Читать книгу Assisted Reproduction Techniques - Группа авторов - Страница 36

Based upon surveys of HIV‐seropositive individuals attending medical clinics, approximately 15–30% of HIV‐infected patients demonstrate an interest in reproductive care [11,12]. A multidisciplinary team approach to the management of HIV‐seropositive patients is advocated. Consultation with the infectious disease specialist treating the infected patient is vitally important to understand the general health status of the prospective patient. Individuals should be medically stable and compliant with medications prescribed by their primary care provider. A review of prescribed drugs should be undertaken in order to recognize any medications that may interfere with or impact upon the success of fertility treatments. This includes the use of androgens which are known to dramatically lower sperm counts and impair fertilization. Social workers, psychologists and psychiatrists may also be called upon to address issues related to anxiety, depression and substance abuse, conditions known to be more prevalent in HIV‐seropositive populations.

Prescribing PrEP for the unaffected partners of sexually active HIV‐seropositive males has been associated with negligible transmission rates when males have undetectable viral loads [13,14]. This has led to renewed debate about whether unprotected timed sexual intercourse is a reasonable option for HIV‐serodiscordant patients to consider. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) has supported unprotected well‐timed intercourse for couples in which the HIV‐positive male has undetectable viral loads. With respect to timed intercourse, patients are encouraged to use ovulation kits or basal body temperature in order to decrease the need for repetitive sexual exposure. However, it has been reported that patients who choose this option are more likely to use condoms inconsistently and therefore may actually increase their risk of transmission over time [13]. In one study, the seroconversion rate was 4.3% in patients trying to establish pregnancies through timed intercourse. Therefore, the American Society for Reproductive Medicine (ASRM) does not endorse this plan for conception [15].

Whether IUI or IVF best addresses the needs of patients with HIV seeking fertility care remains contentiously debated. There are advantages and disadvantages inherent to both methods, and neither has proven to be safer than the other. More attempts have been published using the less invasive IUI approach which is technically simpler and less expensive than IVF [16,17]. However, efficacy per treatment cycle is lower with IUI and therefore multiple attempts, entailing multiple exposures, are often required. Testing specimens used for insemination for HIV is commonly recommended as a necessary precaution against infection but also represents a significant additional expense and is not an evidence‐based requirement. IUI preparations contain millions of recovered cells, including leukocytes if not properly prepared. It has been reported that up to 5% of sperm samples are contaminated with HIV [12]. As a precaution, specimens are often frozen and tested prior to their use, ensuring only HIV‐negative fluids are inseminated. However, freezing may decrease fertilization potential in men who exhibit borderline or abnormal semen profiles [18]. Under optimal circumstance, pregnancies following IUI typically occur in 5–15% of treatment cycles, and couples should anticipate the need for multiple attempts at IUI over an extended period of time.

ICSI has been widely practiced for the treatment of male factor infertility for nearly 30 years. ICSI requires the selection of only a single sperm per retrieved egg although the gametes chosen for injection cannot be HIV tested. Only the highly motile fraction of prepared sperm is chosen for ICSI and typically fewer than 30 sperm are needed per patient. It is believed that mature motile spermatozoa from the fraction of prepped semen do not harbor HIV, and therefore specimens do not need to be virally tested before use, reducing the complexity and cost of implementation. However, ICSI is inherently invasive and expensive and has been associated with a higher risk of multiple births than IUI unless single embryo transfer is practiced. Pregnancies from ICSI typically occur in 35–60% of treatment cycles depending upon the age of the patient, the circumstances of the treatment cycle and the number of embryos transferred. ICSI also commonly produces supernumerary embryos that may be cryopreserved for future use, a feature that cannot be accomplished through any other methodology.