HIV infection and the desire to become parents

Since 1996, improvements in antiretroviral therapy have led to a significant increase in the length and quality of life of people living with HIV/AIDS, at least in countries where HAART is widely available. HIV infection can now be considered a chronic, but treatable, disease. This rethinking of the disease has given many HIV-infected women and men the hope of living a full life, including the possibility of making plans for the future that they could not have dreamed of before. This includes the possibility of family planning. It is now possible to minimize the risk of infecting an uninfected partner in discordant couples and the risk of having an infected child. The successes achieved in reducing the risk of intrauterine transmission of HIV have contributed to a strengthening of positive attitudes 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 partner is HIV-infected can theoretically realize their desire to have children in a variety of ways, from conceiving a child through unprotected intercourse to using various methods of artificial insemination, insemination with donor sperm, or adoption. As a rule, the couple is discouraged from having unprotected intercourse, since the most important thing is to prevent infection of the uninfected partner and the future child.

The probability of HIV transmission during each unprotected heterosexual act is 1/1000 (male to female) or less than 1/1000 (female to male). Such values are hardly a valid argument when counseling a particular couple.

The probability of HIV transmission increases many times in the presence of a high viral load or other sexually transmitted diseases. The viral load in semen or genital secretions is not always proportional to the viral load in blood plasma, and HIV can be detected in semen even when the viral load in blood plasma is below detectable levels.

In other words, partners should be discouraged from engaging in unprotected intercourse, even if the couple argues that it is safe because the infected partner has an undetectable viral load. Consistent condom use reduces the risk of HIV transmission in heterosexual couples by 85%, and not using condoms during ovulation has been suggested as a possible method of conception for discordant couples. Mandelbrot et al. (1997) reported that of 92 discordant couples who used unprotected intercourse during the most fertile times to conceive, 4% of the couples became infected. Although infection occurred only in couples who reported inconsistent condom use during other (non-fertile) times, the available data cannot confirm the safety of this method of conception.

For some couples, insemination with donor sperm may be a safe alternative, but due to regulatory restrictions, this service is only available in a small number of medical institutions. For example, in the UK there are no restrictions on insemination with donor sperm, while in Germany this option is not available to everyone. In addition, most couples want their child to be genetically related to both parents. Adoption is only a theoretical solution in many countries, since HIV infection in one of the spouses usually complicates the adoption procedure, and in some countries it is completely 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 introduce her partner's sperm into her vagina on her own or resort to other methods of artificial insemination.
• If a man is HIV-infected, then artificial insemination of the partner should be performed using sperm previously purified from HIV.

In some (mostly European) countries, IVF services for discordant couples have only begun to be provided in the last few years, and the right of HIV-infected people to IVF has now been enshrined in law in France. Equal access to IVF for HIV-infected men and women is recognized in most, but not all, of these countries.

HIV Infection and Pregnancy: Safety of Using Cleaned Sperm

The technique of washing the sperm of HIV-infected men before insemination of their uninfected female partners was first described by Semprini et al. in 1992. The first inseminations with HIV-washed sperm (i.e., washed live sperm) were performed in Italy in 1989 and in Germany in 1991. By mid-2003, more than 4,500 inseminations with washed sperm had been performed using various in vitro fertilization techniques; more than 1,800 couples had undergone this procedure (including multiple times). More than 500 children were born as a result, and not a single case of seroconversion was recorded in medical institutions that strictly followed the technique of washing and testing sperm for HIV before the in vitro fertilization procedure.

There are three main components of native ejaculate - spermatozoa, sperm plasma and accompanying nuclear cells. The virus has been isolated from seminal fluid, and embedded HIV DNA has been found in accompanying cells and even in immobile spermatozoa. Based on the results of several studies, it has been concluded that viable motile spermatozoa, as a rule, do not carry HIV.

Motile spermatozoa can be isolated from the ejaculate using standardized methods. After separation of the spermatozoa from the seminiferous plasma and associated cells, they are washed twice with liquid nutrient medium and then placed in fresh nutrient medium and incubated for 20-60 minutes. During this time, motile spermatozoa float to the surface of the medium, the upper layer of which (supernatant) is collected for fertilization. In order to ensure the absence of viral particles in the supernatant, it is tested for the presence of HIV nucleic acid using highly sensitive HIV detection methods. The detection threshold of the most highly sensitive methods is 10 copies/ml. Since it is theoretically possible that the supernatant contains HIV in quantities not exceeding the detection threshold, the sperm purification method is currently considered 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 members of the CREATHE network (European Network of Centres Providing Reproductive Assistance to Couples with Sexually Transmitted Infections), which allows for joint efforts in improving the efficiency and safety of fertilization methods, as well as maintaining a common database. There are serious grounds to hope that sufficient clinical experience in artificial insemination with purified sperm will soon be accumulated, confirming the safety and reliability of this method.

HIV Infection and Pregnancy: Preconception Counseling

During the initial consultation, it is necessary not only to provide detailed information on all available fertilization methods, diagnostic examination before fertilization, indications and favorable conditions for the procedure of artificial insemination, but also to pay sufficient attention to the psychosocial problems of the couple. It is very important to discuss the financial situation of the family, existing psychosocial problems, the importance of social support from other family members or friends, talk about plans and prospects for further family life, including what will happen in the event of loss of ability to work or death of one of the spouses. It is recommended to show sympathy, support and understanding during the conversation, since expressing doubts about the couple's rights to have children or finding their desire to become parents unconvincing can cause psychological trauma to the couple. In many cases, it is necessary to remind the spouses of the risk of HIV transmission during unprotected sex not only in the case of a request for reproductive issues, but every time you talk to them. In cases where professional psychological services are not involved in providing assistance to HIV-infected people, it is recommended to establish cooperation with organizations providing counseling services to HIV-infected people, as well as with self-help groups.

During the consultation, it is necessary to talk about various problems that may be revealed during the diagnostic examination or arise during the artificial insemination procedure, and ways to solve them, as well as discuss all the doubts and concerns that the couple has. For example, many couples are afraid that the examination results will show the impossibility of having children.

If the man is HIV-infected, the couple should know that the risk of HIV transmission can be minimized, but not completely eliminated. The HIV-infected woman should be informed about the risk of vertical transmission of HIV and the necessary measures to prevent it. In any case, the couple should be warned that even with the use of the most modern methods of artificial insemination, pregnancy cannot be guaranteed.

HIV Infection and Pregnancy: Infection in Men

After deciding to conceive a child using artificial insemination, the couple must undergo a comprehensive examination to determine the integrity of reproductive functions and the presence of infectious diseases. The doctor who referred the couple for artificial insemination must also provide information about the course of HIV infection in the man. It is necessary to exclude HIV infection in the female partner. In some cases, before the fertilization procedure, the partners must first be cured of genital tract infections.

After separating live sperm and testing the resulting suspension for HIV, any of three artificial insemination methods can be used, depending on the state of the couple's reproductive health - intrauterine insemination (IUI), in vitro fertilization using the conventional method (IVF) or the method of introducing a sperm into the cytoplasm of an egg (ICSI) with subsequent transfer of the embryo into the uterine cavity. According to recommendations adopted in Germany, when choosing a fertilization method, the results of a gynecological and andrological examination, as well as the preferences of the spouses, should be taken into account. It has been found that the likelihood of success of IUI decreases if the washed sperm were frozen (cryopreserved). Sperm must be frozen in those institutions where it is not possible to quickly obtain PCR results for HIV from a sample of washed sperm suspension, and therefore insemination cannot be performed on the day of sperm collection. This circumstance, combined with the fact that some HIV-infected men have poor sperm quality, leads to the fact that in some cases IVF or ICSI is recommended.

The couple must be warned of the following important circumstances:

• Sperm washing followed by HIV testing significantly reduces the risk of infection, but does not eliminate it completely. However, according to recent studies, the risk of infection is only theoretical and cannot be expressed as a percentage.
• It is extremely important to use condoms at all times when undergoing artificial insemination. Infection of a woman early in pregnancy increases the risk of transmitting HIV to the child.
• Most couples who seek artificial insemination services in Europe must pay for them themselves. The cost of the service depends on the method used and ranges from 500 to 5,000 euros per attempt. The exception is France, where couples receive these services free of charge. In Germany, health insurance companies may cover part of the costs, but are not obliged to do so.

Even the use of the most complex artificial insemination techniques cannot guarantee a successful result.

After a successful IVF procedure, the woman and her baby are monitored for 6-12 months after birth (depending on the medical facility), regularly determining their HIV status.

HIV Infection and Pregnancy: Infection in Women

HIV-positive women who do not have reproductive dysfunctions can conceive a child by introducing their partner's sperm into the genital tract. According to clinical standards adopted in Germany, the couple is recommended to undergo an examination for the preservation of reproductive function and other examinations listed in Table 1 (as is the case for a discordant couple in which the man is HIV-positive). In some cases, ovarian stimulation may be necessary. When performing ovarian stimulation, highly qualified supervision is required to exclude the occurrence of multiple pregnancies.

It is very important to accurately determine the moment of ovulation (for example, using ultrasound or rapid urine tests for LH). A simple and inexpensive way to find out whether cycles are ovulatory, which is suitable for women with regular menstrual cycles, is to measure basal body temperature daily for three months before the first attempt to conceive using sperm injection.

On the day of ovulation, couples can either have protected intercourse using a condom without spermicidal lubrication and then insert the ejaculate into the vagina, or obtain sperm by masturbation and either insert it into the vagina with a syringe without a needle or place a cap with sperm on the cervix. This can help avoid outside interference in the conception process.

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

After a year of unsuccessful attempts to become pregnant on their own, the couple must undergo an examination for reproductive disorders and determine the indications for the use of artificial insemination methods.

HIV infection and pregnancy: reproductive dysfunction

Preliminary data recently obtained from several medical institutions indicate that HIV-positive women seem to have higher rates of reproductive dysfunction than HIV-negative women of the same age groups. In some cases, women can only conceive through artificial insemination. Depending on the reproductive health of the couple, IVF and ICSI are the methods of choice.

Many medical institutions in Europe provide artificial insemination services in cases where the man in the couple is infected, but an HIV-positive woman cannot receive such a service everywhere.

According to recent data from Strasbourg, 48 HIV-positive women, of whom 22 had reproductive dysfunctions, were enrolled in a local assisted reproduction programme over a 30-month period. During this time, nine of them became pregnant after assisted reproduction procedures; six children were born.

Artificial insemination services for HIV-positive women are provided in Belgium, France, Germany, Great Britain, and Spain.

HIV infection and pregnancy: infection in both partners

More and more HIV-concordant couples (couples in which both partners are infected with HIV) are seeking reproductive counseling. In some settings, these couples are also offered assisted reproductive technology. One way to conceive is through unprotected sex at the most fertile times, but there is still controversy about the risk of transmitting mutated, drug-resistant strains of the virus from one partner to the other. These couples should be offered preconception counseling and diagnostic testing to the same extent as HIV-discordant couples. Before conceiving, the couple should be examined thoroughly by their physician, an HIV specialist, who should provide a detailed report on each partner’s health.

HIV infection and pregnancy: psychosocial aspects

• More than a decade of experience in reproductive counselling has demonstrated the importance of providing couples with professional psychosocial support before, during and after assisted reproduction services.
• Approximately every third couple gives up their intention to have a child after a thorough discussion. The consultant's approval of the desire to become parents, providing the couple with the opportunity to discuss the underlying prerequisites underlying the desire to have a child, as well as empathy regarding the current psychosocial situation, contribute to the couple being able to recognize the existence of various obstacles to the implementation of their plans during the consultation process, and will also be able to make plans for the future, provided that their desire does not come true for some reason.
• Failures to achieve their dreams (such as multiple unsuccessful attempts at artificial insemination or miscarriages) can cause frustration and hopelessness. Forced to cope with their difficulties alone, couples sometimes decide to conceive through unprotected intercourse, refusing further medical interventions. Depending on the partners' attitudes toward the risk of infection, such a decision may be the result of careful planning or may be born spontaneously out of desperation.
• The presence of mental disorders in one or both partners (i.e. substance abuse, psychosis) may be an indication to at least postpone artificial insemination. In such cases, it is necessary to contact a specialist for diagnosis and further observation.
• It often happens that when conducting medical and psychosocial counseling for couples who have immigrated to a country, their desire to become parents is not given due importance. The presence of a language barrier, mutual difficulties in communication, ignorance of cultural peculiarities and rejection of the "foreign" way of life lead to feelings of discrimination, alienation, helplessness and despair in couples.

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