Providing assisted reproductive care to couples in whom the male partner is known to be HIV-1 seropositive remains a subject of intense controversy1,2. HIV-1 infection occurs primarily in young, reproductively healthy men, and affects hundreds of thousands of Americans3. Many of these individuals desire to have children. However, responsible and safe sexual practices require the constant use of condoms, which reduces the risk of transmitting virus to the uninfected partner, and also precludes any hope of pregnancy.
Materials and Methods
Sperm Washing and Insemination Techniques
The use of sperm preparation techniques, commonly referred to as ‘sperm washing’, has been recommended as a means of reducing the likelihood of the horizontal transmission of HIV-1 for over 10 years4. Processed sperm for intrauterine insemination (IUI) has been offered in several centers, with medical reports (Table 1) documenting pregnancy without HIV-1 seroconversion in the female partner or newborn4–14.
Separating Virus from Sperm
The basis for IUI treatment rests on the premise that isolated motile spermatozoa used in washed inseminations do not carry HIV-1 because spermatozoa lack the receptors needed for the virus to gain entry into the host cell. Non-motile cells, particularly the CD4 lymphocytes and macrophages known to exist in seminal plasma, are principle targets for infection with HIV-1, and are effectively removed by washing.
Intrauterine Insemination or In-vitro Fertilization–Intracytoplasmic Sperm Injection
IUI therapy requires millions of sperm cells to be placed above the natural immunological barrier of the cervix. Catheters placed through the endocervix and into the endometrial cavity also create bleeding, which potentially could further increase risk. It is difficult to ensure that all CD4-positive cells are eliminated from the ‘washed’ preparation15. Cognizant of these concerns, at Columbia University, we elected to offer a therapy that limits viral exposure to a few motile sperm cells16. ICSI has commonly been used to address male factor infertility and is available at most centers providing assisted reproduction. Similar to preparing sperm for IUI, discontinuous density gradient centrifugation techniques are used before ICSI, and only the resultant motile sperm found in the supernatant after swim-up are selected. The published results from clinical studies utilizing IVF or IVF–ICSI are reviewed and summarized in Table 24–18.
Results Through the First 100 Cycles
We have completed over 100 cycles (Table 3) of IVF–ICSI in HIV-1-serodiscordant couples19. Pregnancies typically occur within the first three cycles of treatment. Over time the cumulative pregnancy rate per couple was greater than 50%.
The purpose of all clinical trials involving sperm separation techniques is to provide HIV-1-serodiscordant couples with an opportunity to have a child without the risk of viral transmission. Various techniques have been suggested as a preventative measure to avoid infection in HIV-1-serodiscordant couples intent on reproducing. ICSI requires only the in-vitro contact of a single sperm and egg, and should dramatically reduce the risk of transferring viral particles that are often present in the semen. Reproductive alternatives, including artificial insemination with donor sperm, adoption, and childless living should also be offered. Patients must act intentionally and without controlling influences that would mitigate against a free and voluntary act. Most importantly, women need to understand that no procedure is risk free, and all carry a small possibility of infection.
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19. Pena JE, Thornton MH, Ruman J, et al. Assessing the clinical utility of in-vitro fertilization with intracytoplasmic sperm injection in HIV-1 serodiscordant couples: report of 103 consecutive cycles. Presented at the 58th Annual Meeting of the American Society of Reproductive Medicine. Seattle, WA, USA, 2002 [Abstract 019].