For many heterosexual couples, where one is infected with HIV (serodiscordant or ‘sero-disco’), having children has been full of challenges. However, results from recent major trials in sero-disco couples are offering new hope. In cases where the male partner is sero-positive, standard practice in many developed countries has been to use the assisted reproduction technique of intrauterine insemination with processed sperm (‘sperm washing’).
This technique has been effective and safe (not one case of transmission of HIV from the male partner to the female has been recorded, after more than 12 years of widespread use of this method). However, it is expensive and the probability of a viable pregnancy is around 15-18% per attempted reproduction cycle. For the couples involved it can be medically very invasive and hugely frustrating.
Data from a study of Swiss heterosexual sero-disco couples who have conceived children by ‘natural’ vaginal intercourse is encouraging. This study evolved in 2007 out of an existing program of insemination counselling of sero-disco couples. Prior to having their sperm 'washed' in preparation for insemination into their female partners, 104 HIV-positive male partners were tested for the presence of HIV-RNA in their semen.
These men were all receiving HAART and had undetectable viral loads in their blood for more than six months. Not one had detectable HIV in his semen (detection level 40 copies/ml). This encouraged the study team to offer the possibility of these couples conceiving naturally.
The team used the following guidelines:
- The male partner had undetectable HIV in their blood plasma for at least six months
- There was no report of current genital infections and no unprotected sex with other partners
- The female partner monitored her hormone levels to determine the best time for conception (up to 36 hours after the maximum hormone level)
- The female partner received PrEP with tenofovir, first dose when the hormones were at their peak and a second dose 24 hours later
- Intercourse took place after the second dose of tenofovir
- After six unsuccessful attempts at conception, the couples were referred to test their fertility levels
A total of 46 couples opted for this method of timed intercourse with PrEP.
In these couples nine female partners subsequently declined to take tenofovir as PrEP and relied solely on their partner's undetectable viral load with timed intercourse, judging that the risk of acquiring HIV was too low and not wishing to expose their conceived offspring to HIV antiretrovirals. At their first attempt 26% of the couples conceived a child, this rose to a total of 75% of all the couples at 12 attempts. Of those who failed to conceive a child it was found that reduced fertility was the cause, and this was mainly associated with older age in the male partner. The study team documented 244 instances of unprotected vaginal intercourse. Not one of the women became HIV positive.
These results, together with the results of recent PrEP trials in heterosexual couples, should give hope to many couples who are living with HIV and who wish to have children. The possibility of conceiving a child 'naturally' without resorting to invasive techniques now seems to be within reach.
Vernazza PL, Graf I, Sonnenberg-Schwan U, Geit M, Meurer A. Preexposure prophylaxis and timed intercourse for HIV-discordant couples willing to conceive a child. AIDS. 2011 Oct 23; 25(16): 2005-8.
Mastro TD, Cohen MS, Rees H. Antiretrovirals for safer conception for HIV-negative women and their HIV-1-infected male partners: how safe and how available? AIDS. 2011 Oct 23; 25(16): 2049-51.
Background reading on assisted reproduction in sero-disco couples:
Bujan L, Hollander L, Coudert M, Gilling-Smith C, Vucetich A, Guibert J, et al. Safety and efficacy of sperm washing in HIV-1-serodiscordant couples where the male is infected: results from the European CREAThE network. AIDS. 2007 Sep 12; 21(14): 1909-14.
Lampe MA, Smith DK, Anderson GJ, Edwards AE, Nesheim SR. Achieving safe conception in HIV-discordant couples: the potential role of oral pre-exposure prophylaxis (PrEP) in the United States. Am J Obstet Gynecol. 2011 Jun; 204(6): 488 e1-8.
Levine BA, Nurudeen SK, Gosselin JT, Sauer MV. Addressing the fertility needs of HIV-seropositive males. Future Virol. 2011 Mar; 6(3): 299-306.
Nicopoullos JD, Almeida P, Vourliotis M, Gilling-Smith C. A decade of the sperm-washing programme: correlation between markers of HIV and seminal parameters. HIV Med. 2011 Apr; 12(4): 195-201.
Nicopoullos JD, Almeida P, Vourliotis M, Goulding R, Gilling-Smith C. A decade of the sperm-washing programme: where are we now? Hum Fertil (Camb). 2010; 13(2): 90-7.
Sauer MV, Wang JG, Douglas NC, Nakhuda GS, Vardhana P, Jovanovic V, et al. Providing fertility care to men seropositive for human immunodeficiency virus: reviewing 10 years of experience and 420 consecutive cycles of in vitro fertilization and intracytoplasmic sperm injection. Fertil Steril. 2009 Jun; 91(6): 2455-60.
Savasi V, Ferrazzi E, Lanzani C, Oneta M, Parrilla B, Persico T. Safety of sperm washing and ART outcome in 741 HIV-1 -serodiscordant couples. Hum Reprod. 2007 Mar; 22(3): 772-7.