Hepatitis C: what do you need to know if trying to conceive

Transcription

1 Hepatitis C: what do you need to know if trying to conceive Hepatitis C: what do you need to know if trying to conceive Hepatitis C Infection Hepatitis C Virus (HCV) infects 3% of the world s population. Over 170 million chronic carriers. Approximately 2.7 million Americans (1.8%) are infected with HCV in addition to 30,000 new cases reported yearly. In the United States, 65% of persons with HCV infection are aged years. There are several types of the virus that vary in geographical distribution and response to medications. Genotype 1a occurs in 50-60% of patients in the United States. Genotype 1b occurs in 15-20% of patients in the United States; this type is most prevalent in Europe, Turkey, and Japan. Genotype 1c occurs in less than 1% of patients in the United States Genotypes 2a, 2b, and 2c occur in 10-15% of patients in the

2 United States; are widely distributed and are most responsive to medication Genotypes 3a and 3b occur in 4-6% of patients in the United States; most prevalent in India, Pakistan, Thailand, Australia, and Scotland Genotype 4 occurs in less than 5% of patients in the United States; it is most prevalent in the Middle East and Africa Genotype 5 occurs in less than 5% of patients in the United States; it is most prevalent in South Africa Genotype 6 occurs in less than 5% of patients in the United States; it is most prevalent in Southeast Asia, particularly Hong Kong and Macao Transfusion of blood contaminated with HCV was once an important source of transmission. Since Persons who inject illegal drugs with non-sterile needles or who snort cocaine with shared straws are at now at the highest risk for HCV infection. Transmission of HCV to health care workers may occur via needle-stick injuries or other occupational exposures. Nosocomial patient-to-patient transmission may occur by means of a contaminated colonoscope, via dialysis, or during surgery, including organ transplantation before HCV may also be transmitted via tattooing, sharing razors, and acupuncture. The use of disposable needles for acupuncture, which has become standard practice in the United States, eliminates this transmission route. Other uncommon routes of transmission of HCV, which affect less than 5% of the individuals at risk, include high-risk sexual activity and maternal-fetal transmission. 10% unknown. Tests for detecting hepatitis C virus (HCV) infection include: Hepatitis C antibody testing

3 Recombinant immunoblot assay Qualitative and quantitative assays for HCV RNA HCV genotyping Hepatitis C Treatment Significant progress in the treatment of hepatitis C infection took place in the past year. Several medications or combinations can lead to cure in about 10 weeks in the majority of hepatitis C infected patients. Medications include Sovaldi (sofosbuvir 400 mg), Harvoni (ledipasvir (90 mg)/sofosbuvir 400 mg) or Vikera pak, with or without ribaverin. One treatment regimen is a single daily tablet of ledipasvir 90mg / sofosbuvir 400mg for 8 to 24 weeks (according to genotype, viral load and functional status of the liver). Hepatitis C and Reproduction Significant effort is excreted by reproductive endocrinologist to detect hepatitis C and other viral infections and to prevent the transmission of hepatitis C to women and babies during reproduction. Intimate partners: both partners are screened for HCV antibodies. If one partner is infected, he or she is referred for treatment with one of the modern drug regimens for 8 to 12 weeks before fertility treatment. If viral load does not drop to an undetectable level then a protocol exists for infected men to test semen for the virus and use the frozen sperm for IVF and ICSI to minimize transmission to mother and baby. Egg and sperm donors: extensive history, exam and screening for donors is performed. Those with high risk factors are excluded. Donors with no risk factors are further tested using hepatitis C antibody and hepatitis C RNA performed in an FDA approved lab. Sperm donors are tested before sperm donation, sperm are quarantined for 6 months and the donor is retested

4 again before releasing sperm. Egg donors are tested in an FDA approved lab within one month of egg retrieval. So far, there is no reported case of hepatitis C transmission after sperm or egg donation. Gestational carriers: Intended parents are screened in an FDA lab for viral infections to minimize transmission to surrogates. Gestational carriers are also screened to prevent transmission to the baby. Frozen sperm, eggs and embryos: liquid nitrogen in storage tanks can very rarely transmit infection. All patients are screened before storage. Tissues and cells can be stored in nitrogen vapor and sealed devices. Liquid nitrogen can also be filtered and sterilized using ultraviolet rays. How to Select an Egg Donor How to Select an Egg Donor Egg donation entails the fertilization of eggs of a young woman and transfer of the resulting embryo or embryos into the intended mother uterus. In the majority of cases, women are interested in egg donation when their ovarian reserve is diminished in quantity and quality, commonly after multiple unsuccessful IVF cycles. The eggs of young women are usually high in quality making the chance for pregnancy and delivery very high. Women can select an egg donor from one of two pools

5 Egg Donors Eggs from a Live Donor An young woman is selected for donation, her ovaries are stimulated then eggs are retrieved. Two types of egg donors exist: i. Known Egg donor The egg donor is known to the intended mother. The donor could be a related e.g. sister or not a relative but agreed to open identity egg donation. ii. Anonymous Egg donor The egg donor is not known to the recipient. The majority of eggs donated are contributed by anonymous donors. If you select a closed identity donor you will still be able to know a great deal about her as age, ethnicity, religion, education, medical and family history, prior donations, physical features, childhood or even adult photo. Anonymous egg donors are usually recruited by a third party: IVF clinic or an egg donation agency. Shared Donor cycle: Sometimes the eggs from one donor are shared between two recipients to reduce cost. Sharing however may yield lower chance for pregnancy per couple. Donor Egg Bank An egg bank will recruit the donors, stimulate their ovaries and freeze them. Recipient select from an already frozen

6 inventory. The advantage is that they do not need to wait for a donor to be found, tested and her eggs harvested. In addition it is cheaper because only some of the eggs resulting from stimulation are obtained and no expenses incurred for donor travel and accommodation. On the other hand, it may yield lower chance for pregnancy (eggs are frozen and fewer of them are available). Donor selection is also restricted to available inventory of eggs that were already donated at an earlier time. Results of Donor Egg Cycles Based on Donor Selection Based on hundreds of thousands of donor egg cycles some general expectations of pregnancy and live birth rates can be made: a. Anonymous cycles usually yields a higher pregnancy rates than known donors. Anonymous donors are selected on pure medical grounds first. They tend to have better ovarian reserve and are commonly younger than known donors. Many times known donors are based on other grounds e.g sister donor or a friend that will donate without compensation b. Donor egg cycles distributed to one recipient are more successful than those shared between two recipients due to more eggs and embryos being available for selection and transfer. c. Fresh eggs from live donors produce more babies than frozen donor eggs. A study of 11,148 egg donation cycles performed in 380 U.S. clinics in 2013, including 2,227 that used frozen eggs indicated that for each IVF cycle the live birth rates were 50% with fresh eggs, and 43% with frozen eggs and for each embryo transfer, 56% of embryos created with fresh eggs resulted in a live birth, compared to 47% of embryos

7 created with frozen eggs. The Process of Selecting an Egg Donor The process of selecting an egg donor is complex that involves you, your partner, your reproductive endocrinologist and sometimes other parties. The guiding principals for selecting a donor are a. Selecting a donor with good ovarian reserve b. Protecting the mother from the transmission of infectious diseases c. Protecting the babies from the transmission of genetic diseases d. Protection of the egg donor from potential complications of IVF e. Partners preferences. Ovarian reserve: an egg donor should have an excellent ovarian reserve. This predicts excellent response to treatment with fertility medications and the collection of large number of mature goo quality eggs. Egg reserve is assessed through history taking, vaginal ultrasound estimation of antral follicle count, day 3 FSH and estradiol assay and AMH levels. Donors should be younger than 32 years and preferably younger than 30. Infectious disease screening: donor are screened using first a thorough history and examination. Donor practicing in high risk behavior and those that lived in certain geographical areas are excluded. Lab tests are obtained for hepatitis B, hepatitis C, HIV I/II, Syphilis, gonorrhea and chlamydia. Other tests for infectious diseases could include testing for human T lymphocyte virus I/II, West Nile virus and South American trypanosomiasis. Tests are run at initial encounter then repeated in specialized labs within 30 days of retrieval to minimize the possibility of acquiring any of these infections at a later time. Genetic screening: Extensive genetic and family history is first obtained from the donor. This is followed by screening for at minimal cystic fibrosis and any genetic disease related

8 to donor ethnicity e.g hemoglobin abnormalities in African, Asian and Meditranean donors-ashkenazi pannel in Jewish donors. Spinal muscular atrophy and fragile X syndromes are commonly also screened. More recently a universal genetic test that include 100 most common genetic diseases is routinely used. If an abnormality is found, a genetic counselor is consulted. Donor related precautions: Egg donors should have the ability and intelligence to understand the process. This is evaluated by a trained psychologist. egg donors are counseled that the process does not impair their ability to conceive children of her own. Stimulation is tailored to avoid excessive stimulation and ovarian hyperstimulation syndrome. Donor are followed up after the procedure to monitor for any complications form retrieval and that the ovaries regained their normal size after stimulation. Partners preference: Partners are offered a session with a psychologist to express their feelings about the process and to discuss some of the early and long term aspects of the process inducing legal issues an disclosure to children when they reach maturity. Partners may prefer certain race or ethnicity e.g Asian, Jewish Some agencies specialize in recruiting donors of specific demographics. Physical features are also strongly considered and discussed with couples. Academic achievements are also desired by many couples. Other considerations: Male partner sperm analysis and labs are obtained. The mother is assessed for any medical disorder and the ability to carry a pregnancy safely. The uterine cavity is evaluated using hysteroscopy or saline sonography. The endometrium is evaluated for its response to hormones. The cervix is mapped to avoid difficult embryo transfer. The process of egg donation is commonly satisfying to recipients, donors and physicians and is flexible to allow for safe selection of an egg donor and still consider your

9 preferences and aspirations. Fertility Treatment Options Fertility Treatment Options: What Are Infertility Treatments? Following detailed fertility investigation of the male tubal and ovarian factors, patient and her reproductive endocrinologist decide together on the optimal fertility treatment options. Factors to consider in selecting the best fertility treatment options include: Sperm source Is there a male partner: if so what is the ejaculate volume, sperm concentration, motility and shape? if >10 million moving sperm then pregnancy through intercourse or IUI is possible. Lower numbers indicates IVF or ICSI. If azospermia (no sperm in the ejaculate) then surgical sperm retrieval may be needed (TESE) or donor sperm can be used. If there is no male partner: anonymous or known donor sperm is used Tubal Factor 1. Open fallopian tubes allow for natural conception or IUI. 2. Blocked fallopian tubes require IVF. Sometimes tubes can

10 be fixed using tubal surgery. 3. Blocked and dilated fallopian tubes (Hydrosalpinx) require surgical removal of the dilated tubes followed by IVF. Dilated tubes are very difficult to fix and can leak fluid into the uterine cavity and prevent implantation of the embryo. Ovarian Factor Women who do not ovulate due to polycystic ovary syndrome (PCOS): ovulation can be induced using oral medications (clomid or letrozole) or injection medications (gonadotropins). This is usually combined with IUI. Women who do not ovulate due to defect in the master gland in the brain (Hypothalamic amenorrhea): ovulation can be induced using injection medications (gonadotropins). This is usually combined with IUI. Women diminished ovarian reserve and unexplained (idiopathic) infertility commonly have lower quality eggs and may benefit from inducing multiple ovulation followed by IUI or IVF, to increase the chance that one of the eggs is healthy (chromosomally normal). Donor Eggs Donor eggs are needed in women with low egg reserve that fail multiple IVF cycles after menopause or those who carry some genetic abnormalities. Donor eggs can enable same sex male couples parent a child (together with a gestational carrier). Gestational carriers 1. Gestational carriers enable women to parent a child if the uterus is absent or was removed due to a disease e.g endometrial cancer or if the lining of the uterus is damaged e.g intrauterine scarring due to prior scrapping.

11 2. Gestational carrier enable women who cannot get pregnant to parent a child e.g history of breast cancer 3. Gestational carriers enable same sex male couples to parent a child. Genetic analysis of the eggs or embryos (PGD) Women and men with risk of conceiving a child with a specific genetic disorder e.g cystic fibrosis, sickle cell anemia should consider testing their embryos before transfer into the uterus (PGD) PGD can also be used for selecting the sex of the baby for family balancing. PGD can be used to test the chromosomes of the embryo to increase the chance for pregnancy in women select women but its efficacy for that purpose is still being investigated. Fertility Preservation Women at risk for diminished fertility due to a medical problem or treatment e.g breast cancer can freeze their eggs or embryos to use later Men at risk for azospermia due to genetic factors, cancer and cancer treatment can freeze sperm for use later Many other techniques for fertility preservation can also be applied to adults and children to preserve reproductive organs and tissue. Many fertility treatment choices exist to help women and men conceive a child. One or more of these methods can be tailored to each i. individual circumstances: singles women or men,

12 heterosexual couples or same sex couples. ii. reproductive aim: wants to get pregnant now versus later, wants one child only or accepts twins, wants to conceive a child of certain sex, will use own uterus or a gestational carrier, will use own gametes- sperm or egg or donor gametes. To learn more about fertility treatment options please visit nycivf.org