Outcome of ICSI in HIV-1-infected women

P. Terriou1,5, P. Auquier2, V. Chabert-Orsini1, J.M. Chinchole1, L. Cravello3, C. Giorgetti1, P. Halfon4, J. Salzmann1 and R. Roulier1

1 Institut de Médecine de la Reproduction, 6 rue Rocca, 13008 Marseille, 2 Laboratoire de Santé Publique de la Timone, Marseille, 3 Maternité de l’hôpital de la Conception, Marseille and 4 Laboratoire Alphabio, Hôpital Ambroise Paré, Marseille, France

5 To whom correspondence should be addressed: philippe.terriou{at}numericable.fr


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
BACKGROUND: Since 2001, French law has permitted the use of assisted reproductive technology in human immunodeficiency virus (HIV)-1 infected women under strict conditions. This report describes a preliminary series of seropositive women who underwent assisted reproduction treatment at our facility. To minimize contamination of culture media, equipment, and therefore of male gametes and embryos, we chose to perform ICSI in all cases. The outcome of ICSI was compared with the outcome in an age-matched group of non-HIV-1-infected women. Since several previous reports have indicated that HIV infection may be associated with a decrease in spontaneous fertility, our goal was also to assess the fertility status of the HIV-1-infected women entering our ICSI programme. METHODS: The French law governing the use of assisted reproduction protocols in HIV-1-infected women was strictly applied. The inclusion criteria were absence of ongoing disease, CD4(+) count >200 cells/mm3, and stable HIV-1 RNA level. Since mean age at the time of ICSI was higher in HIV-1-infected women than in the overall group of non-HIV-infected women, we compared outcome data in HIV-1-infected women (group I) to a group of non-HIV-1-infected women matched with regard to age and follicle retrieval period (group II) as well as to the overall group of women who underwent ICSI at our institution (group III). RESULTS: A total of 66 ovarian stimulations was performed in 29 HIV-1-infected-infected women. The percentage of cancelled cycles was higher in infected women than in matched controls (15.2 versus 4.9%, P < 0.05). The duration of ovarian stimulation (13.3 versus 11.7 days, P < 0.05) and amount of recombinant FSH injected (2898 versus 2429 IU, P < 0.001) were also higher in infected women. The number of retrieved oocytes, mature oocytes, and embryos obtained as well as embryo quality was similar in all groups. The fertilization rate was higher in infected women than in matched controls (67 versus 60%, P < 0.01). The pregnancy rate was not significantly different between groups I and II (16.1 versus 19.6%) in spite of the fact that the number of embryos transferred was purposefully restricted in the HIV-1-infected group to minimize multiple pregnancy (2.0 versus 2.4, not significant). CONCLUSION: The results of this preliminary series of ICSI cycles in HIV-1-infected women indicate that optimal ovarian stimulation is slightly more difficult to achieve than in matched seronegative women. However, when criteria for oocyte retrieval were fulfilled, ICSI results were similar to those of age-matched controls.

Key words: AIDS/fertility/HIV/ICSI/IVF/women


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Until recently women with chronic human immunodeficiency virus (HIV) were strongly advised against pregnancy due to relatively short life expectancy and to high mother-to-child transmission risk. Currently highly active antiretroviral treatment (HAART) has led to a significant improvement in life expectancy and reduced mother-to-child virus transmission to 1–2% in developed countries (Delfraissy, 2004Go; Newell and Thorne, 2004Go). As a result of these new conditions, more and more couples wish to have children. Since 2001, French law has allowed the use of assisted reproductive technology in couples in which the man and/or the woman is HIV-infected (Journal Officiel de la République Française, 2001Go). To our knowledge, there have been no previous reports describing assisted reproduction protocols exclusively in HIV-1-positive women. However, several reports have questioned the quality of spontaneous fertility in HIV-positive women. In this regard it has been shown that HIV infection results in chronic systemic disease with multiple organ involvement and in alterations of endocrine and metabolic functions (Sellmeyer and Grunfeld, 1996Go; Hinz et al., 2002Go). Women with HIV infection also appear to have a higher incidence of gynaecological complications (Watts et al., 1999Go), anovulation and early menopause (Clark et al., 2001Go) and to experience more difficulty in becoming pregnant (Gray et al., 1998Go; Desgrees du Lou et al., 1999Go; Ross et al., 1999Go; Yaro et al., 2001Go; Blair et al., 2004Go). Concerning impact on menstrual function, results have been contradictory with some studies showing disturbances in seropositive women without AIDS (Chirgwin et al., 1996Go) and others showing no differences between seropositive women and controls with regard to either menstruation (Shah et al., 1994Go; Ellerbrock et al., 1996Go) or hormone levels in women with self-reported normal menstrual cycle (Cu-Uvin et al., 2000Go).

This report presents results of IVF in HIV-1-infected women. Although mother-to-child HIV transmission occurs mainly in the perinatal phase, we decided to minimize the risk of viral contamination of gametes and embryos but also of media, incubators and other equipment by performing ICSI in all cases. Indeed as HIV is present in follicular aspirates contaminated by blood, we hypothesized that complete decoronization followed by repeated oocyte washings is the best way to prevent viral contamination of culture media and incubators. Informed consent for ICSI was obtained in all cases. Results in seropositive women were compared to those obtained using ICSI in matched seronegative controls treated for male factor infertility as well as to those obtained in our overall ICSI programme. Controls were matched with age and follicle retrieval period. The 2-fold purpose of this study is to describe what is, to our knowledge, the first ICSI series involving exclusively HIV-1-positive women and to assess the fertility status of HIV-1-positive women.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
The strict criteria defined by French law were used for inclusion of seropositive HIV-1 women in our assisted reproduction programme (Table I). In some cases HAART was modified to avoid possibly adverse effects on pregnancy and child. Eligible couples entering the protocol gave informed consent to undergo ICSI. To ensure spatial segregation, between gametes and embryos of Seronegative and Seropositive couples and thus avoid cross-contamination, all in vitro procedures were performed in a separate laboratory including an ICSI area. If the male partner was also HIV-1 positive, ICSI was performed in accordance with French law after washing the sperm once by Percoll gradient centrifugation and then twice in culture medium. When possible, a second sperm selection was performed using the swim-up technique. Detection of HIV-1-RNA was performed on seminal plasma (Cobas Amplicor Monitor®; Roche, sensitivity: 50 copies/ml) using the modified protocol that we described elsewhere (Solas et al., 2003Go). The final sperm preparation was frozen (Spermfreeze®; JCD, France) and screened for proviral HIV DNA (Cobas Amplicor Monitor®; Roche, sensitivity: 50 copies/ml) using the modified protocol for sperm preparation that we described elsewhere (Lafeuillade et al., 2001Go). Virus-free straws were used to perform ICSI several weeks after freezing. Straws were discarded either if virus was detected in the sperm preparation or if the virus load in the seminal plasma was >10000 copies/ml. In accordance with the recommendations of the French experts group, when the female partner received a treatment included in the list of therapies suspected to have deleterious effects on newborns, the suspected treatment was stopped and replaced by another one (Delfraissy, 2004Go). This replacement was generally done 3 months before the beginning of assisted reproduction treatment. In cases of untreated female partner with CD4 >350/mm3 and unquantifiable viral load, the prevention of mother-to-child transmission was conducted on a case-to-case basis following the same recommendations.


View this table:
[in this window]
[in a new window]
 
Table I. Criteria imposed by French law for inclusion of HIV-1-positive women in an assisted reproduction program (Journal Officiel de la République Française, 2001Go)

 

All women underwent hypopituitary desensitization using either GnRH agonist (Decapeptyl®; Ipsen-Biotech, France) or GnRH antagonist (Cétrotide®; Serono, France) and ovarian stimulation using recombinant (r)FSH (Gonal-F®; Serono; or Puregon®; Organon, France). Ovulation was induced using rhCG (Ovitrelle®; Serono, France) or urinary-hCG (Endo®, Organon). Oocyte retrieval was performed in the surgery room usually used, but seropositive women underwent oocyte retrieval at the end of the oocyte retrieval programme after seronegative women. To minimize contamination of media and equipment, all retrieved follicles were washed three times in pre-warmed, CO2-equilibrated (overnight) Earle’s balanced salt solution and decoronized. Denuded oocytes were further washed three times prior to ICSI. Embryo transfer was performed 2 days after oocyte retrieval. Since HIV-1-seropositive pregnancies are considered as hazardous and Caesarean section are sometimes programmed to minimize the mother-to-child transmission, we chose to transfer fewer embryos as a means of minimizing multiple pregnancies. In order to optimize the success rate, the quality of transferred embryos was evaluated according to our embryo quality score (Giorgetti et al., 1995Go.). Previous findings (Terriou et al., 2001Go) have shown that embryo quality is a better predictor of pregnancy than the number of transferred embryos and female age. Successful pregnancies were followed up by obstetricians specialized in the field of HIV as legally required (French Ministry of Health, 2002Go). After delivery, the newborns were examined by specialized pediatricians who looked for malformations and particularly for eventual neurological symptoms of antiviral therapy complications. Both detection of HIV-1 by PCR and HIV-1 serology were performed at 3, 6, 12, and 18 or 24 months of life. When necessary, follow-up also included a haematological screening and dosage of transaminases, creatine kinase, lacticodeshydrogenase, lipase, amylase and lactate.

Statistical analysis
All independent variables were continuous. Univariate analysis was performed by comparing groups. Statistical significance was determined by the Mann–Whitney test or Student’s t-test depending on whether or not the normality assumption was met. The Shapiro–Wilk test was used to check the normality assumption in analysis of variance (ANOVA). Results were expressed as means (SD) and range or median (range) depending on the distribution. Three-way group comparisons were performed using the F-test in ANOVA or the non-parametric Kruskal–Wallis test. Means ± SE were calculated for continuous variables. Differences with P < 0.05 were considered significant.


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
From February 2002 to May 2004, a total of 66 ovarian stimulation procedures were undertaken in 29 consenting HIV-1-infected women meeting the selection criteria defined by the French law. The type of virus transmission, frequency of co-infection with hepatitis B and/or C viruses, and indication for assisted reproduction treatment are shown in Table II. Twenty-seven out of the 29 women (93%) were undergoing HAART at the time of enrolment and 19 (66%) presented negative virus load in repeated blood samples. Since mean female age was higher in HIV-1-positive women undergoing ICSI than seronegative women undergoing ICSI, i.e. 35.8 years (range: 21–45) versus 34.4 years (range: 18–45) (P < 0.05), results from infected women (group I) were compared both to results in an age-matched control group of seronegative women undergoing ICSI during the same period (group II) and to results in the overall population of seronegative ICSI patients (group III). Female parameters of the HIV-1-positive population and age-matched seronegative group are compared in Table III. There were no significant differences between these two groups with regard to type and duration of infertility, mean day 3 FSH, LH and estradiol levels. Distribution of the different gynaecological pathologies were similar in the two groups. As expected, the percentage of ICSI procedures performed due to sperm defect was significantly lower in the HIV-positive group than in the age-matched group (16 versus 93%, P < 0.01). Since the main goal of performing ICSI in HIV-positive women was to minimize viral contamination of material and equipment as opposed to treating male factor infertility, sperm parameters were better in HIV-1-positive women. The sperm count was 43x106/ml in the HIV-1-positive group and 6x106/ml in seronegative group (P < 0.001), progressive motility was 25% and 5% respectively (P < 0.001) and the percentage of normal forms using the David classification were 48 and 36% respectively (P < 0.01). Mean trial rank was lower in the HIV-positive group than in the control group (1.7 versus 2.5; P < 0.05).


View this table:
[in this window]
[in a new window]
 
Table II. Type of virus transmission, frequency of co-infection with hepatitis B and/or C and indications for assisted reproductive treatment in 29 HIV-1-positive women undergoing ICSI (56 cycles)

 

View this table:
[in this window]
[in a new window]
 
Table III. Comparison of female parameters in the HIV+ group and matched seronegative group

 

The main outcomes of the performed cycles are summarized in Table IV. Cancellation rate was increased in the HIV group (group I: 15.2%; group II: 4.9%; group III: 6.9%; P < 0.05). The duration of ovarian stimulation was higher in the HIV group (group I: 13.3 days; group II: 11.7 days; group III: 12.1 days; P < 0.01). Total injected rFSH dose was also higher (group I: 2898 IU; group II: 2429 IU; group III: 2107 IU; P < 0.001). None of the female parameters described in Table III could be associated with cancellation rate, duration of stimulation or total dose of rFSH injected.


View this table:
[in this window]
[in a new window]
 
Table IV. Outcome of ICSI in HIV-1-positive women (group I), seronegative controls matched with regard to age and oocyte retrieval period (group II), and overall population of seronegative women treated at our facility (group III)

 

The fertilization rate was higher in the HIV-infected group (group I: 67%; group II: 60%; group III: 63%; P < 0.05). Pregnancy rate was higher in the overall ICSI population (group III: 26.1%) than in either seropositive patients or age-matched seronegative controls (group I: 16.1%; group II: 19.6%; P < 0.05). The most likely explanation for this latter difference was female age. There was no significant difference in pregnancy rate between seropositive- and seronegative-matched women.

To assess the influence of viral load on outcome, we compared all the above parameters in HIV-1 patients with quantifiable viral load (QVL) and HIV-1 patients with unquantifiable viral load (UVL). Oocyte retrieval was cancelled in 29% of cycles undertaken in QVL patients versus 9% in UVL patients (P = 0.06). The only parameter that significantly differed between QVL and UVL patients was day 3 LH level (5.9 versus 4.9 IU/ml respectively; P < 0.05).

Nine clinical pregnancies were achieved in HIV-1-positive women including one set of monochorionic diamniotic twins and five sets of twins despite the lower number of transferred embryos. The implantation rate was 12.5% per transferred embryo. One twin pregnancy ended in miscarriage at the fourth month. Before inclusion in our assisted reproduction treatment programme, the patient received HAART including two reverse transcriptase inhibitors and one non-nucleosidic reverse transcriptase inhibitor. As this treatment was effective (unquantifiable viral load, CD4(+) >400 copies/ml) and was not contraindicated by the French experts group pregnancy guideline (Delfraissy, 2004Go), it was continued during pregnancy. One of the twins, who probably died during the first trimester, displayed an oligoamnios and was macerated. Autopsy revealed neither malformation nor histological abnormalities in either twins. There have been five deliveries of eight children including three sets of twins. All eight children are healthy and are not HIV-infected at this time. The other three pregnancies are ongoing.


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Infection by HIV has been associated with derangement of many organ systems. Changes in endocrine function may be attributed to glandular infection, systemic effects of HIV or opportunistic infection, infiltration by a neoplasm such as Kaposi’s sarcoma, therapeutic complications, or generation of cytokines (Bhasin et al., 2001Go). Abnormalities of the pituitary–adrenal and pituitary–ovarian axes have been observed in women with CD4(+) counts <200 cells/mm3 (Hinz et al., 2002Go). Dysfunction can be transient and resolve after successful treatment of the intervening illness.

Women may exhibit subtle changes in endocrine function in early, relatively asymptomatic stages of HIV infection (Sellmeyer and Grunfeld, 1996Go). In a study involving measurement of progesterone and FSH levels in stored serum samples from adult female patients enrolled in selected AIDS clinical trials, Clark et al. (2001)Go observed anovulation in 16 (48%) of 33 women and early menopause in two (8%) of 24 women. In a multicentre study including 248 pre-menopausal HIV-infected women without AIDS and 82 HIV-negative women, Chirgwin et al. (1996)Go found an increase in amenorrhoea and menstrual cycle intervals >6 weeks and decrease in pre-menstrual breast symptoms that did not appear to be attributable to clinically apparent secondary complications of the virus. Gynaecological complications are common among HIV-positive women with CD4(+) lymphocyte counts <500 cells/µl and may be severe in association with more advanced immunodeficiency (Watts et al., 1999Go).

Regarding fertility, there is evidence that pregnancy is less likely to occur in women with a history of AIDS-opportunistic illness or CD4(+) counts <200 cells/µl and no opportunistic illness than in women with HIV but not AIDS (Blair et al., 2004Go). Similarly it has been reported that pregnancy is less frequent in HIV-positive women than uninfected women exposed to the same risk of pregnancy (Desgrees du Lou et al., 1999Go). A study in Ugandan women who did not use modern contraceptives showed that fertility decreased at the earliest asymptomatic stages of HIV infection resulting in lower pregnancy rate and higher miscarriage rate (Ross et al., 2004Go). Lower conception rates were also reported in a prospective study of pregnant women aged >25 years in Burkina Faso (Yaro et al., 2001Go). Decrease in pregnancy rate and increase in miscarriage rate were also found in a prospective cross-sectional study of a rural population in Uganda (Gray et al., 1998Go). However, Ellerbrock et al. (1996)Go found no clinically relevant effect of either HIV infection or immunodeficiency on menstruation or other vaginal bleeding, and Shah et al. (1994)Go found no clinically significant effect of infection with HIV and related immunodeficiency on menstruation. One multicentre study concluded that HIV-infected women with self-reported normal menstrual cycles have normal levels of progesterone and estradiol during the menstruation (Cu-Uvin et al., 2000Go).

There is a paucity of data about HIV-1-infected women and assisted reproduction treatment. In their 18 month experience using assisted reproduction treatment in couples with discordant HIV serostatus (one infected partner), Ohl et al. (2003)Go observed no pregnancy after three intrauterine inseminations and only one pregnancy after 12 IVF or ICSI in HIV-positive women (pregnancy rate, 8.3%). In their review of medically assisted reproduction in patients presenting chronic viral diseases, Englert et al. (2004)Go reported an increase in severe ovarian dysfunction in a first group of seropositive women in Brussels but did not provide any further details. To our knowledge no series involving exclusively HIV-infected women and assisted reproduction treatment has been reported previously.

Since 2001, French law has allowed assisted reproduction teams to treat HIV-1-infected women under strict conditions: absence of current pathology, CD4(+) counts >200/mm3, and stable HIV-1 RNA level (Table I). Regarding HIV-1 RNA level, the law stipulates that assisted reproduction protocols must be cancelled if HIV-1 RNA increase is >0.5 log between 4 months before the demand and inclusion and between two trimester blood analyses during the protocol. Based on these selection criteria, a total of 29 HIV-1-infected women underwent assisted reproduction treatment at our facility from February 2002 to April 2004. In order to minimize virus contamination to culture media and equipment and therefore to male gametes and embryos, we decided to perform ICSI in all IVF cases after careful washing of both follicles and oocytes.

Probably as a result of the backlog created previously, pending passage of the French law, the mean age of our HIV-1-infected patients was >1 year higher than that of the other patients undergoing ICSI at our facility (34.4 versus 35.8, P < 0.05). Because of this difference, we compared the outcome of ICSI obtained in HIV-1-infected women (group I) to those obtained in a matched control group of ICSI patients who underwent ICSI for male infertility (group II: mean age = 35.9 years) as well as to those in the overall ICSI programme (group III). Controls were matched with regard to age and oocyte retrieval period. Table III shows that percentage of primary infertility, infertility duration, distribution of the different female pathologies, day 3 FSH, LH and estradiol level were comparable in the HIV-positive group and age-matched seronegative group. Mean trial rank was lower in seropositives patients because our study included all oocyte retrievals of HIV-seropositive patients since the beginning of our programme. Many HIV oocyte retrievals were thus rank 1 punctures. Most of the assisted reproduction parameters studied, including number of retrieved oocytes, mature oocytes, maturation rate, number of obtained embryos, and percentage of good quality embryos, were also comparable between the seropositive group and seronegative control group (Table IV).

For no clear reason the fertilization rate was significantly higher in the HIV-1-infected women group than in the matched control group (67 versus 60%, P < 0.01). This could be partially due to the better quality of the sperm used for ICSI in HIV-infected women as compared to the sperm used in ICSI performed for male infertility in HIV-negative women. Probably as a result of our decision to transfer fewer embryos in HIV-1-infected patients than in other ICSI patients as a means of minimizing the risk of multiple pregnancies (2.0 versus 2.4, not significant), the pregnancy rate was slightly lower in HIV-1-infected patients (16.1 versus 19.6%, not significant). The only parameters suggestive of hypofertility in HIV-1-infected patients in comparison with seronegative controls was the increase in cancellation rate (15.2 versus 4.9%, P < 0.05), the total dose of rFSH injected (2898 versus 2429 IU, P < 0.001) and the duration of ovarian stimulation (13.3 versus 11.7 days, P < 0.01). These findings indicate that satisfactory ovarian stimulation was more difficult to achieve in HIV-1-infected women than in matched seronegative controls. Neither distribution of female pathologies, duration and type of infertility nor day 3 hormonal level could account for these hypofertility parameters. However, when oocyte retrieval was performed with ultrasonographic and biological criteria, outcome was similar in seropositive patients and matched seronegative controls. Comparison of seropositive patients according to viral load showed that only day 3 LH level differed: 5.9 IU/ml in QVL group versus 4.9 IU/ml in UVL group (P < 0.05).

The major finding of this study is that the outcome of ICSI in HIV-1-infected patients and seronegative controls is similar provided that optimal ovarian stimulation is achieved. However, two points should be noted before drawing any conclusions. The first is that all HIV-1-infected women enrolled in our IVF/ICSI programme satisfied the standard ICSI inclusion criteria regarding clinical examination and day 3 hormone levels. No patient with obviously untreatable infertility was in our programme. The second is that our infected patients also presented favourable clinical and biological viral status, i.e. were in relatively good health. Further data will be required to confirm this preliminary series of 66 ICSI procedures in HIV-1-infected women. The spontaneous abortion occurring at the second trimester of pregnancy in one set of twins could not be attributed to either maternal infection (viral load was unquantifiable and CD4(+) count was >400 copies/ml) or antiviral therapy (no malformation nor histological abnormalities at autopsy). The eight babies born in this series were healthy at the time of birth. Nevertheless, a complete 2 year follow-up in a larger population of newborns is needed to draw a definite conclusion about the safety of assisted reproductive technologies in HIV-1-infected women. We will present data if abnormalities develop in any children born in our programme.


    Acknowledgements
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
We thank N.Barbier, B.Barry, M.Bourlière, B.Colombani, E.Glowaczower, F.Franquebalme, J.P.Franquebalme, H.Gallais, J.A.Gastaud, G.Michel, J.Moreau, G.Ruf, M.C.Sitri and MC.Thibaut for their clinical follow-up and O.Charles, E.Hans and V.Urrutia for their technical assistance in the IVF laboratory.


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Bhasin S, Singh AB and Javanbakht M (2001) Neuroendocrine abnormalities with HIV infection. Endocrinol Metab Clin North Am 30,749–764.[CrossRef][ISI][Medline]

Blair JM, Hanson DL, Jones JL and Dworkin MS (2004) Trends in pregnancy rates among women with human immunodeficiency virus. Obstet Gynecol 103,663–668.[Abstract/Free Full Text]

Chirgwin KD, Feldman J, Muneyyirci-Delale O, Landesman S and Mink H (1996) Menstrual function in human immunodeficiency virus-infected women without acquired immunodeficiency syndrome. J Acquir Immune Defic Syndr Hum Retrovirol 12,489–494.[ISI][Medline]

Clark RA, Mulligan K, Stamenovic E, Chang B, Watts H, Andersen J, Squires K and Benson C (2001) Frequency of anovulation and early menopause among women enrolled in selected adult AIDS clinical trial group studies. J Infect Dis 184,1325–1327.[CrossRef][ISI][Medline]

Cu-Uvin S, Wright DJ, Anderson D, Kovacs A, Watts DH, Cohn J, Landay A and Reichelderfer PS (2000) Hormonal levels among HIV-1 seropositive women compared with high-risk HIV-seronegative women during the menstrual cycle. Women’s Health Study (WHS) 001 and WHS 001a Study Team. Womens Health Gend Based Med, 9,857–863.[CrossRef]

David G, Bisson JP, CyZglik F, Jouannet P and Gernigon G (1975). Anomalies morphologiques du Spermatozoide human. 1 Propositions pour un Systeme de Classification. J Gynaecol Obstet Biol Reprod 4,17–19.

Desgrees du Lou A, Msellati P, Yao A, Noba V, Vibo I, Ramon R, Welffens-Ekra C and Dabis F (1999) Impaired fertility in HIV-1 infected pregnant women: a clinical based survey in Abidjan, Cote d’Ivoire, AIDS 13,517–521.[CrossRef][ISI][Medline]

Delfraissy JF (2004) Prise en charge therapeutique des personnes infectees par le VIH. Recommandations du groupe d’experts. Rapport 2004. Medecines-Sciences, Flammarion, Paris.

Ellerbrock TV, Wright TC, Bush TJ, Dole P, Brudney K and Chiasson M (1996) Characteristics of menstruation in women infected with human immunodeficiency virus. Obstetr Gynecol, 87,1030–1034.[Abstract/Free Full Text]

Englert Y, Lesage B, Van Vooren JP, Liesnard C, Place I, Vannin AS, Emiliani S and Delbaere A (2004) Medically assisted reproduction in the presence of chronic viral diseases. Hum Reprod Update 10,149–162.[Abstract/Free Full Text]

French Ministry of Health (2002) Prise en charge des personnes infectées par le VIH. Recommandations du groupe d’experts. Rapport 2002. Medecines-Sciences, Flammarion, Paris, pp 223–238.

Giorgetti C, Terriou P, Auquier P, Hans E, Spach JL, Salzmann J and Roulier R (1995) Embryo Score to predict implantation after in-vitro fertilization: based on 957 single embryo transfers. Hum Reprod 10, 101–104.

Gray RH, Wawer MJ, Serwadda D, Sewankambo N, Li C, Wabwire-Mangen F, Paxton L, Kiwanuka N, Kigozi G, Konde-Lule J, Quinn T, Gaydos CA and McNairn D (1998) Population-based study of fertility in women with HIV-1 infection in Uganda. Lancet 351(9096), 98–103.[CrossRef][ISI][Medline]

Hinz S, McCormack D and van der Spuy ZM (2002) Endocrine function in HIV-infected women. Gynecol Endocrinol 16,33–38.[ISI][Medline]

Journal Officiel de la République Française (2001) Decree Concerning Assisted Reproductive Treatment of Patients with Viral Risks, May 15, 2001.

Lafeuillade A, Poggi C, Chadapaud S, Hittinger G, Khiri H and Halfon P (2001) Impact of immune interventions on proviral HIV-1 DNA decay in patients receiving highly active antiretroviral therapy. HIV Med 2,189–194.[CrossRef][Medline]

Newell ML and Thorne C (2004) Antiretroviral therapy and mother-to-child transmission of HIV-1. Expert Rev Anti Infect Ther 2,717–732.[CrossRef][Medline]

Ohl J, Partisani M, Wittemer C, Schmitt MP, Cranz C, Stoll-Keller F, Rongieres C, Bettahar-Lebugle K, Lang JM and Nisand I (2003) Assisted reproduction techniques for HIV serodiscordant couples: 18 months of experience. Hum Reprod 18,1244–1249.[Abstract/Free Full Text]

Ross A, Morgan D, Lubega R, Carpenter LM, Mayanja B and Whitworth JA (1999) Reduced fertility associated with HIV: the contribution of previous existing subfertility. AIDS 13,2133–2141.[CrossRef][ISI][Medline]

Ross A, Van der Paal L, Lubega R, Mayanja BN, Shafer LA and Whitworth J (2004) HIV-1 disease progression and fertility: the incidence of recognized pregnancy and pregnancy outcome in Uganda. AIDS 18,799–804.[CrossRef][ISI][Medline]

Sellmeyer DE and Grunfeld C (1996) Endocrine and metabolic disturbances in human immunodeficiency virus infection and the acquired immune deficiency syndrome. Endocr Rev 17,518–532.[Abstract]

Shah PN, Smith JR, Wells C, Barton SE, Kitchen VS and Steer PJ (1994) Menstrual symptoms in women infected by the human immunodeficiency virus. Obstet Gynecol 83,397–400.[Abstract]

Solas C, Lafeuillade A, Halfon P, Chadapaud S, Hittinger G and Lacarelle B (2003) Discrepancies between protease inhibitor concentrations and viral load in reservoirs and sanctuary sites in human immunodeficiency virus-infected patients. Antimicrob Agent Chemother 47,238–243.[Abstract/Free Full Text]

Terriou P, Sapin C, Giorgetti C, Hans E, Spach JL and Roulier R (2001) Embryo score is a better predictor of pregnancy than the number of transferred embryos or female age. Fertil Steril 75,525–531.[CrossRef][ISI][Medline]

Watts DH, Spino C, Zaborski L, Katzenstein D, Hammer S and Benson C (1999) Comparison of gynaecologic history and laboratory results in HIV-positive women with CD4+ lymphocyte counts between 200 and 500 cells/microl and below 100 cells/microl. J Acquir Immune Defic Syndr Hum Retrovirol 20,455–462.[Medline]

Yaro S, Meda N, Desgree Du Lou A, Sombie I, Cartoux M, Tiendrebeogo S, Oangre A, Dao B, Nacro B, Kpozehouen A et al (2001) Impaired fertility in women infected with HIV-1. Implications for sentinel serosurveillance. Rev Epidemiol Santé Publ 49,221–228.[ISI][Medline]

Submitted on January 20, 2005; resubmitted on April 28, 2005; accepted on May 5, 2005.