HIV-discordant Couple Intrauterine Insemination
HIV-discordant Couple Intrauterine Insemination
The investigators propose to treat couples who wish to have a child in which the man is
 HIV-positive and the woman is HIV-negative. The investigators call these couples
 HIV-discordant. On the average, an HIV-positive man, who does not participate in high-risk
 activities, will transmit HIV to a female partner one in every one thousand acts of
 intercourse without a condom. To reduce transmission of HIV, HIV-discordant couples are
 counseled to avoid intercourse altogether, or to use condoms during every act of intercourse.
 In order to have a child, these patients can use donor insemination. If they wish to have a
 natural child of the infected man, they can use a combination of medication of the man to
 reduce the amount of virus in his semen, and condom use except at the time of ovulation when
 the woman produces an egg. This reduces the chance of infecting the woman, but studies have
 shown that about 4% of women will be infected with HIV using this approach. Alternatively,
 they can use vitro fertilization (IVF) with intra cytoplasmic sperm injection (ICSI) in which
 eggs are collected from the woman after hormone-stimulation and are fertilized in the
 laboratory by injecting a single washed sperm from her husband into each egg. The resulting
 embryos can be transferred to the wife's uterus and/or frozen for later use. These procedures
 are believed to minimize the risk of HIV transmission (although the number of cases is low),
 but IVF-ICSI is very expensive and are not an option for everyone. A simpler method used for
 over 15 years in Europe is to collect the man's semen, wash the sperm in the laboratory, and
 test the sperm sample for HIV before placing it in the woman's uterus (intrauterine
 insemination; IUI). Although the risk of HIV transmission to the woman is presumably not zero
 with this method, over 4000 inseminations reported have not resulted in infection of any
 female patients or resulting children.
This study will enroll couples who wish to have a child in which the man is HIV-seropositive
 and the woman is HIV-seronegative. The couple will be counseled about their reproductive
 options, including in vitro fertilization (IVF) donor insemination and adoption. The male
 patient will be using appropriate therapy to reduce the virus in his semen. Semen will
 undergo specialized washing to reduce viral contamination of sperm. The sperm are first
 separated from leukocytes and other seminal constituents by centrifugation over a stepwise
 gradient. Motile sperm will be separated from the resulting pellet by a swim-up step in which
 washed sperm are overlaid with fresh medium into which sperm migrate. The final sperm
 suspension will be stored while testing for HIV is performed by reverse transcription
 polymerase chain reaction (RT-PCR). Specimens found negative for HIV will then be used for
 IUI (review: Gilling-Smith et al, 2006; Bujan et al 2007). There is presumably some risk of
 HIV transmission to the woman and resulting child with this approach; however, over 4000
 inseminations reported in Europe over the last 15 years have not resulted in infection of any
 female patient or resulting child. The woman will be followed for a year after the final IUI
 to assess seroconversion. If a child is born, he or she will be tested for HIV at 3 months of
 age.
Inclusion Criteria:

 Couple must:

 -  attest to safe sex practices

 -  know the HIV-status of their partner

 -  be informed of risks of this procedure and alternatives, including donor insemination

 -  have the ability to provide informed consent

 -  been referred or self-refer to Dr. Schust for infertility treatment

 Female must:

 -  be 18-38 years of age

 -  have a normal menstrual cycle before the IUI cycle

 -  be negative for HIV, gonorrhea, chlamydia, syphilis, hepatitis B and hepatitis C

 -  have a standard infertility evaluation and be a candidate for intrauterine
 insemination

 Male must:

 -  be at least 18 years of age

 -  be HIV-seropositive

 -  be under the care of an infectious disease specialist

 -  disease must be under control without evidence of acquired immunodeficiency syndrome
 (AIDS), with viral load <50,000 copies/mL and CD4 count > 250 cells/mL for the
 preceding 6 month period

 -  have semen quality adequate for intrauterine insemination

 If the couple does not achieve pregnancy after IUI, they may continue in the study for 5
 additional treatment subsequent cycles. The man must continue to receive care for his HIV
 and the disease must continue to be under control. Before each cycle of insemination, the
 couple must each sign an attestation statement that he/she is following safe sex practices,
 and have repeat testing for sexually-transmitted infections.