HIV and infertility

In developed countries HIV infection has now become a chronic but manageable disease. Highly active HIV drugs (HAART) has substantially increased life expectancy and quality of life for both adults and children infected with HIV. Most HIV infected people are young and fertile.

Infertility has been shown to be higher in HIV-positive patients than controls (tubal factor infertility 41% vs. 14% and male factor infertility 45% vs. 26%). The use of effective anti-HIV drug treatment for mother and baby, delivery by elective caesarean section and avoiding breast feeding can reduce the risk of HIV transmission from mother to her baby to less than 1%. As a result of this improvement, pregnancy is now an option for many HIV patients and has led to a rise in the number of HIV-positive patients seeking advice on conception.

Concerns have been raised with regard to fertility treatment for HIV-positive patients because of the welfare of the unborn child. In particular, vertical transmission of HIV to the child, life expectancy of the infected parent and potential teratogenic effects of HIV medication. Furthermore, there is a risk of transmission of HIV to other patients and staff.

Very few centres have the facilities and expertise to offer this service. These centres must follow strict safety guidelines, use a separate laboratory and incubators as well as separate tanks to freeze and store embryos and sperm from infected patients.

Before embarking on treatment, the couple should be offered in-depth counselling which should address:

• The stability of the relationship, current health and medication
• The plan for future in the event of ill health or death of the infected partner or of both partners
• The couple should be made aware that semen washing is a risk reduction and not risk elimination technique

The treatment options available to HIV-positive couples depend in part on which partner is affected.

HIV-positive male and female partner is unaffected

• Unprotected intercourse is not advisable because of risk of transmission to the female partner through infected semen. Staszewski (1997) reported 4 out of 92 patients became seropositive. It is interesting that some men have substantial virus concentration in their semen, even when they have undetectable blood plasma load with antiretroviral treatment (Vernazza,2000)
• If the man is HIV positive the risk of HIV transmission to his female partner is negligible through unprotected sexual intercourse when all of the following criteria are met: the man is compliant with highly active antiretroviral therapy (HAART) the man has had a plasma viral load of less than 50 copies/ml for more than 6 months, there are no other infections present and unprotected intercourse is limited to the time of ovulation (NICE guidelines (2013) .
• Donor insemination sperm donation
• Adoption adoption
• Assisted conception treatment in order to conceive a child without contaminating the female partner. The semen has to be washed, processed and tested by PCR to exclude HIV RNA before it is used for IUI, IVF, or ICSI. Couples should be advised that the risk of a sample remaining positive after washing is about 5%. Sauer et al (2003) advocated ICSI rather than IUI or IVF because in ICSI fewer sperm are used compared to million for IUI.

HIV-positive female and male partner is unaffected

• Timing self insemination, this is a simple procedure and insemination is performed using quills. Self insemination is recommended for 6 to 12 months
• IUI and ovulation induction if conception has not occurred after 6 to 12 months of self-insemination.
• IVF if the tubes are blocked
• ICSI if there is a severe male factor infertility

Outcome of assisted conception treatment for HIV-positive patients

Pregnancy rate per intrauterine insemination cycle varies between 10.8% and 18.6% (Gilling–Smith et al., 2003; Semprini et al., 2003, Vitorino et al, 2011)). This is similar to results achieved in HIV-negative patients. As for IVF treatment, it has been reported that HIV-positive women have lower pregnancy rates than HIV-negative women 11-21% compared to 26% in matched control ( Van der Leuwen Human Reprod Update 2007).The reduced pregnancy rates after IVF has been observed in HIV infected women when they used their own eggs. However, no significant reduction in pregnancy rates was found when donated eggs were used.

How safe is Assisted conception treatment?

There is a lack of long-term safety data on anti-HIV drugs taken during pregnancy and the potential risks for teratogenic effects, mitochondrial damage, and neonatal death (Blanche et al., 1999). However, to date, over 15,000 cycles of IUI and IVF with washed semen have been performed in Europe, without reported transmission of HIV (ESHRE 2010).Gilling-Smith and colleagues (2003) reported no cases of seroconversion in either partner or child born after sperm washing in over 3000 cycles of treatment .

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