HIV and infertility: time to treat

No established guidelines exist for defining access to fertility care for individuals infected with HIV. Although many in vitro fertilisation units in the United Kingdom screen patients for HIV, only a handful are prepared to treat couples if one or other partner tests positive. A premise of offering assisted conception treatment is a consideration for the welfare of any child born or affected as a result of treatment. In the case of HIV the primary concern is over the life expectancy of the infected parent and the risk of viral transmission to either the uninfected partner or offspring.¹,² The ethical dilemmas these issues raise have, until now, provided sufficient grounds for most units offering assisted conception to close their doors to patients infected with HIV who ask for help or who test positive in their preliminary investigation.³

Combination antiretroviral therapy has produced radical improvements in life expectancy and quality of life for both children and adults infected with HIV in developed countries. Current estimates suggest that a disease previously associated with certain death is compatible with a life expectancy of at least 20 years from time of diagnosis. Is it therefore justifiable to deny HIV positive adults fertility treatment on the grounds that children born as a result are unlikely to see childhood through before one or both parents die? There are many similarities between HIV and other once fatal diseases afflicting women in their reproductive years, such as diabetes, cystic fibrosis, congenital heart disease, and breast cancer. Cardiac disease and cystic fibrosis, in particular, may worsen considerably during pregnancy, with effects on both maternal and fetal health. Yet fertility treatment is rarely refused in these cases, despite the risks of pregnancy to mother and fetus.

As regards viral transmission to the offspring, without intervention a mother infected with HIV has a 13%-30% risk of infecting her baby.⁴ Judicious use of combination antiretroviral therapy during pregnancy and labour, delivery by caesarean section, and avoidance of breast feeding are proved measures which have reduced the risk of vertical transmission to less than 2%.⁵,⁶ Compare this with an HIV negative mother, who has a 2.5% risk of giving birth to a baby with a significant congenital malformation, a risk increasing fourfold if she has insulin dependent diabetes and tenfold if she has congenital heart disease. In vitro fertilisation clinics treat many such women and many women over 40, whose age related risk of giving birth to a child with Down's syndrome is 1% and increases steeply with age. Potential teratogenic effects of antiretroviral drugs taken during pregnancy remain an issue. Serious adverse effects appear rare, although mitochondrial cytopathy leading to neonatal death has been documented.⁷

Reproductive assistance to HIV discordant couples can make a significant impact in preventing viral transmission. The female partner of an HIV positive man runs a 0.1%-0.2% risk of acquiring HIV in an act of unprotected intercourse,⁸ and attempting to conceive naturally carries a serious risk to the uninfected woman and her child.⁹ In men infected with HIV, virus is present in semen as free virus in the seminal plasma and as cell associated virus in the non-sperm cells. Although the issue is controversial, there is little evidence to support HIV being able to attach to or infect spermatozoa. A highly significant reduction in the risk of viral transmission is achieved if spermatozoa are first washed free of seminal plasma and non-sperm cells before insemination into the woman at the time of ovulation. This technique of “sperm washing,” pioneered in Milan,¹⁰ is now practised in several centres in Europe, including the Chelsea and Westminster unit in the United Kingdom.¹¹ As a risk reduction option, results are convincing. Three hundred healthy children have now been born after more than 3000 cycles of sperm washing and intrauterine insemination treatment or in vitro fertilisation, with no reported seroconversions in either partner or children.^10–12 Prevention of viral transmission from an infected woman to an uninfected man is less sophisticated and relies on timed self insemination using quills. Couples who fail to conceive in this way are likely to revert to unprotected intercourse if fertility advice and treatment are not available.

HIV is a changed disease. Life expectancy has increased dramatically and effective treatments are available to reduce the risk of viral transmission from man to woman and from mother to child. We believe that couples in whom one or both partners are infected should have access to the same fertility advice and treatment as non-infected individuals to allow them to conceive with the minimum of risk to their partners or children. We further recommend that all infertile couples should be tested for HIV as part of their investigation, not for the purpose of excluding HIV positive patients from treatment but to offer them preconceptional counselling and risk reducing fertility treatments and antenatal care. In terms of controlling the epidemic, the cost of failing to recognise the needs of these patients will be a high price to pay in both the short and long term.