Original Title: Lavado de semen en parejas VIH serodiscordantes para su uso en técnicas de reproducción humana asistida

Authors' objectives: 1) Assess the effectiveness of sperm washing for use in assisted human reproduction techniques (AHRT) in reducing the risk of the HIV transmission in serodiscordant couples. 2) Assess the effectiveness of semen washing with AHRT in those cases in which the man presents a low viral load. 3) Assess the effectiveness of semen washing with AHRT in those cases in which the man is receiving high activity antiretroviral treatment (HAART). 4) To estimate the effectiveness and safety of pre-exposure prophylaxis with antiretrovirals in the uninfected member of the serodiscordant couple. 5) To know the risk of transmission of «programmed intercourse» in serodiscordant couples. 6) Analyse the economic impact of incorporating this procedure into the portfolio of services in the NHS. These objetives are embodied in the following research questions: 2.1.1. Does semen washing with AHRT reduce the risk of HIV transmission in serodiscordant couples? 2.1.2. What does semen washing with AHRT contribute in serodiscordant couples in which the man infected with HIV presents a low or undetectable viral load? 2.1.3. What does semen washing with AHRT contribute in serodiscordant couples in which the man receives HAART? 2.1.4. Is pre-exposure prophylaxis with antiretrovirals in uninfected member of serodiscordant couple indicated? 2.1.5. Which is the risk of «programmed intercourse» (only unprotected intercourse at the time of ovulation) in serodiscordant couples? 2.1.6. What would the economic impact of incorporating this procedure into the portfolio of NHS services be?

Authors' results and conclusions: Washing procedures reduce the presence of HIV in semen and thereby reduce the risk of transmitting the infection. However, this is not completely eliminated. Studies published on the subject provide information on at least 7,400 semen washing cycles with IUI or IVF/ICSI and not a single case of seroconversion has been detected either in women or newly born children and it is considered therefore that transmission is very low. Viral load is an important predictor of the risk of heterosexual transmission of HIV-1 and the risk of transmission decreases significantly in people with less than 1,500 copies/ml of HIV-1 RNA. The treatment of the man with HAART therapy in serodiscordant HIV couples reduces the transmission of infection. There is no unanimity with regard to the most recommendable AHRT to be used in serodiscordant HIV couples. Some authors argue in favour of the use of IUI as it is a simple, cheap technique, while other authors indicate that in order to reduce the risk it is convenient to reduce the contact of the woman with the semen as much as possible and therefore recommend the application of IVF/ICSI in spite of the additional cost of the procedure. Recent CPGs consider offering semen washing with AHRT only to those couples who do not present a good adherence to the treatment, more than 50 copies/ml of viral load in plasma or which present other Sexual Transmission Infections (STI), or in those couples who, in spite of presenting a low risk, show a concern for the potential risk of transmission. For the remaining couples, they recommend resorting to unprotected intercourse during ovulation, bearing in mind the low risk of transmission if these conditions do not exist and the low fertility rates obtained by means of AHRT. Other experts believe that natural conception should not be considered as the first reproductive choice in these couples, not being ruled out the risk of transmission and once granted the access to AHRT. With regard to the economic impact of the implementation of these procedures in the portfolio of NHS services, the cost in 2012 of each AHRT procedure with semen washing varies between 282 € and 335 €, depending on whether it is done with freezing or not. The cost of each complete cycle of the procedure (semen washing, ovarian stimulation and AHRT) is 1,327 € and 5,432 € depending on whether IUI or IVF-ICSI is applied. The economic impact of the incorporation of semen washing in the portfolio of NHS services is estimated at 1,091,465 €, if IUI or IVF-ICSI is applied in accordance with the fertility conditions of the couple, and 1,347,146 € if IVF-ICSI is carried out in all couples that comply with the selection requirements. In the performed univariate sensitivity analysis it can be observed that, by varying the number of cycles per couple, the annual cost of scenario 1 (76 % of discordant couples seeking seminal washing treatment, the technique IUI is performed and in the case of 24 % the IVF / ICSI technique) was reduced by 15 % (1.75 cycles / partner). In contrast, increasing to 3 the number of cycles per couple, the annual cost of scenario 1 is increased by 54 % and 66.67 % in scenario 2 (in all discordant couples seeking for seminal washing treatment, the IVF technique / ICSI is performed).

Authors' methods: 1. Methodology applied to respond to research questions 1 to 5: We looked for the highest quality available evidence, and did not take into account the data analysed in studies considered to be of low methodological quality. 2. Methodology applied to respond to research question 6: The economic cost of semen washing in serodiscordant VIH couples together with Assisted Human Reproduction Techniques (AHRT) was estimated: Artificial Insemination (IUI) and in vitro fertilisation (IVF-ICSI).

Project Status: Completed

Year Published: 2014

URL for published report: https://www.euskadi.eus/contenidos/informacion/2014_osteba_publicacion/es_def/adjuntos/Lavado%20de%20semen.pdf

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: <p>Osteba (Basque Office for Health Technology Assessment) Health Department of the Basque Government</p>