Much of the following information is based on the BHIVA 2005 Pregnancy Guidelines

Planning parenthood for positive women can feel a more viable option for many women than previously. ART means that women may expect to live longer and healthier lives than before and the risk of vertical transmission can be greatly reduced using the preventative measures listed above. However, the decision to have children remains a difficult one both on a practical and emotional level.

The attitudes of health care professional and assumptions about women’s reproductive choices can make this decision even more difficult. It is important that a positive woman receives sound information and advice about the options available to her so she can choose whether or not to go ahead with planning a pregnancy.

It was previously thought that pregnancy itself could be damaging to the health of positive women as pregnancy could have a negative effect on the immune system. It now seems pregnancy is only likely to have an impact on a woman’s physical health if she is already unwell or has very low CD4 counts. However, it is often not immediate health worries that are of greatest concerns to positive women. For some women even the greatly reduced risk of vertical transmission feels too high and they may decide not to start a family. Women will also have worries about longer-term issues for their child should they themselves or, in some circumstances, their partner become unwell or terminally ill.

However, for many women being diagnosed with a life-threatening condition may intensify the desire to have children, especially if she is not yet a mother. There is often, also, external societal pressure to have children and it is possible that this pressure is stronger amongst African communities.

When any woman is pregnant she will be concerned about the effect of medicines and other drugs on her unborn baby. Positive women on treatment will share these concerns and may express worries about the intra-uterine effects of ART. Due to ethical and other constraints there is little and sometimes conflicting evidence about the safety of ART in pregnancy. However, these concerns must be balanced against the health needs of the positive mother herself and the desire to reduce vertical transmission.

Conception

There are three aspects to consider: interventions that can minimise transmission risk between discordant couples during conception, the management of any fertility issues and the state of health and medication of the infected partner pre-conceptually.

BHIVA guidelines state that

• Self-insemination of partner’s semen is recommended to protect the uninfected male partner of an positive woman and is easily performed by the couple.
• Sperm-washing is recommended to protect the uninfected female partner of a positive male.
• Fertility assessment is indicated if conception has not occurred after 6-12 months of self-insemination.

Self-insemination – in couples in which the female partner is positive and the male partner is negative, self-insemination using quills, syringes and sterile containers should be performed. Women should be advised to perform this procedure during her fertile period of her ovulation cycle.

Sperm-washing– in couples in which the male partner is positive infected sperm-washing is recommended. In the case of a negative female partner this will reduce the risk of HIV transmission to the mother and child, if the female partner is positive this will reduce the risk of becoming infected with new resistant mutations of the virus.

Sperm-washing is a relatively simple procedure which involves separating live sperm which do not carry HIV from sperm contaminated HIV. This is done by taking a sample of sperm and putting it through a centrifuge ‘wash’. After the sperm is separated it is tested for HIV before being used. The wash sample can then be used for insemination.

BHIVA reports that in reviewing studies which included over 3000 cycles of sperm-washing no HIV negative women or children born as a result of the procedure sero-converted to become HIV- positive.

Unfortunately, despite it being a relatively simple and inexpensive technique, sperm-washing is not widely available within the UK, with only one clinic (at the Chelsea and Westminster Hospital, London) providing it on the NHS, with long waiting lists. National Institute of Clinical Excellence guidelines (NICE, 2004) recommend sperm-washing to be considered in couples where the male is positive and the woman negative. The availability of this technique should be discussed with the woman’s doctor. Sperm-washing done privately is likely to cost several thousand pounds; this however is not due to the expense of the technique but because many men with HIV have low fertility, caused in part by mitochondrial damage in sperm caused by NRTI anti-retroviral drugs.

Clinics that perform sperm-washing also exist in Milan, Italy, where Dr Augusto Semprini invented the technique (see Semprini 1992), Barcelona and Valencia, Spain, Belgium and France. In 1997 Semprini said there had been no instance of HIV infection in 350 couples he had treated in over 1,000 cycles of insemination with washed sperm. In the USA, sperm-washing is contrary to Centers for Disease Control guidelines, after an incident in 1992 where a women became infected with HIV after antificial insemination with her partner’s unwashed sperm.

Conception via unprotected intercourse This is not recommended due to risks of transmission between partners and subsequently to the child. Only one study has been performed where couples tried to conceive in this way and limited intercourse to the fertile period of ovulation and in this 4% of women seroconverted which is a relatively high risk.

Unpublished data by Semprini says that out of 487 couples treated with sperm-washing, 270 (55%) achieved pregnancy, but that of the remaining 45%, 58 (27%) had continued trying to have a child via unprotected intercourse. One woman seroconverted.

Unprotected intercourse is not recommended between couples who are both positive as there is the risk of transmission as noted above.

Donor insemination – this would eliminate risk of transmission from an infected male partner but brings its own issues in terms of availability of samples and the acceptability of this type of conception for many couples. Another option for a woman who is HIV–negative and whose partner is HIV–positive might be artificial insemination with another man's semen either from an anonymous donor, or someone known (such as a member of her partner's family). This is an option that many women use if their partner is infertile or risks passing on other infectious or congenital conditions.

Infertitility Treatment

For similar reasons as noted above, that is, increased life expectance and reduced risk of vertical transmission, more positive women may become interested in fertility treatment. Historically, there has been reluctance for some treatment centres to offer fertility treatment to couples affected by HIV. For example, the results of a survey published in December 2001 in the British Medical Journal highlighted a serious inequity in the availability of both infertility investigation and access to infertility treatment.

In total 57 of the 75 UK clinics (76%) responded to the questionnaire. 27 of the 57 clinics had not seen an HIV-positive person in the past year. Units that had seen an HIV-positive person in the past year were more likely than not to offer infertility investigation and treatment where the male partner was HIV-positive but this trend was not observed where the female partner was HIV-positive or both partners were HIV-positive. A total of 38 of the 57 clinics (67%) that responded to the survey said that they would not offer infertility treatment to couples where both partners are HIV-positive.

The Human Fertilisation and Embryology Act 1990 states that the welfare of the child should be considered before any course of treatment starts. BHIVA suggests that where a couple are seeking treatment ideally they should be in good health (i.e. undetectable viral load, CD4 count >400 and, for positive women, have a commitment to comply with interventions to reduce vertical transmission risks.)

BHIVA also recommends that procedures such as IVF should only be offered within research settings as it is not clear what associated risk of transmission there might be with such invasive procedures.

No category of women (including women with HIV) is excluded from consideration for infertility treatment. It should be hoped that the BHIVA guidelines and wider appreciation of the developing techniques to prevent vertical transmission will help reduce inequality of access to treatment for positive people.

References

Semprini AE et al. Insemination of HIV-negative women with processed semen of HIV-positive partners. The Lancet 340(28): 1317-1319, 1992.

Semprini AE et al. Reproductive counselling for HIV-discordant couples (letter). The Lancet 349: 1401-1402, 1997.