This Month in HIV: Having a Baby When You're HIV Positive
These choices mostly focus on mixed status heterosexual couples -- negative men with positive women, positive men with negative women. For gay male couples, however, things are still a little bit difficult.
To talk with us today about this new era of reproductive technology, we are pleased to feature three guests: an HIV fertility doctor and researcher, and two women -- one positive and one negative -- who have both successfully had negative children using reproductive technologies.
Our first guest is Dr. Ann Kiessling, Associate Professor of Surgery at Harvard Medical School and Director of the Bedford Stem Cell Research Foundation. Dr. Kiessling, who is not a physician, has a Ph.D. in biochemistry/biophysics. She has helped more than 40 couples affected by HIV safely deliver healthy babies, through the foundation's Special Program of Assisted Reproduction -- also called SPAR. The foundation's success has inspired other fertility centers in the United States to start SPAR programs. Dr. Kiessling is a widely published author and a noted researcher. She is also the mother of three daughters and a son. Welcome, Dr. Kiessling.
Dr. Kiessling: Thank you. Happy to be here.
Our second guest is Christa (not her real name). Christa is HIV negative and her husband of seven years is HIV positive. They conceived safely thanks to a combination of having her husband's sperm washed in a special procedure and then mixing the washed sperm with her egg in an in vitro fertilization [IVF] procedure. Dr. Kiessling's foundation did the sperm washing, but the couple flew all the way from the east coast to Arizona for the in vitro fertilization procedure. Luckily, Christa got pregnant on the first try. Today she is the proud mom of a four-year-old, HIV-negative son. Thanks for being here, Christa.
Christa: Hi. You're welcome. Happy to be here.
Our third guest is Wendy Williams (not her real name). Wendy is HIV positive and her husband is negative. Wendy safely conceived and delivered an HIV-negative son with the help of artificial insemination and fertility drugs. But her journey to motherhood was not as easy: She spent nearly two years going through insemination procedures and had to take expensive fertility medications in order to get pregnant, all the while struggling to keep her viral load undetectable. Her HIV-negative son is now six years old. She has worked as an HIV educator, writer and volunteer since 1993. Welcome, Wendy.
Wendy Williams: Thank you.
Dr. Kiessling, I know it has taken a long time to get fertility clinics to take on mixed-status couples for fear that they will be sued if a child is either born HIV positive or a woman gets infected. When did you first start taking on mixed-status couples, and how have legal considerations affected your work?
Dr. Kiessling: This program actually started with an editorial that I wrote in 1989 to a journal called Fertility and Sterility, and it seemed like a pretty benign observation that we were going to have to help people with HIV disease parent through assisted reproduction.
This came about because I had studied the HIV virus for a long time. At that time, there were concerns [about helping HIV-positive people parent], and those concerns persisted until about three or four years ago. The concerns were partly legal, but the other part of the concern was that the assisted reproduction laboratories were not really clear on exactly how to handle semen from somebody who was infected. I realized that if they could be provided sperm from specimens where the sperm was free of the virus, they would be more willing to go ahead and help couples who were in this circumstance.
So it was partly concerns that women might get infected with HIV, but the underlying concern for assisted reproduction clinics was that they didn't want anybody to know that they were helping people with HIV disease in their clinic. The other [concern] was that the laboratories were not equipped to handle the problem.
Why were the assisted reproduction clinics afraid to let anyone know that they were helping couples who were positive?
Dr. Kiessling: Throughout the late '80s, and all the way through the '90s, HIV disease was considered a very mysterious and scary disease. For business reasons, the clinics thought that [HIV-negative] couples were going to be uncomfortable if they thought that somebody who was HIV infected actually had their eggs and sperm in the same incubators as somebody who was not HIV infected.
Dr. Kiessling: Double wow.
What made you feel differently?
Dr. Kiessling: I understood the virus a little better -- a lot better probably -- because we'd studied this virus. We did the very first experiments to understand the burden of the virus in semen specimens in the early '80s, when I was still at the medical school in Oregon. So we had studied this disease for a long time. The virus is pretty fragile. We knew how to handle it -- how to inactivate it -- and we felt comfortable that this could be done safely.
What are the most common requests in your clinic?
Dr. Kiessling: Common requests?
From mixed-status couples. Is it negative women with positive men?
Dr. Kiessling: Yes. That's the most common. There are a number of clinics that can figure out how to help a woman who is HIV infected achieve a pregnancy, because we have become very successful at treating HIV disease in women. We know how to keep them on antiviral therapy and protect their offspring from infection throughout the pregnancy. There are a number of centers that know how to do that. So that problem generally doesn't come to us.
Do you find that the couples you have helped had a hard time finding you, or finding a clinic?
"What we have found now is that many of the assisted reproduction clinics that collaborate with this program don't necessarily want it widely advertised that they do."
-- Dr. Kiessling
Dr. Kiessling: Yes, they did have a hard time finding us. Obviously, advertising and PR [public relations] is not our strong point. What we have found now is that many of the assisted reproduction clinics that collaborate with this program don't necessarily want it widely advertised that they do.
If the couple has not already organized a clinic, we usually have them come and talk with us. We figure out their geography and their timeline and their circumstances, and then we choose two or three clinics that we know will help them, as long as they are going through our program, so that the clinics themselves don't have to advertise this service.
It's astonishing that all this is so secretive! Is there still a fear that their other patients would find out that they are taking care of HIV-infected people?
Dr. Kiessling: I think that's less and less. I just think that they don't know how to answer the questions when people call. So it's much easier if they start out through us. We can answer the questions; tell them exactly what they have to do. In many ways I think it's a logistics problem with their office staff.
Can you walk us through all the methods an HIV-negative woman can use to get pregnant from an HIV-positive man? Please discuss the safety of each procedure, in terms of HIV transmission risk.
Dr. Kiessling: We hope the transmission risk is zero. Of course, there's no way to really guarantee that. The way this works now is, the man submits a semen specimen. We first of all make sure that he's in care for his disease. He has to convince me that he's serious about taking care of himself, that he's in the care of a qualified physician for his disease.
We don't have any particular clinical benchmarks. He doesn't have to have an undetectable burden of virus [i.e., viral load] in blood. I really leave that up to his infectious disease physician. But he has to be healthy, and he has to be serious about taking care of himself now. And the couple has to be serious about having safe sex.
Do you do the first initial discussion on the telephone? Or do you have to see the HIV-infected man or couple in person?
Dr. Kiessling: The whole process works best if we get to talk to people in person, because there's a lot that the woman needs to know.
There are a lot of life details to go through. It all works better in person.
Under certain circumstances, if that's just a huge burden and they can't manage it, then we'll do a phone conference. But we sort of have a pretty hard policy now that if there's going to be a surrogate involved, they have to come in person.
"If we detect any virus, the sperm are discarded. It's not a matter of how much virus can you wash away. It's really a matter of using sperm from a specimen that wasn't exposed to virus to begin with."
-- Dr. Kiessling
Once that is sort of established, and we have some guidelines about his disease status and the care he's under, then he submits a semen specimen to the laboratory. The sperm from that specimen is cryopreserved and the rest of the specimen is tested for virus. If we detect any virus, the sperm are discarded. It's not a matter of how much virus can you wash away. It's really a matter of using sperm from a specimen that wasn't exposed to virus to begin with.
We actually still don't know where in the male reproductive tract HIV arises. We're sure that the sperm themselves are not infected. They are exposed to virus by some of the other fluids from the reproductive tract that are part of the semen specimen. Since we don't know exactly where it comes from, each specimen is pretty unique. I worry just as much about infected cells as we do free virus particles.
What's measured in the bloodstream is free virus particles. That's an RNA burden that's measured. However, I think for semen transmission, a more dangerous form and infectious form of the virus is its virus-infected cells in the semen specimen. So we do this research, this sort of complicated research assay, that we've done for a long time. That assay detects both free virus particles and virus-infected cells in the semen specimen.
If we don't detect any virus in that specimen, and those sperm have already been washed, then those are sort of checked off, and those are eligible for use in assisted reproduction. [To view illustrations of the sperm washing process, click here]
What do you mean by "washed?"
Dr. Kiessling: Well, when the semen specimen comes into the laboratory, you have to recover the sperm away from the seminal plasma, away from all the fluid part of the semen -- and away from the transport medium that was used to ship the sperm, if it was shipped overnight by carrier.
In that process, the sperm themselves get -- you know, everything gets washed away from them, so that what's cryopreserved has already been washed. Then the sperm are frozen in a special way that keeps them alive when you thaw them out, and they are stored in liquid nitrogen. It's sort of standard sperm banking practice.
As a result of the freezing, are the sperm less fertile?
Dr. Kiessling: Not all of them survive the thaw, but for a healthy guy with normal sperm, well over 50 percent of them will survive this procedure, and they are stable in liquid nitrogen for quite a long time. I think we store them for two years.
Then what happens?
Dr. Kiessling: Then, it depends on the couple. It depends on her age, and it depends on the sperm count, whether we recommend in vitro fertilization (IVF) or whether they are eligible for a simpler procedure, which is called oligospermia cup insemination.
Now, in vitro fertilization is a little more invasive, although, for a woman who is over 35, it's going to take her a shorter time to conceive, probably, if she goes through in vitro fertilization. That's the most popular method with most of the infertility clinics that are helping us.
But about five years ago or so, we were contacted by a couple of physicians who had been taking care of HIV-infected women, some perinatologists. They really encouraged us to come up with a less invasive and less expensive way for people to have children with tested sperm.
We were very reluctant to use a procedure that is more common in infertility clinics, a procedure called intrauterine insemination [also called IUI]. There's a big program, I think in Italy -- and perhaps one in England -- that uses this procedure.
I'm reluctant to do intrauterine insemination, for a couple of reasons. One: our Centers for Disease Control and Prevention in Atlanta, Georgia, have on their books a white paper that says that they don't think this approach has been proven safe. The other reason is, I worry so much about these infected cells, which are very difficult to detect. You have to use up almost a whole specimen to be able to detect these infected cells. For those two reasons we were reluctant -- or, actually refuse -- to use washed sperm for intrauterine insemination.
The cup insemination procedure is less invasive. It is well established. It's a very old method; it's been around a long time. It was originally designed for couples when the male has a low sperm count. In that procedure the washed and tested sperm are placed in a plastic device that sits very close to the cervix. Only the sperm can swim through, avoiding the risk of putting an infected cell directly into the uterus. Those are the two options.
How long does this cup have to stay in place?
Dr. Kiessling: A couple of hours.
The woman stays in one place for a few hours?
Dr. Kiessling: No. She can walk around. It's very similar to wearing a diaphragm. I think most women don't even know it's there.
Do they go home with it?
Dr. Kiessling: They go home with it. That's right.
Research suggests that HIV virus replication is compartmentalized between blood and semen. Thus an undetectable viral load in blood may not indicate an undetectable viral load in semen. Similarly, treating HIV in blood may not treat HIV in semen.
And then they can take it off themselves.
Dr. Kiessling: Yes.
Do you coordinate this with her menstrual cycle?
Dr. Kiessling: Yes. You have to do this exactly at the time she's going to ovulate. We still do that procedure here in Boston. We also now have a couple of collaborating clinics -- one in Florida that's willing to help us with that; I think the other one is in Washington, D.C.
But most clinics have not used the approach of oligospermia cup insemination, once assisted reproduction became a specialty. The cup insemination is really more well known to gynecologists than it is to fertility centers.
We had somebody just get pregnant last week through this method, though.
So, are there other methods?
Dr. Kiessling: No. Those two.
I understand that you used to offer in vitro fertilization, but now you don't. Do you refer people?
Dr. Kiessling: Yes. We refer people. We only offered IVF until we could find a few clinics in various parts of the country that were willing to help. Some people don't want to go through assisted reproduction in their local community for confidentiality reasons. So for a while, we offered IVF just to those couples who were happier to come to Boston than to try to find a clinic at home. Now I think we're up to about 26 or 27 collaborating infertility centers. It's much easier now for us to find help.
Great. Christa, you were Dr. Kiessling's patient?
When did you first decide you wanted to have a baby?
Christa: Before I married my husband. About, I would say, a year prior to making the decision we were going to get married. I never really wanted children and he always did. I decided that he would be a great dad and that I would be willing to have a child.
You know, it's a big thing for me. Two weeks after we had the conversation, he was found to be positive for HIV. It was really devastating for both of us. It was before we actually got married.
At the time, we didn't know anything about anything. We thought it was a death sentence and we were scared. It was a process. It took time just getting educated and getting him started in [HIV] treatment. It wasn't long after he was in treatment and his viral load had come down -- it was actually undetectable at that point -- that he had asked one of his doctors at a clinic that he was being treated in if he knew anything about how someone in his position could have a child. This was after talking to a number of other doctors and people, and just hearing, "No, no, no, no, no."
This doctor threw out the term, "sperm washing." That's all he said. He said he heard of something called "sperm washing," and that there was some success with that. At that point, I started scouring the Internet every night for hours, searching and searching and searching -- and really was coming up with nothing. It took, I don't remember exactly how long, but I want to say weeks and weeks.
What year was this, when you started?
Christa: I think it was -- and Dr. Kiessling might know better -- I think it was back in '98, maybe?
Dr. Kiessling: Yes, it might have been. Or '99.
Christa: Finally, I found a little article that referenced -- at the time it was Duncan Holly Biomedical -- and then it took me a while to actually find that. I think I found Duncan Holly, I actually found a link to Dr. Semprini, who is the doctor in Italy that you were talking about.
They were doing this procedure that Dr. Kiessling had mentioned -- I'm sorry, I don't know the technical term for it -- pretty successfully without any seroconversion over there. But going to Italy really wasn't an option for us at the time. You know, just financially, from a time constraint ... We would have if that were the only avenue that we had ended up finding. But I found the link to Duncan Holly and then I started to pursue that, just because it was closer to home.
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