Reproduction and fertility in human immunodeficiency virus type-1 infection

The association of medications and supplements with human male reproductive health: a systematic review

Some medications used to treat comorbidities and conditions in reproductive-aged individuals could have a negative impact on fertility. This may occur through hormonal disruption, toxicity to germ cells and spermatozoa, functional impact on the sperm, teratogenicity potential, or ejaculatory abnormalities. Having knowledge of these potential interactions between medications and reproductive potential is important for clinicians to be aware of and guide the patient, along with their treating clinicians, to reproductively favorable alternatives when available. This review aims to summarize the state of the literature regarding medication interactions with human male reproduction using the Anatomical Therapeutic Chemical Classification System of medications.

Childlessness and Development in Sub-Saharan Africa: Is There Evidence for a U-shaped Pattern?

In high-income countries, women increasingly remain permanently childless. Little is known about the relationship between childlessness and socioeconomic development in non-Western societies and particularly sub-Saharan Africa. At lower levels of development, poverty-driven (i.e., involuntary) childlessness may decrease with increases in levels of development, while at higher levels of development opportunity-driven (i.e., voluntary and circumstantial) childlessness may rise with development. Thus, we expect a U-shaped relationship between childlessness and development overall. We examine this idea for sub-Saharan Africa. We further contribute by differentiating between female and male childlessness; and between involuntary, voluntary and circumstantial childlessness. Moreover, we construct new indicators of subnational historical development to assess both inter- and intra-country variation, and distinguish between three components (health, education and income) to investigate the drivers behind the hypothesized U-shaped relationship. Using 291 Demographic and Health Surveys between 1986 and 2018 from 38 countries and 384 regions, we find a U-shaped relationship between female childlessness and development, and a linear relationship for men. The U-shape for women results from negative associations of female involuntary childlessness with health and educational advancements, combined with positive correlations of voluntary and circumstantial childlessness with education and income improvements. While these positive associations are stronger among men than women, the negative relationships of involuntary childlessness with health and education observed for women are absent for men, resulting in an overall positive and linear relationship between development and childlessness among men. Our findings have implications for how we might expect childlessness rates to evolve with future levels of development.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10680-022-09608-5.

Assisted reproductive technology outcomes in women with a chronic viral disease

OBJECTIVE

The aim of this study was to evaluate the cumulative live birth rate in women undergoing in-vitro fertilization/intracytoplasmic-sperm-injection (IVF/ICSI) according to the type of chronic viral infection [HIV, hepatitis-B virus (HBV) and hepatitis-C virus (HCV)].

DESIGN

A cohort study.

SETTING

A tertiary-care university hospital.

PARTICIPANTS

Women with a chronic viral illness HIV, HBV or HCV- were followed until four IVF/ICSI cycles had been completed, until delivery or until discontinuation of the treatment before the completion of four cycles.

MAIN OUTCOME MEASURES

The primary outcome was the cumulative live birth rate after up to four IVF/ICSI cycles.

RESULTS

A total of 235 women were allocated to the HIV-infected group (n = 101), the HBV-infected group (n = 114) and the HCV-infected group (n = 20). The cumulative live birth rate after four cycles was significantly lower in the HIV-infected women than in those with HBV [39.1%, 95% confidence interval (95% CI): 17.7-60.9 versus 52.8%, 95% CI: 41.6-65.5, respectively; P = 0.004]. Regarding the obstetrical outcomes, the mean birth weight was lower in the HIV-infected women than in those with HBV or HCV. Multivariate analysis indicated that the age, the anti-Müllerian hormone and the number of cycles performed were significantly associated with the chances of a live birth.

CONCLUSION

HIV-infected women had lower cumulative live birth rate than women with chronic hepatitis, and this was due to less favourable ovarian reserve parameters. These findings underscore the need to better inform practitioners and patients regarding fertility issues and the importance of early fertility assessment. However, larger studies are necessary to gain more in-depth knowledge of the direct impact of HIV on live birth rates.

Subfertility among HIV-affected couples in a safer conception cohort in South Africa

BACKGROUND

Subfertility among couples affected by HIV has an impact on the well-being of couples who desire to have children and may prolong HIV exposure. Subfertility in the antiretroviral therapy era and its determinants have not yet been well characterized.

OBJECTIVE

The objective of the study was to investigate the burden and determinants of subfertility among HIV-affected couples seeking safer conception services in South Africa.

STUDY DESIGN

Nonpregnant women and male partners in HIV seroconcordant or HIV discordant relationships desiring a child were enrolled in the Sakh'umndeni safer conception cohort at Witkoppen Clinic in Johannesburg between July 2013 and April 2017. Clients were followed up prospectively through pregnancy (if they conceived) or until 6 months of attempted conception, after which they were referred for infertility services. Subfertility was defined as not having conceived within 6 months of attempted conception. Robust Poisson regression was used to assess the association between baseline characteristics and subfertility outcomes; inverse probability weighting was used to account for missing data from women lost to safer conception care before 6 months of attempted conception.

RESULTS

Among 334 couples enrolled, 65% experienced subfertility (inverse probability weighting weighted, 95% confidence interval, 0.59-0.73), of which 33% were primary subfertility and 67% secondary subfertility. Compared with HIV-negative women, HIV-positive women not on antiretroviral therapy had a 2-fold increased risk of subfertility (weighted and adjusted risk ratio, 2.00; 95% confidence interval, 1.19-3.34). Infertility risk was attenuated in women on antiretroviral therapy but remained elevated, even after ≥2 years on antiretroviral therapy (weighted and adjusted risk ratio, 1.63; 95% confidence interval, 0.98-2.69). Other factors associated with subfertility were female age (weighted and adjusted risk ratio, 1.03, 95% confidence interval, 1.01-1.05 per year), male HIV-positive status (weighted and adjusted risk ratio, 1.31; 95% confidence interval, 1.02-1.68), male smoking (weighted and adjusted risk ratio, 1.29; 95% confidence interval, 1.05-1.60), and trying to conceive for ≥1 year (weighted and adjusted risk ratio, 1.38; 95% confidence interval, 1.13-1.68).

CONCLUSION

Two in 3 HIV-affected couples experienced subfertility. HIV-positive women were at increased risk of subfertility, even when on antiretroviral therapy. Both male and female HIV status were associated with subfertility. Subfertility is an underrecognized reproductive health problem in resource-limited settings and may contribute to prolonged HIV exposure and transmission within couples. Low-cost approaches for screening and treating subfertility in this population are needed.

Reduced fecundity in HIV-positive women

STUDY QUESTION

Is HIV associated with increased time to pregnancy (TTP)?

SUMMARY ANSWER

HIV-positive women who discontinue a contraceptive method to become pregnant have increased TTP, particularly among those who likely do not know their status.

WHAT IS KNOWN ALREADY

HIV-positive women have fewer children on average than their HIV-negative counterparts due to both behavioral and biological factors. There is a need to better describe and quantify fecundity patterns associated with HIV in the general population.

STUDY DESIGN, SIZE, DURATION

This cross-sectional study was based on data from 12 Demographic and Health Surveys (DHSs) conducted between 2003 and 2013 in 11 African countries. All studies collected dried blood spot samples for HIV testing and included a retrospective calendar module that recorded women's monthly reproductive status in the 5 years preceding the survey. TTP was measured among 3181 women discontinuing a contraceptive method within 2 years of the survey in order to become pregnant.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We use Cox proportional hazard models for discrete survival data to model TTP and estimate fecundability odds ratios (FOR) and 95% CIs for the 12-month period following contraceptive discontinuation. In addition to employing a binary measure of HIV status, we also develop an additional explanatory measure that combines HIV status with information on whether respondents had ever been tested for HIV and received their results (which proxies for knowledge of HIV status) to reduce the threat of confounding from behavioral changes following an HIV diagnosis.

MAIN RESULTS AND THE ROLE OF CHANCE

In our sample, 10.3% of women were HIV-positive, and a little more than half (51.8%) of women received test results and likely knew their status. Over a 12-month observation period, HIV-positive women had a 25% average reduction in fecundity compared to HIV-negative women [adjusted FOR (aFOR) = 0.75 (0.62-0.92)] after adjusting for confounders. The 12-month fecundity patterns differed by women's likely knowledge of their status such that results were primarily driven by HIV-positive women who likely did not know their status. Moreover, reductions in fecundity attributable to HIV were not uniform over time. Among women who were still trying for pregnancy after 3 unsuccessful months, HIV-positive women had half the odds of becoming pregnant compared to HIV-negative women [aFOR = 0.50 (0.35-0.71)]. Conversely, there were no significant differences in FORs between HIV-negative and HIV-positive women in the first 3 months.

LIMITATIONS REASONS FOR CAUTION

Because dried blood spot samples for HIV testing were collected at the time of the survey but reproductive calendar data were collected retrospectively, it is possible that we introduced misclassification bias, as we have no knowledge if the acquisition of HIV occurred before or after pregnancy attempt.

WIDER IMPLICATIONS OF THE FINDINGS

As life expectancy and quality health status improve due to earlier initiation of antiretroviral (ARV) treatment in HIV-positive women, there has been growing awareness that services should also address the fertility desires of HIV-positive women who want children. These findings indicate that if a pregnancy does not occur after 3 months of attempting pregnancy, HIV-positive women and HIV-discordant couples should request access to HIV and reproductive pre-pregnancy counseling and health assessments.

STUDY FUNDING/COMPETING INTEREST(S)

A.G. was supported by the National Institutes of Health (contract T32-HD007275) during the study. During the conceptualization, data collection and analysis time frame, S.vdP. was supported by WHO/RHR/HRP Special Program in Reproductive Health and Research, Geneva, Switzerland, and HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction). The authors have no conflicts of interest to declare.

Nucleoside reverse transcriptase inhibitor-induced rat oocyte dysfunction and low fertility mediated by autophagy

Low fertility is one of the most common side effects caused by nucleoside reverse transcriptase inhibitors (NRTIs), whereas the molecular mechanism underlying this process were largely unclear. This study was conducted to investigate whether autophagy plays a role in NRTIs-induced oocyte dysfunction and low fertility in female rat. Both in vivo and in vitro experiments were conducted. For the in vivo experiment, female adult Sprague-Dawley rats were subjected to zidovudine (AZT) and lamivudine (3TC) intragastric treatment for 3, 6, 9, and 12 weeks; a control was also set. Oocytes were collected for maturation evaluation, in vitro fertilization and mitochondrial function assays, and apoptosis and autophagy analysis. For the in vitro experiment, oocytes were collected and assigned to the control, 3-methyladenine (3-MA, an effective autophagy inhibitor), AZT, AZT+3-MA, 3TC, and 3TC+3-MA groups. The oocytes were cultured with the abovementioned drugs for 24, 48, and 72 h and then, subjected to the same assays as in the in vivo study. The results showed a significant time-dependent decrease in oocyte maturation-related maker levels, oocyte cleavage rate, blastocyst formation rate, mitochondrial DNA copy number and adenosine triphosphate level, and apoptosis, and a significant increase in the reactive oxygen species levels (all P-values < 0.05), in both the in vivo and the in vitro experiments. These changes, except for the changes in the oocyte maturation-related markers, were partially attenuated by 3-MA. In conclusion, we demonstrated that NRTIs can cause rat oocyte dysfunction and low fertility, and this damage was, at least partially, mediated by autophagy.

Effect of Monotherapy with Darunavir/Ritonavir on Viral Load in Seminal Fluid, and Quality Parameters of Semen in HIV-1-Positive Patients

Patients with human immunodeficiency virus type 1 (HIV-1) who receive antiretroviral therapy (ART) often achieve increased survival and improved quality of life. In this respect, monotherapy with darunavir/ritonavir (mDRV/r) can be a useful treatment strategy. This prospective study analyses the effect of mDRV/r on sperm quality and viral load in a group of 28 patients who had previously been given conventional ART and who had recorded a viral load <20 copies/mL for at least six months. These patients were given mDRV/r at a dose of 800/100 mg for 48 weeks. At baseline (V0), CD4, CD8, FSH, LH and testosterone levels were measured, together with HIV-1 viral load in plasma and semen. In addition, seminal fluid quality was studied before mDRV/r treatment was prescribed. At week 48 (V1), HIV-1 viral load in plasma and semen and the quality of the seminal fluid were again measured. The results obtained indicate that at V0, 10% of the patients with ART had a positive viral load in seminal fluid (>20 copies/ml), and that at V1, after mDRV/r treatment, this figure had fallen to 3%. The quality of seminal fluid was close to normal in 57% of patients at V0 and in 62% at V1. We conclude that, similar to ART, mDRV/r maintains HIV-1 viral load in most patients, and that there is no worsening in seminal fluid quality.

Decreased ovarian reserve in HIV-infected women

OBJECTIVE

To evaluate HIV directly or indirectly related altered ovarian function, using serum anti-Müllerian hormone (AMH) levels in HIV-infected women as compared with seronegative women.

DESIGN

We conducted a matched cohort study from January 2008 to December 2013 in a tertiary university centre. Two hundred and one HIV-infected women requesting assisted reproductive technology and 603 age and cause of infertility-matched HIV seronegative women were enrolled in this study.

METHODS

All data were prospectively collected using a semistructured questionnaire. Serum AMH levels in HIV-infected women and matched controls were compared. To find out the contributing factors to increased serum AMH levels in HIV-infected women, a backward multiple linear regression was performed.

RESULTS

Serum AMH levels were significantly lower in HIV-infected group as compared with seronegative controls (3.0 ± 2.8 vs 3.7 ± 3.5 ng/ml; respectively, P = 0.001). Looking for factors associated with altered AMH among HIV-infected women, an association has been shown between tubal disease and a further decrease in serum AMH levels (2.4 ± 2.4 vs 3.4 ± 3.0 ng/ml; respectively, P = 0.011). Among HIV-infected women, after multivariate linear regression analysis, we showed that increased age, BMI and viral load were associated with decreased serum AMH levels whereas in striking contrast an increase in CD4⁺ cell count was associated with an increase of serum AMH levels.

CONCLUSION

Serum AMH levels were lower in the HIV-infected group than in the control group. Age, BMI, CD4⁺ cell count and viral load were the independent contributors affecting serum AMH levels among HIV-infected women.

The demographic impact of HIV and AIDS across the family and household life-cycle: implications for efforts to strengthen families in sub-Saharan Africa

HIV is no longer a new or emerging disease in southern Africa. In the era of HIV and AIDS, families and households have continued to form, build, migrate and dissolve. Children born in the 1980s with the risk of mother-to-child HIV transmission have already gone on to start the next generation of families and households. Isolating the impact of HIV and AIDS on families and households is complex given that the epidemic has become part of the direction and force of contemporary demographic, social and economic processes and trends. Cycles of family and household life have occurred in a changing HIV and AIDS public-health environment, one in which HIV treatment access has increased rapidly. As part of an on-going process to assess the relevance and effectiveness of policies and programmes designed to protect and support children affected by HIV and AIDS, it is necessary to update our knowledge about the family and household circumstances in which children live. This paper summarises findings from a review on the "Demographic Evidence of Family and Household Changes in Response to the Effects of HIV/AIDS in Southern Africa: Implications for Efforts to Strengthen Families". The review examined published literature presenting data from empirical studies, primarily large, cross-sectional or longitudinal population-based or sample surveys. The family or household life-cycle is used as a conceptual and organisational framework. The implications of the demographic evidence are discussed in relation to policy and programme responses to strengthen families and households in the region.

Fertility choices and management for HIV-positive women

PURPOSE OF REVIEW

It is becoming increasingly important to address the issue of reproductive counselling and management of HIV-infected individuals during their reproductive years. Sexual and reproductive health-related needs and aspirations are similar to those of uninfected individuals but some differences require specific attention, which are discussed in this review.

RECENT FINDINGS

Hormonal contraception should be used with caution in women on antiretroviral treatment. Its impact on both HIV infectivity and disease progression is still controversial. An intrauterine device can be considered for pregnancy prevention and pregnancy termination should be offered in safe conditions. HIV-infected women have a lower spontaneous fertility rate, which may persist after assisted reproduction. Data on safety of antiretroviral treatment during conception are reassuring. No clear association can be found between exposure to antiretrovirals and fetal abnormalities. Secondary prevention remains crucial and condom use remains a key method.

SUMMARY

Different topics related to fertility choices among HIV-infected patients should be addressed. Family planning methods and termination of pregnancy have specific aspects among infected individuals. When needed, medically assisted reproduction may be required and antiretroviral treatment should be adapted before conception. Secondary prevention has a key role in reducing newly acquired infections.

Sperm washing to prevent HIV transmission from HIV-infected men but allowing conception in sero-discordant couples

BACKGROUND

Sperm washing is a term used to describe the process in which individual spermatozoa are separated from the seminal fluid. Sperm washing is used to prevent HIV transmission but allow conception in sero-discordant couples, where the male is HIV positive, but the female is HIV negative. This procedure is based on the observation that HIV cannot attach itself to spermatozoa, but it can be found in the fluid and cells surrounding spermatozoa.

OBJECTIVES

To determine the benefits and harms of sperm washing of HIV-infected males when used to prevent the transmission of HIV but allowing conception in the HIV-negative female.

SEARCH STRATEGY

We searched the Cochrane HIV/AIDS Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SCORPUS, AIDsearch, AJOL, LILACS and INDEX MEDICUS. We also searched the following conference proceedings for relevant abstracts:The International AIDS Conference; The Conference on Retroviruses and Opportunistic Infections (CROI); The British HIV Association (BHIVA) Conference; The International Conference of Obstetricians and Gynecologists (FIGO); The American Academy of HIV Medicine Conference; The Australasian HIV/AIDS Conference; The American Society for Reproductive Medicine (ASRM) conferences and website; The European Society for Human Reproduction and Embryology (ESHRE) conferences and websites, and the British Fertility Society (BFS) conferences and website. We also conducted a search of the website: www.ClinicalTrials.gov. The date of the most recent Cochrane HIV/AIDS Group Controlled Trials Register search was on the 10th of November, 2010.

SELECTION CRITERIA

We preferentially looked for randomised or quasi-randomised controlled trials on sperm washing, aimed at preventing HIV transmission from HIV infected men but allowing conception in sero-discordant couples, irrespective of publication status, year of publication, or language in the review.

DATA COLLECTION AND ANALYSIS

No relevant trials were identified for inclusion in this review.

MAIN RESULTS

Forty four studies were identified, but none of them were suitable for inclusion in this review.

AUTHORS' CONCLUSIONS

Reports on the use of sperm washing to prevent HIV transmission from HIV infected men but allowing conception in sero-discordant couples is currently limited to observational studies. No randomised controlled trial has assessed the benefit or risk of sperm washing to prevent HIV transmission from HIV infected men but allow conception in sero-discordant couples. Thus, this systematic review identifies the need for a multicentre randomised controlled trial assessing the benefits and possible risks of sperm washing in preventing HIV transmission from HIV infected men but allow conception in sero-discordant couples.

Human immunodeficiency virus serodiscordant couples on highly active antiretroviral therapies with undetectable viral load: conception by unprotected sexual intercourse or by assisted reproduction techniques?

Until recently, only assisted reproduction was proposed to serodiscordant couples wishing to conceive. Nevertheless, recent publications have proposed unprotected sexual intercourse, targeting fertile days, for couples where antiretroviral treatment has lowered blood viral load to an undetectable level. Available data and the arguments for and against conception by safe sex versus the use of a strategy of unprotected sexual intercourse targeting fertile days are reviewed and analyzed. Although the rate of transmission of human immunodeficiency virus in serodiscordant couples in precise conditions (such as an undetectable viral load on treatment by highly active antiretroviral therapies and sexual intercourse limited to the fertile days) is very low, not zero, here we stress the various factors which can increase the risk of seroconversion in this particular population. In this context, it seems less cautious to abandon the recommendations of safe sex in serodiscordant couples desiring a child. The recourse to medically assisted procreation is advised, as long as evidence from further studies does not show that unprotected sexual intercourse, targeted to fertile days, does not have unexpected harmful consequences.