Here's to the Miracle of Life

Any discussion of love sooner or later leads to talks about marriage or partnerships, and that can lead to the question of whether to have kids. Fortunately, this discussion no longer has to exclude HIV-positive people. Much has been written of the dramatic reduction in the risk of transmission of HIV from a mother to a fetus with the use of antiretrovirals. However, the use of fertility techniques to allow an HIV-positive man to impregnate an HIV-negative woman is just starting to be studied. The reports coming in are promising, though. In 1989, Augusto Semprini, a physician in Milan, started using 'sperm washing' followed by intrauterine insemination to allow HIV-serodiscordant couples'in this case the man is positive and the woman is negative'to safely achieve pregnancy. When polymerase chain reaction testing became available, this second step was added to ensure that the sperm sample was HIV-negative. This procedure has been performed worldwide 3,000 times without a single case of serconversion of the woman. Because semen contains free HIV along with white cells that may be HIV-infected and other seminal products, there has been ongoing concern about the risk to the mother, and this process has never been adopted in the United States. It is still not clear if spermatozoa are actually infected, and millions of sperm are placed in the uterus during intrauterine insemination. Even when using in vitro fertilization (when eggs are extracted from the mother, fertilized in the lab with semen from the father, and then implanted into the mother's uterus) the eggs are exposed to about 5,000 sperm. However, it is now possible to expose just one egg to one sperm during in vitro fertilization by using a technique called intracytoplasmic sperm injection. In theory, this should greatly reduce the risk of HIV transmission to the mother. Researchers at Columbia University have reported on 54 couples who have gone through a total of 103 of the above-described procedures without one transmission of HIV. Some women required several attempts at implantation, and there were ultimately 27 pregnancies. This success rate was no different than in HIV-negative couples undergoing IVF. In addition, since multiple births are common with IVF, out of 27 pregnancies, nine resulted in twins and two resulted in triplets. That is something to think about! These data along with the perception that HIV is now a manageable chronic disease have led the ethics committee of the American Society for Reproductive Medicine to support the treatment of HIV-serodiscordant couples in ongoing study protocols. Certainly there are nonmedical issues to consider, such as the challenges to the mother and child if the father becomes ill or dies and even contingencies if the mother does become infected and then both parents become ill. But these issues should always be discussed whenever pregnancy is contemplated, and because psychosocial counseling is mandatory with these protocols, preparations for pregnancy might be even better than in the general population. It is also important to note that these procedures are costly and are not ordinarily covered in general health insurance policies. Because recent studies have suggested that HIV can infect human eggs at the time of fertilization, there is always going to be some theoretical risk to a mother. So for those who want an even safer option, the use of frozen, anonymous-donor sperm can be considered. And finally, of course, adoption has many wonderful benefits. Let me conclude by saying that this has to be the happiest article on HIV issues that I have ever written. For years we have talked about illness, disease, and sometimes death. But now we can talk about life. Bowers is board-certified in family practice and is a senior partner with Pacific Oaks Medical Group, one of the nation's largest practices devoted to HIV care, located in Beverly Hills, Calif. He has served on the boards of AIDS Research Alliance of America and Lambda Legal Defense and Education Fund.