Infectious diseases and IVF

First, we need to define what infectious diseases are. Those are the communicable diseases, which can be spread from one person to another, so of course sexually transmitted diseases, the STDs – number one disease that may lead to infertility. We also need to keep in mind that usually the diseases are caused by viruses and bacteria or fungi. There is also a group of diseases which are still not defined by the scientist. There’re bacteria or some other ones called the intracellular parasites such as mycoplasma in your plasma and chlamydia. Most of you probably have heard before that these diseases may lead to infertility. Few things that we also need to understand. Usually, the diseases caused by the intracellular parasites, are the ones causing the difficulty in the passage of either the embryo or the sperm, to fertilize. Chlamydia or your plasma might affect the passage in the ovarian tubes or the canals, where the sperms are moving. Those are the main causes of female and male infertility caused by the intracellular parasites. The viruses, on the other hand, that’s something that I would emphasize on, and that’s why usually the couples that are reaching doctors when they are planning a pregnancy, they are being asked about herpesviruses families, previously the testing was quite limited. It was mainly limited to rubella virus it was limited to herpes labialis, herpes zoster. Herpesviruses have eight types it is a huge family of viruses. We’ve realized that endometriosis can be caused by Cytomegalovirus infection (CMV) or Epstein-Barr virus (EBV). Possibly, you’ve heard of the Epstein-Barr virus – we call it kissing disease. It transmits our saliva and people can easily contract it from using the utensils or using the same glasses. That’s why this is the field that is bringing more and more attention right now of infectious diseases doctor. A lot of bacterial infections I would say probably more of chronic diseases of the UTI (urinary tract infection)they might affect the fertility functions.

There is evidence, and it’s been already confirmed by various studies that viral infections affect the mobility, the motility of the sperm. It can get weakened. One of the most common causes of the sperm ineffectiveness – the sperm immotility is caused by the hepatitis B virus. It’s quite a common cause in the population.

I probably knew that I’m going to choose infectious diseases when I just joined medical school. The world of germs is amazing, it’s a separate universe, and unfortunately, we know very little about it. I love the study which was performed in the United States. They have studied the normal microflora of the pregnant women. They have a special microflora in the vagina, to provide a special environment. It is crucial for hygiene purposes, and women’s health and of course for the reproduction. You probably have heard of Lactobacillus subtilis. The lactobacteria shows how nature has made an agreement with a female body because the vaginal mucosa products volatile, and it is some sort of food for lactobacteria. This process is required to maintaining the natural barrier against the bad bacteria which the inner reproductive organs are exposed to if there is no barrier. The acidic environment of the vagina, and the presence of lactobacteria that’s the first-line defence. The reason why I’m bringing up this topic is that these bacteria it spreads around the pregnant female, and then once she goes through labour, the baby also gets these bacteria on its body, and then eventually it’s protected from surrounding bad bacteria. Other bacteria help us to digest food f. e., we have bacteria that a lot of people heard about, it is called E. coli. Usually, I explain to my students that E. coli produces vitamin K, and it is crucial and essential against bleeding. We do have these bacteria throughout our life, however, kids still they require vitamin K, so this is how nature provides us with all necessary things. It’s interesting how we learned how our body taught us how to use the bacteria around to protect ourselves from diseases without even us realizing that. It is also related to contracting diseases including coronavirus, and there are procedures we need to maintain like social distancing, keeping certain hygiene etc., but the presence of good microflora protects us from contracting it as well. The good example is as well is epidermidis which our skin is covered. That’s why we also need to remember that we need to use the soap and always remember about hygiene and sanitizers, but at the same time we also need to nurture and apply moisturizers for the skin. I’ve recently read on Facebook, a complaint from one of the mothers. She brought her child to the store, and now all the stores they have sanitizers, so the child used that alcohol-based sanitizer, and there was a huge rash all over the skin, she was complaining why the store is using it. And it’s not about the sanitizer, it’s about nurturing the skin after you use it.

Let’s talk about HIV first. If the female is already pregnant and is HIV positive, then usually we follow the protocol on how to maintain the HIV positive pregnancy. If one of the partners has HIV, and they’re planning the pregnancy, that’s a different story. There’s something we can do when it comes to men, but we cannot do the same when it comes to women. Hepatitis, it depends on which kind of hepatitis, because there are two types of hepatitis – B and C. Both can be either sexually transmitted or during the cosmetics procedures or dentistry. From my experience, I’d say that mainly through dentistry, and poor sterilization of the equipment which is the most common cause.  Hepatitis is not a bad diagnosis, we can still manage IVF. With HIV, it depends on which partner is infected. What if a woman gets infected with hepatitis during pregnancy? If the hepatitis was contracted during pregnancy, from being infected to developing an actual disease we still have some time. Usually, the incubation period of hepatitis C may be up to several months, and in hepatitis B, it is up to one month. Then, we have acute hepatitis, and this will depend on the person itself, it’s not specific because everyone has a different course of the disease. For acute hepatitis, there is no treatment. What we do is only the supervision of the patient, and usually, this patient has to be supervised by infectious diseases doctor, and gynaecologist, afterwards, there are certain things that we need to do. For instance, if that is hepatitis B, then we have to vaccinate the newborn within the first 12 hours after birth. If that’s hepatitis C, we have certain tasks we need to do, to find out what is the genotype of the virus, and what treatment we can provide.  I would advise before you even plan the pregnancy you should check whether you’ve been vaccinated for hepatitis B before if not, I would advise getting vaccinated. Hepatitis B vaccine protects you your entire life, and you should remember that there is no treatment for hepatitis B. As stated by the European Association for the Study of the Liver (EASL), we should prescribe the interference, that helps the immune system to attack the virus, as well as, the liver, and it is contraindicated in pregnancy.

It is more ethical, I would say. Unfortunately, historically wise and mentally wise, a lot of us, still considers HIV as something very bad. It is serious, but we have learned how to manage the disease, how to maintain patients with long life expectancy. Healthy patients, do not want any of their biological material to be anywhere close to the HIV patients material, they do not want any risk of contamination. Not many clinics have outsourced labs where they can process the material for HIV patients.  At the clinic, that I work with, we have an agreement with the HIV centre, which specifically works with HIV/AIDS patients, and they have their own lab where they provide the services for us. They do the sperm washing, the testing etc. It’s very budget consumptive, and it requires a lot of facilities and staff, so not many clinics can afford it. Secondly, most of them do not have access to specific labs, so it is probably one of the main reasons.

I would advise seeing a specialist, but I would probably go for a surrogate, and also egg donation. There’s quite strong evidence that eggs can be contaminated, you can do sperm washing which is quite easy, but with eggs, it’s way different, so that is why I would say, the best option would be egg donation and surrogate. The vertical transmission is quite high. We’ve learned that the antiretroviral treatment may avoid the transmission, however, the risks are still high, and it’s not that easy to give any guarantee to the patient.

The recommendations for HIV positive for the males will be the sperm washing, and then there’s going to be the PCR testing, and only in case of PCR negative results, we would advise the conception. In all such cases, there has to be a strong understanding of all the details. All the steps should be thoroughly discussed with the doctor. The pharmaceutical business and pharmaceutical companies are trying to produce safe medications as much as possible. They still can affect, probably not as much on the fetus, but it may affect the health of the mother. It’s always good to protect yourself, before planning a pregnancy so, in this case, I would say it’s good to be vaccinated, before getting pregnant.  It is also good to check the vaccines that you might have got before.

For rubella, it is not indicated, even for the varicella-zoster virus (VZV) – the chickenpox. It’s always better to get vaccinated before you get pregnant itself because there are a lot of complications from the disease itself. Respiratory diseases, which we’re facing a huge pandemic outbreak of one of those,  right now. Unfortunately, if there’s no vaccine there’s no way we can protect ourselves at this stage.

There’s no clear evidence whether COVID-19 can go vertically from mother to child. There were cases registered, and ESHRE provided some reports on the 2nd of April 2020, they state that there’s no evidence between the vertical transmission from mother to child. However, there were cases, so we can’t exclude it for now. The treatment itself can influence the fetus more than the actual virus.

As I said before, maintaining good hygiene, and you know what’s interesting the World Health Organization provided very Simple recommendations such as hands washing, wearing a mask in the crowds, and social distancing.IVF patient goes through a series of hormonal changes, and pregnancy itself is in an immunosuppressive state. That means, the immune system goes down a bit, so that’s why we need to make sure that we are protected.

Hydroxychloroquine is an empirical treatment, there is no evidence that it helps. It’s antiviral it helps to reduce the immune response. When the immune system is attacking your body during the COVID-19, it reduces the inflammatory response and calms down the immune system.  It does affect pregnancy, there are various data on this, and currently, it is not recommended taking it during pregnancy.

There is no evidence that this virus is transmitted vertically. When it comes to implantation, there’s again no evidence on that, so just taking the responsibility on myself, any viral disease causes an immune response which is inflammation and inflammation very often results in the elevation of fever. It might cause problems with implementation because the environment where implementation should occur changes.

Yes, it is possible. We know that rubella may cause miscarriages. We know that several diseases can cause it. It depends on the reactivity of the body because even chickenpox sometimes may lead to miscarriages. Measles, in early stages, can lead to miscarriage. A lot of viral diseases can lead to miscarriages. In the early stages, not necessarily due to the infectious disease, but the response of the body. F.e. diarrheal disease, not because of the bacteria itself but because of diarrhoea, may lead to miscarriage. Infection diseases have a huge role in pregnancy.

Again, that depends on the antiviral treatment prescribed. In Southern Africa f.e. there are a lot of people that have HIV, and we do have evidence of HIV negative children because their parents were on the antiretroviral treatment. The quality of oocytes would-be probably reduced, due to the virus itself because we do have the evidence that the virus can reach the ovum inside and influence it. And it can also depend on the treatment availability because we do have options which help HIV-positive couples when both parents are HIV-positive and are having a baby without the HIV itself.

Hydroxychloroquine doesn’t just reduce the TNF – it also reduces the interleukins, and basically for the COVID-19, we reduce the interleukin 4 and 6. In your case, the indication probably was because your immune system was too aggressive, and probably that was the reason why the doctor prescribed this medication. It’s always important to consult the doctor and see the figures which you have right now, and how good is your immune system because you need to make sure, it’s not too low nor too high. I would advise to have a consultation with your doctor and see where you are with TNF-alpha right now and then pursue that.

Travelling itself may endanger you and the child as well, so I’m pretty sure that the hospital that you’re planning to deliver at, has the facility which is dedicated to the infected patients, and of course the facilities that are for non-infected patients. That is the main recommendations from the World Health Organization, to redirect the healthy and potentially sick patients. Remember, that during delivery, you should feel as safe and comfortable as possible.