Assisted Reproductive Technologies for HIV-Discordant Couples

Mark V. Sauer (2003) has eloquently advocated for the reproductive rights of human immunodeficiency virus (HIV)-serodiscordant couples. He posits that assisted reproductive technologies can be made available safely to HIV-infected men and their uninfected partners, and he argues persuasively that such technologies should be made available to these couples in the United States as they are in Europe. His institution currently offers in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI) to serodiscordant couples in an attempt to reduce the risk of HIV transmission from an infected man to his uninfected partner. The ethical principles he and his institution considered in deciding to offer these services included respect for autonomy, nonmaleficence, beneficence, and justice. While we agree with Sauer and his colleagues regarding the ethical responsibility to support the reproductive rights of all persons, including those infected with HIV, we would like to clarify several points.

It is important that we first define assisted reproductive technologies (ART) and the specific indications for each intervention. ART often refers to a wide variety of interventions developed to treat infertility. Intrauterine insemination (IUI) with processed semen involves collecting a semen specimen and processing it to remove prostaglandins and other contaminants so that it can be safely deposited directly into the uterus transcervically via a small cannula. This is not generally considered ART in the United States; U.S. laws reserve this term for procedures in which both sperm and egg are handled outside the body (Fertility Clinic Success Rate and Certification Act of 1992, Public Law 102-493, 1992). Extracorporeal fertilization involves artificially inducing ovulation and retrieving eggs, followed by in vitro fertilization and transcervical transfer of the embryo(s) (IVF-ET). A more invasive approach involves fertilization under a microscope, using a pipette to select and inject the spermatozoa directly into the cytoplasm of an oocyte (IVF-ICSI), and transferring fertilized embryos into the uterus.

A discussion of the risks and potential benefits of ART in HIV-discordant couples is central to any consideration of the ethics of these interventions. One issue in the use of these technologies among HIV-discordant couples is that the risk of the procedures is not well defined. In 1990 the Centers for Disease Control and Prevention (CDC) recommended against all insemination with semen from HIV-infected men based on a report of an HIV infection in a woman who underwent artificial intrauterine insemination of processed semen from her HIV-infected husband (CDC 1990). In that case the mode and timing of transmission could not be determined definitively. The woman lacked other risk factors for transmission, however, and reported symptoms suggestive of an acute retroviral syndrome after the first of three insemination attempts. CDC investigated the methods used to prepare the semen and found that they did not effectively separate lymphocytes—the largest reservoir of the virus in semen—from spermatozoa (CDC 1990).

Since that time methods for processing semen and testing for seminal HIV have improved. Semprini and others have developed techniques for processing semen using gradient centrifugation and a "swim-up" method to remove HIV from spermatozoa. Prior to intrauterine insemination (IUI), processed semen is tested for HIV RNA and DNA (Semprini et al. 1992). Although the reports from Semprini and others are promising, the literature on these procedures is incomplete in several ways. Few such reports have appeared in peer-reviewed literature, and because follow-up of treated couples is incomplete we cannot rule out HIV infection in women lost to follow-up. Moreover, even if complete follow-up were available, it would be difficult to assess whether IUI with processed semen is less risky than unprotected intercourse, because the rate of sexual transmission of HIV is very low. The rate reported from several studies of HIV-discordant couples is one to two transmissions per 1000 acts of unprotected intercourse. Given that data...