Reproductive Assistance for HIV-Discordant Couples

Since the advent of highly active antiretroviral therapy (HAART) for patients with human immunodeficiency virus (HIV) infection, a number of authors have challenged the long-standing view that it is ethically unjustifiable to provide reproductive assistance to HIV-positive individuals (Minkoff and Santoro 2000; Gilling-Smith and Smith 2001; Lyerly and Anderson 2001; Englert et al. 2001; Marina et al. 1998a; 1998b). Mark V. Sauer (2003) has contributed to this debate by arguing that for HIV-discordant couples in which the male is HIV-positive, assisted reproduction using intracytoplasmic sperm injection (ICSI) is ethically justifiable and, furthermore, might involve a lower risk of transmission than intrauterine insemination (IUI) or traditional IVF in which sperm and egg are mixed in culture. It is worth noting that the type of case on which Sauer focuses is only one of a variety of scenarios involving HIV-discordant couples, each of which is ethically distinct. Consider the following examples:

1. The male partner is HIV-positive, the woman HIV-negative, and the couple requests IUI with the man's processed sperm.

2. The male partner is HIV-positive, the woman HIV-negative, and the couple requests ICSI with the man's processed sperm. (This scenario is the main concern of Sauer's paper.)

3. In the early 1990's, prior to the use of zidovudine or HAART during pregnancy, serodiscordant couples sometimes requested reproductive assistance. Suppose that the male is HIV-negative, the female HIV-positive, and they request IUI. Here the risk of vertical transmission is approximately 25%.

4. In the mid 1990's, zidovudine began to be used to reduce the rate of vertical transmission. Again suppose the male is HIV-negative, the female HIV-positive and willing to use zidovudine, and they request IUI. In this scenario the risk of vertical transmission is approximately 8%.

5. In a more contemporary case the man is HIV-negative, the woman HIV-positive, they request IUI, and the woman is in stable condition on HAART. Here the risk of vertical transmission is approximately 2% if the woman's viral load is below 1000 copies/mL at the time of delivery or if her viral load is above 1000 and a scheduled cesarean section is performed prior to onset of labor or rupture of membranes (Public Health Service Task Force 2002).

Each of the above scenarios has two versions: in one it is learned, either because the couple volunteers the information or provides it in response to questioning, that the couple plans to attempt procreation by intercourse if assistance is not provided; in the other the couple states an intent to abstain from unprotected intercourse if reproductive assistance is not obtained.

Similar issues involving assisted reproduction when the potential child is at risk can arise outside the context of HIV-infected partners. Consider, for example:

6. An infertile couple seeks reproductive assistance. Both are carriers for cystic fibrosis, and the woman is unwilling to have an abortion if the fetus has cystic fibrosis. The chance that a given child will have cystic fibrosis is 25% (approximately the same probability as in scenario 3).

In the future, there will be a variety of scenarios similar to the following:

7. Genetic testing of a couple indicates that if they reproduce, there will be a (pick one) 5%/10%/15%/and so on chance the offspring will develop (pick one) diabetes/schizophrenia/breast cancer, and so on.

One of the fundamental issues raised by these scenarios concerns how to decide when the risk to offspring is so high that it would be wrong to attempt procreation. With regard to the type of case Sauer discusses (scenario 2), I agree that it is ethically justifiable to provide the type of reproductive assistance in question, and I would like to lay out what I consider to be the arguments supporting this view. The arguments differ, depending on whether the couple intends to try to conceive naturally if...