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Preconception Counseling among HIV Serodiscordant Couples

Print [pdf 30kb] - Updated 8/2010

HIV positive woman with HIV negative male partner

Female-to-male HIV transmission likely occurs as a result of infection at either the base of the foreskin in uncircumcised men or via the urethra in circumcised men. Given the risk of HIV acquisition with unprotected vaginal sex, serodiscordant couples are encouraged to use safe sex and home insemination techniques in order to conceive.

General principles

  • Given risk of teratogenicity in early gestation, avoid efavirenz in any woman of reproductive age who is considering pregnancy
  • Review standard pregnancy expectations including precautions, prenatal vitamins, standard pregnancy symptoms, possible complications
  • Highlight concerns specific to HIV including assurance of clinic visits and laboratory monitoring to assure viral suppression with utilization of HAART, planned induction of labor, administration of zidovudine during labor and post-partum infant zidovudine (for six weeks)
  • Emphasize goals of care for pregnancy that focus on optimizing the physical health and well being of the patient
  • Disclose strong guidelines against breast feeding in the U.S. in the context of HIV 
  • Engage in standard counseling regarding fertility for women of advanced maternal age (>35) with consideration of referral for more advanced techniques through UWMC/Roosevelt Reproductive and Endocrinology/Infertility services if intravaginal techniques are unsuccessful after 3-6 months

Ovulatory Monitoring

  • Advise women to start monitoring their menstrual cycle by measuring cycle length (day 1 is referred to as first day of menstrual period).  Purchase over the counter ovulation prediction kits (allows for timing of intercourse to achieve pregnancy that is not possible with basal body temperature charts)
      • Urine testing for detection of LH surge.  A favorable urine sample is the first morning void
      • Testing, for those who have 28 day cycles, begins on day 10 and continues for seven day

Partner Testing

  • HIV and STD testing for male partner (including C. trachomatis, N. gonorrhoea, RPR)
  • Semen analysis is not generally recommended at outset but may be considered later in the event of difficulty conceiving

Intravaginal Insemination

  1. Ideal insemination days occur 24-36 hours after the positive ovulation prediction kit.
  2. Male partner/donor is advised to ejaculate into a container (a plastic urine cup is acceptable)
  3. Woman draws up the fresh ejaculate into 5-10 ml syringes and releases the contents of syringe directly into her vagina  (women should NOT place the semen into or through the cervix)
  4. Fourteen days after insemination, await a missed menses and then test urine HCG (standard over-the-counter pregnancy kits)

Women who do not become pregnant within six months of this method may consider office intrauterine insemination (IUI) with either a known male donor/partner or a sperm donor (via sperm bank). If the sample is from a known male donor, the donor must undergo clinical evaluation and laboratory testing, including basic lab work and sperm analysis (number of viable sperm, motility, etc). 

These services are available through University Reproductive Care (URC) at Roosevelt: Drs. Brenda Houmard and Kat Lin.  The semen will be washed by the Male Fertility Laboratory under the direction of Dr. Charles Muller. They offer intra-uterine insemination (IUI), a procedure that should not be attempted without the assistance of an experienced clinician, given the risk of infection.  The client meets with either Dr. Houmard or Dr. Lin, who conducts a general ob/gyn history and clinical exam that may includes some basic laboratory testing and further fertility testing and, depending on history, may include more extensive infertility assessment including serologic testing and a hysterosalpingogram.

For Natural Cycle IUIs, the client informs the URC staff of the first day of her menstrual cycle.  On the day of her LH surge, the client calls the URC clinic to schedule an IUI the following day.  Unlike intra-vaginal inseminations, IUIs are performed in a clinic setting with sperm that are prepared by the UW andrology lab from frozen samples or from a male partner.

  1. The initial part of the procedure mirrors a general gynecologic examination with the client in the lithotomy position. 
  2. A speculum is inserted and the sperm are injected into the uterus utilizing a long flexible and thin flexible catheter that enters the os.

The procedure is generally well tolerated.  These services are available 365 days a year.

HIV positive man with HIV negative female partner

Male-to-female HIV transmission occurs via infection of endocervical or possibly vaginal epithelial cells.  Women are thought to be at higher risk of acquiring HIV compared to men, possibly because of a larger vulnerable surface area and longer exposure to infectious semen. Unfortunately, there are no low-cost alternatives to allow for safer conception for these discordant couples.

We highly recommend close multi-clinic collaboration between: Madison HIV provider and University Reproductive Care physicians.

General principles:

  • Male viral suppression is key
  • Standard STD screening/testing (RPR, GU C. trachomatis and N. gonorrhoea testing) applies for both partners

The most standard methods of attempting to conceive with an HIV-positive male partner include a few options that include:

  • Insemination of the female partner with sperm from a known HIV negative male source (frozen specimens from a sperm bank)
  • In-vitro fertilization (IVF) with Intracytoplasmic Sperm Injection (ICSI): removal of the sperm from the positive partner and collection of eggs from the female partner.  The eggs are directly injected with the sperm and then implanted into the female partner; this method is costly and still carries some, though, minimal risk of HIV transmission.  This requires the male partner to be on suppressive medications to minimize his viral load.

A research study exploring more economical fertility options for HIV Discordance in male+/female- couples is ongoing at the University of Washington.  This study is not enrolling human participants at this time but utilization of various separation procedures to yield a sperm specimen that is negative by PCR for the HIV virion.  This specimen could theoretically be inseminated.  This method, though theoretically ideal for discordant male+/female- couples, is not standard practice in the U.S. at this time.

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