Peter Kovacs, MD, PhD

Disclosures

August 14, 2003

Question

What is the consensus about discordant HIV couples undergoing in vitro fertilization (IVF) and the risks of transmitting the infection to the uninfected partner and fetus?

Dr. Fernanda Luisa Galvani Rodrigues

Response From Expert

Peter Kovacs, MD
Clinical Instructor, Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, New York, and Fellow in Reproductive Endocrinology, Albert Einstein College of Medicine, Bronx, New York

 

The management of infertility in couples in which one or both of the partners is HIV-positive raises a number of medical and ethical questions. With changes in the medical management of HIV, the approach to infertility treatment has changed in the past few years. In the late 1970s and early '80s, HIV/AIDS was associated with short survival. It was also believed to be the disease of homosexual men and intravenous-drug users. Although it still not curable, HIV infection today can be managed as a chronic disease because of the efficacy of antiretroviral drug therapy. And, more recently, most new cases of HIV infection result from heterosexual contact. Therefore, an increasing number of reproductive-age heterosexual couples are living with HIV infection. HIV infection is often associated with infertility. Spermatogenesis can be reduced in men, and tubal infertility is common among women infected with HIV.

A number of issues need to be addressed before deciding about the treatment of such couples. How will the offspring be affected? How can we avoid seroconversion in the unaffected partner in discordant couples? What is the life expectancy of the parents? What is the risk to healthcare providers? If we withhold treatment will the couple try to achieve pregnancy anyway, putting themselves at greater risk?

Some of these couples seek care for known infertility factors (oligozoospermia, tubal infertility), some to avoid seroconversion if the couple is discordant for HIV. If the male partner is affected there are several options. With sperm washing and subsequent PCR testing, virus-free specimens can be obtained and transmission essentially can be eliminated. Alternatively, the use of donor sperm or adoption can be offered.

If the female partner is affected, insemination or IVF can prevent the transmission to the male partner. The question is how the offspring will be affected. First, the risk of vertical transmission needs to be evaluated. Before the routine availability of drug treatment, vertical transmission rates were on the order of 25%. Zidovudine treatment during pregnancy, or at least during delivery, was found to lower transmission rates to around 5%.[1] If a planned cesarean section were performed, the vertical transmission rate could be further reduced to 2%.[2] However, the potential teratogenic effect of some of the HIV drugs needs to be considered. Information about the effects when administered in the first trimester is limited. Some of these drugs have been shown to be teratogenic. Ideally, drug treatment would be suspended during the first trimester.

One could say that even a 2% vertical transmission rate is still a significant risk. However, the risk of having an "affected" offspring is much higher for some other conditions -- for example, genetic conditions in which the parents are both carriers of abnormal genes (autosomal recessive disorders) and the offspring has a 25% chance of having the condition. Similarly, chronic, not well-controlled medical conditions (eg, type 1 diabetes) are associated with higher risks of malformations, intrauterine growth retardation, and preterm delivery. Following appropriate counseling, most physicians would help such couples achieve pregnancy.

A frequently used argument against treatment of couples with HIV is the anticipated shorter lifespan of the affected parent. As mentioned above, with the advent of potent antiretroviral therapy, HIV can be managed as a chronic disease. Similar shorter lifespan is anticipated in the case of women with medical conditions (hypertension, diabetes, lupus, renal disease) or in the case of an older donor egg recipient. Following appropriate evaluation and counseling, most of us would not withhold infertility treatment from these couples. We should apply the same general guidelines in the case of HIV.

Healthcare providers treating HIV-positive patients need to follow universal precautions to avoid contamination with body fluids and the risk of possible infection. It is also important that only those centers that have the appropriate laboratory equipment to handle infectious material offer treatment to couples with HIV.

Prior to receiving treatment, these couples should be appropriately counseled about the risks for themselves and their offspring. Patients with low viral load and who are well controlled with antiretroviral drug therapy or even not currently taking antiretroviral drug therapy should be offered infertility care. They should be screened for other sexually transmitted infections, and the possibility of substance abuse needs to be explored. Access to treatment should not depend on the HIV status of the patient but rather every effort should be made to reduce the risk of transmission to the other partner and to the offspring if the couple decides to proceed following counseling.

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