may also be called upon to address issues related to anxiety, depression and substance abuse, conditions known to be more prevalent in HIV‐seropositive populations.
Prescribing PrEP for the unaffected partners of sexually active HIV‐seropositive males has been associated with negligible transmission rates when males have undetectable viral loads [13,14]. This has led to renewed debate about whether unprotected timed sexual intercourse is a reasonable option for HIV‐serodiscordant patients to consider. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) has supported unprotected well‐timed intercourse for couples in which the HIV‐positive male has undetectable viral loads. With respect to timed intercourse, patients are encouraged to use ovulation kits or basal body temperature in order to decrease the need for repetitive sexual exposure. However, it has been reported that patients who choose this option are more likely to use condoms inconsistently and therefore may actually increase their risk of transmission over time [13]. In one study, the seroconversion rate was 4.3% in patients trying to establish pregnancies through timed intercourse. Therefore, the American Society for Reproductive Medicine (ASRM) does not endorse this plan for conception [15].
Whether IUI or IVF best addresses the needs of patients with HIV seeking fertility care remains contentiously debated. There are advantages and disadvantages inherent to both methods, and neither has proven to be safer than the other. More attempts have been published using the less invasive IUI approach which is technically simpler and less expensive than IVF [16,17]. However, efficacy per treatment cycle is lower with IUI and therefore multiple attempts, entailing multiple exposures, are often required. Testing specimens used for insemination for HIV is commonly recommended as a necessary precaution against infection but also represents a significant additional expense and is not an evidence‐based requirement. IUI preparations contain millions of recovered cells, including leukocytes if not properly prepared. It has been reported that up to 5% of sperm samples are contaminated with HIV [12]. As a precaution, specimens are often frozen and tested prior to their use, ensuring only HIV‐negative fluids are inseminated. However, freezing may decrease fertilization potential in men who exhibit borderline or abnormal semen profiles [18]. Under optimal circumstance, pregnancies following IUI typically occur in 5–15% of treatment cycles, and couples should anticipate the need for multiple attempts at IUI over an extended period of time.
ICSI has been widely practiced for the treatment of male factor infertility for nearly 30 years. ICSI requires the selection of only a single sperm per retrieved egg although the gametes chosen for injection cannot be HIV tested. Only the highly motile fraction of prepared sperm is chosen for ICSI and typically fewer than 30 sperm are needed per patient. It is believed that mature motile spermatozoa from the fraction of prepped semen do not harbor HIV, and therefore specimens do not need to be virally tested before use, reducing the complexity and cost of implementation. However, ICSI is inherently invasive and expensive and has been associated with a higher risk of multiple births than IUI unless single embryo transfer is practiced. Pregnancies from ICSI typically occur in 35–60% of treatment cycles depending upon the age of the patient, the circumstances of the treatment cycle and the number of embryos transferred. ICSI also commonly produces supernumerary embryos that may be cryopreserved for future use, a feature that cannot be accomplished through any other methodology.
Prevention
Clinical outcomes of patients undergoing sperm washing techniques to prevent HIV infection have been good both in terms of disease prevention and pregnancy results. Throughout treatment couples should be encouraged to continue practicing safe sex with condoms. A seroconversion occurred in one woman preparing to undergo ICSI that was secondary to noncompliance with safe sex practices [19]. Since the Centers for Disease Control (CDC) reported in 1990 an alleged HIV infection of a patient following the insemination of processed semen [20], practitioners in the USA and elsewhere have been reluctant to provide assisted reproductive care to HIV‐seropositive patients [21]. However, the increasingly favorable results of clinical studies from both IUI and IVF methods used to prevent infection in HIV‐serodiscordant couples has led to greater acceptance of their clinical utility and safety. The cumulative tally of over 4,000 published cases without a single infection is compelling evidence. Reversal of prohibitions that limited the availability of such services in states such as California are a testament to the willingness of physicians and patient advocacy groups to work together to adopt new guidelines for patient evaluation and treatment [22].
The American College of Obstetricians and Gynecologists (ACOG) and the ASRM have published recommendations for the treatment of virally infected patients embracing a broad policy of nondiscrimination [15,23]. Included are the use of sperm washing techniques for both IUI and IVF. The underlying purpose common to all clinical programs, whether offering IUI or IVF, relates to access to care. Congruent with the basic principles of bioethics, HIV‐seropositive patients should have the opportunity to have a biologic child without causing harm to uninfected partners and their children. As preventive health care measures, IUI and IVF both appear very promising in accomplishing this goal. Although it remains uncertain as to whether one method is superior to the other in this regard, both do appear to be safe and efficacious choices.
Albeit small, all patients undergoing fertility treatments are at theoretical risk of disease transmission. Therefore, it is important to engage them in a frank discussion related to the biology of HIV and inform them that other options, including artificial insemination with donor sperm and adoption also present safe traditional choices. Not all patients will choose sperm washing techniques once they are aware of the infectious risk inherent to all procedures. However, respecting a patient’s right to exercise autonomy and choose to be treated or not is justified since the risk of infection is quite low and the benefit of childbearing so great [24].
Key points
Challenge: Caring for the fertility needs of HIV‐seropositive males
Background:
40 million people are living with HIV.
Most HIV‐infected individuals are males of reproductive age.
At least one‐third of infected individuals wish to have a family.
Patients require a multidisciplinary approach.
Safe sex practice with condoms is recommended to prevent infection in the partner, and partners should talk to their doctors about pre‐exposure prophylaxis (PrEP).
Co‐infection with hepatitis is a common comorbidity.
Management options:
IUI in men with normal semen analysis and partners without fertility problems.
ICSI which has highest efficacy per treatment cycle.
Well‐timed intercourse or self‐insemination if viral load undetectable, males are compliant with HAART and women are prescribed PrEP.
Partners should be tested following treatment and throughout pregnancy.
Baby should be tested for HIV at delivery and 3 months postpartum.
No prophylaxis is required in women receiving processed specimens.
Prevention:
Sperm washing techniques separate sperm from infected seminal plasma.
Sperm lack viral receptors and co‐receptors and are unlikely to be viral vectors.
HIV has not been detected in aliquots obtained from properly prepared sperm specimens.
Answers to questions patients ask
1 Q1 Do sperm cells carry HIV? A1. HIV infection can be transmitted through semen since the virus is