Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
1 To whom correspondence should be addressed. Email: cgs{at}chelwest.nhs.uk
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Abstract |
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Key words: HIV/welfare of the child/assisted conception
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Introduction |
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The demand for assisted reproduction in HIV discordant and concordant couples is expected to rise as life expectancy for patients on highly active antiretroviral treatment (HAART) improves and vertical transmission risk falls to <1% (Frodsham et al., 2001). Retrospective data from sub Saharan Africa suggests that HIV positive woman are more likely to be subfertile (Ross et al., 1999
). Cohort studies indicate an increase in the severity of pelvic inflammatory disease when coexisting with HIV, a factor which is likely to increase the prevalence of tubal factor infertility amongst positive women (Kamenga et al., 1995
; Irwin et al., 2000
) and consequent demand for IVF in positive women. It is clear that these women are going to present a number of complex welfare of the child issues, particularly if the male partner is also infected. A further concern in providing IVF treatment is the theoretical possibility of increasing vertical transmission risk through the invasive procedures of oocyte collection and embryo transfer.
Our unit has treated 59 discordant couples, where the man is HIV positive, with sperm washing since 1999. A programme for the treatment of HIV positive women and HIV concordant couples was initiated in April 2002 and 47 couples have been seen. Significant welfare of the child issues sufficient to withhold treatment were identified in five cases. In this review we use three case histories to exemplify the complex welfare of the child issues encountered in our patient cohort that are specific to HIV positive couples.
Case histories
Case report 1:
Miss A was a 39 year old woman who presented to our clinic with her partner of 2 years. She was originally from Uganda and was diagnosed HIV positive in 1992 following the delivery of her second child. Unfortunately this pregnancy had ended as a stillbirth following an abruption of the placenta at 28 weeks gestation. As a result, the attending obstetrician advised HIV screening. Shortly after Miss A was diagnosed, her 5 year old daughter became unwell and died of AIDS related illness. Miss A then emmigrated to the United Kingdom.
Mr A was seronegative at the start of their relationship and they consistently practised protected intercourse to avoid transmission of the virus. He had fathered three children with previous partners. Six months into her relationship with Mr A, they sought advice on conceiving from an assisted conception unit. In view of his seronegativity they were appropriately advised to self inseminate with his ejaculated semen. After six months of self-insemination they had failed to conceive and returned to the clinic for further advice. They were told that further help was not available as Miss A was HIV positive. Unfortunately, in the absence of a further advice, they decided to have unprotected intercourse to try and achieve a pregnancy. Six months later, Mr A was identified as HIV positive following an episode of lymphadenopathy and malaise.
At the time of review in our clinic, Mr A had advanced HIV disease (high viral load and low CD4, despite HAART) and had coexisting tuberculosis. His semen analysis was poor, with a low count and poor motility and was suitable only for intracytoplasmic sperm injection (ICSI), despite a normal count prior to infection. At his most recent review, his HIV was better controlled on a different antiretroviral regimen but the semen analysis remained suitable for ICSI only. They were unable to afford ICSI and so could not proceed with treatment.
Case report 2:
31 year old HIV positive Mrs B attended clinic with her HIV negative husband. His HIV status was stated by Mrs B to be negative on the basis of a previous test some time ago in Africa. They both originated from sub Saharan Africa and had been married for 15 years. Mrs B had had five pregnancies with Mr B; two early miscarriages, two live births and one termination of pregnancy. Their two children died before one year of age of gastroenteritis and pneumonia, respectively. Mrs B was tested and diagnosed as HIV positive when her second child died. She terminated a pregnancy shortly after diagnosis, as she felt unable to cope at the time.
The couple had used protected intercourse consistently since her diagnosis. The couple had been attempting to conceive since 1993 without success using self-insemination quills. Prior to referral to our unit, fertility investigations had revealed that she had bilateral tubal occlusion and in vitro fertilization (IVF) was advised. Subsequent investigations in our unit indicated a poor sperm count with reduced sperm motility necessitating ICSI.
In the second consultation, documentary evidence of Mr B's HIV status was requested. He was unable to produce this and refused further testing. Our unit policy requires full viral screening (HIV, hepatitis B and C) of both partners before proceeding to treatment and we informed the couple that, with their permission, their case would need to be discussed fully with both the referring doctors and our local ethics committee due to his continued refusal to have an HIV test.
Discussion with Mrs B's HIV physician revealed a number of welfare of the child issues. Mr B had never attended any of the preconceptual counselling consultations with his wife and she had complained of his excessive alcohol intake that had affected the frequency of inseminations. Also of note was that he frequently travelled to Kenya on business, leaving her alone for long periods of time. Mrs B had advanced HIV disease and had been on many different drug regimens. Her current regimen was not advisable in pregnancy due to potential teratogenic effects and an alternative was not feasible as her HIV was multi-drug resistant.
Mr B's General Practitioner had frequently advised him to have an HIV test because he had suffered from pyrexia of unknown origin and was known to have a low CD4 count. He had failed to attend four appointments that were made to discuss this. In the third consultation with us, Mr B agreed to an HIV test. The result was positive. He subsequently stopped drinking and his HIV status and medication are under evaluation. The couple remain keen to have ICSI treatment.
Case report 3:
Mrs C was a 36 year old African housewife who attended with her British husband of 13 years. They were both HIV positive and were diagnosed in 1993. HIV testing was performed because of Mrs C's unusual skin lesions. Shortly after diagnosis she developed a spastic parapesis and became bed bound. This was later found to be an HIV related vacuolar myelopathy. Her spastic deformity of the lower limbs persisted but mobility had improved since diagnosis and she walked with the aid of two sticks. Her HIV was well controlled with HAART, with an undetectable viral load and CD4 count >300 but she had some drug resistance.
Mr C was well with a viral load of 1500 RNA/ml and CD4 of 1000 cells/mm3 without any medication. He had his own business in Kenya and so was frequently abroad.
Mrs C had had two pregnancies with a previous partner. One pregnancy proceeded to term but the baby died in the neonatal period. Her second pregnancy was a ruptured ectopic and partial salpingectomy was performed at an emergency laparotomy in Kenya. Mr C had never fathered a child. They had practised unprotected intercourse since meeting in 1990 but had never achieved a pregnancy together (protected intercourse was advised to reduce the transmission of drug resistant viral strains). A laparoscopy in 2001 demonstrated bilaterally blocked tubes which indicated that IVF with sperm washing (to reduce the transmission of drug resistant viral strains from male to female) would be necessary to conceive (Gilling-Smith and Almeida, 2003).
Welfare of the child issues were discussed at length during counselling with the couple and a written report from Mrs C's HIV physician reassured us that although Mrs C was disabled, she was independent. Mr C stated he would find employment in this country if she was to conceive and they would care for their child together.
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Discussion |
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Mr and Mrs B's case raises some important ethical dilemmas. Whilst they had shown substantial commitment to each other (by the longevity of their relationship and commitment to protected sex) and their desire to have a living child (years of self insemination), they presented relationship difficulties that could affect the welfare of the child. Mr B's alcohol abuse and failure to attend preconceptual counselling could have been secondary to his fear of being diagnosed HIV positive, but might also indicate his lack of commitment to having another child.
Their HIV disease raises important welfare of the child issues. Whilst we feel it is appropriate to treat carefully assessed HIV concordant couples, Mrs B's advanced illness would make management of her pregnancy difficult. She was on a salvage therapy that is inadvisable in pregnancy due to the unknown teratogenic effects of the medication on the fetus. Her options to change to a more suitable regimen were limited by multi drug resistance. Mr B's HIV disease is currently an unknown entity and it is possible that he will have similar drug resistance to his wife. If this were the case, both parents' life expectancies would be at risk of being shortened.
In the case of Mr and Mrs C, the severity of her disease at the time of diagnosis had left her with significant disability. Her neurologist had reassured us that her HIV related vacuolar myelopathy was unlikely to deteriorate in the future and was not thought to be advanced by pregnancy. It is possible that the weight of the gravid uterus would render her wheelchair bound in pregnancy and her degree of disability would require the presence of another parent or carer to assist in the care of any child born through treatment. However, after prolonged discussion with her HIV physician we were reassured that they were a committed couple who had made adequate plans if she were to conceive.
In treating HIV positive couples on our programme (which is the largest in the UK), we have encountered many complex issues. The treatment of seronegative fertility patients can pose ethical dilemmas for the reproductive specialist when considering welfare of the child, but HIV positive couples may bring additional complicated medical and social dilemmas that are pertinent to their fertility management. Their disease control is complex and requires very close liaison between the reproductive specialist, HIV physician and HIV specialist obstetrician.
The HIV positive women seen in our clinic often have poor obstetric histories, which not only have implications for future pregnancies but also increase the emotive issues surrounding their assessment.
Assessment of disease stage and management by the use of antiretroviral therapy is best considered by the HIV physician who may have known the patient for many years and has extensive experience in the use of these complex and ever evolving drugs. Social issues arising from the stigmatization of disease, psychosexual issues or emotional issues related to fertility treatments can be jointly managed by the in house fertility counsellor and specialist HIV health advisor.
Specialist counselling support from HIV Health Advisors is invaluable in the preliminary assessment of patients. Issues surrounding support networks, if one partner were to become ill or die, should be discussed at length. Social stigma to their disease may make it difficult for couples to seek support following failed or declined treatment and so it is essential for treating units to provide adequate counselling support. As many of our couples are immigrants to the United Kingdom, we have found that they may not have local family support networks and are further isolated by their disease. Even British Nationals may not feel that they wish to divulge their HIV status to family or friends and are often paradoxically relieved to have a diagnosis of infertility requiring treatment rather than having to undergo sperm washing purely as a risk reduction treatment, so that they can discuss their intended treatment, without fabrication, with friends or family.
The issue of unprotected sexual intercourse in the HIV discordant and concordant couple is difficult to assess and manage. The Swiss HIV Cohort group have demonstrated that significant numbers of discordant couples practice unprotected sex (only 73% of 114 couples questioned used condoms consistently) in order to conceive. Their questionnaire survey of infected couples indicated a lack of confidence in their health professionals and unwillingness to divulge issues surrounding sexuality in consultation (only 47% were willing to discuss sexuality in consultation; Panozzo et al., 2003). Whilst risk reduction treatments such as sperm washing are not universally state funded, it is impossible to expect couples desperate for a child to practise protected sex exclusively if they do not have sufficient funds for sperm washing. The cost of sperm washing is tiny compared with the cost of supporting a mother and child on antiretroviral medication.
The doctor can only be expected to be responsible for informing both parties of the risk of unprotected sex in terms of cross infection in the discordant, and transmission of variant viral strains in the concordant couple. Most importantly, patients who are seen in units that do not have facilities and expertise in this field should refer for a specialist opinion to a unit that does, so that patients who chose to practice unprotected sex do so with informed consent of both parties and knowledge of alternative, safer means of achieving a pregnancy.
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Conclusion |
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References |
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Drapkin-Lyerly A and Anderson J (2001) HIV and assisted reproduction: reconsidering evidence, reframing ethics. Fertil Steril 75, 843860.[CrossRef][ISI][Medline]
Dulioust E et al. (2002) Semen alterations in HIV-1 infected men. Hum Reprod 17, 21122118.
Englert Y, Van Vooren J, Place I et al. (2001) ART in HIV affected couples. Hum Reprod 16, 13091315.
Emanuel EJ (1988) Do Physicians Have An Obligation To Treat Patients With AIDS? New Eng J Med 318, 16861690.[ISI][Medline]
Frodsham LCG, Boag F, Barton S and Gilling-Smith C (2003) An Estimation of the UK demand for Fertility Services in HIV positive couples. BHIVA (oral presentation, April 2003).
Gilling-Smith C and Almeida P (2003) HIV, Hepatitis B and C Infertility: BFS Practice and Policy. HIV, Hep B&C-Practice and Policy. Hum Fertil 6, 106112.
Gilling-Smith C, Smith JR and Semprini AE (2001) HIV and Infertility: time to treat. BMJ 322, 567568.
Irwin K et al. (2000) Influence of Human Immunodeficiency Virus Infection on Pelvic Inflammatory Disease. Obstet Gynaecol 95, 525533.
Kamenga M, de Cock K, St. Louis M, Toure C, Zakana S, N'gbichi JM, Ghys P, Holmes KK, Eschenbach DA, Gayle HD and Kreiss JK (1995) The impact of human immunodeficiency virus infection on pelvic inflammatory disease: A case control study in Abidigan, Ivory Coast. Am J Obst and Gynecol 172, 915925.
Minkoff H and Santoro N (2000) Ethical Considerations in the Treatment of Infertility in Women with Human Immunodeficiency Virus Infection. New Eng Jour Med 342, 17481750.[CrossRef][ISI]
Panozzo L, Battegay M, Friedl A and Vernazza P and the Swiss HIV Cohort Study (2003) High risk behaviour and fertility desires among heterosexual HIV-positive patients with a serodiscordant partner-two challenging issues. Swiss Med Wkly 133, 124127.[ISI][Medline]
Ross A, Morgan D, Lubega R et al. (1999) Reduced fertility associated with HIV: the contribution of pre-existing subs fertility. AIDS 13, 21332141.[CrossRef][ISI][Medline]
Ryan K (2001) Using metaphor to deal with human immunodeficiency infection and infertility. Fertil Steril 75, 859860.[CrossRef][ISI][Medline]
Sauer M (2003) Providing Fertility Care to Those With HIV: Time to Re-examine Healthcare Policy. Am J Bioethics 3, 3340.
Sharma S, Gilling-Smith C, Semprini AE, Barton SE and Smith JR (2003) Assisted conception in couples with HIV infection. J Sex Trans Infect 79, 189190.[CrossRef]
Smith JR, Reginald PW and Forster SM (1990) Safe sex and conception: a dilemma. Lancet 335, 359.
Smith JR, Kitchen VS, Munday PE et al. (1991) Infertility management in HIV positive couples: a dilemma. BMJ 302, 14471450.[ISI][Medline]
Submitted on February 25, 2004; accepted on May 14, 2004.
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