HIV and Reproductive Care

Enrico Ferrazzi, Valeria Savasi
European Urological Review, 2010;5(2):55-8
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Abstract

Three-quarters of individuals infected with HIV are in their reproductive years and can expect an almost normal life expectancy under antiretroviral treatment. Men and women with HIV face the possibility of viral transmission to their partner or offspring if they want to have a child by way of spontaneous conception. When only the man is infected, spermatozoa can be isolated from seminal plasma and leukocytes containing cell-free and cell-associated HIV. After processing, the spermatozoa must be tested for residual contamination and, when negative, can be used for intrauterine transfer or in vitro fertilisation (IVF) embryo transfer/intracytoplasmatic sperm injection (ICSI). In women with HIV, self-insemination may be indicated when the couple is fertile or IVF embryo transfer/ICSI when there are infertility problems. Pregnancy should be planned to minimise the risk of drug-induced toxicity for the conceptus while reducing the vertical transmission rate to a minimum. Elective Caesarean birth is the recommended mode of delivery and breastfeeding is contraindicated.
Keywords
HIV, insemination, reproduction, in vitro fertilisation (IVF), intracytoplasmatic sperm injection (ICSI), sperm washing, fertility, highly active antiretroviral therapy (HAART)
Disclosure The authors have no conflicts of interest to declare.
Received: June 01, 2010 Accepted June 28, 2010
Correspondence: Valeria Savasi, Department of Obstetrics and Gynaecology, Sacco Clinical Sciences Institute, University of Milan Medical School, Via GB Grassi 74, 20157 Milan, Italy. E: valeria.savasi@unimi.it

At the beginning of the AIDS epidemic, because of the poor prognosis of those infected with the disease, couples with an HIV-infected partner were discouraged from planning a pregnancy. AIDS remains a serious condition worldwide, with continuing mortality. Even in industrial countries where efficient and innovative treatments are available, HIV infection remains a chronic disease with high morbidity.1 Nevertheless, due to antiretroviral therapies, life expectancy and quality of life of many seropositive patients have dramatically improved over the last 10 years and many couples with an HIV-positive partner can consider pregnancy planning.2–4

Assisted reproductive technology (ART) reduces the risk of contaminating the uninfected partner and helps couples conceive.2,5,6 Furthermore, in recent years the vertical transmission (the risk of infecting the newborn baby) has drastically decreased (to less than 2%) due to the ability to reach undetectable maternal viral loads during pregnancy, the liberal use of Caesarean section and restricted breastfeeding.7 Finally, certain authors have observed that pregnancy does not worsen the progression of HIV infection or its immunological parameters.8,9 The American Society for Reproductive Medicine Committee on Ethics10 and the International Federation of Gynecology and Obstetrics (FIGO)11 guidelines concerning assisted reproduction in people infected by HIV have been modified to allow assisted reproduction in HIV-discordant couples.

The paper from FIGO11 reported that access to antiretroviral drugs and ART for populations suffering from HIV or for seropositive patients must be promoted on an equitable basis, and that any restriction on access to assisted reproduction should be clearly justified and not based on discrimination.

Women, including sex workers, have the right to make choices about their sexual behaviour. Public information and access to the means to prevent HIV transmission for women and men at all stages of their reproductive lives are of utmost importance and need to be a concern for all member organisations and individual practitioners. Seropositive healthcare providers have an obligation to ensure that they engage in no behaviour that puts patients at risk. Prevention – by providing information about high-risk behaviour – is essential. The need for patients to behave responsibly to avoid spreading the virus, including the necessity of accepting antiretroviral treatment during pregnancy, must be highlighted.

Finally, FIGO suggested that it is essential to offer appropriate advice to women and men with HIV or whose partners are HIV-positive who wish to reproduce so that their health, the health of their partner and that of any future child is protected. Treatment of seropositive couples by assisted reproductive means that reduce the chance of the woman and her offspring being exposed to HIV are of proven efficiency. It is therefore ethical to offer such techniques in appropriate cases.

Two medical aspects are analysed in this paper: reproductive assistance in a discordant couple with male positivity and in a discordant couple with female positivity.

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