• * The center of assisted medical procreation of the CHU St Pierre is specialised in reproductive medicine. Reference center: quality label ISO 9001 obtained in 2008 and accredited by the AFMPS (Agence Fédérale des Médicaments et Produits de Santé).

Care of infected patients

The life expectancy of patients affected by the human immunodeficiency virus (HIV) has considerably improved in recent years thanks to the arrival of new therapies.  These therapies essentially combine three classes of medication and are commonly called “tritherapies”. One of their special features is to improve the patient’s immune system (the virus’ particular target) whose increasingly weakened state is responsible for the appearance of potentially fatal diseases, and another is to reduce the quantity of the virus circulating in the blood.

 

AR and HIV

The majority of people infected by HIV are also of an age to reproduce and very often desire a pregnancy. It is therefore inevitable and natural to see an increase in demand for assisted reproduction among this population. Over the past few years, some centres have agreed to offer their services to such couples where the man or woman, or even both, are HIV seropositive. More and more practitioners are indeed starting to consider HIV infection as a chronic disease, just like other more well-known or better-accepted diseases (diabetes, high blood pressure, hepatitis, etc.).

The main method of contamination in European countries is through sexual relations. The virus can indeed be present in large quantities in sperm and vaginal secretions.

What can assisted reproduction offer these couples?  

 

When the man is seropositive, couples are formally advised against sexual intercourse without a condom. It is therefore impossible for these couples to conceive without the assistance of the various centres. 

An anonymous sperm donor is the only solution that doesn’t involve any risk of contamination for the partner. But since 1992, there is an alternative technique called “sperm washing”. Sperm contains seminal fluid, spermatozoa and other “non-spermatic” cells such as white corpuscles. HIV, which can be found in large quantities in sperm, doesn’t appear to be present on the surface of the spermatozoon itself. 

This technique therefore consists of separating the spermatozoa from the rest of the infected sperm. A final analysis is carried out after washing to exclude the presence of the virus. 

It would seem that this technique considerably reduces the risk of infecting the partner. This “washed sperm” is either used for intrauterine insemination or for ICSI (intracytoplasmic sperm injection) according to the etiology of the sterility (quality of the sperm and permeability of the fallopian tubes). 

The results of more than 5000 inseminations of patients with “washed sperm” have been published in scientific literature and no cases of contamination have been reported. 

It is important to remember that a child can’t be infected by HIV during the pregnancy if the mother herself isn’t contaminated.

 

 

When the woman is seropositive the most serious risk is the transmission of the virus to the child. For many years, seropositive women were strongly advised against pregnancy.  Transmission from mother to foetus occurs mainly at birth when the baby passes through the vagina and, more rarely, during the final trimester of the pregnancy. Before 1994, this risk of contamination was 20 % to 40 %. An unacceptable figure considering that these children’s chances of survival were very low (more than 15 % of these children died during the first year of their life).

  • The first step towards reducing this risk appeared thanks to a treatment (known as AZT) administered to the mother through a drip during birth and to the baby in syrup form during the first six weeks of its life. This greatly reduced the quantity of the virus present in the blood and secretions.
  • The second step was to perform a planned caesarean at the end of the pregnancy to prevent the baby passing through the birth canal and coming into contact with vaginal secretions.
  • The third and final step, and probably the most important, was the appearance of tritherapies given to pregnant women. Indeed, the main factor determining the risk of transmission to the child is the quantity of virus present in the blood and the vaginal secretions at the end of pregnancy and during birth. This tritherapy causes the virus to almost completely disappear from the blood and, to a lesser degree, from the vaginal secretions.

Thanks to all these measures, the mother-to-foetus transmission rate has fallen to approximately 1 % and delivery by caesarean is no longer necessary if there is no trace of the virus in the blood at the end of the pregnancy.

These couples, who have long been victims of stigmatisation and rejection, can finally consider having a family.

These major changes have drastically altered the data and have led certain AR centres to take care of women infected by HIV.

To avoid contamination of the male partner in fertile couples, the patients undergo “self-insemination”: the man ejaculates into a container during his partner’s period of ovulation. After being placed in a syringe, the sperm is then injected by the patient deep into the vagina.

This technique has the same success rate as normal sexual intercourse.

If self-insemination fails or if there are known infertility problems, different assisted reproductive techniques can be used: insemination, in vitro fertilization with or without intracytoplasmic sperm injection depending on the origin of the sterility.e seront utilisées : inséminations, fécondation in vitro avec ou sans injection intra-cytoplasmique de spermatozoïde en fonction de l’origine de la stérilité.

 

Special infrastructures and precautions are required when applying these techniques to avoid any risk of contaminating other patients or the medical staff.

A multidisciplinary team comprised of a gynaecologist specialising in fertility, a paediatrician, a psychiatrist, an infectologist, an obstetrician and a social worker will meet the various couples.

This structure serves to inform the patients (risks of transmission, treatment required for the mother, risk of the treatment for the child, etc.) but also to assess their state of health, their knowledge and their ability to care for a child. 

 

AR and hepatitis B 

The hepatitis B virus is very widespread: more than 350 million people worldwide are believed to carry the virus. One million of these people will die every year from the resulting complications (fulminant hepatitis, cirrhosis and cancer of the liver).

The prevalence of this virus (percentage of people infected in a population) varies according to the part of the world concerned: 0.1 to 2 % in areas with low prevalence (USA, Canada, Western Europe), 3 to 5 % in intermediary areas (Mediterranean countries, Japan, South America) and 10 to 20 % in areas with high prevalence (South-East Asia, China, Sub-Saharan Africa).

The methods of transmission are:

  • Perinatal transmission (i.e. from mother to child): 9 children out of 10 born to mothers with chronic hepatitis B will be infected and this transmission essentially occurs at birth (when the newborn comes into contact with the mother’s blood). Luckily, transmission has been eradicated in the majority of cases through gamma globulin injections (antibodies) and vaccination of the newborn. Some patients with large quantities of the virus circulating in their blood will have to be given an antiviral treatment during their pregnancy to avoid transmission.
  • Breast-feeding doesn’t seem to increase the risk of transmission and women carrying the hepatitis B virus can breast-feed their child.
  • Transmission from the father to the child is impossible during conception.
  • Sexual transmission is the main source of contamination in our industrialised countries (39 % of newborns)
  • Injecting drugs intravenously, work accidents involving blood from infected people, dirty razors, toothbrushes, tattoos and piercings can also be sources of transmission.

 

The vast majority of these contaminations can be avoided by vaccination against the hepatitis B virus.

  

As regards assisted reproduction among couples where one of the partners carries hepatitis B: 

  • It is necessary to ensure that the non-infected partner has been properly vaccinated and that this vaccination has worked (by measuring the level of antibodies in the blood). If this isn’t the case, this partner will be vaccinated as quickly as possible.
  • If the woman carries the hepatitis B virus, she will need to be checked (blood test and ultrasound scan of the liver) to assess the severity of the infection and to decide on possible treatment during the pregnancy. The newborn will receive gamma globulins (antibodies) and will be vaccinated at birth.
  • The gametes (oocytes or sperm) will be handled in a “special area” of the laboratory to prevent any contamination.
  • The virus can only be transmitted from mother to child. The virus can never be transmitted by the sperm to the “embryo”.

 

AR and hepatitis C

Chronic hepatitis C is one of the most widespread chronic liver diseases.

For instance, the prevalence of this infection is 1.6 % in the USA (4.1 million infected people). This often asymptomatic infection can evolve into chronic hepatitis, which in turn can transform into cirrhosis and cancer of the liver (very rarely, it can also lead to chronic hepatitis).

 

The methods of transmission are:

  • in a great number of new cases, the cause is actually unknown!!
  • injecting drug users (significant decrease since free distribution of needles and syringes)
  • tattoos, scarification and the like (if sterile conditions are not respected)
  • blood transfusion (transmission is currently exceptional in our countries with less than one in a million risk of infection)
  • health workers and hospitalised patients are also at greater risk of catching this virus
  • organ transplants and haemodialysis
  • sexual transmission: the risk of transmitting the virus during heterosexual intercourse is practically nonexistent! Anal intercourse and intercourse during menstruation can increase the risk (probably due to the presence of blood). There is no recommendation regarding the use of condoms in couples where one of the partners is infected with the hepatitis C virus!
  • mother-to-child transmission: the mother-to-child transmission rate is 5 % and occurs when giving birth. It is twice as great if the mother is infected by HIV as well. This transmission only occurs if there are large quantities of the hepatitis C virus in the mother’s blood. No specific treatment is recommended during pregnancy.
  • Breast-feeding doesn’t appear to increase the risk of transmission and women carrying the hepatitis C virus can breast-feed their child.

  

Unfortunately, there is no vaccine for hepatitis C! (But there are medical treatments)

 

As regards assisted reproduction for couples where one of the partners carries the hepatitis C virus:

  • The partner must of course be tested; if the partner is negative, he/she must be given certain recommendations (avoid using the same razor, the same toothbrush, etc.).
  • If the woman has hepatitis C, she must be checked (blood test and ultrasound scan of the liver) to assess the extent of the infection. Treatment may sometimes be necessary before beginning AR.
  • The gametes (oocytes or sperm) will be handled in a “special area” of the laboratory to prevent any contamination.
  • The virus can only be transmitted from mother to child. The virus can never be transmitted by the sperm to the “embryo”.


 

Plan du site CHU Saint Pierre - Bâtiment 200, 5è étage . Département de Gynécologie-Obstétrique

Centre de Fécondation In vitro - 322, Rue Haute - Bruxelles Tel +32(0)2 535 3406 Fax +32(0)2 535 3409