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Serodiscordant couples present new challenges
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An increasing body of research indicates that an HIV-serodiscordant couple’s desire to have children is no different than that of any other couple, which has prompted a whole new set of challenges for HIV specialists to tackle.
Most research indicates that getting pregnant without transmission is more difficult when the man has HIV and the woman does not.
“We think that HIV can be in seminal fluid, but also in seminal white blood cells,” Deborah Cohan, MD, MPH, associate professor in the department of obstetrics, gynecology and reproductive Sciences at the University of California San Francisco, and medical director of the Bay Area Perinatal AIDS Center, said in an interview with Infectious Diseases in Children. “It is not in the spermatazoa itself. If you can separate the spermatazoa from the semen, transmission should not occur.”
Sperm washing and in vitro or intracytoplasmic sperm injection are reasonably reliable methods, according to Cohan.
“Injection of the sperm directly into the egg is safe and reliable, but a lower-tech method is to inject the washed sperm into the uterus, also called intrauterine insemination,” she said. “The problem is that both of these methods are too expensive to work in low-resource countries.”
Karen P. Beckerman, MD, of the department of obstetrics & gynecology and women’s health at Albert Einstein College of Medicine in New York, agreed. “Assisted reproductive technology gets a lot of attention in the literature,” she said. “But the likelihood is that most people will never have access to these methods. We are missing the forest for the trees on this one. Whether high tech or low, HIV exposure must be limited to conception attempts alone, and safer sex practices must not be abandoned, especially during pregnancy.”
Sperm washing and intrauterine insemination methods are used most frequently in European fertility clinics. Although sperm washing is done in the United States, fewer centers are doing it here than there, according to Cohan.
Beckerman said there may be more fundamental concerns. “Some men with HIV may be azoospermic,” she said. “In which case, there is obviously no chance of conception. Some could have easily treated inflammatory conditions of the genital tract causing increased viral load in the ejaculate. Semen analysis is essential so that we can minimize risks of exposing women to HIV. We should be focusing on counseling serodiscordant couples on these issues.”
If the woman is infected, home insemination can work, according to Cohan. This strategy depends largely on maintaining effective long-term ART use and pre-exposure prophylaxis.
“There are about 10 major pre-exposure prophylaxis trials going on right now,” Cohan said. “We are hoping to have more definitive answers when they are completed.” – by Rob Volansky