IVF and HIV, Hepatitis B, CMV, and Chlamydia
Over 20 million reproductive age people world-wide have been infected with the human immunodeficiency virus (HIV). It is clear that hetero-sexual transmission is responsible for many of the cases throughout the world. Other modes of transmission include male homosexual intercourse, blood transfusion, unscreened blood products, needle sticks in health care providers and maternal-fetal transplacental passage. The HIV virus replicates inside monocytes and escapes recognition by the immune system while doing so using a “Trojan Horse Mechanism” (1). Studies of men with HIV indicated a latency period averaging 10 years from HIV infection to AIDS (2). Patients may be infective during this time. It is alarming that women and children world-wide are being infected at increasing rates. The women-to-children vertical transmission rate is 15 % to 20% and may increase with disease progression (3). The prognosis for HIV infected babies is grave, 17% die with in one year of like and the maternal disease severity correlates directly with severity of disease in the neonate (3). Ethical debates concerning ART in serodiscordant individuals conclude that ART will likely produce more good than harm and violates no ethical principles (4). The American Society for Reproductive Medicine Ethics Committee has issued a statement concerning HIV and infertility treatment concluding that the most appropriate care may be given at institutions with facilities that have in place evaluation, treatment and follow-up of patients with HIV. Alternately, they should be counseled about the availability of donor sperm, adoption or child-free living (5). Ohl et al (6) reported their experience on serodiscordant couples and IVF (47 men and 10 women HIV positive). Seropositive men had an IVF-ICSI pregnancy rate of 48 % and seropositive women had a pregnancy rate of 9.1% with IVF. While the numbers of patients were small, no seroconversion of the offspring occurred. Cleary-Goldman et al (7) had 25 seronegative women pregnant with IVF-ICSI from positive partners and all 40 neonates and gravidas remained negative after 3 months of delivery. Pregnant women should receive anti-retroviral medication during pregnancy and lactation should be avoided (3). HIV can be definitely ruled out in the offspring if all testing of the child is negative at 18 months. Standard precautions should be taken in the IVF lab, and separate cryopreservation containers are needed due to the risk of transmission in the container (3). For many small IVF clinics, the cost of providing the extra equipment would be prohibitive. In a study of ART patients in an inner London hospital the prevalence of HIV in screened patients was 0.13% - 1 positive out of 815 patients (8). The majority of clinics in the USA do fewer than 200 cycles per year, thus referral to larger programs with specialists in HIV care would be reasonable.
All ART patients are universally screened for HIV. Whether the program actually has the capabilities to treat them (referral can be made), knowledge of the diagnostic testing is important in our patients. Enzyme linked immunosorbant assays (ELISA) using viral lysates or recombinant or synthetic proteins corresponding to the immunodominant epitopes from the serotype B variants (LAI and MN strains) and HIV-2 subtype A have a sensitivity and specificity approaching 100% to detect HIV-1 and HIV-2 (9). A reactive ELISA has relatively low positive predictive value in low risk populations, thus a confirmatory test is needed to exclude false-positives. The Western Blot is most commonly used. Viral proteins are separated on polyacrylamide gel electrophoresis and transferred by blotting to nitrocellulose strips. The strips are then reacted with test serums to see which viral proteins are present. Viral antigens include gp160, gp120, gp41 (env gene products) and p55, p24, and p17 (gag products) and p34 (pol gene products). These coat the wells and antibodies in the serum react with these (9).
A patient that has a negative test is free to do ART. Patients that have HIV without AIDS may be considered carriers and those with AIDs fully affected. After exposure to the virus HIV RNA can be detected from day 12 and p24 antigen from day 14-16. p24 has a sensitivity of 90% and specificity of 100 % for acute infection. Antibodies to envelope proteins are detected after day 21 (gp 160, gp 120, gp41). Therefore acute shows p24 positive and plasma HIV-1 RNA >10,000 copies /ml, early infection shows Evolving Wesern pattern and ELISA negative by detuned assay. The US CDC ansd WHO want at least 2 of the envelope proteins positive on WB (9). Carrier and infected should be treated the same.
Cytomegalovirus (CMV) is the most common intrauterine infection affecting 1% of live- borns in the US. It is a herpes virus. Most cases are asymptomatic. About 1% of pregnancies are complicated by primary CMV. 2/3 of infants will not be affected and 10%-15% of the remaining 1/3 will have symptoms in the neonate at birth. There is little risk (1%) in women infected more than 6 months before pregnancy (cdc.gov, 10). There is no treatment in pregnancy. Symptomatic infants may have jaundice, hepatosplenomegaly, pancytopenia, deafness or mental retardation. Maternal primary CMV infection is viremic with transplacental spread. Reactivation CMV may be less severe due to maternal IgG anti-CMV crossing the placenta (11). The gold standard for diagnosis is viral culture from maternal blood, cord blood saliva, fetal tissues or urine. The typical nuclear inclusions are not always diagnostic. CMV IgM may be present in newly acquired or reactivation CMV, so it is not always helpful. For immunocompetent patients, primary infection is best diagnosed with conversion from CMV IgG negative to positive and a positive IgM. A carrier may be IgG positive and IgM negative (i.e. 1%). A patient that has never been infected (negative IgG and IgM) would be at high risk if she were to become infected. She should exercise good personal hygiene, wash hands after contact with diapers of oral secretions, especially with children in day-care. Almost 80 % of adults have been exposed and have positive CMV IgG and would not have problems in pregnancy.
Hepatitis B is a double stranded DNA virus that replicates by reverse transcriptase and is spread by blood-blood contact and sex. There are nine subtypes of hepatitis B. It causes liver disease and may cause hepatocellular carcinoma. The serologic tests are as follows:
The chance of a chronically infected mother is 2-15% to pass it to the child when she is only HBsAg positive and 80%-90% HBsAg positive and HBeAg positive with HBV DNA positive (3). Immunoprophylaxis should be given within 24 hours of birth to decreases by 85 % the chance of the child being infected. A future mother that is HBsAg positive should be counseled about the risks in pregnancy. It is best to perform ART when the viral load is low.
Chlamydia are obligate intracellular bacteria that can not replicate outside cells or synthesize ATP. They exist in two forms, and elementary body which is a dense sphere with rRNA and rigid cell wall that has limited extracellular life (infectious form), and the reticulate body which is intracellular. Both forms have closed circular DNA. The elementary body outer wall has the major outer membrane protein which induced different antibodies. Lipopolysaccharide is also in the wall which is antigenic and the basis for genus specific testing. Chlamydia trachomatis is the most common STD in the US. It causes lymphogranuloma venereum and urethritis/cervicitis and associated complications (endometritis, tubal disease, PID). Since most infections involve mucus membranes (cervix or urethra) these are generally tested. Cell culture has sensitivity of about 85 %. Cells lines (McCoy or Buffalo green monkey cells) have been used with cell fixation and monoclonal antibody staining. Generally most labs now use PCR based tests which has 97% sensitivity and >99% specificity. Serologic tests have little value because the antibodies may persist after infection resolves and many serologic tests may not detect the specific genus involved with the infection (13). It is important to screen due to the risk of neonatal conjunctivitis and pneumonia. If either the male or female are positive with the PCR test, both should be treated using Doxycycline for 14 days.
1. Sander DM. Who gets AIDS. 1999. www.tulane.edu/~dmsander/www/335/aidsII.html
2. Sander DM, The pathogenesis of AIDS. 1999. www.tulane.edu/~dmsander/www/335/aidsI.html.
3. Steyaert SR, Leroux-Roels GG, Dhont M. Infections in IVF: review and guidelines. 2000. Hum. Repro. Update. 6(5): 432-441.
4. Spriggs M, Charles T. Should HIV discordant couples have access to assisted reproductive technologies. 2003. J. Med. Ethics. 29(6):325-9.
5. ASRM Ethics Committee. Human immunodeficiency virus and infertility treatment. 2002. Fertil. Steril. 77(2):218-222.
6. Ohl J, Partisani M, Wittemer C, Schmitt M-P, Cranz C, Stoll-Keller F, Rongieres C, Bettahar-Lebugle K, Lang J-M, Nisand I. Assisted reproduction techniques for HIV serodiscordant couples: 18 months of experience. 2003. Human Repro. 18(6):1244-1249.
7. Cleary-Goldman J, Pena JE, Thornton MH 2nd, Robinson JN, D’Alton ME, Sauer MV. Obstetric outcomes of human immunodeficiency viris-1-serodiscordant couples following in vitro fertilization with intracytoplasmic sperm injection. 2003. Am J. Perinatol. 20(6):305-11.
8. Hart R, Khalaf Y, Lawson R, Bickerstaff H, Taylor A, Braude P. Screening for HIV, hepatitis B and C infection in a population seeking assisted reproduction in an inner London hospital. 2001. BJOG. 108:654-656.
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10. CDC. Cytomegalovirus infection. www.cdc.gov/ncidod/diseases/cmv.htm
11. Costello M, Yungbluth M. Viral infections. In Infectious Diseases. 2nd ed. Ed. Cohen J, Powderly WG. Mosby, New York 2003, pp.1183-1110.
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