How to deal with infectious samples within your clinic – HBV, HCV and HIV

HBV, HCV and HIV

Infertility treatment in couples where one or both parents are infected with viral load raises many concerns about transmission of the infection to the baby, laboratory technicians and medical staff, and contamination of other gametes/embryos that are from virus-free parents in the same laboratory. This risk can only be minimized or eliminated using SOPs for safety in fertility clinics and by the use of proper initial detection and segregation of potentially hazardous materials.(1)

Patients should be checked for three main viral infections before starting any Assisted Reproduction treatment. These are HCV, HBV and HIV. These tests are mandatory for both the male and female partners, irrespective of the type of treatment. The viral markers should be recent and not older than 6 months.

Requirement for treatment

Couples in which one or both partners are infected with a sexually transmissible pathogenic virus, should receive in-depth preconception counselling on the risks of sexual and vertical transmission of their infections. In circumstances involving an infected man and uninfected woman, donor insemination should be presented as the safest options. Couples who decide to proceed with partner-intrauterine insemination (IUI) or other fertility treatments, must agree to reasonable interventions aimed at reducing the transmission risk.

Counselling and education concerning safe sex practices should be provided and emphasized. In cases where the male, but not the female, partner is infected, the couple should understand the merits of using condoms throughout fertility treatment, pregnancy, and the postpartum period. Serial diagnostic testing of the uninfected partner is recommended throughout treatment and pregnancy and for both mother and infant during the first year after birth. Informed consent should be explicit and as thorough as possible, emphasizing that the risk of transmission cannot be eliminated even when specific risk reduction strategies are employed.(3)

Whether to induct patients with a viral load at your centre will depend on:

(1) Whether you have the infrastructure to handle such patients separately, e.g., Cryotank, provision to do density gradient separate equipment for culturing and so on.
(2) You are willing to handle such patients without compromising the outcome of the patients both infected and others.

We personally feel that Hepatitis C and HIV patients should be taken for treatment only if you have a robust infrastructure and the staff to handle it. For such patients, it would be best to have a separate semen processing lab and incubator since the infection rate is high. In case you do not have the provision, it would be practical to avoid treatment as it puts everyone, the staff and embryos of other patients at risk. Patients with Hepatitis B can be enrolled and treated in the aforementioned stepwise protocol for their induction and precautions to be taken in the laboratory and OT.

Hepatitis B

When female partner is negative, male is positive Detailed counselling Female partner to be counselled regarding immunization (0,1,6 doses and to wait for 4 weeks post last dose)Use of condoms advised Check HBeAg (envelope antigen) and anti IgM (antibody for the core antigen)Patient to be accepted for treatment only HBeAg is negative (indicates no acute infection/viral load)Specific semen wash techniques like density gradient to be followedEmbryo freezing to be done only if separate cryocans are available. May not be possible at all centers.
When female partner is positive, male is negative Detailed counselling Reports from Liver specialist to confirm fitness for pregnancy Risk of vertical transmission explained Specific informed consent to be signed Check HBeAg (envelope antigen) and anti HBc IgM (Antibody for core antigen)Patient to be accepted for treatment only if HBeAg is negative (indicates no acute infection/viral load)Specific protocols to be followed for OPU and ET (As below)Embryo freezing to be done only if separate cryocans are available. May not be possible at all centres
When both partners are positive Detailed counselling Reports from Liver specialist to confirm fitness for pregnancy Risk of vertical transmission explained Specific informed consent to be signed Check HBeAg (envelope antigen) and anti HBc IgM (Antibody for core antigen)Patient to be accepted for treatment only HBeAg is negative (indicates no acute infection/viral load)Specific protocols to be followed for OPU and ET (As below)Embryo freezing to be done only if separate cryocans are available. May not be possible at all centres

Protocols for Semen washing

  • Universal precautions to be followed.
  • No other sample to be handled at the same time.
  • Semen wash (Density gradient) with swim up technique to be done 2 times for hepatitis B positive samples.
  • Wear gloves and protective gear.

For ICSI

  • Patient to be taken last.
  • All tubes and pipettes on the micromanipulator to be changed immediately after procedure.
  • Dedicated Minc incubator to be used for embryo culture.
  • Incubator to be sterilized after ET.

For both semen processing and ICSI

  • Remaining samples and all other consumables to be disposed off immediately following standard biohazard disposal protocols with least handling.
  • Table tops to be cleaned with distilled water.
  • Any fluid spill to be cleaned immediately with 70% alcohol.

Protocols for OPU and ET

  • Notation to be made on the patient file, clearly visible, regarding ‘biohazard’ status, preferably as a special mark on the file and against the name of the positive partner. The mark should be recognised by the staff.
  • All clinical staff should be immunized (as per HR policy).
  • Cases to be kept as the last case of the day.
  • Universal precautions to be observed.
  • Avoid spill, use disposable material as far as permissible.
  • Unnecessary instruments to be removed from OT to avoid contamination.
  • Care while handling needles and sharps to avoid injury.
  • All materials to be disposed immediately and safely following standard biohazard disposal protocols, with least handling.
  • Body fluid spill to be cleaned with 70% alcohol and distilled water as per the regular cleaning protocols. The incubators to be kept shut always during this.
  • To use separate minc incubators, no other samples to be handled concurrently.
  • All instruments to be meticulously sterilized post procedure.

Apart from this, the lab and OT personnel should wear protective gear, which includes overall, glasses and double layer of gloves. It is very important to dispose of them in the correct manner. As medical professionals we must never refuse treatment but we should always remember the golden rule – “First Do no Harm”.

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