I delivered this talk in a HIV awareness workshop in BHU centenary celebration, BHU, Varanasi U.P. India During last two decades understanding and treatment of HIV-infected persons and lab techniques for the preparation of virus-free sperms have improved substantially. Current treatments for HIV can limit the risk of viral transmission to the partner and offspring. Infertility treatment in Sero discordant couple Sero concordant couple Knowingly conceiving a child who may be born with HIV HIV testing for couples seeking fertility assistance Potential risks to the health- care providers Improving access to infertility care for HIV-infected individuals Providing third party assisted reproductive services

1. Fertility Management in HIV
Discordant Couple
Dr. Neelam Ohri.
MS, FICOG,
Medical Director

2. Biologic Parenthood in HIV Discordant
Couple
• HIV is a serious but manageable chronic
disease
• The largest group affected (86%) are
persons of reproductive age (15–44 years
old)
• HIV-serodiscordant couples are actively
seeking reproductive assistance for
biologic parenthood.

3. Improved Understanding and
Treatment
During last two decades understanding and
treatment of HIV-infected persons and lab
techniques for the preparation of virus-free
sperms have improved substantially
Current treatments for HIV can limit the risk of
viral transmission to the partner and offspring

4. Ethical Issues with Infertility
treatment
• Infertility treatment in
Sero discordant couple
Sero concordant couple
• Knowingly conceiving a child who may be born
with HIV
• HIV testing for couples seeking fertility assistance
• Potential risks to the health- care providers
• Improving access to infertility care for HIV-
infected individuals
• Providing third party assisted reproductive
services

5. Issues to be addressed
• Potential deleterious effects of HIV-1 infection
on fertility
• The impact of ARV therapy on fertility.
• The impact of co-morbidities (e.g.STDs, drug
abuse) on fertility.

6. For Couples Who Want to Conceive
Discordant or Concordant
• Expert consultation is recommended (AIII).
• Partners should be screened and treated for
genital tract infections (AII).
• The HIV-infected partner(s) should attain
maximum viral suppression before attempting
conception (AIII).
• PrEP for uninfected partner may offer an
additional tool to reduce the risk of sexual
transmission (CIII).
(CDC recommendations)

7. Male infertility and HIV
Since 1987, > 4000 published data for processed spermatozoa from HIV-
seropositive men
HIV and ARVs impact on semen parameters and sexual function
• Controversial results: may be associated with borderline semen
abnormalities. For others, no impact. Semen parameters correlate
positively with CD4 counts
• Erectile and ejaculatory dysfunction is estimated to affect 60% of men
with advanced disease
HIV transmission rate to an uninfected partner
Approximately 1 in 500–1,000 episodes of unprotected intercourse.
The risk increases dramatically - if infected partner's viral load is high or
- the uninfected partner has a concomitant
genital infection,

8. Infertility Treatment in discordant
couple (Male)
Semen analysis is recommended, If abnormalities are present, the
uninfected female partner may be exposed unnecessarily
Ways in which conception can occur:
1.Timed unprotected intercourse: Using condoms
except at the time of ovulation appear to reduce, but not eliminate,
the risk of seroconversion
The seroconversion rate was 4.3% of 92 HIV-uninfected women with HIV- infected
partners. Two of the women in that study seroconverted during pregnancy, and
another 2 converted in the postpartum period.
This practice is not recommended
- Cohen MS et all.N Engl J Med 2011;365:493-505

9. Infertility Treatment in discordant
couple (Male)
2. ARV therapy during the time conception is attempted and
PrEP in the uninfected female partner during the.
In a study of 46 serodiscordant couples, the female was treated with oral tenofovir,
(One dose was taken at LH peak and a second 24 hours later)
none of the women became infected with HIV and pregnancy rates reached 75% after
12 attempts.
This and other studies indicate that adherence to clinical
protocols is essential for preventing transmission.
The US FDA has approved only daily dosing of combination
tenofovir and emtricitabine for PrEP
3. Use of donor sperms

10. Infertility Treatment in discordant
couple (Male)
4.The use of sperm preparation techniques
coupled with either IUI or IVF with ICSI
Based on the principal that HIV virus is present
in seminal plasma and seminal leucocytes but
is not associated with sperms.
Sperms lack CD4 and CCR5 receptors on their
surface that allow the virus to bind with and
enter the cell.

11. Infertility Treatment in discordant couple
(Male)
IUI-IVF ICSI
• IUI or ICSI has proven to be highly effective in avoiding
seroconversion of uninfected women and offspring.
• HAART can reduce the viral burden in a person's serum and
semen.
• PrEP may reduce further the susceptibility of the uninfected
female partner.
• Some centers have also adopted testing of sperm by using a
PCR assay (RNA)after preparation, but the utility and
effectiveness of this added step has been questioned by other
centers that have eliminated PCR from their protocols.

12. Sperm Preparation Technique
Sperm Washing

13. Sperm Preparation Techniques

14. Infertility Treatment in discordant
couple (Male)
IVF with ICSI
• Recent data on the use of ICSI are
promising in terms of avoiding
transmission to uninfected women.
• In a 10-year retrospective review of a
program stated no female
seroconversions and no infections in any
of the offspring. Sauer MV et all. Fertil Steril 2009;91:2455-60

15. HIV infection and Female
Reproductive Potential
• Fertility is 25– 40% lower
• Systemic illness, stress, weight loss may
impact reproductive potential
• Co-morbid conditions, PIDs, higher rates of
concomitant M. hominis, candida,
streptococcal, HPV and HSV-2
• HIV infection has contributed to a worldwide
increase in the incidence of TB
• ARVs may adversely affect reproductive
potential via damage to mitochondrial
biogenesis in gametes.

16. Infertility Treatment in Discordant
couple (Female)
• Assess the reproductive potential of female
• Ways for conception:
• 1. IUI by using homologous insemination
will suffice in order to prevent horizontal infection.
• 2. Self-inseminate with the partner’s sperm during the
periovulatory period is other option. Condom use should
be advised at all times.
• 3. Timed intercourse, assuring suppressed viral load of
woman and the uninfected male is taking PrEP. This
option is not as safe as homologous IUI, it does represent
an alternative option for select couples.

17. Infertility Treatment in Discordant
couple (Female)
• The resulting pregnancy may still pose some
risk to the HIV- infected woman and her child
• Opportunistic infections occurring during
pregnancy
• Invasive procedures (Amniocentesis and
CVB), may also increase risk of transmission
to the fetus.
• In addition there is variable risk of vertical
transmission

18. Infertility Treatment in
Concordant Couples
• Assessment of the fertility potential
• Both should be on cART with maximum viral
suppression before attempting conception.
• The risk of HIV superinfection or infection with a
resistant virus is negligible when both partners are on
cART and have fully suppressed plasma viral loads.

19. Ethical Issues Raised by Knowingly
Risking the Birth of a Child with HIV
• The risk of vertical transmission can be greatly
reduced but not completely eliminated.
• This raises ethical issues concerning the scope of
freedom to reproduce.
• The ethical issues are similar to carriers of an
autosomal recessive disease, where the risk of
transmitting the disease through natural
conception cannot be reduced below 25%,
whereas the risk of HIV transmission can be
reduced to a substantially lower number—in
some cases, to less than 2%.

20. Testing Infertile Couples for HIV
• The ACOG recommends that ObGy routinely screen their
female patients aged 19–64 years for HIV regardless of
individual risk factors
• Repeated testing is recommended for those with ongoing risk
for HIV infection
• ART Regulation Bill 2010,The Bank shall ensure that the sperm
/ egg donor, Surrogate is free from HIV and repeated every 6
months and only frozen thawed samples should be provided

21. Laboratory
Cross-contamination of the gametes
or embryos , Myths and Realities
• Numerous ART centers worldwide equipped with
separate lab space and provide separate storage
tanks for freezing infected gametes and embryos
• There are no reports of HIV infection of lab
personnel resulting from processing the
gametes/embryos adopting standard universal
precautions.
• Cross-contamination of the gametes or embryos of
other couples in the same laboratory has also not
been reported.
• To avoid even the possibility of cross-contamination,
the ASRM Practice Committee recommends that
samples from a viral carrier be processed in a
separate laboratory or designated space within the
main laboratory, utilizing a dedicated storage tank.

22. HIV AND THE HEALTH PROFESSIONAL
Health professionals may be legally, as well
as ethically, obligated to provide requested
reproductive assistance, unless they can
show that they lack the skill and facilities
to treat these patients safely
Clinics without sufficient resources to offer
care should assist in referral to providers
equipped to manage such patients.

23. • Despite improved outcomes in the use of
sperm washing access to these
reproductive technologies fo
seropositive individuals is extremely
limited.
• Fewer than 3% of US ART practices
registered with the Society for ART
provide service to these couples
HIV AND THE HEALTH PROFESSIONAL

24. THIRD-PARTY ASSISTED REPRODUCTION FOR
HIV-INFECTED INTENDED PARENTS
• Disclosure of an intended parent's HIV status
to gamete donors or surrogate should
commensurate with principles of informed
consent.
• When an intended parent's HIV status poses
no medical risk to gestational carriers, it
should be regarded the same as any chronic
health condition.

25. CONCLUSION
• The potential for HIV-infected persons to live long and
healthy lives, have uninfected children, and not
transmit the virus to their partners has resulted in
increasing numbers of individuals to seek out optimal
means for creating biologic families.
• Evidence-based practice and social justice suggest that
our field should increase access to care for HIV-
serodiscordant couples
• Fertility treatment is a safe option for HIV-discordant
couples, and may be safer than attempted natural
conception.

26. CONCLUSION
• Sperm washing should only be carried out in
dedicated units using a multidisciplinary
approach ensuring adequate pre-conceptional
counseling, detailed sexual health and fertility
assessment and careful monitoring of the
woman’s HIV status during treatment and
pregnancy.
• Clinics without sufficient resources to offer care
should assist in referral to providers equipped to
manage such patients.

27. • Thank you!