Can a serodiscordant couple have a child?

Thanks to scientific advances and the medicine available for HIV (Human Immunodeficiency Virus), seropositive people these days have a better quality of life and that is why it is common for many couples in this situation to consider the possibility of having a family.

WHEN THE MAN IS INFECTED WITH HIV

When the male partner has tested positive for HIV antibodies, couples can undergo Artificial Insemination if they wish to have children. This reduces the possibility of the infection transmission both to the woman and the foetus.

This technique consists of separating the motile spermatozoa from the rest of the ejaculate as the possible HIV virus is contained in the seminal liquid. Moreover, in this way the possibility of fertilisation increases because the number of motile spermatozoa in the sample is higher.

It should be mentioned that Artificial Insemination techniques have been applied for some time. Therefore, the available experience is extensive.

Over the last few years this technique has been carried out successfully by using washed sperm for HIV cases. Although there is a theoretical risk of infection, so far there has been no case of seroconversion of the woman or of the foetus.

In order to maximize the efficiency of the procedure and minimize the number of insemination attempts, the cycle of the woman is controlled pharmacologically.

The chances of a resulting pregnancy after two or three attempts range between 50% and 60%.

WHEN THE WOMAN OR BOTH PARTNERS ARE INFECTED WITH HIV

It is important to bear in mind that when a pregnant woman is a HIV carrier and does not receive the appropriate treatment, the risk of the infection transmission to the child ranges between 15% and 20%.

Over the last few years this risk has been reduced to less than 1% as a result of the introduction of new effective medicine for AIDS and later on the use of combined antiretroviral pharmaceuticals as well as strict pregnancy and birth protocols. However, these drugs are potentially teratogen (they can cause malformations in the newborn) and have to be administered under specialized control.

In order to reduce the pregnancy risk the woman has to be in a stable condition which helps her avoid changes in the medication (they are not advised) as well as any developing infections.

If there is no other infertility factor Artificial Insemination is recommended either with fresh or washed sperm, in cases where the male partner is also a HIV carrier.

Requirements for Artificial Insemination

The infection of the male partner has to be stable, in such a way that no other illness has been diagnosed recently and he is otherwise in good health. Both partners have to undergo a series of additional checks before the insemination to determine their general wellbeing and identify a possible unknown infertility problem.

In this case it may be necessary to apply other Assisted Reproduction Technique such as In Vitro fertilisation.

Requirements for a minimal risk pregnancy

- The woman should be in the best possible physical condition before deciding to become pregnant.

- To know the associated risks of the medication and, if possible, to avoid those parts of the treatment which represent the most risk for the foetus.

- For both partners their condition has to be stable thus confirming the absence of any recent illness.

- When the man is not infected with HIV it is recommended to use Assisted Reproduction Techniques such as Artificial Insemination in order to avoid the transmission of the disease.

Advice for couples who want to have children

Advice for couples where one partner is seropositive and who want to have children. When in a couple one or both partners are infected with HIV, they should be aware that if they want to have a child they need specialized help and attention in order not to risk their health and that of the newborn. This help involves four aspects:

Base illness stability and control by a specialist.
Reproductive advice in order to programme the pregnancy under the best possible conditions or rule it out in some cases.
Artificial Insemination with washed sperm for HIV cases.
Assisted Reproduction Techniques in cases where a sterility problem may exist.

Artificial Insemination with prepared sperm

ARTIFICIAL INSEMINATION BY HUSBAND (AIH) IN SERODISCORDANT COUPLES NON RESIDENT IN BARCELONA

There are very few centres offering experience and standard procedures to help HIV infected patients who want to have children. Barcelona and Milan are two pioneering cities in the development of this technique which essentially consists of using the previously prepared sperm for Artificial Insemination.

Although Artificial Insemination procedure with previously prepared sperm has to be carried out in Barcelona, in some cases most of the fertility study and the hormone preparation of the woman can be efficiently undertaken in the couple’s home town or area.

The whole process is coordinated by post or the Internet. Therefore, many couples non resident in Barcelona can take advantage of Assisted Reproduction Techniques in a convenient way. This allows them to reduce the cost of the treatment as they do not have to travel to the clinic more than is absolutely necessary.

Extra checks for the man

Before starting the technique, a series of analytical results and additional tests are necessary for both partners. This information can be obtained in the couple’s home town in collaboration with the infectious disease specialist who normally attends to the case.

The following tests are needed for the man:

Spermogram This spermogram focuses on the fertilisation potential of the male partner’s sperm after undergoing the sperm washing. For this reason it has to be taken in Barcelona following the same procedure that will be carried out on the day of Artificial Insemination.

Blood tests They are required in order to be able to control the infection as well as a possible associated pathology. A complete hemogram, hepatic and renal biochemical tests, serologies (HBsAg, anti-HC, lues) and HIV study (viral load levels and CD4 values) can be taken in the couple’s home area.

Urethral smear Sometimes it is taken in order to rule out STD’s (sexually transmitted diseases) such as gonococcus and Chlamydia. These cultures can either be taken in the patient’s home town or in Barcelona.

The report from the specialist in infectious diseases It has to be done by the specialist who attends to the male partner’s case and controls his base pathology. This report evaluates the current condition of the illness and specifies the treatment the patient is undergoing. The specialist fills in a standard form to simplify the information provided.

Psychiatrist report This report is necessary only if the male partner is undergoing a substitutive treatment with opiates or psychiatric drugs.

Extra checks for the woman

Gynaecological check-up It consists of an updated cytology and takes place at the first appointment in Barcelona.

Blood tests They consist of a complete hemogram, hepatic and renal biochemical tests, serologies (HBsAg, anti-HBs, anti-HC, rubella, toxoplasmosis, lues, HIV), blood group and Rh. These tests are taken for the correct preconception evaluation which will be necessary if the outcome of the procedure is successful and the pregnancy does occur. These results can be brought to the clinic from the patient’s home town if they are recent.

Hormone analysis It is taken on the third day of the menstrual cycle and is made up of FSH, LH and 17 β-Estradiol. If this falls on a holiday it can be taken between the second and the fifth day of the cycle. The woman can bring the results from her home town.

Smear test It is necessary in order to rule out STD’s (gonococcus and Chlamydia) and the results can be brought to the clinic.

Hysterosalpingography The permeability of the uterus and the Fallopian tubes is checked by means of a contrast x-ray technique. It should be carried out between the eighth and twelfth day of the cycle and can be done in the patient’s home town. This test is not always necessary.

Basal temperature This is normally taken using the rectal method every day starting on the first day of the menstrual cycle and for the duration of approximately two cycles. There are specific graphs to record the given temperature.

Viral load determination via PCR This has to be carried out before the insemination takes place and one month later. If the pregnancy does occur, the HIV antibody determination has to be performed every three months until the birth in order to control the seronegativity. This test is important as Artificial Insemination will not be applied without a negative result.

Artificial Insemination requirements

The infection of the male partner has to be stable, in such a way that no other illness has been diagnosed recently and he is otherwise in good health. Moreover, an updated report from the patient’s specialist has to be provided in order to have a professional opinion about his state of health at this time.

Regarding the woman, the basic requirement is a negative HIV result. If the woman is a HIV carrier too she has to meet the same requirements as the man, and consider other Assisted Reproduction Techniques such as In Vitro fertilisation.

In order to maximize the efficiency of the techniques and minimize the number of insemination attempts, the cycle of the woman is induced pharmacologically. The couple has to sign a consent form.

Coordination of Artificial Insemination procedure

Artificial Insemination technique with prepared sperm is carried out in Barcelona. However, the case study, preparation and the cycle control can take place in the patients’ home town as they travel to the clinic only to bring their tests and for the treatment follow-up. Normally it is enough to have four appointments in Barcelona but if the patients have their own gynaecologist in their area, the whole process can be completed in two appointments: one on the first visit and the other on the day of the insemination.

Artificial Insemination with prepared sperm (short procedure)

First appointment

This first visit is specifically focused on the topic of Reproduction. It is very important as it allows for a global evaluation of the case. It takes place in Barcelona. After analysing the information provided by the patients the case is evaluated by the doctor and its follow-up is planned.

On the day of the appointment and after four days of sexual abstinence, the male partner provides a semen sample which is used for a spermogram and the evaluation of sperm function. As for the woman, it is recommended that she is not menstruating and can undergo a gynaecological check-up.

Taking into consideration the available results and the interview, the medical team will prescribe additional tests which are necessary to complete the case study. An andrologic check-up for the male partner will be scheduled and take place during the same appointment in order to reduce the number of visits to the clinic.

If an anomaly is detected during the case study, it will be further studied to confirm whether Artificial Insemination is the most suitable technique for the couple. This study can be coordinated by the specialist in infectious diseases who passes on information and comments in an efficient way via the Internet (eugin@euvitro.com). The patient’s gynaecologist’s cooperation is also invaluable. If the internet is not available, the information can be sent via fax (93 322 11 22) or by post.

Procedure follow-up in the home area

The procedure is much simpler if the patient has a gynaecologist in her home area he can help the couple to compile all the additional tests as well as carry out follicular controls. In this way there is no need to come to Barcelona when not strictly necessary.

To be precise the specialist will evaluate the acquired results of both partners.

When finally all the requirements applicable to the case are met, a detailed explanation about the hormone treatment to follow for the ovulation induction before the insemination will be given to the woman. At this time the supervision of the patient by the gynaecologist is of utmost importance.

When it has been decided in which cycle the insemination will take place, on the first or second day of her period the woman will call Barcelona to confirm the procedure and the dosage for the hormone treatment to follow. As a rule, the treatment begins on the third day after the menstrual cycle starts.

At the same time an appointment with the patient’s gynaecologist is scheduled so that she can see the doctor after having followed the treatment for seven days. With this appointment an ultrasound scan via the vagina is carried out in order to check the ovarian response and, according to the results, another follicular control is scheduled. The patient will continue with the treatment and the check-ups until the ovaries are ready for the insemination.

Second appointment

This appointment is the last compulsory visit to the clinic. When the follicular controls show the appropriate ovarian response, the Artificial Insemination treatment will be programmed. It will take place in Barcelona two days after the last ultrasound scan. On the same day the male partner has to come to the clinic after not having had sexual intercourse for four days.

Early on the day of the insemination the semen sample has to be taken to the andrologic centre in Barcelona where the PCR technique will be performed on it in order to rule out the presence of any viral particles. If the result is negative (the sample is virus free) this sperm will be used for the insemination of the female partner in the afternoon. Therefore, the couple has to be in Barcelona early in the morning so that there is time to prepare the semen for the treatment.

The patients can leave the clinic and return home immediately after the procedure. It is important to remember that before this insemination cycle and one month after it, the woman has to undergo a HIV antibody determination via PCR so that her seronegativity is confirmed. If the pregnancy does occur the procedure has to be performed every three months up to the birth.

Artificial Insemination with prepared sperm (long procedure)

First appointment
This first visit is specifically focused on the topic of Reproduction. It is very important as it allows for a global evaluation of the case. It takes place in Barcelona. After analysing the information provided by the patients the case is evaluated by the doctor and its follow-up is planned.

Second appointment

Depending on the time necessary to compile the tests required on the first appointment (between three and six weeks) the second visit is scheduled.

This appointment also takes place in Barcelona and during it the doctor evaluates the obtained results from both partners, among them the spermogram of the previously provided semen sample. If all the available information for both patients allows the doctor to suggest Artificial Insemination, an appointment with an andrologist may be scheduled for the male partner if needed.

When finally all the requirements applicable to the case are met, a detailed explanation about the hormone treatment to follow for the ovulation induction before the insemination will be given to the woman. At this point the treatment consent forms are signed by the patients.

Third visit

At the same time the third appointment at the clinic is scheduled so that she can see the doctor after having followed the hormone treatment for seven days. With this appointment an ultrasound scan via the vagina is carried out in order to check the ovarian response and, according to the results, another follicular control is scheduled.

Fourth visit

When the follicular controls show the appropriate ovarian response the Artificial Insemination treatment will be programmed. It will take place in Barcelona two days after the last ultrasound scan. On the same day the male partner has to come to the clinic after not having had sexual intercourse for four days.

Related information

Can I be a father after a vasectomy?

I do not have a partner but I would like to be a mother

Can I have a child after a tubal ligation?

Can a serodiscordant couple have a child?

Can illnesses in the foetus be found before pregnancy?

Artificial Insemination in couples not residing in Barcelona

In Vitro fertilisation for couples not residing in Barcelona