HIV infection and the desire to become parents

Since 1996, improvements in antiretroviral therapy have led to a significant increase in the duration and quality of life of people living with HIV / AIDS, at least in countries where HAART is widely available. To date, HIV infection can be considered a chronic, however, treatable disease. Such a revision of the views on this disease gave many HIV-infected people, women and men, a hope to live a full life, including the possibility of drawing up such plans for the future, the fulfillment of which they could not even dream of earlier. This includes the possibility of family planning. At present, the risk of contracting an uninfected partner in discordant couples and the risk of having an infected child can be minimized. The successes achieved in reducing the risk of intrauterine transmission of HIV contributed to the strengthening of a positive attitude towards planned pregnancy in seropositive women. In many European countries, ethical and legal differences on this issue have already been overcome.

A couple in which at least one of the partners is HIV-infected can theoretically realize their desire to have children in different ways, from conceiving a child with unprotected sexual intercourse to using various methods of artificial insemination, insemination with donor sperm or adoption. As a rule, a couple tries to dissuade from carrying out an unprotected sexual intercourse, since the prevention of infection of an uninfected partner and a future child is most important.

The probability of HIV transmission for each unprotected heterosexual intercourse is 1/1000 (from male to female) or less than 1/1000 (from woman to man). Such values can hardly serve as a weighty argument when advising a particular couple.

The likelihood of HIV transmission increases many times against a background of high viral load or in the presence of other sexually transmitted diseases. The magnitude of viral load in semen or secretions of the genital tract is not always proportional to the magnitude of the viral load in the blood plasma, and HIV can be detected in the sperm even in cases when the viral load in the blood plasma is below the defined level.

In other words, partners should be discouraged from conducting unprotected sex acts, even if the couple argues for their safety in that the infected partner has undetectable viral load. Continuous use of condoms reduces the risk of HIV transmission in heterosexual couples by 85%, and the refusal to use condoms during ovulation was suggested as one of the possible methods of conception for discordant couples. Mandelbrot et al. (1997) reported that of the 92 discordant couples who used unprotected intercourse for the onset of the concept in the most fertile periods, 4% of couples contracted a partner. Despite the fact that infection occurred only in couples who reported the occasional use of condoms during other periods of time (which are not favorable for conception), the available data can not confirm the safety of this method of conception.

For some couples, insemination by donor sperm can be an alternative safe method, but due to regulatory restrictions this service is provided by a very small number of medical institutions. For example, in the UK there are no restrictions on the procedure for insemination with donor sperm, while in Germany this option can not be used by all. In addition, most couples want their child to be genetically related to both parents. Adoption in many countries is only a theoretical way out, because the presence of HIV infection in one of the spouses, as a rule, complicates the adoption procedure, and in some countries makes it absolutely impossible (for example, in Germany).

To minimize the risk of HIV transmission, the following methods of conception are recommended:

• If a woman is HIV-infected, she can enter her partner's sperm into the vagina alone or resort to other methods of artificial insemination.
• If a man is HIV-infected, then artificial insemination of a partner with pre-purified sperm from HIV should be performed.

In some (mostly European) countries, services for artificial insemination of discordant couples have only been introduced in the last few years, and right now, the right of HIV-infected to artificial insemination has been legislated in France. Equal opportunities for using methods of artificial insemination by HIV-infected men and women are recognized in most of these countries, but not in all.

HIV infection and pregnancy: safe use of purified sperm

The description of the technology for the purification of sperm of HIV-infected men before insemination of their uninfected partners was first published by Semprini et al. In 1992. The first insemination of HIV-free sperm (i.e. Washed alive spermatozoa) was carried out in Italy in 1989 and in Germany in 1991. By mid-2003, more than 4500 inseminations with washed spermatozoa were performed using various methods of artificial insemination; More than 1,800 pairs were subjected to such a procedure (including repeatedly). As a result, more than 500 children were born, and no cases of seroconversion were registered in medical institutions that strictly adhered to the technology of cleaning and testing sperm for HIV before the procedure of artificial insemination.

There are three main components of the native ejaculate - spermatozoa, spermoplasm and accompanying nuclear cells. A virus was isolated from the seminal fluid, and the inserted HIV DNA was detected in the accompanying cells and even in immobile spermatozoa. Based on the results of several studies, it was concluded that viable mobile spermatozoa, as a rule, do not carry HIV in themselves.

Movable spermatozoa can be isolated from the ejaculate by standardized methods. After separation of spermatozoa from spermoplasm and accompanying cells, they are washed twice with liquid nutrient medium, and then placed in a fresh nutrient medium and incubated for 20-60 minutes. During this time, mobile spermatozoa float to the surface of the medium, the top layer of which (supernatant) is taken away for fertilization. In order to verify the absence of viral particles in the supernatant, it is tested for the presence of HIV nucleic acid using highly sensitive methods of detecting HIV. In the most highly sensitive methods, the detection threshold is 10 copies / ml. Since it is theoretically possible that the supernatant contains HIV in an amount not exceeding the detection threshold, the method of semen purification is currently considered as a highly effective way to reduce the risk of HIV transmission to a minimum, but not as a completely safe method.

Most European medical institutions providing artificial insemination services to discordant couples are part of the CREATHE (European Network of Providing Reproductive Assistance for Couples with Sexually Transmitted Infections) network, a European network of medical institutions providing artificial insemination services to couples suffering from sexually transmitted infections ), which allows us to unite efforts in the work to increase the effectiveness and safety of fertilization techniques, as well as maintain a common database. There are good reasons to hope that soon enough clinical experience will be accumulated on artificial insemination with purified sperm, confirming the safety and reliability of this method.

HIV infection and pregnancy: counseling before conception

During primary counseling, you should not only provide detailed information on all available methods of fertilization, a diagnostic examination before fertilization, indications and favorable conditions for performing an artificial insemination procedure, but also give sufficient attention to the psychosocial problems of the couple. It is very important to discuss the financial situation of the family, the existing psychosocial problems, the importance of social support from the rest of the family or friends, talk about plans and prospects for further family life, including what will happen in case of loss of capacity for work or death of one of the spouses. It is recommended during the conversation to be sympathetic, supportive and understanding, because expressing doubts about the rights of the couple to have children or finding their lonely desire to become parents can cause a psychological trauma. In many cases, it is necessary to remind spouses of the risk of HIV transmission in unprotected sexual intercourse, not only in case of addressing reproductive issues, but every time they talk with them. In cases when professional services for the provision of psychological assistance are not involved in the provision of assistance to HIV-positive people, it is recommended to cooperate with organizations providing counseling services to HIV-infected people, as well as self-help groups.

During counseling, one should talk about the various problems that may arise during a diagnostic examination or arise during the procedure of artificial insemination, and about the ways of their solution, and also discuss all the doubts and fears that arise in the couple. For example, many couples are afraid that the results of the survey will show the inability to have children.

If a man is HIV-infected, then the couple should be aware that the risk of HIV transmission can be minimized, but not completely ruled out. An HIV-infected woman needs to be informed about the risk of vertical HIV transmission and the necessary preventive measures. In any case, the couple should be warned that even with the most modern methods of artificial insemination, the onset of pregnancy is impossible to guarantee.

HIV infection and pregnancy: an infection in a man

After making a decision to conceive a child with the help of artificial insemination, the couple should undergo a comprehensive examination for the safety of reproductive functions and the presence of infectious diseases. A doctor who sends a couple for artificial insemination should also provide information on the course of HIV infection in a man. It is necessary to exclude HIV infection from a partner. In some cases, before the procedure of fertilization, partners should first recover from infections of the genital tract.

After separation of live spermatozoa and testing of the suspended suspension for HIV, one can use any of the three methods of artificial insemination, depending on the reproductive health condition of the pair - intrauterine insemination (VMI), in vitro fertilization with the usual method (IVF) or the method of introducing the spermatozoon into the egg cytoplasm (ICSI) with the subsequent transfer of the embryo into the uterine cavity. According to the recommendations adopted in Germany, the choice of the method of fertilization should take into account the results of the gynecological and andrological examination, as well as the preferences of the spouses. It was found that the probability of success of ICU decreases if the washed spermatozoa were frozen (cryopreservation). Freezing spermatozoa occurs in those institutions where it is not possible to quickly get the PCR results for HIV of a sample of washed sperm suspension, and therefore it is impossible to perform insemination on the day of sampling of sperm. This circumstance, coupled with the fact that some HIV-infected men suffer from sperm quality, leads to the fact that in some cases IVF or ICSI is recommended.

The couple must be warned about the following important circumstances:

• Washing sperm with subsequent testing for HIV significantly reduces the risk of infection, but does not exclude it completely. However, judging by the results of recent studies, the risk of infection is only theoretical, and can not be expressed as a percentage.
• Against the background of artificial insemination it is extremely important to constantly use condoms. Infection of a woman early in pregnancy increases the risk of HIV transmission to a child.
• Most couples who apply to European medical institutions for artificial insemination services must pay for them themselves. The cost of the service depends on the method used and is from 500 to 5000 euros per attempt. The exception is France, where couples are provided these services free of charge. In Germany, health insurance companies can assume part of the costs, but are not required to do so.

Even the application of the most complicated methods of artificial insemination can not guarantee a successful outcome.

After successful procedure of artificial insemination, a woman and her child are observed for 6-12 months after childbirth (depending on the medical institution), regularly determining their HIV status.

HIV infection and pregnancy: an infection in a woman

HIV-positive women who do not have reproductive harm, can conceive a child by injecting a partner's sperm into the genital tract. According to the clinical standards adopted in Germany, a pair is recommended to undergo a test for the safety of the reproductive function and other examinations listed in Table 1 (as well as to the discordant couple in which a man is HIV-infected). In some cases, it may be necessary to stimulate the ovaries. When carrying out stimulation of the ovaries, a highly qualified observation is required to exclude the onset of multiple pregnancies.

It is very important to accurately determine the moment of ovulation (for example, using ultrasound or rapid urine analysis on LH). A simple and inexpensive way to find out whether the cycles are ovulatory, which is suitable for women with a regular menstrual cycle, is a daily basal temperature measurement for three months before the first attempt at conception with the introduction of sperm.

On the day of ovulation, couples can either perform a protected sexual intercourse using a condom without spermicide lubrication, and then inject the ejaculate into the vagina, or get the sperm by masturbation and either insert it into the vagina with a syringe without a needle, or put a cap on the cervix with the sperm. So you can avoid outside interference in the process of conception.

It is not recommended to carry out more than two inseminations during one cycle, since the number of mobile spermatozoa with each subsequent attempt may decrease. In addition, the couple may experience psychological discomfort due to an excessive number of attempts at conception.

After one year of unsuccessful independent attempts to conceive a couple, it is necessary to undergo an examination for reproductive disorders and determine indications for the use of methods of artificial insemination.

HIV infection and pregnancy: reproductive harm

Preliminary data, recently obtained from several medical institutions, suggest that HIV-positive women appear to have more reproductive harm than those of HIV-negative women of the same age group. In some cases, women can conceive only through artificial insemination. Depending on the state of reproductive health of the spouses, the methods of choice are IVF and ICSI.

Many medical institutions in Europe provide artificial insemination services when a man is infected with a couple, but an HIV-positive woman can not always get such a service.

According to data recently received from Strasbourg, 48 HIV-positive women were included in the local IVF program within 30 months, of which 22 were found to have reproductive disorders. During this time, 9 of them had a pregnancy after the procedure of artificial insemination; six children were born.

Services of artificial insemination to HIV-positive women are provided in Belgium, France, Germany, Great Britain, Spain.

HIV infection and pregnancy: infection in both partners

More and more HIV-concordant couples (couples where both partners are infected with HIV) seek reproductive advice. In some medical institutions, these couples are also provided with artificial insemination services. One of the ways to conceive is to perform unprotected sexual acts at the moments most favorable for conception, but there are still disputes about the danger of transmitting mutated strains of viruses resistant to medications from one partner to another. Such couples should be offered counseling prior to conception and a diagnostic examination in the same volume as HIV-discordant couples. Before conception, the spouses should undergo a thorough examination from the attending physician, an HIV specialist, who must compile a detailed report on the health status of each spouse.

HIV infection and pregnancy: psychosocial aspects

• The experience of reproductive counseling, accumulated over more than a decade, demonstrates the importance of providing couples with professional psychosocial support before, during and after providing artificial insemination services.
• Approximately every third couple rejects the intention to give birth to a child after a thorough conversation. The consultant's approval of the desire to become parents, the opportunity for the couple to discuss the underlying assumptions underlying the desire to give birth to a child, as well as empathy over the prevailing psychosocial situation, contribute to the fact that the couple will be able to recognize in the counseling process the existence of various obstacles to the implementation of their plans, plans for the future, provided that their desire for some reason does not materialize.
• Failures on the way to the realization of your dream (for example, several unsuccessful attempts at artificial insemination or miscarriages) cause disappointment and a feeling of hopelessness. Forced to cope alone with their difficulties, couples sometimes decide on conception by unprotected sex, refusing further medical interventions. Depending on the partners' attitude to the risk of infection, such a decision can be the result of careful planning, and may be born spontaneously due to desperation.
• The presence of mental disorders in one or both partners (i.e., substance abuse, psychosis) may serve as an indication to at least postpone the implementation of artificial insemination. In such cases, you need to contact a specialist for diagnosis and follow-up.
• It often happens that during medical and psychosocial counseling for couples who immigrated to the country, their desire to become parents is not given due importance. The presence of a language barrier, mutual difficulties in communication, ignorance of cultural characteristics and rejection of the "alien" way of life lead to feelings of discrimination, alienation, helplessness and despair in couples.

[1], [2], [3], [4]