1. Find a Sensitive Medical Provider
- See resources at the end. Ask members of your support system, such as other people living with HIV and your medical providers.
- Be aware that your doctor may have to sign a statement verifying that you're in good health. The wording of these statements varies among the fertility clinics (example: "Does this individual have a life-threatening disease?"). Many doctors will feel able to say "no" in good conscience.
2. Get Money
- Reproductive services are expensive. If your insurance won't cover the costs or you don't have insurance, you will need to pay out-of-pocket at the time of the service.
3. Check for Fertility Problems in Both Partners Before Proceeding
4. Lower Viral Load
- The lower the man's viral load, the lower the risk of infection.
- Research has found that plasma viral load differs from viral load in seminal fluid. Someone who has an undetectable viral load in their blood may have detectable viral load in their genital fluids, and vice versa (this is true for the female genital tract as well). Please note that "undetectable" means not able to be detected with the test used. HIV is still there.
- At least one study has found protease inhibitors to have different effectiveness in the genital tract.
5. Look for Other STDs
- The presence of other sexually transmitted diseases should be looked for and treated. They increase the risk of both HIV transmission and infertility. They may also increase seminal viral load even if there is no change in the plasma viral load.
- If the male also has hepatitis A or B, the woman should be vaccinated against those viruses.
- If the male has hepatitis C, for which there is no vaccine, it should be eliminated during sperm washing at the same time as the HIV and the sample tested for its presence afterwards (just as with HIV). It is currently unclear whether hepatitis C is transmitted easily during sex.
6. Use Sperm Washing
- Sperm washing is a procedure long used to help couples trying to conceive without passing on diseases or genes for disease. Sperm are separated from the surrounding seminal fluid by a centrifuge, a device that separates components of a liquid as it spins at high speed. The sperm are then washed twice in a solution, in an effort to remove the undesirable materials.
- Not all reproductive service laboratories can conduct sperm washing for HIV.
7. Test the Sperm Sample
- Not all reproductive service laboratories can test sperm samples for HIV after it's been washed -- a step considered key to safer conception.
- PCR (polymerase chain reaction), the same technology behind viral load testing, is used to test the sperm sample. There are different PCR tests that can be used. The best test to use is not established.
8. Store the Sperm Sample
- The sample is frozen and stored until the HIV test results come back. It may also be stored for use during the woman's next fertility cycle if she is past ovulation when the results come back.
- There is a cost for storage.
- In vitro fertilization (IVF) represents the "test tube" baby. Eggs are removed from the woman's ovary and fertilized with sperm in a petri dish, resulting in zygotes (or "pre-embryos") that are placed in the woman's uterus or stored for later use. IVF is considered the safest method for conceiving with HIV.
- Intracytoplasmic sperm injection (ICSI -- pronounced "icksy") is another type of IVF. ICSI is when a single sperm cell is used to fertilize the egg. It is an additional step that can be taken, so it's more expensive. However, it also increases the level of safety. It is especially useful with a low sperm count when the fertilization otherwise would not occur.
- Intra-Uterine Insemination (IUI)
- Washed sperm is placed directly into the cervix or the uterus itself.
- Sperm washing with IUI may be just as safe and less expensive than other insemination methods.
- Cervical cup. The Duncan Holly Clinic offers an oligospermic cup, inserted over the cervix by a doctor. The washed sperm then travels into the uterus. Anti-HIV medication is given at the time of insertion. The safety in preventing transmission of HIV is not well-established. For example, there might be the potential for microscopic tears of the vagina.
Low-Tech Methods at Home
- PEP stands for "post-exposure prophylaxis." It's HIV medicine that can be taken to prevent transmission following exposure. In this case, it can also stand for "pre-exposure prophylaxis" (or "PREP") meaning that the woman takes medicine to prevent transmission before exposure to HIV. This is where knowledge of HIV medicine comes in handy (see past issues of Positively Aware). Many HIV specialists are willing to prescribe PREP to serodiscordant couples (where one partner is HIV positive and the other is not) who are trying to conceive. Cost will likely be out-of-pocket, and you may want to avoid using your insurance because it could raise red flags on your coverage that may haunt you later. Some organizations may clandestinely have limited quantities of pills for HIV therapy available for free. It is illegal to give prescription medicine to someone other than the person for whom it was prescribed. These services make use of leftover pills for situations such as a gap in refills or for out-of-towners who forgot their medicines at home. There are also programs that send medications abroad. You can check with them.
- The effects of PEP or PREP on fetuses and children born to women who used either PEP or PREP, if any, are currently unknown.
- Ovulation kits can help a woman determine when she is most likely to conceive, thereby limiting sexual exposure to this time. Kits are available at most drugstores at an affordable price.
- Do-it-yourself insemination (the "turkey baster" method) can be done with a syringe (without the needle) and washed sperm or unwashed semen. According to WORLD, "It's best if the woman is on her hands and knees, shoulders down and hips in the air, and stays there as long as possible [after insemination]."
Even after sperm washing, there's no 100% guarantee that HIV will not be transmitted. Ironically, sperm doesn't seem to be infected by HIV; however, HIV may be present in the seminal fluid surrounding the sperm. In addition, while sperm washing and testing may be relatively simple and inexpensive, the processes and procedures involved with in vitro fertilization, zygote implantation, and clinical insemination are complex and expensive. These are, however, the safest ways to conceive. Please note that the clinics listed have differences of opinion in which procedure is best to use. The Web sites or a consultation will clarify those differences.
Using a turkey baster or syringe (without the needle) at home is more risky. Here, too, is another irony: the risk of infection with one act of vaginal intercourse is relatively low. The risk of infection increases with the presence of other sexually transmitted diseases or lesions, repeated unprotected intercourse, higher HIV viral load and biological factors in the man and the woman that are still largely not understood and which cannot be detected at home. Doctors cannot publicly advocate for these procedures -- another good reason why you need a compassionate physician to guide you in private.
- American Society for Reproductive Medicine. Visit www.asrm.org.
- Bay Area Perinatal AIDS Center (BAPAC), at the University of California, San Francisco's (UCSF) Positive Health Program in San Francisco General Hospital. Offers pre-conception counseling and infertility work-up to seroconcordant and discordant couples (both partners positive or one partner is positive). Also conducts prenatal care to HIV-positive women. Call (415) 206-8919. Visit http://php.ucsf.edu/bapac.
- Center for Women's Reproductive Care, at Columbia University in New York City. Conducts IVF for serodiscordant couples. Call (646) 756-8282.
- Duncan Holly Biomedical. Operates the Special Program of Assisted Reproduction (SPAR), started in 1994 as a support group for couples living with incurable sexually transmitted virus diseases such as HIV. Developed a mail-in product for shipping sperm-washed samples to fertility clinics around the country, as well as an HIV testing kit for sperm that can be mailed to you at home. Complete details and in-depth articles available on its Web site, including the story of Baby Ryan, the first baby conceived through SPAR. Call (781) 665-0750 or (617) 623-7447, or visit www.duncanholly.com/idi/spar/spar_main.html.
- Reproductive Lab Service, 233 East Erie St. Suite 309, Chicago, IL 60611. Call toll-free: (877) REPROLAB (737-7652). Visit www.reprolab.org.
- SMART (Sisterhood Mobilized for AIDS/HIV Research & Treatment), New York City, provides treatment and prevention education and support for women impacted by HIV/AIDS. Call (917) 593-8797, write firstname.lastname@example.org or visit www.smartuniversity.org.
- "Sperm Washing: Reducing the Risk of Father-to-Mother Transmission." Comprehensive article, although written in 2001. Visit http://hivinsite.ucsf.edu.
- Women Organized in Response to Life-Threatening Diseases (WORLD), 414 13th Street, 2nd floor, Oakland, CA 94612. Call (510) 986-0340. Visit www.womenhiv.org. Unfortunately, not all copies of their excellent newsletter and articles are available on-line. However, an abbreviated version of their article "Reducing the Risks of Conception: Getting Pregnant When One or Both Partners is HIV positive," is available at www.PositiveWords.com. The article is very easy to understand and extremely detailed.