Access to infertility investigations and treatment in couples infected with HIV: questionnaire survey

Life expectancy among patients infected with HIV has increased since combination anti-HIV therapies were introduced. This has led to calls for infertility in people with HIV to be treated in an identical way to that in patients with other chronic medical conditions.¹

Two broad groups of patients infected with HIV are likely to request infertility treatment. The first group consists of couples in which only one partner is infected with HIV (serodiscordant couples) who would like to have children but who wish to avoid the transmission of the virus to the uninfected partner; they may not be subfertile. The second group consists of serodiscordant couples who are subfertile and have tried to conceive spontaneously (with the attendant risks) without success and subfertile couples in which both partners are infected with HIV who would like to have children. We determined whether couples presenting to infertility clinics are offered investigations and treatment when one or both partners are known to be infected with HIV.

Methods and results

Clinics providing assisted conception as of December 2000 were identified from the records of the Human Fertilisation and Embryology Authority, which licenses the use of such techniques in Britain (www.hfea.gov.uk). All 75 clinics were sent a questionnaire (see appendix on BMJ 's website). Statistical relations between the categorial variables were analysed with SPSS software, using χ² analysis or the Cochran Q test for related dichotomous variables.

We received responses from 57 (76%) of the 75 clinics. Forty one units (72%) had a policy on treating patients infected with HIV. Most (25 (61%)) of these had not seen a patient infected with HIV in the previous year. Only one (6%) of 17 units that had seen a patient infected with HIV in the previous year did not have a policy. The responses to some of the questions asked are given in the table.

Units that had seen patients infected with HIV in the past year were more likely than units that had not to investigate or to offer treatment when the man was infected with HIV (13 (87%) v 20 (57%) for investigation, P=0.05; 12 (75%) v 13 (37%) for treatment, P=0.01). The same trend was not seen when the woman or both partners were infected with HIV.

We further analysed the responses by looking at differences between clinics in and outside London; these results are available on the BMJ 's website.

Comment

In general, infertility clinics are biased against patients infected with HIV—for example, only 44% of units would treat a couple where only the man was infected with HIV. With this type of serodiscordant couple, donor insemination is a safe technique, and couples wishing to have a child that is theirs biologically would benefit from sperm washing.²,³

The risk of the virus being transmitted to the child in couples in which both partners are infected with HIV can be reduced by the mother taking antiretroviral drugs during pregnancy and labour⁴ and having a caesarean section, by the child receiving antiretroviral therapy at birth, and by avoiding breast feeding.

The Human Fertilisation and Embryology Act 1990 requires the welfare of the child to be taken into account before treatment starts, but it does not exclude any category of woman from being considered for infertility treatment. A blanket refusal to provide infertility investigations and treatment to couples infected with HIV may lead to an increase in seroconversion of the uninfected partners of serodiscordant couples trying to conceive naturally.⁵

Not all patients infected with HIV will be suitable for infertility treatment, but whether couples are offered assisted conception in Britain is a lottery, as there are no established guidelines. Centres offering assisted conception should have a less restrictive attitude towards patients infected with HIV.

Table.

Responses from infertility clinics asked whether they would offer infertility investigations and treatment to couples when one or both partners were infected with HIV. Values are numbers (percentages)

		Yes	No	No response
Would you offer infertility investigations to a couple when:
The male partner is HIV positive?		33 (58)*	17 (30)	7 (12)
The female partner is HIV positive?		25 (44)	24 (42)	8 (14)
Both partners are HIV positive?		24 (42)	25 (44)	8 (14)
Would you offer infertility treatment to a couple when:
The male partner is HIV positive?		25 (44)*	26 (46)	6 (10)
The female partner is HIV positive?		14 (25)	36 (63)	7 (12)
Both partners are HIV positive?		12 (21)	38 (67)	7 (12)

^*P=0.001.