Family Building HIV
Dreams to Reality:
Family Building for Men Living with HIV
Men living with HIV can safely have biological children of their own. Since the early 1990’s sperm washing and assisted reproductive techniques have been used to help minimize the transmission of the virus HIV negative recipients. Over the past twenty years the medical treatments for both HIV and infertility have made significant advances. HIV has become a chronic illness managed by antiviral medication instead of a life-threatening disease, and success rates with fertility treatments such as IVF have increased two to three fold.
The goal of assisted reproduction for individuals with HIV is to help build families with minimal risk to the unborn child and the birth mother. For heterosexual couples living with HIV, the risk of viral transmission from infected sperm provider to female sexual partner is approximately 0.1 to 1.0% per act of sexual intercourse. For sero-discordant couples where the husband is HIV positive and the mother is HIV negative, the risk of infection over many months of attempted conception is considerable. Once infected, the mother poses risk of spreading the virus to the fetus (referred to as a vertical infection). Assisted reproductive techniques for couples with HIV have been designed to limit the risk of infection to both the mother and unborn child. Gay men with HIV who would like to build families through egg donation and gestational surrogacy can follow similar treatment protocols.
Research has shown that the amount of virus present in blood is not a reliable predictor of the amount present in semen. The testis are protected from exposure to blood by a barrier that thus the viral burden in semen is different than the level in the blood stream, even in men on antiviral therapy. An undetectable viral load in the blood may not indicate an undetectable viral load in the semen. HIV virus can be intermittently present in the semen. The presence of virus can be triggered by genitourinary tract infections such as sexually transmitted diseases or prostatitis.
Procedures to Reduce the Risk of HIV Transmission
The initial step to minimize the risk of transmitting infection from HIV positive sperm provider to HIV negative recipient is to reduce the amount of viral particles present in semen. Antiviral therapy can help reduce the amount of virus present in serum even though it may not eliminate the virus from semen. Sperm wash procedures can significantly reduce the amount of virus present by separating virus from the sperm cells. The viral particles are present in the liquid and particulate portions of the ejaculate, but not in sperm. A sperm wash procedure involves separating sperm from seminal fluid, thereby removing the viral particles that may be present.
To process the ejaculate, semen is placed onto a density gradient of culture medium, centrifuged, and the sperm collected. The sperm are then washed again, and allowed to swim-up through fresh culture medium. This process allows for the isolation of motile sperm from the non-motile viral particles and leukocytes that may carry the virus. The collected sperm may then be used in reproductive procedures or frozen for use at a later time. The culture medium used to wash the sperm can be tested for the presence of virus. Studies have shown an incidence of 0-10% of washed samples to contain viral particles.
Washed sperm may be placed into the cervix at the time of ovulation as an intracervical insemination (ICI); placed inside the uterine cavity as an intrauterine insemination (IUI); or may be used to fertilize eggs in an IVF cycle.
The first reports of sperm washing and insemination (IUI) for couples with HIV were published in 1992, and since that time over 5000 treatment cycles worldwide have been published utilizing both IUI and IVF with no reports of infection to the recipient.
Fertility Treatment Options for Men with HIV
The ideal starting point is a viral free semen sample. There is evidence that men on antiviral medications that have been remained virus free for years have a low chance for detection of virus in semen, however to further minimize risk, the Bedford Foundation, a non-profit laboratory in Boston, has developed a highly sensitive PCR-based assay to detect presence of small amounts of virus directly in the semen. In Bedford’s Special Program for Assisted Reproduction (SPAR) program, semen samples are analyzed for the presence of HIV and then frozen. Once two virus free samples are obtained, the sperm are washed and used in assisted reproductive procedures: ICI, IUI, or IVF.
In an ICI and IUI procedure several million sperm are placed into the cervix, or uterus, respectively, at the time of ovulation. In an IVF cycle several thousand washed sperm placed into a petri dish containing the eggs. ICSI may be used during the IVF cycle to optimize fertilization rates and further minimize the exposure of the eggs to sperm. In this procedure, a single sperm is injected directly into each egg, thereby minimizing exposure to sperm and any viral contaminants. The combination of semen testing for the presence of HIV, followed by sperm wash and IVF/ICSI, should afford the least amount of risk of viral transmission to the embryos, the recipient of the embryos, and the future child. The Bedford team has reported results from over 500 treatment cycles with no evidence of viral transmission to the recipient of the sperm or the babies born.
In summary, the fertility treatment options include sperm washing with or without testing of the semen sample for presence of virus, followed by IUI or IVF. For optimal effectiveness, the post-washed specimen should contain at least 4 million motile sperm. If the total number of motile sperm after the wash were less than four million motile sperm, then IVF with assisted fertilization (ICSI) would provide a more optimal fertilization and pregnancy rates.
Additional benefits of IVF over IUI are less exposure of the recipient to sperm and potential contaminating virus. The pregnancy rates for IVF like IUI are directly related to the age of the women producing the egg, however IVF pregnancy rates are several fold greater than IUI per cycle of treatment.
Sponsored by a generous educational grant from:
In this video, Dr. Guy E. Ringler, Dr. Bradford Kolb, and Dr. Daniel H. Bowers discuss advances in HIV treatment and Assisted Reproductive Technology that allow men living with HIV to have biological children of their own.
Thank you to the following physicians for their contributions to this article:
Daniel H. Bowers, M.D. - Diplomate, American Board of Family Medicine AAHIVM Certified HIV Specialist
Bradford Kolb, M.D. - HRC Fertility
Guy E. Ringler, M.D. - California Fertility Partners