Screening standards in assisted reproductive technologies. Is the British Andrology Society recommendation to recruit cytomegalovirus negative semen donors only, a reasonable one?

Possible CMV transmission via intrauterine insemination: case report

BACKGROUND

Maternal cytomegalovirus (CMV) infection at conception can cause congenital CMV (cCMV) infection and substantial morbidity. Although CMV screening is mandated for sperm donors, the risk of acquiring CMV from donor sperm is unknown. Experience with HIV may lead clinicians to expect that standard sperm-washing reduces CMV transmission risk for procedures including intrauterine insemination. However, limited data suggests that CMV may differ importantly from other herpesviruses and from HIV after sperm washing.

CASE PRESENTATION

A 29-year-old CMV immunoglobulin (Ig)M- and IgG-negative patient underwent intrauterine insemination with a directed donor. The donor was CMV IgM-negative and IgG-positive at the time of donation but had been serum IgM-positive 128 days before donation, and urine CMV PCR-positive 107 days before donation. Following intrauterine insemination, the patient developed clinical evidence of acute CMV infection, CMV viremia, and positive CMV IgM and IgG. The intrauterine insemination did not result in pregnancy. No sources of CMV transmission other than intrauterine insemination could be identified.

CONCLUSIONS

Because screening and prevention options for perinatal CMV transmission are limited, a systematic research agenda to understand and reduce CMV transmission risk from seropositive sperm donors is needed to create clear guidelines for fertility treatments and support shared decision-making. Novel approaches to lower risk of transmission from sperm donors with detectable CMV IgG should also be further evaluated. These might include CMV DNA testing of washed sperm samples prior to fertility treatments, antiviral therapy prior to semen collection and/or CMV PCR or IgM screening in pregnant patients who conceived using sperm from antibody-positive donors.

The negative impact of most relevant infections on fertility and assisted reproduction technology

Infections may act with variable impact on the physiopathology of the reproductive organs, determining infertility or reducing the outcomes of assisted reproduction technology. The aim of this narrative review is to describe the existing evidence regarding the pathogens with a supposed or recognized role in reproductive medicine. Viral hepatitis, as well as HIV, can reduce sperm quality. Syphilis carries a risk of erectile dysfunction and increased endometrial thickness. Chlamydia is the main cause of pelvic inflammatory disease. In relation to Mycoplasma and Ureaplasma spp., only few species seem to show a correlation with infertility and poor in-vitro fertilization outcomes. There is evidence of a role for bacterial vaginosis in early pregnancy loss. HPV infection in males seems to determine infertility. Herpesviruses are more a risk for fetuses than for fertility itself. Zika virus is responsible for altered early embryo development and waiting to conceive is recommended in suspected or confirmed cases. The impact of SARS-CoV-2 is yet to be elucidated. Rubella and toxoplasmosis can provoke important congenital defects and therefore screening is mandatory before conception; a vaccine for Rubella is recommended. Further and well-designed studies are still needed to better elucidate the role of some infectious agents, to improve fertility and its treatments.

UK guidelines for the medical and laboratory screening of sperm, egg and embryo donors (2008)

This article updates the 1999 British Andrology Society (BAS) guidelines for the screening of sperm donors and the 2000 British Fertility Society (BFS) guidelines for the screening of egg and embryo donors and combines the new recommendations into a single document. This was achieved by a multidisciplinary working group composed of representatives from the Association of Biomedical Andrologists, the Association of Clinical Embryologists, the BAS, the BFS and the Royal College of Obstetricians and Gynecologists. The major changes to the guidelines include a requirement to consider a donor's risk of transmissible spongiform encephalopathies and the recommendation to screen for human T cell lymphotropic viruses 1 and 2. The role of nucleic amplification tests for the detection of blood borne viruses such as HIV is discussed, but it remains the recommendation that this be achieved by serological testing to detect antibody or antigen as appropriate with a quarantine period of 180 days.

Heterologous assisted reproduction and kernicterus: the unlucky coincidence reveals an ethical dilemma

Secrecy and anonymity related to heterologous assisted reproduction may hide basic newborn data to neonatologists. Secrecy and anonymity are discussed in view of their possible consequences on relational dynamics and on developmental psychology. Nevertheless, they can also involve the offspring's genetic status regarding inheritable diseases. International guidelines have been recently published on this topic. Because no guidelines are 'ideal' unfortunate and possibly dramatic consequences can occur. We aimed to embark on a debate about this matter starting with a real clinical experience. In our case a rarely fatal but widespread disease, together with the lack of knowledge about parental status led, in a fast succession of clinical events, to the unavoidable insurgence of kernicterus.

Epidemiology, pathogenesis and prevention of congenital cytomegalovirus infection

Cytomegalovirus is the most common cause of congenital infection. Congenital cytomegalovirus infection can follow both primary and recurrent maternal infections. It is associated with a significant burden of disease and death. The determinants of mother-to-child transmission and the pathogenesis of symptomatic fetal infection remain poorly understood. For a long time, congenital cytomegalovirus infection has been a neglected disease. Recently, the Institute of Medicine has recognized that the development of a vaccine against congenital cytomegalovirus infection is a public health priority, which should stimulate research in this area. The development of antiviral therapies to prevent symptoms in infected newborns also represents an important area of research.

Transmission virale et assistance médicale à la procréation : le cas des Herpesviridae

Procreation with sperm donation is at present achieved by insemination either in the uterus or in vitro, always from ejaculated and washed spermatozoa. Then, the infectious risk only exists if the donor sperm is capable of transporting the virus or its DNA, either by adhesion or by integration. With CMV, HSV1 and HSV2, medically assisted procreation in couples (AI or IVF-ET) does not increase the risk of viral contamination as compared with natural procreation, except possibly the cases of surgical procedure to pick up testicular sperm to be used in ICSI. Animal experiments show that, even if viral material is introduced in the oocyte, it may be eliminated from the embryo, at least for CMV.

Cryopreservation, screening and storage of sperm the challenges for the twenty-first century

The advent of HIV and the serious nature of the sequelae resulted in a major reassessment of artificial insemination practices in the UK. The development of human semen cryopreservation had enormous impact on reproductive medicine and the availability of cryopreserved quarantined donor semen became a mainstay for the treatment of male infertility in the UK. The regulation and accreditation of assisted reproductive technologies and the introduction of peer-reviewed guidelines have largely standardized clinical and laboratory practice. The introduction of assisted fertilization techniques such as intracytoplasmic sperm injection, testicular sperm retrieval and improved oncology treatments have placed pressure on reproductive biologists and cryobiologists to design and use cryopreservation protocols for the optimum survival of sperm.