women had requested advice on conceiving. An audit of the Chelsea and Westminster HIV fertility clinic demonstrated a 40% prevalence of tubal factor infertility in HIV-infected women. CONCLUSION(S): Demand is high, and set to increase, but current suboptimal practice in some centers is placing unaffected partners and the unborn child at risk of seroconversion.

Laboratory safety during assisted reproduction in patients with blood-borne viruses.

For couples where one or both partners are infected with human immunodeficiency virus or hepatitis C, the doors to receiving fertility care are opening as a result of better antiviral medication, better long-term prognosis and consequent changes in attitude. In line with this, fertility centres electing to treat couples with blood-borne viral (BBV) infection need to re-examine their policies and procedures to ensure the safety of their staff and both non-infected and infected patients during assisted reproduction treatments. At a time when the European Tissue Directive aims to introduce quality standards for assisted reproduction throughout Europe, we highlight the risks involved when treating patients with known BBV infections and argue that safety cannot be met with any certainty unless samples from such patients are handled within a separate high security laboratory or laboratory area, technically adapted to ensure minimal cross-contamination risk to uninfected gametes and embryos.

Use of surgical sperm retrieval in azoospermic men: a meta-analysis.

OBJECTIVE: To compare the outcome of intracytoplasmic sperm injection (ICSI) cycles [1] using epididymal and testicular sperm in patients with obstructive azoospermia (OA); [2] using surgically retrieved sperm in patients with OA and nonobstructive azoospermia (NOA); and [3] using fresh and frozen-thawed sperm. DESIGN: Meta-analysis of published data. SETTING: Assisted conception unit. PATIENT(S): Ten reports (734 cycles: 677 transfers) were identified as suitable to assess source of sperm; 9 reports (1,103 cycles: 998 transfers) to assess etiology; and 17 reports (1,476 cycles: 1,377 transfers) to assess the effect of cryopreservation. INTERVENTION(S): Surgical sperm retrieval/ICSI. MAIN OUTCOME MEASURE(S): Fertilization rate (FR), implantation rate (IR), clinical pregnancy rate (CPR), and ongoing pregnancy rate (OPR) per embryo transfer. RESULT(S): Meta-analysis demonstrated no significant difference in any outcome measure between the use of epididymal or testicular sperm in men with OA. Meta-analysis showed a significantly improved FR (relative risk [RR] 1.18; 95% confidence interval [CI]: 1.13-1.23) and CPR (RR 1.36; 95% CI: 1.10-1.69) in men with OA as compared to NOA with a nonsignificant increase in OPR. There was no difference in either IR or miscarriage rate between the two groups. Comparing fresh with frozen-thawed epididymal sperm there was no difference in FR or IR, a significantly higher CPR (RR 1.20; 95% CI: 1.0-1.42), and no difference in OPR. No difference in fertilization or pregnancy outcome was noted when the testicular cycles were analyzed separately, but IR was significantly impaired using frozen-thawed sperm (RR 1.75; 95% CI: 1.10-2.80). CONCLUSION(S): Meta-analysis of published data confirms that etiology of azoospermia and cryopreservation of surgically retrieved sperm impacts on ICSI outcome, and allows us to make several recommendations for clinical practice. Origin of sperm, in men with similar etiology, does not affect outcome.

Effect of time since vasectomy and maternal age on intracytoplasmic sperm injection success in men with obstructive azoospermia after vasectomy.

OBJECTIVE: To determine the effects of time since vasectomy and maternal age on intracytoplasmic sperm injection (ICSI) outcome in azoospermic men after vasectomy. DESIGN: Retrospective analysis. SETTING: Assisted conception unit. PATIENT(S): Thirty-seven azoospermic men (after vasectomy) who were undergoing 56 cycles of ICSI. INTERVENTION(S): Surgical sperm retrieval and standard ICSI protocol. The ICSI cycles were analyzed in four groups, according to years since vasectomy, and were reanalyzed in three groups, according to maternal age. MAIN OUTCOME MEASURE(S): Fertilization rate, implantation rate, clinical pregnancy rate, and live-birth rate (LBR) per ET. RESULT(S): No effect of time since vasectomy was seen on any outcome. The highest fertilization rate and LBR were found in the group with the longest time interval. These findings could not be explained by differences in either patient characteristics or stimulation regimes. When reanalyzed by maternal age, there was an improvement in implantation rate and LBR with decreasing maternal age. Live birth rates of 38.5%, 22.7%, and 11.8% were achieved for maternal ages of <32, 32-37, and >38 years, respectively. Logistic regression confirmed a statistically significant effect on outcome of maternal age but not time since vasectomy. CONCLUSION(S): Our data suggest that maternal age, and not interval since vasectomy, remains the principal determinant of ICSI success in men with obstructive azoospermia after vasectomy.

The effect of human immunodeficiency virus on sperm parameters and the outcome of intrauterine insemination following sperm washing.

BACKGROUND: This is the first study to assess the outcome of sperm washing and intrauterine insemination (IUI) cycles in human immunodeficiency virus-positive (HIV(+)) men to determine any predictors of success, as well as evaluating the effect of HIV on sperm parameters. METHODS: Semen characteristics were evaluated in 106 HIV(+) men and a control group of 234 HIV(-) men, and the effect of markers of HIV disease assessed. Age, stimulation regime, sperm parameters, markers of HIV disease and the use of anti-retrovirals were assessed as predictors of the outcome of sperm washing/IUI cycles in the HIV(+) men. RESULTS: Ejaculate volume, sperm concentration, total count, progressive motility and normal morphology were all significantly higher in the control group compared to the HIV(+) men (P<0.05). A significant positive correlation was observed between CD4 count and sperm concentration, total count, motility, progressive motility type 'a'+'b' and post-preparation concentration and a significant negative correlation with normal sperm morphology of both raw and post-preparation samples. No correlation was observed between viral load (VL), years since diagnosis, use of anti-retrovirals or duration of use and any sperm parameter. The only factors that significantly improved IUI outcome were a VL <1000 copies/ml and the use of anti-retrovirals. CONCLUSIONS: These data demonstrate that sperm parameters are significantly impaired by the presence of HIV infection and in particular correlate with CD4 count. Undetectable VL and the use of anti-retrovirals improve the outcome of IUI/sperm washing in HIV(+) men.

Synchronous sperm retrieval and sperm washing in an intracytoplasmic sperm injection cycle in an azoospermic man who was positive for human immunodeficiency virus.

OBJECTIVE: To present the first reported case of synchronous sperm retrieval followed by sperm washing before an intracytoplasmic sperm injection (ICSI) cycle in an HIV-positive azoospermic man. DESIGN: Case report. SETTING: Assisted reproduction center. PATIENT(S): A 40-year-old HIV-positive man with obstructive azoospermia due to vasal aplasia. INTERVENTION(S): Synchronous sperm retrieval, sperm washing, nucleic acid-based sequence amplification testing, and intracytoplasmic sperm injection. MAIN OUTCOME MEASURE(S): Successful sperm retrieval sufficient for sperm washing and fertilization. RESULT(S): Sufficient quantity of spermatozoa for washing was obtained at epididymal aspiration. After the wash, HIV ribonucleic acid (RNA) was undetectable with nucleic acid-based sequence amplification testing, enabling injection of oocytes collected after routine gonadotropin superovulation. Of seven oocytes collected from the 39-year-old woman partner, six were injected and five fertilized (83%). Three embryos were transferred on day 2. The pregnancy test was negative on this occasion. CONCLUSION(S): This case demonstrates that sperm washing can be applied in cases of sperm retrieval where sperm volume and density is low, allowing the treatment of azoospermic HIV-positive men.

Frozen embryos generated from surgically retrieved sperm from azoospermic men: are they clinically viable?

PURPOSE: To assess the viability of frozen-thawed embryos derived from intracytoplasmic sperm injection (ICSI) in azoospermic men. METHODS: Retrospective analysis of 154 consecutive ICSI cycles using surgically retrieved sperm from azoospermic men and case-control comparison of subsequent frozen transfer cycles with those using embryos generated from ejaculated sperm. RESULTS: Patient and fresh cycle characteristics were similar in both groups. There were no differences between the two groups in the proportion of pronucleate (54% and 62%), and cleavage-stage embryos thawed (46% and 38%), post-thaw survival rates (retrievals: 69%; ejaculated: 73%) or quality of frozen embryos subsequently transferred. Implantation was significantly lower in frozen cycles where embryos were generated from surgically retrieved sperm (0% versus 11.5%; p = 0.03). Both clinical pregnancy rate (5% versus 21%) and live-birth rate (0% versus 21%) were lower in this group, but only the difference in LBR reached borderline statistical difference (p = 0.10). CONCLUSION: This small series demonstrates a significant impairment in implantation in FET cycles using embryos generated from surgically retrieved sperm and a trend towards a poorer pregnancy outcome.