guidance on fertility treatment says that sperm washing may no longer be
necessary for couples where the man has HIV and the woman does not. As long as
the man is on effective antiretroviral treatment and unprotected sex is limited
to days when his partner is ovulating, “sperm washing may not further reduce
the risk of infection.”
On the other hand, the
guidance does not support the use of pre-exposure prophylaxis (PrEP) by the
National Institute for Health and Clinical Excellence (NICE) is an influential
body which issues recommendations to the NHS about the most effective and
cost-effective treatments to provide. Their draft guidance on fertility treatments –
an update to a document previously issued in 2004 – was issued today and is open for consultation.
As in the previous version, people with HIV are not
excluded from access to fertility treatments, such as intrauterine insemination
(IUI) or in vitro fertilisation (IVF). Moreover, the authors have removed a
previous recommendation that the implications of the parent’s HIV infection for
the child’s welfare “should be taken into account”.
The writing group reviewed in detail the scientific evidence
for different methods that a couple could use to become pregnant, where the man
has HIV and the woman does not. Previous guidance recommended sperm washing,
but the experts also looked at the evidence for effective antiretroviral
treatment and for pre-exposure prophylaxis.
“The evidence showed that whilst sperm washing did not
appear to completely eliminate the virus in the semen on the basis of post-wash
testing of prepared semen, the procedure appears to be very effective in
reducing viral transmission in that no cases of seroconversion of the woman or
the baby has been documented,” they found.
On the other hand, sperm washing has the disadvantage of
reducing the likelihood of pregnancy occurring.
Moreover, the writing group identified effective HIV
treatment as an alternative “which is equally effective, less invasive and more
They propose a criteria, similar to that of the ‘Swiss statement’, to determine whether unprotected vaginal intercourse would be an
appropriate way to conceive. All the following conditions should be met:
- Unprotected intercourse is
limited to the time of ovulation.
- The man is complying with
highly active antiretroviral therapy (HAART).
- The man has a plasma viral load
of less than 50 copies/ml.
- There are no other sexually transmitted infections.
The authors insist that their recommendation is limited to
the situation of a heterosexual couple wishing to conceive and who limit
unprotected sex to days when the female partner is fertile (ovulating). The
authors have not provided guidance that is relevant to the risk of HIV
transmission in other circumstances: “The context of this recommendation should
not be extrapolated away from this remit,” they say.
Should the man have problems with adherence to
antiretroviral therapy or were his plasma viral load to be detectable, the guidance
recommends that his seminal viral load be tested. If HIV is undetectable in
semen, doctors should inform the couple that the risk of HIV transmission
during timed unprotected intercourse is “negligible”.
In situations other than these, sperm washing should still be recommended.
Moreover, the document acknowledges that some couples may
still be anxious about the risk of HIV transmission during unprotected
intercourse when the male partner is on effective treatment. In such a case,
sperm washing would still be considered.
In terms of pre-exposure prophylaxis (PrEP), the experts
looked at whether, for a couple in which the HIV-positive man was on effective
treatment, there would be an additional benefit for his HIV-negative female
partner in taking PrEP. They found only two studies in peer-reviewed journals
that shed light on the question and that this evidence did not support the use
Consultation is open until 3 July.