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Guidelines for risk reduction when handling gametes from infectious patients seeking assisted reproductive technologies

      Abstract

      According to the Americans with Disabilities Act (1990), couples with blood-borne viruses that lead to infectious disease cannot be denied fertility treatment as long as the direct threat to the health and safety of others can be reduced or eliminated by a modification of policies or procedures. Three types of infectious patients are commonly discussed in the context of fertility treatment: those with human immunodeficiency virus (HIV), hepatitis C or hepatitis B. Seventy-five per cent of hepatitis C or HIV positive men and women are in their reproductive years, and these couples look to assisted reproductive techniques for risk reduction in conceiving a pregnancy. In many cases, only one partner is infected. Legal and ethical questions about treatment of infectious patients aside, the question most asked by clinical embryologists and andrologists is: “What are the laboratory protocols for working with gametes and embryos from patients with infectious disease?” The serostatus of each patient is the key that informs appropriate treatments. This guidance document describes protocols for handling gametes from seroconcordant and serodiscordant couples with infectious disease. With minor modifications, infectious patients with stable disease status and undetectable or low viral load can be accommodated in the IVF laboratory.

      Keywords

      Introduction

      Around 4.2 million people of childbearing age in the USA are infected with HIV, hepatitis C (HCV), hepatitis B (HBV), or a combination. For those seeking assisted reproductive techniques, laboratory protocols can be developed to safely accommodate virus-positive patients. These protocols will reduce the risk of infection to the staff, to the patients themselves and to other patients. The main risk to clinical staff is through needle punctures and splash or aerosol exposures. The risk to laboratory staff may come at the time of oocyte retrieval when blood products are introduced into the laboratory; at the time of semen processing; at the time of in-vitro insemination; during culture of gametes and embryos; and at the time of cryopreservation of oocytes, embryos or sperm. Patients may be exposed to risk if protocols are not in place to prevent cross-contamination of samples or if protocols are not strictly followed. Unsafe procedures include improper labelling of containers, inadequate sanitation between patients, improper handling of body fluids and use of blood products contaminated with infective agents.
      Control of disease transmission requires a team management approach. It is critical to have open communication among the laboratory and clinical staff about protocols, testing, tests results, precautions and care offered to the patient. It is essential that universal or standard precautions be observed at all times. That is, all tissues and cells should be handled as if they are from an infectious patient. Each fertility programme should determine its comfort level with handling gametes from infectious patients. These patients are entitled to fertility options, so caution and appropriate modification on the part of the laboratory staff is required whenever possible. In this guideline, handling gametes and embryos from patients with HIV, HBV and HCV will be discussed (Table 1).
      Table 1Blood-borne viruses that can be sexually transmitted and are routinely screened in fertility couples.
      Name of virusVirus type and target
      Human immunodeficiency virus types 1 and 2Retrovirus primarily infects helper T-cells (CD4) causing immunodeficiency syndrome.
      Hepatitis C virusRNA virus infects liver cells.
      Hepatitis B virusDouble-stranded DNA virus infects liver cells.
      Human T-lymphotrophic virus I and IIRetrovirus primarily infects CD4 T-cells causing adult T-cell leukaemia and myelopathy.
      CytomegalovirusHerpes virus threatens immunocompromised individuals and is leading cause of congenital infection.

      Published guidelines

      Published guidelines on laboratory safety when handling gametes from infected patients are limited and do not offer comprehensive hands-on recommendations for laboratory staff (
      • Clarke G.N.
      Sperm cryopreservation: is there a significant risk of cross-contamination?.
      ,
      • Gilling-Smith C.
      • Emiliani S.
      • Almeida P.
      • Liesnard C.
      • Englert Y.
      Laboratory safety during assisted reproduction in patients with blood-borne viruses.
      ,
      • Practice Committee of American Society for Reproductive Medicine
      Recommendations for reducing the risk of viral transmission during fertility treatment with the use of autologous gametes: a committee opinion.
      ).
      The European Society of Human Reproduction and Embryology Committee of the Special Interest Group on Embryology published guidelines for good practice in IVF laboratories (
      • Magli M.C.
      • Van den Abbeel E.
      • Lundin K.
      • Royere D.
      • Van der Elst J.
      • Gianaroli L.
      Embryology Committee of the Special Interest Group
      Revised guidelines for good practice in IVF laboratories.
      ), recommending treatment of patients infected with HIV, HBV or HCV using dedicated laboratory space at allocated times, and processing within a biosafety cabinet to prevent cross-contamination of patient specimens.
      The
      • Practice Committee of American Society for Reproductive Medicine
      Recommendations for reducing the risk of viral transmission during fertility treatment with the use of autologous gametes: a committee opinion.
      recently issued guidelines for treating patients with infectious disease. These guidelines advise counselling, education and informed consent, and provide standards for screening sperm and egg donors. The ASRM also recommends separation in time or space, separate frozen storage and special sperm washing with viral check before freezing, if possible.
      The United States Food and Drug Administration regulates third-party reproductive tissues, including sperm, oocytes and embryos as products for transplantation. Regulations include donor screening for infectious diseases, as well as quarantine, storage and labelling requirements.
      The Human Fertilization and Embryology Act of the UK mandates separate frozen storage for sperm, oocytes and embryos for which the source patient tests positive for infectious disease. Heat-sealed cryopreservation straws are used by most European IVF centres treating HIV and HBV and HCV positive patients with no reported cases of cross-contamination (
      • Clarke G.N.
      Sperm cryopreservation: is there a significant risk of cross-contamination?.
      ).

      HIV infection

      In the case of HIV, no vaccine is available (
      • Mascola J.R.
      HIV. The modern era of HIV-1 vaccine development.
      ). The HIV virus uses reverse transcriptase to transcribe RNA into DNA (
      • Schnittman S.M.
      • Fauci A.S.
      Human immunodeficiency virus and acquired immunodeficiency syndrome: an update.
      ). Once the virus binds to the cell surface, commonly that of the helper T-cell (CD4+) of the immune system, and fuses with the cell, the viral RNA is reverse transcribed into DNA that combines with the host cell DNA. Some infected CD4+ cells in lymphoid tissues destroy themselves, leading to falling CD4+ counts over time (
      • Doitsh G.
      • Galloway N.L.
      • Geng X.
      • Yang Z.
      • Monroe K.M.
      • Zepeda O.
      • Hunt P.W.
      • Hatano H.
      • Sowinski S.
      • Munoz-Arias I.
      • Greene W.C.
      Cell death by pyroptosis drives CD4 T-cell depletion in HIV-1 infection.
      ,
      • Monroe K.M.
      • Yang Z.
      • Johnson J.R.
      • Geng X.
      • Doitsh G.
      • Krogan N.J.
      • Greene W.C.
      IFI16 DNA sensor is required for death of lymphoid CD4 T cells abortively infected with HIV.
      ). When the serum CD4+ count falls below 200 per mm3 (or about a drop of blood), HIV infection can become acquired immunodeficiency syndrome. The lymph nodes are infected by HIV, which travels into the blood to gain entrance to other body fluids, such as semen and breast milk (
      • Schnittman S.M.
      • Fauci A.S.
      Human immunodeficiency virus and acquired immunodeficiency syndrome: an update.
      ). HIV is typically detected in the serum, and the viral load is expressed as viral RNA copies per ml of serum, measured by polymerase chain reaction (PCR) assay (
      • Hart C.
      • Schochetman G.
      • Spira T.
      • Lifson A.
      • Moore J.
      • Galphin J.
      • Sninsky J.
      • Ou C.Y.
      Direct detection of HIV RNA expression in seropositive subjects.
      ).

      Is HIV associated with the sperm cell?

      Although many are convinced that HIV is not associated with sperm cells selected by gradient separation (
      • Anderson D.J.
      • Politch J.A.
      • Nadolski A.M.
      • Blaskewicz C.D.
      • Pudney J.
      • Mayer K.H.
      Targeting Trojan Horse leukocytes for HIV prevention.
      ,
      • Gilling-Smith C.
      • Nicopoullos J.D.
      • Semprini A.E.
      • Frodsham L.C.
      HIV and reproductive care–a review of current practice.
      ,
      • Le Tortorec A.
      • Dejucq-Rainsford N.
      HIV infection of the male genital tract–consequences for sexual transmission and reproduction.
      ), controversy remains. Convincing evidence was published by
      • Quayle A.J.
      • Xu C.
      • Mayer K.H.
      • Anderson D.J.
      T lymphocytes and macrophages, but not motile spermatozoa, are a significant source of human immunodeficiency virus in semen.
      ,
      • Quayle A.J.
      • Xu C.
      • Tucker L.
      • Anderson D.J.
      The case against an association between HIV-1 and sperm: molecular evidence.
      reporting no association of HIV with motile sperm collected by gradient separation followed by swim-up. Both immunohistochemical and nested PCR failed to detect HIV associated with sperm. However, HIV, was found free in seminal plasma and was associated with leukocytes (white blood cells). Further research found that HIV receptors CD4, CXCR4, CCR5, which are involved in HIV infection of leukocytes, are not present on the sperm surface (
      • Kim L.U.
      • Johnson M.R.
      • Barton S.
      • Nelson M.R.
      • Sontag G.
      • Smith J.R.
      • Gotch F.M.
      • Gilmour J.W.
      Evaluation of sperm washing as a potential method of reducing HIV transmission in HIV-discordant couples wishing to have children.
      ), although HIV can attach avidly to sperm apparently via sperm surface mannose or heparin sulphate receptors (
      • Bandivdekar A.H.
      • Velhal S.M.
      • Raghavan V.P.
      Identification of CD4-independent HIV receptors on spermatozoa.
      ,
      • Ceballos A.
      • Remes Lenicov F.
      • Sabatte J.
      • Rodriguez Rodrigues C.
      • Cabrini M.
      • Jancic C.
      • Raiden S.
      • Donaldson M.
      • Agustin Pasqualini Jr., R.
      • Marin-Briggiler C.
      • Vazquez-Levin M.
      • Capani F.
      • Amigorena S.
      • Geffner J.
      Spermatozoa capture HIV-1 through heparan sulfate and efficiently transmit the virus to dendritic cells.
      ,
      • Fanibunda S.E.
      • Velhal S.M.
      • Raghavan V.P.
      • Bandivdekar A.H.
      CD4 independent binding of HIV gp120 to mannose receptor on human spermatozoa.
      ), which may be important for HIV transmission in vivo.
      Conversely, some older studies suggest that HIV may be associated with germinal cells in the testis (
      • Shevchuk M.M.
      • Nuovo G.J.
      • Khalife G.
      HIV in testis: quantitative histology and HIV localization in germ cells.
      ). Although the use of electron microscopy and atomic force microscopy that HIV is found in motile sperm from HIV-infected men selected by gradient followed by swim-up, HIV can enter the sperm in vitro. It can transfer to oocytes, as the virus was found in eight-cell embryos after IVF (
      • Baccetti B.
      • Burrini A.G.
      • Falchetti E.
      Spermatozoa and relationships in Palaeognath birds.
      ,
      • Baccetti B.
      • Benedetto A.
      • Burrini A.G.
      • Collodel G.
      • Ceccarini E.C.
      • Crisa N.
      • Di Caro A.
      • Estenoz M.
      • Garbuglia A.R.
      • Massacesi A.
      • Piomboni P.
      • Solazzo D.
      HIV-particles in spermatozoa of patients with AIDS and their transfer into the oocyte.
      ,
      • Barboza J.M.
      • Medina H.
      • Doria M.
      • Rivero L.
      • Hernandez L.
      • Joshi N.V.
      Use of atomic force microscopy to reveal sperm ultrastructure in HIV-patients on highly active antiretroviral therapy.
      ).
      More recent work has shown that even after complete elimination of non-sperm cells, sperm with gross morphological abnormalities are positive for HIV (
      • Muciaccia B.
      • Corallini S.
      • Vicini E.
      • Padula F.
      • Gandini L.
      • Liuzzi G.
      • Lenzi A.
      • Stefanini M.
      HIV-1 viral DNA is present in ejaculated abnormal spermatozoa of seropositive subjects.
      ).
      Leukocytes in semen are the main mode of HIV infection (
      • Nicopoullos J.D.
      • Almeida P.
      • Vourliotis M.
      • Goulding R.
      • Gilling-Smith C.
      A decade of sperm washing: clinical correlates of successful insemination outcome.
      ). It is important to recognize that serum viral load is not always correlated with semen viral load (
      • Coombs R.W.
      • Speck C.E.
      • Hughes J.P.
      • Lee W.
      • Sampoleo R.
      • Ross S.O.
      • Dragavon J.
      • Peterson G.
      • Hooton T.M.
      • Collier A.C.
      • Corey L.
      • Koutsky L.
      • Krieger J.N.
      Association between culturable human immunodeficiency virus type 1 (HIV-1) in semen and HIV-1 RNA levels in semen and blood: evidence for compartmentalization of HIV-1 between semen and blood.
      ). Even if HIV seropositive males receive highly active anti-retroviral therapy (HAART) and have serum viral loads below the detection limit of the assay, semen samples from these men may still test positive for HIV (
      • Ferraretto X.
      • Estellat C.
      • Damond F.
      • Longuet P.
      • Epelboin S.
      • Demailly P.
      • Yazbeck C.
      • Llabador M.A.
      • Pasquet B.
      • Yazdanpanah Y.
      • Matheron S.
      • Patrat C.
      Timing of intermittent seminal HIV-1 RNA shedding in patients with undetectable plasma viral load under combination antiretroviral therapy.
      ,
      • Lambert-Niclot S.
      • Tubiana R.
      • Beaudoux C.
      • Lefebvre G.
      • Caby F.
      • Bonmarchand M.
      • Naouri M.
      • Schubert B.
      • Dommergues M.
      • Calvez V.
      • Flandre P.
      • Poirot C.
      • Marcelin A.G.
      Detection of HIV-1 RNA in seminal plasma samples from treated patients with undetectable HIV-1 RNA in blood plasma on a 2002–2011 survey.
      ,
      • Politch J.A.
      • Mayer K.H.
      • Welles S.L.
      • O'Brien W.X.
      • Xu C.
      • Bowman F.P.
      • Anderson D.J.
      Highly active antiretroviral therapy does not completely suppress HIV in semen of sexually active HIV-infected men who have sex with men.
      ).

      Hepatitis C infection

      About 1% of the global population is infected with HCV. Although a virtual cure for HCV has been recently developed, it is extremely costly with limited usage at this time. An HCV vaccine is still not available (
      • Li H.C.
      • Lo S.Y.
      Hepatitis C virus: virology, diagnosis and treatment.
      ), so patients with chronic HCV infection who have not been prescribed the cure may seek fertility treatment. HCV viral RNA in serum is quantified by PCR assay as international units (IU)/ml. In general, about 90% of HCV RNA positive samples have a viral load above 10,000 IU/ml (
      • Fytili P.
      • Tiemann C.
      • Wang C.
      • Schulz S.
      • Schaffer S.
      • Manns M.P.
      • Wedemeyer H.
      Frequency of very low HCV viremia detected by a highly sensitive HCV-RNA assay.
      ). In contrast to HIV, HCV can profoundly reduce semen quality (
      • Lorusso F.
      • Palmisano M.
      • Chironna M.
      • Vacca M.
      • Masciandaro P.
      • Bassi E.
      • Selvaggi Luigi L.
      • Depalo R.
      Impact of chronic viral diseases on semen parameters.
      ).

      Hepatitis B infection

      One of the major causes of liver disease worldwide is HBV, which is a DNA virus. It occurs in acute and chronic forms, and is about 100 times more infective by parenteral exposure (e.g. needle stick) than HIV. A HBV vaccination has been available since 1981 and its efficacy is measured by a HBV surface antibody (sAb) titre of 10 mIU/ml or greater (
      • Greub G.
      • Zysset F.
      • Genton B.
      • Spertini F.
      • Frei P.C.
      Absence of anti-hepatitis B surface antibody after vaccination does not necessarily mean absence of immune response.
      ). In the case of HBV infection of either the male or female partner, the reasonable precaution is to have all laboratory staff vaccinated for HBV. In discordant couples, vaccination of the uninfected partner is indicated. The effects of HBV on sperm quality have not been widely studied. In one study, however, semen parameters concentration, motility, viability and morphology from HBV-positive men were all significantly reduced compared with semen from virus-negative men (
      • Lorusso F.
      • Palmisano M.
      • Chironna M.
      • Vacca M.
      • Masciandaro P.
      • Bassi E.
      • Selvaggi Luigi L.
      • Depalo R.
      Impact of chronic viral diseases on semen parameters.
      ).

      Ebola virus and Zika virus

      In the context of global travel, new and potentially untreatable viruses that can lead to serious infectious disease are being seen for the first time in the USA, including in couples of reproductive age. Treatment of these couples should at all times follow the latest guidance issued by the Centers for Disease Control and by ASRM. The 2014 Ebola outbreak in select regions of West Africa was the largest in history. At this time, no specific treatment is available, only experimental agents (www.who.int/ebola). No studies have been published on the safe handling of semen infected with Ebola virus. Because of catastrophic outcomes for mothers and fetuses affected with Ebola, patients should wait 21 days after their return from an Ebola-infected country before receiving infertility treatment. As they will be monitoring their own symptoms and self-quarantining, waiting 21 days is a realistic recommendation (
      • Affairs
      SRBT Statement on Ebola Virus.
      ).
      Men and women exposed to the Zika virus may have no symptoms or mild symptoms but the effect of Zika viral infection on a fetus in utero is similarly catastrophic. According to the Centers for Disease control, women who have Zika virus disease should wait at least 8 weeks after symptom onset to attempt conception, and men with Zika virus disease should wait at least 6 months after symptom onset to attempt conception. Women and men with possible exposure to the Zika virus but without clinical illness consistent with Zika virus disease should wait at least 8 weeks after exposure to attempt conception. At present no data or recommendations are available for purifying sperm away from these viruses in semen; all counselling, precautions and procedures recommended for other viruses should be followed if there is any suspicion of infection.

      Assisted reproduction techniques and risk reduction

      A checklist of good laboratory practice and potential modifications to reduce risk when handling gametes from virus-positive patients in the laboratory is presented in Table 2. These include using universal precautions, using personal protection equipment, minimizing aerosol formation during sample processing and properly decontaminating the work area. Regardless of viral status, it is recommended that these precautions be in place for each patient as part of good laboratory practice.
      Table 2Checklist for minimizing risk of bloodborne pathogen transmission when handling gametes from infectious patients.
      • Strictly follow universal or standard precautions.
      • Strictly follow protocols to avoid cross-contamination between patients.
      • Avoid sharps injuries and needle punctures.
      • Avoid splash injuries and minimize aerosol exposure.
      • Use personal protective equipment
        • Scrubs, hair cover, shoe covers
        • Gown/laboratory coat that covers wrists
        • Gloves
        • Mask
        • Face shield or goggles
      • Properly label containers, samples, etc.
      • Decontaminate work areas using hydrogen peroxide and distilled water.
      • Strictly follow hand hygiene.
      • Strictly follow infectious waste management.
      • No mouth pipetting.
      • Seal tubes so no aerosol-borne viruses escape; cover tubes in centrifuge.
      The “gold standard” we recommend for handling HIV-discordant couples in a fertility clinic, in which the male is HIV-seropositive and the female is HIV-seronegative is presented in Table 3. We strongly recommend this as the standard of care for couples composed of HIV seropositive males and seronegative females. Generally, the disease should be stable and the viral load in the serum should be undetectable (40–75 viral copies/ml of blood). Patients with chronic detectable viral load in the serum, however, may also seek fertility treatment through assisted reproduction techniques. If possible, these patients should be treated with HAART under the care of an infectious disease specialist until viral load and CD4+ count are within acceptable limits for assisted reproduction, generally taken as viral load less than 200 copies/ml and CD4 count greater than 250 cells/mm3 for the preceding 6-month period. Note that patients within the first 6 months of detectable disease have the highest infectivity. Patients unable to attain this control of their disease should be considered on a case-by-case basis in order to ensure management of infection risks and appropriate counselling and communication. It is not recommended that patients with detectable viral load in the serum be brought through the laboratory for semen processing for establishing a pregnancy in a seronegative partner.
      Table 3Standard for treating a male patient who is HIV-positive and his HIV-negative female partner.
      • Couple is counselled on the risks of HIV transmission to the female partner and potential offspring.
      • Consider the safer options of donor insemination, adoption or remaining childless.
      • Couple undergoes a standard infertility evaluation and are judged to have healthy reproductive tracts with good fertility potential for the treatment method to be used.
      • Couple is counselled on reducing the risk of HIV infection and attests to use of safe sexual practices and no intravenous drug use during treatment and pregnancy.
      • Man attests to no sexual contact with an infected man in the last 5 years, and couple attests to no intravenous drug use in the last 5 years.
      • Couple has no concomitant sexually transmitted infections.
      • Woman has had two negative HIV antibody tests at 6-month interval.
      • Man is under the care of an infectious disease specialist, is taking highly active anti-retroviral therapy, and his HIV disease is under control and stable for 1 year.
      • High CD4 count > 200 cells/mm3.
      • Low or undetectable (<200 viral copies/ml) serum viral load.
      • Woman is taking pre-exposure prophylaxis if appropriate.
      HIV, human immunodeficiency virus.

      Virus-positive female

      If the female partner is HIV-positive or HCV-positive, fertility options may include intrauterine insemination (IUI) or IVF, or intracytoplasmic sperm injection without fear of infecting her male partner. Vertical transmission refers to mother-to-child-transmission of virus, bacteria or parasite to the embryo, to the fetus during pregnancy, to the baby during childbirth, or both. The potential for vertical transmission of the virus to her child should be considered and the patient counselled appropriately. Both HIV and HCV can be transmitted to the fetus in utero and at birth. Appropriate medical management of the pregnant patient has reduced vertical transmission of HIV to less than 2% (
      • Practice Committee of American Society for Reproductive Medicine
      Recommendations for reducing the risk of viral transmission during fertility treatment with the use of autologous gametes: a committee opinion.
      ). The rate of vertical transmission of HCV, however, averages 5%, with significant variation among study populations (
      • Benova L.
      • Mohamoud Y.A.
      • Calvert C.
      • Abu-Raddad L.J.
      Vertical transmission of hepatitis C virus: systematic review and meta-analysis.
      ).
      If the HIV-positive or HCV-positive female patient seeks insemination via IUI, there is no burden on the laboratory regarding processing of female gametes. If IVF or intracytoplasmic sperm injection (ICSI) is indicated, virus-positive oocytes should be handled according to the recommendations set out in Table 4. For women who are HIV, HCV or HBV positive, ICSI is recommended over IVF, to reduce the number of granulosa and cumulus cells in culture and to reduce handling of those cells by embryologists. Hepatitis C virus has been measured in follicular fluid and may attach to granulosa cells.
      • Devaux A.
      • Soula V.
      • Sifer C.
      • Branger M.
      • Naouri M.
      • Porcher R.
      • Poncelet C.
      • Neuraz A.
      • Alvarez S.
      • Benifla J.L.
      • Madelenat P.
      • Brun-Vezinet F.
      • Feldmann G.
      Hepatitis C virus detection in follicular fluid and culture media from HCV+ women, and viral risk during IVF procedures.
      showed in 17 HCV-positive women that Hepatitis C RNA was detected by PCR in 89% of follicular fluid samples. After denuding the oocytes of granulosa cells, inseminating the oocytes via ICSI, washing the oocytes and embryos and refreshing the media during culture, the viral load became undetectable, irrespective of the original follicular fluid status. Therefore, the authors concluded that follicular fluid must be considered as potentially infected, but all oocytes can be inseminated by ICSI resulting in virus-free embryos in culture. In a smaller study,
      • Papaxanthos-Roche A.
      • Trimoulet P.
      • Commenges-Ducos M.
      • Hocke C.
      • Fleury H.J.
      • Mayer G.
      PCR-detected hepatitis C virus RNA associated with human zona-intact oocytes collected from infected women for ART.
      found HCV associated with unfertilized oocytes denuded of follicular cells.
      Table 4Recommendations for handling virus-positive oocytes in the IVF laboratory.
      • Consider placing the patient at the end of the daily workflow to isolate the patient in time.
      • Consider culturing the gametes and embryos in a separate incubator to isolate the patient in space.
      • At the time of oocyte retrieval, the virus may be in follicular fluid and may attach to granulosa cells surrounding the oocyte, hence the need to denude the oocytes completely and inseminate via ICSI. Cut away granulosa and cumulus cells and wash oocyte thoroughly in sterile media to dilute the viral titre.
      • Move the oocytes to a new dish with fresh media and proceed with ICSI and embryo culture.
      • Wipe down surfaces after oocyte retrieval with 6% hydrogen peroxide followed by distilled water.
      • At embryo transfer, base selection of the number of embryos to transfer on the importance of avoiding a higher-order multiple pregnancy, a complicated delivery, or both. Elective single embryo transfer is recommended.
      • Store frozen embryos in the same cryopreservation tank as other embryos if you use a leak-proof system such as heat-sealed high security vitrification straws made of ionomeric resin. Otherwise, check with a long-term storage facility to see if they will accept frozen embryos with positive infectious disease status. Freeze the embryos and keep them separately in a holding tank until shipped off-site to a long-term storage facility. Or freeze and store in separate cryopreservation tanks according to virus (HIV, hepatitis B virus, hepatitis C virus).
      HIV, human immunodeficiency virus; ICSI, intracytoplasmic sperm injection.

      Virus-positive male

      According to the Centers for Disease Control and Prevention guidance document published in 2014, couples in the USA with a virus-positive male may use IUI, IVF or ICSI if the virus-positive semen has undergone procedures that remove seminal fluid that may contain HIV (sperm washing) (
      • Centers for Disease Control and Prevention
      • National Institutes of Health
      • American Academy of HIV Medicine
      • International Association of Providers of AIDS Care
      • National Minority AIDS Council
      Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, 2014.
      ). If the male partner is HIV positive, and the patients are good candidates for IUI, special washing of the sperm is a safe, cost-effective treatment method that is widely used (
      • Barnes A.
      • Riche D.
      • Mena L.
      • Sison T.
      • Barry L.
      • Reddy R.
      • Shwayder J.
      • Parry J.P.
      Efficacy and safety of intrauterine insemination and assisted reproductive technology in populations serodiscordant for human immunodeficiency virus: a systematic review and meta-analysis.
      ,
      • Moragianni V.A.
      Why are we still, 20 years later, depriving human immunodeficiency virus-serodiscordant couples of equal access to fertility care?.
      ). The concern is that, although cases have been confirmed of post-wash contamination (with zero reports of infection of women or babies in over 8000 IUI cycles with washed sperm), there is no way to guarantee that HIV viral particles are not present in the final sample for IUI. Detection of virus is dependent on in-house PCR methods developed and used. In infected cells in the semen, HIV DNA may be detected, and viral RNA may be free or cell associated. Detection of viral RNA may represent non-infectious small RNAs that are not part of a viral particle. A guideline should be developed at each IVF programme to define the lowest acceptable level of virus in samples to be used for insemination, based on local PCR methods and sensitivity, and physicians' and ethics committee recommendations.
      Additionally, the use of sperm from a seropositive partner to inseminate a woman who is seronegative, particularly for HIV, may be dictated by US state law.
      • Richardson R.
      • Golden S.
      • Hanssens C.
      Ending and defending against HIV criminilization. A manual for advocates.
      details each US state's laws specific to HIV up to the present time . In general, these laws are meant to prohibit HIV-positive individuals from donating their blood, organs and tissues, and from selling their semen. To date, no criminal charges have been brought against a specific clinic or individual that processes known HIV-positive semen for IUI in a HIV-negative female. Because of the coverage of an HIV-positive individual under the Americans with Disabilities Act, laws that would specifically limit a serodiscordant couple's right to procreate and use infertility services would face an uphill battle. The law is always changing and is dependent on the state in which the couple seeks assisted reproduction technique treatment. Fertility clinics intending to perform such procedures should first seek legal counsel to ensure that they do not unwittingly break the law. Men who are HCV-positive have not been restricted in the USA from IUI as have HIV-positive men. At present, IUI is offered to couples in which the man is infected with HBV or HCV, without the legal and regulatory issues applied to HIV.
      If semen analysis is carried out at a clinic, it should also be available for known virus-positive men. No special expertise or equipment is required other than that used with universal or standard precautions. It is not necessary to notify other patients that virus-positive specimens are processed in your laboratory. Appropriate procedures and sanitation are in place to control for cross-contamination. As an analogy, a patient who is scheduled for surgery does not need to be notified that surgeries are being carried out on virus-positive patients using the same facilities and instruments.

      Special washing of semen for virus-positive men

      Recommendations for the laboratory handling of virus-positive (HIV, HCV, HBV) semen are presented in Table 5. In processing semen that is virus-positive, the goal is to greatly reduce the viral titre that can be measured in the final sample by PCR. Many peer-reviewed articles have described the use of special sperm washing protocols effective in removing HIV from motile sperm for IUI, IVF or ICSI. In none of these procedures has there been seroconversion of the female partner or babies born (
      • Nicopoullos J.D.
      • Almeida P.A.
      • Ramsay J.W.
      • Gilling-Smith C.
      The effect of human immunodeficiency virus on sperm parameters and the outcome of intrauterine insemination following sperm washing.
      ,
      • Nicopoullos J.D.
      • Almeida P.
      • Vourliotis M.
      • Goulding R.
      • Gilling-Smith C.
      A decade of sperm washing: clinical correlates of successful insemination outcome.
      ,
      • Savasi V.
      • Ferrazzi E.
      • Lanzani C.
      • Oneta M.
      • Parrilla B.
      • Persico T.
      Safety of sperm washing and ART outcome in 741 HIV-1-serodiscordant couples.
      ,
      • Schuffner A.
      • Lisboa A.P.
      • Rosa V.B.
      • Silva M.M.
      Use of assisted reproductive technology to separate sperm from human immunodeficiency virus infected men resulting in pregnancy among serodiscordant couples.
      ,
      • Semprini A.E.
      • Levi-Setti P.
      • Bozzo M.
      • Ravizza M.
      • Taglioretti A.
      • Sulpizio P.
      • Albani E.
      • Oneta M.
      • Pardi G.
      Insemination of HIV-negative women with processed semen of HIV-positive partners.
      ,
      • Semprini A.E.
      • Macaluso M.
      • Hollander L.
      • Vucetich A.
      • Duerr A.
      • Mor G.
      • Ravizza M.
      • Jamieson D.J.
      Safe conception for HIV-discordant couples: insemination with processed semen from the HIV-infected partner.
      ,
      • Vitorino R.L.
      • Grinsztejn B.G.
      • de Andrade C.A.
      • Hokerberg Y.H.
      • de Souza C.T.
      • Friedman R.K.
      • Passos S.R.
      Systematic review of the effectiveness and safety of assisted reproduction techniques in couples serodiscordant for human immunodeficiency virus where the man is positive.
      ,
      • Zafer M.
      • Horvath H.
      • Mmeje O.
      • van der Poel S.
      • Semprini A.E.
      • Rutherford G.
      • Brown J.
      Effectiveness of semen washing to prevent human immunodeficiency virus (HIV) transmission and assist pregnancy in HIV-discordant couples: a systematic review and meta-analysis.
      ). Special washing refers to an additional swim-up step of sperm from the pellet that results from the density gradient. The swim-up step into clean media further separates the sperm from any leukocytes in the pellet, resulting in a cleaner sperm sample for insemination.
      Table 5Recommendations for handling virus-positive semen in the IVF laboraotory.
      • It is not recommended that men with detectable viral load in the serum be brought through the laboratory for semen processing for establishing a pregnancy in a seronegative partner.
      • Use universal precautions.
      • Use disposable contact materials. Particularly use disposable counting chambers for sperm.
      • Schedule at a different time than other patients to allow undivided attention of personnel and time to sanitize completely afterwards.
      • Process within a biosafety cabinet if possible (
        • Muller C.H.
        • Coombs R.W.
        • Krieger J.N.
        Effects of clinical stage and immunological status on semen analysis results in human immunodeficiency virus type 1-seropositive men.
        ), although it must be remembered that a high efficiency particulate arrestance filter will not filter out virus particles. If not possible, turn off the fan in a laminar flow hood and use the hood to process the semen.
      • Prevent aerosol formation during pipetting, centrifugation and mixing.
      • Use a physically separate space, if possible.
      • Use separate, dedicated instruments and equipment, if possible.
      • Sperm are first separated from leukocytes and other seminal constituents by centrifugation over a gradient, and motile sperm are separated from the resulting pellet by a swim-up step in which washed sperm in a clean tube are overlaid with fresh medium into which motile sperm migrate.
      • Once the sperm is processed and the final sample released for insemination, wipe down surfaces with 6% hydrogen peroxide followed by distilled water.
      In 2003, some of the larger centres providing sperm washing for HIV-discordant couples joined together to form the Centres for Reproductive Assistance Techniques to HIV Couples in Europe (CREAThE), featuring centres in the UK, Italy, France, Belgium, Spain, Italy, Switzerland and Israel. By 2006, over 2800 cases of IUI, IVF and ICSI involving HIV-negative women and sperm separated from the semen of their HIV-positive partners had been reported, with none of the women or the hundreds of children born getting infected (
      • Bujan L.
      • Hollander L.
      • Coudert M.
      • Gilling-Smith C.
      • Vucetich A.
      • Guibert J.
      • Vernazza P.
      • Ohl J.
      • Weigel M.
      • Englert Y.
      • Semprini A.E.
      C. R. Network
      Safety and efficacy of sperm washing in HIV-1-serodiscordant couples where the male is infected: results from the European CREAThE network.
      ). A recent systematic review (
      • Barnes A.
      • Riche D.
      • Mena L.
      • Sison T.
      • Barry L.
      • Reddy R.
      • Shwayder J.
      • Parry J.P.
      Efficacy and safety of intrauterine insemination and assisted reproductive technology in populations serodiscordant for human immunodeficiency virus: a systematic review and meta-analysis.
      ) accounted for 8212 IUI and 1888 IVF or ICSI cycles with no seroconversion of HIV-seronegative female partners or any of the offspring.
      Much less clinical research has been conducted for assisted reproduction in HCV-discordant couples than there has been for HIV. For HCV-positive males with detectable viral load in the serum, the density gradient with swim-up protocol (
      • Garrido N.
      • Meseguer M.
      • Bellver J.
      • Remohi J.
      • Simon C.
      • Pellicer A.
      Report of the results of a 2 year programme of sperm wash and ICSI treatment for human immunodeficiency virus and hepatitis C virus serodiscordant couples.
      ,
      • Mencaglia L.
      • Falcone P.
      • Lentini G.M.
      • Consigli S.
      • Pisoni M.
      • Lofiego V.
      • Guidetti R.
      • Piomboni P.
      • De Leo V.
      ICSI for treatment of human immunodeficiency virus and hepatitis C virus-serodiscordant couples with infected male partner.
      ,
      • Pasquier C.
      • Daudin M.
      • Righi L.
      • Berges L.
      • Thauvin L.
      • Berrebi A.
      • Massip P.
      • Puel J.
      • Bujan L.
      • Izopet J.
      Sperm washing and virus nucleic acid detection to reduce HIV and hepatitis C virus transmission in serodiscordant couples wishing to have children.
      ) can be used before IUI or ICSI to reduce the viral titre in the final sperm sample. The infected partner can be treated with peginterferon alfa and ribavirin to reduce viral load before assisted reproduction (
      • Nie R.
      • Jin L.
      • Zhang H.
      • Xu B.
      • Chen W.
      • Zhu G.
      Presence of hepatitis B virus in oocytes and embryos: a risk of hepatitis B virus transmission during in vitro fertilization.
      ). Treatment should be used for 48 weeks, during which time two forms of contraception should be used followed by a 6-month washout period to reduce the teratogenic and embryocidal risks of ribavirin, which is a pregnancy category X drug. No PCR of the final semen sample is recommended at this time for HCV positive men.
      A small number of people vaccinated against HBV do not produce anti-hepatitis B surface antibody titre levels detectable by commercial assays. Others lose detectable anti-hepatitis antibodies at some point after vaccination. The risk for these “non-responders” becoming infected with HBV or developing clinical hepatitis B is not well defined. If the female patient is a “non-responder” with a partner who is HBV-positive, she may still be protected against hepatitis B infection after insemination owing to antibody titres below the assay detection limit (less than 1.5 mIU/ml) (
      • Greub G.
      • Zysset F.
      • Genton B.
      • Spertini F.
      • Frei P.C.
      Absence of anti-hepatitis B surface antibody after vaccination does not necessarily mean absence of immune response.
      ). If a seronegative patient desires pregnancy with her seropositive partner, special sperm washing is recommended as described above to reduce the titre of HBV in the final sample. No PCR of the final semen sample is recommended at this time for HBV positive men.

      Risk of vertical transmission

      With special washing of sperm from HIV seropositive men and insemination of HIV seronegative women in thousands of assisted reproduction technique cycles, no cases have been reported of seroconversion of the female or vertical transmission of the virus from the seronegative mother to the resulting offspring (
      • Barnes A.
      • Riche D.
      • Mena L.
      • Sison T.
      • Barry L.
      • Reddy R.
      • Shwayder J.
      • Parry J.P.
      Efficacy and safety of intrauterine insemination and assisted reproductive technology in populations serodiscordant for human immunodeficiency virus: a systematic review and meta-analysis.
      ,
      • Zafer M.
      • Horvath H.
      • Mmeje O.
      • van der Poel S.
      • Semprini A.E.
      • Rutherford G.
      • Brown J.
      Effectiveness of semen washing to prevent human immunodeficiency virus (HIV) transmission and assist pregnancy in HIV-discordant couples: a systematic review and meta-analysis.
      ). In cases in which the female patient is HIV positive at the time of the assisted reproduction technique cycle, combined antepartum, intrapartum, and infant antiretroviral prophylaxis are recommended to reduce perinatal transmission by several mechanisms, including lowering maternal viral load and providing infant pre- and post-exposure prophylaxis. A cesarean delivery should be scheduled at 38 weeks with intravenous antiretroviral drugs. Finally, oral antiretroviral drugs should generally be given for at least 6 weeks to all infants perinatally exposed to HIV to reduce perinatal transmission of HIV (
      • Chappell C.A.
      • Cohn S.E.
      Prevention of perinatal transmission of human immunodeficiency virus.
      ).
      Vertical transmission of HCV is possible; even when every effort is made to produce a virus-free embryo by assisted reproduction techniques, the fetus may become infected in utero or at birth (
      • Benova L.
      • Mohamoud Y.A.
      • Calvert C.
      • Abu-Raddad L.J.
      Vertical transmission of hepatitis C virus: systematic review and meta-analysis.
      ). The prevalence of paediatric HCV infection varies between 0.05% and 0.36% in developed countries and between 1.8% and 5% in the developing world. No preventive intervention is available. Spontaneous viral clearance takes place in 25% of infected children within 6 years of age. Chronic infection has a mild to moderate course in most children, although severe liver damage may develop (
      • Tovo P.A.
      • Calitri C.
      • Scolfaro C.
      • Gabiano C.
      • Garazzino S.
      Vertically acquired hepatitis C virus infection: correlates of transmission and disease progression.
      ,
      • Yeung C.Y.
      • Lee H.C.
      • Chan W.T.
      • Jiang C.B.
      • Chang S.W.
      • Chuang C.K.
      Vertical transmission of hepatitis C virus: current knowledge and perspectives.
      ). In the context of IVF, in a single study of 30 women positive for HCV antibodies treated with ICSI, one out of 30 newborns tested positive for HCV antibody and HCV RNA (
      • Nesrine F.
      • Saleh H.
      Hepatitis C virus (HCV) status in newborns born to HCV positive women performing intracytoplasmic sperm injection.
      ).
      Maternal infection with either HBV or HCV has been linked to adverse pregnancy and birth outcomes, including MTCT. In the case of HBV, MTCT has been reduced to about 5% overall in countries, including the USA, that have instituted postpartum neonatal HBV vaccination and immunoprophylaxis with hepatitis B immunoglobulin (
      • Dunkelberg J.C.
      • Berkley E.M.
      • Thiel K.W.
      • Leslie K.K.
      Hepatitis B and C in pregnancy: a review and recommendations for care.
      ). In analysing IVF cycles from HBV men and women,
      • Nie R.
      • Jin L.
      • Zhang H.
      • Xu B.
      • Chen W.
      • Zhu G.
      Presence of hepatitis B virus in oocytes and embryos: a risk of hepatitis B virus transmission during in vitro fertilization.
      suggested that the sperm and oocytes may act as vectors for the vertical transmission of HBV to the embryos, but the presence of HBV surface antigen in oocytes and embryos may not result in the vertical transmission of HBV in the offspring of HBV carriers (
      • Jin L.
      • Nie R.
      • Li Y.
      • Xiao N.
      • Zhu L.
      • Zhu G.
      Hepatitis B surface antigen in oocytes and embryos may not result in vertical transmission to offspring of hepatitis B virus carriers.
      ).

      Cryopreserving semen positive for HIV or HCV

      Ideally, patients who freeze autologous sperm are tested for infectious disease status. Viral load should be measured and found undetectable. If frozen in heat-sealed and leak-proof CBS High Security straws (CryoBiology), sperm can be stored safely on-site. If no CBS straws, confirm that positive infectious disease status sperm will be accepted at a long-term storage facility, then freeze in regular cryovials and store in quarantine tank until moved off-site. Use 1% bleach to decontaminate the tank after use.

      Additional protocols for processing virus-positive semen

      PCR testing for HIV

      As a quality control for the procedure and to protect the programme from medico-legal action, an aliquot of washed sperm (about 100 µL) may be tested for detectable HIV RNA before the sample being used for treatment. No test for HIV in sperm suspensions is commercially available. About 3–8% of washed semen specimens from men with virus-positive serum contain HIV RNA detectable by PCR after washing and cannot be used. As this is within the range of false positive results for this test, these may represent samples that test positive but contain no HIV.
      Alternatively, the sperm may be contaminated with HIV from the seminal plasma or leukocytes during the steps of the sperm washing process. Contamination by leukocytes during sperm processing is believed to be the source of most of the HIV in the final sperm suspension (
      • Nicopoullos J.D.
      • Almeida P.
      • Vourliotis M.
      • Goulding R.
      • Gilling-Smith C.
      A decade of sperm washing: clinical correlates of successful insemination outcome.
      ). In addition to HIV associated with leukocytes, some virus particles are free in semen (
      • Kiessling A.A.
      Isolation of human immunodeficiency virus type 1 from semen and vaginal fluids.
      ). Some of this HIV is sedimented to the lower gradient phase during centrifugation and may be a source of contamination, particularly if the gradient separation is not followed by a swim-up (
      • Fiore J.R.
      • Lorusso F.
      • Vacca M.
      • Ladisa N.
      • Greco P.
      • De Palo R.
      The efficiency of sperm washing in removing human immunodeficiency virus type 1 varies according to the seminal viral load.
      ). For confirmatory testing by PCR, the washed sperm sample can be stored at room temperature, at 4oC or cryopreserved while testing for HIV is carried out. The PCR technique can take up to 20 h, during which the processed sperm lose viability and motility, although newer kits can provide results in as little as 6 h. Cryopreservation allows for the PCR to be re-run if positive or negative controls fail on the day of testing (
      • Bujan L.
      • Hollander L.
      • Coudert M.
      • Gilling-Smith C.
      • Vucetich A.
      • Guibert J.
      • Vernazza P.
      • Ohl J.
      • Weigel M.
      • Englert Y.
      • Semprini A.E.
      C. R. Network
      Safety and efficacy of sperm washing in HIV-1-serodiscordant couples where the male is infected: results from the European CREAThE network.
      ). Specimens found negative for HIV are then used for IUI or for IVF–ICSI. Insemination should not be carried out if HIV DNA or RNA is detected.
      Quality control for PCR has not been consistently applied in programmes treating HIV-discordant couples. Although different methods of HIV RNA detection were used, assay sensitivity was 82% and specificity for detection of 500 copies RNA/million sperm was 95% (
      • Pasquier C.
      • Souyris C.
      • Moinard N.
      • Bujan L.
      • Izopet J.
      Validation of an automated real-time PCR protocol for detection and quantitation of HIV and HCV genomes in semen.
      ). More recent assays such as the AMPLICOR HIV-1 MONITOR test, which detects HIV RNA has a sensitivity of 100% for the detection of 7.5 copies of HIV-1 RNA per reaction (400 copies/ml) and a specificity of 100% as validated by the supplier for testing of serum (
      • Zamora M.J.
      • Obradors A.
      • Woodward B.
      • Vernaeve V.
      • Vassena R.
      Semen residual viral load and reproductive outcomes in HIV-infected men undergoing ICSI after extended semen preparation.
      ).
      In semen samples pre-loaded with known concentrations of HIV-1 virus,
      • Fiore J.R.
      • Lorusso F.
      • Vacca M.
      • Ladisa N.
      • Greco P.
      • De Palo R.
      The efficiency of sperm washing in removing human immunodeficiency virus type 1 varies according to the seminal viral load.
      found that neat semen samples containing 1000–50,000 copies viral RNA/ml had no virus detectable after the density gradient centrifugation step. In semen samples containing 10,000–500,000 copies viral RNA/ml, complete removal of the virus was observed only after the swim-up step after gradient. In semen samples containing 1–3 million copies of viral RNA/ml, persistence of viral RNA after two standard washing procedures was observed in some of the aliquots tested. These findings indicated to the investigators that the efficiency of sperm washing in removing HIV-1 varies according to the amount of virus present in the sample.

      Use of microbicide

      The microbicide, PPCM, has been investigated as a prophylactic during assisted reproduction techniques against HIV transmission. Adding PPCM to sperm washing medium reduced the viral titre of HIV-positive semen by 3–4 logs or 99.94% compared with 1–2 logs or 92% for washing alone under research laboratory conditions. This irreversible inhibition of HIV-1 had no adverse effect on sperm motility, forward progression or acrosome reaction (
      • Anderson R.A.
      • Brown D.
      • Jackson E.M.
      • Feathergill K.A.
      • Bremer J.W.
      • Morack R.
      • Rawlins R.G.
      Feasibility of repurposing the polyanionic microbicide, PPCM, for prophylaxis against HIV transmission during ART.
      ). The use of microbicides against transmission of HIV-1, however, has not completed phase III clinical trials for HIV prevention.

      Pre-exposure prophylaxis

      Pre-exposure prophylaxis (PrEP) with daily HAART has demonstrated clinical efficacy against HIV-1 acquisition (
      • Andrews C.D.
      • Heneine W.
      Cabotegravir long-acting for HIV-1 prevention.
      ) and is strongly recommended by the World Health Organization for non-HIV infected individuals at high risk of exposure (
      • World Health Organization
      Guideline on When to Start Antiretroviral Therapy and on Pre-Exposure Prophylaxis for HIV.
      ). Current federal guidance recommends that providers address the use of PrEP for couples attempting conception (
      • Centers for Disease Control and Prevention
      • National Institutes of Health
      • American Academy of HIV Medicine
      • International Association of Providers of AIDS Care
      • National Minority AIDS Council
      Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, 2014.
      ).
      Truvada, a combination tablet containing emtricitabine and tenofovir disoproxil fumarate, has been approved by the United States Food and Drug Administration to prevent infection in uninfected partners of HIV-positive men. Because Truvada must be taken daily, adherence to daily dosing is a limitation. Use of Truvada has been studied in high-risk populations, primarily in Africa. Several small have reported on the use of PrEP with sexual intercourse limited to the fertile period for HIV-discordant couples; however, little has been reported on the use of PrEP in the context of assisted reproduction techniques. This may prove to be a useful modality of risk reduction for serodiscordant couples, where the female partner can take Truvada while being inseminated by her HIV-positive partner's semen following special washing.

      Double tube method

      A method for limiting contamination of sperm during the gradient separation procedure is the double tube method (
      • Loskutoff N.M.
      • Huyser C.
      • Singh R.
      • Walker D.L.
      • Thornhill A.R.
      • Morris L.
      • Webber L.
      Use of a novel washing method combining multiple density gradients and trypsin for removing human immunodeficiency virus-1 and hepatitis C virus from semen.
      ,
      • Politch J.A.
      • Xu C.
      • Tucker L.
      • Anderson D.J.
      Separation of human immunodeficiency virus type 1 from motile sperm by the double tube gradient method versus other methods.
      ). Recently, it was shown that men who were seropositive for HIV had semen samples decontaminated with density gradient followed by ProInsert (Nidacon) (
      • Fourie J.M.
      • Loskutoff N.
      • Huyser C.
      Semen decontamination for the elimination of seminal HIV-1.
      ). This product is a polypropylene tube insert that forms a double-tube system for sperm processing, allowing for retrieval of the sperm pellet at the bottom of the tube through a channel, which leads all the way down to the pellet without coming in contact with gradient material contaminated with leukocytes and free virus. With this protocol, there is reportedly no need for a swim-up step after density gradient.
      • Fourie J.M.
      • Loskutoff N.
      • Huyser C.
      Semen decontamination for the elimination of seminal HIV-1.
      , found that 54% of initial neat semen samples tested positive for HIV-1 DNA, RNA or both. Of 103 samples from 95 men, only two samples after processing were positive for HIV-1 DNA and none for RNA (
      • Fourie J.M.
      • Loskutoff N.
      • Huyser C.
      Semen decontamination for the elimination of seminal HIV-1.
      ). Semen processing using the double tube method followed by PCR validation of processed sperm samples may provide a safe method for reducing the time and processing stress, and increasing the number of purified sperm obtained, using the current gradient/swim-up method.

      Conclusion

      The current recommended treatment for HIV serodiscordant couples seeking pregnancy through assisted reprduction techniques in the USA is ICSI, despite compelling evidence of successful IUI treatment for years in Europe and other countries without any transmission to mother or baby. Use of ICSI is associated with risks and costs that can be minimized by the use of IUI for some couples, such as those with hepatitis B or hepatitis C. The risk–benefit analysis must consider both the higher cost and the higher success rate of IVF–ICSI compared with IUI. Significantly fewer cycles with the potential for contamination may be needed using IVF–ICSI. At all times, the goal of the laboratory is to reduce risk of viral transmission to staff and patients. A number of accommodations in laboratory protocol and workflow can be made to achieve risk reduction, which allows clinics to offer fertility treatment to those with chronic infectious disease.

      Acknowledgements

      The authors wish to thank Stanley Harris, Melanie Clemmer and Marlane Angle for their thoughtful review of state laws regarding use of HIV-positive sperm in assisted reproduction techniques.

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      Biography

      Dr Sangita K Jindal is an Associate Professor and the Laboratory Director of the IVF programme at Albert Einstein College of Medicine/Montefiore Medical Center, Bronx NY. Dr Jindal received her PhD in reproductive physiology at the University of Toronto. She has published over 40 peer-reviewed articles and book chapters. Dr Jindal is active on national committees within The American Society for Reproductive Medicine (ASRM), the Society for Assisted Reproductive Technologies (SART), and the Society for Reproductive Biologists and Technologists (SRBT), the affiliate society within ASRM representing all scientists and laboratorians in reproductive biology.