Lights and Shadows about the Effectiveness of IVF in HIV Infected Women: A Systematic Review

'Womb for work' experiences of Thai women and gestational surrogacy practice in Thailand

Risks to gestational surrogates became a concern for public health. In commercial gestational surrogacy arrangements, gestational surrogates are commonly recruited from low- to middle-income countries. Thailand is well known as a surrogacy hub in this regard. However, little is known concerning Thai surrogacy practice and the risks that Thai gestational surrogates experiences. The semi-structured interviews with fifteen Thai women who had been gestational surrogates were conducted over the telephone in Thai between March and May 2020 and lasted approximately 30 minutes. Thematic analysis was applied to analyse the translated interviews. The findings indicated that 'womb for work' was perceived as a surrogacy career among Thai women. 'Womb for work' was defined as a superordinate theme that consisted of three subthemes: (i) gestational surrogacy arrangements in Thailand; (ii) the business model of gestational surrogacy arrangements in Thailand; and (iii) risk experiences of gestational surrogates. Clear deficiencies in surrogacy practice and regulations were identified, which put gestational surrogates at risk, including those associated with embryo transfer, transnational gestational surrogacy, and unsupported pregnancies. This study shows the urgent need to introduce regulations to protect women's health transnationally in this domain more effectively.

Medically assisted reproduction for people living with HIV in Europe: A cross-country exploratory policy comparison

OBJECTIVE

To explore the availability and accessibility of medically assisted reproduction (MAR) for people living with HIV in Europe, including the feasibility of cross-border care.

METHODS

We used a polymorphous engagement approach, primarily based on digital and email-based interviews with representatives of national HIV organizations, clinical researchers (infectious disease and/or infertility specialists), European and national professional societies (fertility and/or infectious disease), national regulatory authorities and individual clinics in 14 countries in the WHO European region. The research design and results were also informed by two surveys and a review of the secondary literature, news articles and clinic websites.

RESULTS

Although MAR is possible for people living with HIV in 12 out of the 14 countries mapped, accessing services can be challenging for logistical or financial reasons. People living with HIV also face barriers to MAR independent of their HIV status, such as limitations on single women and same-sex couples accessing services. Cross-border care is available for most patients who are self-financing but is limited for publicly funded patients.

CONCLUSIONS

Even when MAR is available to and accessible for people living with HIV, there may still be barriers to treatment. Further research on patient experiences is needed to understand these discrepancies between availability and accessibility on paper and in practice.

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.

ESHRE guideline: medically assisted reproduction in patients with a viral infection/disease

STUDY QUESTION

What is the recommended management for medically assisted reproduction (MAR) in patients with a viral infection or disease, based on the best available evidence in the literature?

SUMMARY ANSWER

The ESHRE guideline on MAR in patients with a viral infection/disease makes 78 recommendations on prevention of horizontal and vertical transmission before, during and after MAR, and the impact on its outcomes, and these also include recommendations regarding laboratory safety on the processing and storage of gametes and embryos testing positive for viral infections.

WHAT IS KNOWN ALREADY

The development of new and improved anti-viral medications has resulted in improved life expectancy and quality of life for patients with viral infections/diseases. Patients of reproductive age are increasingly exploring their options for family creation.

STUDY DESIGN SIZE DURATION

The guideline was developed according to the structured methodology for the development of ESHRE guidelines. After the formulation of nine key questions for six viruses (hepatitis B virus, hepatitis C virus, human immunodeficiency virus, human papilloma virus, human T-lymphotropic virus I/II and Zika virus) by a group of experts, literature searches and assessments were performed. Papers published up to 2 November 2020 and written in English were included in the review. Evidence was analyzed by female, male or couple testing positive for the virus.

PARTICIPANTS/MATERIALS SETTING METHODS

Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. There were 61 key questions to be answered by the guideline development group (GDG), of which 12 were answered as narrative questions and 49 as PICO (Patient, Intervention, Comparison, Outcome) questions. A stakeholder review was organized after the finalization of the draft. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

This guideline aims to help providers meet a growing demand for guidance on the management of patients with a viral infection/disease presenting in the fertility clinic.The guideline makes 78 recommendations on prevention of viral transmission before and during MAR, and interventions to reduce/avoid vertical transmission to the newborn. Preferred MAR treatments and interventions are described together with the effect of viral infections on outcomes. The GDG formulated 44 evidence-based recommendations-of which 37 were formulated as strong recommendations and 7 as weak-33 good practice points (GPP) and one research only recommendation. Of the evidence-based recommendations, none were supported by high-quality evidence, two by moderate-quality evidence, 15 by low-quality evidence and 27 by very low-quality evidence. To support future research in the field of MAR in patients with a viral infection/disease, a list of research recommendations is provided.

LIMITATIONS REASONS FOR CAUTION

Most interventions included are not well-studied in patients with a viral infection/disease. For a large proportion of interventions, evidence was very limited and of very low quality. More evidence is required for these interventions, especially in the field of human papilloma virus (HPV). Such future studies may require the current recommendations to be revised.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides clinicians with clear advice on best practice in MAR for patients with a viral infection/disease, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in the field.

STUDY FUNDING/COMPETING INTERESTS

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive any financial incentives, all work was provided voluntarily. A.D. reports research fees from Ferring and Merck, consulting fees from Ferring, outside the submitted work. C.P. reports speakers fees from Merck and MSD outside the submitted work. K.T. reports speakers fees from Cooper Surgical and Ferring and consultancy fees as member of the advisory board BioTeam of Ferring, outside the submitted work. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at  www.eshre.eu/guidelines.).

Reproductive considerations in the setting of chronic viral illness

Special considerations must be taken when patients with human immunodeficiency virus (HIV), hepatitis B, or hepatitis C desire to become pregnant. Patients with chronic viral illnesses desire to have children at rates similar to the general population, and options are available to decrease both vertical transmission and viral transmission between partners. Preconception counseling or consultation with fertility specialists is imperative in patients with HIV, hepatitis B, and hepatitis C so that reproductive goals can be addressed and optimized. In couples in which one partner has HIV, the use of highly active antiretroviral therapy or preexposure prophylaxis can significantly reduce the risk of transmission between serodiscordant partners. The use of density gradient sperm-washing techniques and intrauterine insemination or in vitro fertilization results in an apparent lack of transmission of HIV between partners when the male partner is HIV-positive. Vertical transmission of HIV from mother to child can be reduced by use of highly active antiretroviral therapy regimens throughout pregnancy or by cesarean delivery in the setting of high maternal viral load. Transmission of hepatitis B between partners can be eliminated by vaccinating the uninfected partner. Vertical transmission from a hepatitis B-infected mother to a child can be reduced by vaccinating neonates with the standard hepatitis B vaccine series as well as hepatitis B immune globulin. Recent data have shown the antiviral medication tenofovir to be an effective way to reduce vertical transmission in the setting of high maternal viral load or the presence of hepatitis B e antigen. There are multiple antiviral medications available to treat chronic hepatitis C, although access to these medications often is limited by cost. Similar to HIV-positive patients, in settings in which the male partner is infected with hepatitis C, density gradient sperm washing can be used before intrauterine insemination or in vitro fertilization to reduce transmission of hepatitis C between partners. No safe and effective method exists to reduce vertical transmission of hepatitis C once a woman becomes pregnant, highlighting the importance of treatment of hepatitis C before pregnancy.