Objective
The objective of the study was to evaluate the safety of semen washing with intrauterine insemination (SW-IUI) for achieving pregnancy when the man is human immunodeficiency virus (HIV) infected and the woman is HIV negative.
Study Design
We conducted a retrospective analysis of 635 HIV-discordant couples enrolled in a SW-IUI program and followed up 367 Italian women. We computed pregnancy, live birth, and multiple delivery rates and assessed the women’s postinsemination HIV status.
Results
The retrospective analysis included 635 couples (2113 SW-IUI cycles): 41% of the women (95% confidence interval [CI], 37–45%) had a live birth (per-cycle live birth rate 13%; 95% CI, 11–14%). HIV status after SW-IUI was negative when available but unknown for 26% of the women: missing HIV status was not associated with correlates of HIV risk. The follow-up study included 367 couples (1365 cycles): 47% of the women (95% CI, 42–52%) had a live birth (per-cycle rate 14%; 95% CI, 12–16%). Ascertainment of postinsemination HIV status was complete and confirmed no HIV transmission attributable to SW-IUI. The upper 95% confidence limit of the HIV transmission rate was 1.8 per 1000 cycles in the retrospective analysis and 2.7 per 1000 cycles in the follow-up study.
Conclusion
SW-IUI appears to be a safe and effective method for achieving pregnancy in HIV-discordant couples in which the man is HIV infected.
Human immunodeficiency virus (HIV)-affected couples may need assisted reproduction to avoid sexual transmission of the virus or to overcome infertility. The American Society for Reproductive Medicine (ASRM) and the American College of Obstetricians and Gynecologists (ACOG) support fertility services for HIV-discordant couples. The Centers for Disease Control and Prevention (CDC) recommends that reproductive counseling be noncoercive and supportive of patient decisions. The ASRM recently issued recommendations that fertility clinics make fertility treatments aimed at reducing the risk of transmission more easily accessible to couples who live with HIV.
Risk avoidance through conception with donor sperm or adoption may not be acceptable or accessible to many couples. Risk-reduction strategies that may enable couples to conceive their biological children include semen washing (SW) followed by intrauterine insemination (IUI) and in vitro fertilization (IVF) followed by embryo transfer. Early semen-processing techniques did not yield virus-free spermatozoa and 1 documented case of seroconversion led the CDC to recommend against exposing an HIV-negative woman to her HIV-infected partner’s semen. Today assisted conception offered to HIV-discordant couples in the United States primarily is based on IVF with intracytoplasmic sperm injection (IVF-ICSI).
A 3-step SW technique was developed in Italy in 1987 and evaluated in combination with IUI. Reproductive health clinics in Europe have since offered SW-IUI to patients, reporting no HIV transmission attributable to the procedure. Incomplete follow-up, however, has been a source of uncertainty in previous studies. We conducted this study to improve follow-up of a cohort of couples treated in Milan, Italy, between 1989 and 2005.
Materials and Methods
The study comprised a retrospective review of patient records from a program based at the San Paolo University Hospital and the Studio Semprini clinic and a follow-up study of couples in Italy who attended the program. The protocol was approved by the Ethics Committee of the Local Health Agency of the City of Milan and by the CDC Institutional Review Board.
Semen washing includes centrifugation with silica-based discontinuous density gradient, double washing and centrifugation, and sperm swim-up ( Figure 1 ). In laboratory conditions, the technique reduces the HIV titer by 1000-fold so that washed motile sperm is not infectious to peripheral blood lymphocytes. Since 1997, washed sperm in this program has been routinely tested using polymerase chain reaction and discarded if HIV positive. HIV is infrequently detected in washed sperm.
At enrollment in the program, women were required to provide documentation of a negative HIV test within the previous 30 days. Women and their partners were evaluated for genital tract infections and infertility and treated as indicated. Women in fertile couples were offered SW-IUI, whereas IVF was used if indicated by infertility or if the motile sperm count after SW was below 1.5 × 10 6 /mL. All women were asked to undergo HIV serologic testing quarterly for a year after the last SW-IUI cycle.
As part of routine care, clinic staff inquired about missing HIV test results by telephone, probing as much as possible the veracity of the report by asking specific questions about the clinic or laboratory at which the test was performed, the reasons for not sending the test result in, and broadly inquiring into the health of the woman and her male partner.
From the clinic roster, 811 couples who were not currently undergoing treatment at the time of the research participated in the program between July 1, 1989, and April 30, 2005. For the retrospective analysis, we excluded couples in which the man was not HIV infected, who had never completed an SW-IUI cycle, or whose charts were missing. Deidentified data obtained from these couples included demographic characteristics, an HIV-related medical history, a fertility profile of the couple, assisted conception treatment and its outcome, and the postinsemination HIV status of the woman.
Evidence of HIV status consisted of an HIV-antibody test dating 90 or more days after the last SW-IUI cycle; a written note from a follow-up call made by clinic staff; or a new assisted conception cycle (eg, IVF-ICSI) 90 or more days after the last SW-IUI cycle. Women with missing HIV status after the last SW-IUI were compared with those with known status with respect to demographics, medical history, HIV risk behaviors, history of participation in the program, and immune compromise and history of HIV treatment of the man.
For the follow-up study, the same 811 couples were potentially considered for inclusion. However, in addition to the exclusion criteria for the retrospective analysis, the follow-up study also excluded women whose charts contained inadequate tracing information or whose current address or telephone number could not be identified after following up 50 possible leads, whose residence address was not in Italy, who could not speak Italian or English, or whose partner objected to the woman’s participation.
The physician who administered treatment initiated recruitment by telephone, and study staff made a second call to explain study procedures and obtain informed consent. Both partners were asked to consent to medical record review and to a telephone interview. Women were asked to provide evidence of, or at least tell about, their postinsemination and current HIV status. Women who refused to participate (nonparticipants) were probed to ascertain whether their refusal was due to HIV transmission. The institutional review board allowed analysis of limited data from women who could not be reached for recruitment (untraced) and from nonparticipants to assess whether these groups were at a higher risk of HIV acquisition than were follow-up participants.
The objectives of data analysis were to describe the characteristics of couples included in the retrospective analysis or in the follow-up study by computing univariate statistics and frequency distributions; to assess the effectiveness of SW-IUI by computing pregnancy, live birth rates, and multiple delivery rates; to assess the safety of SW-IUI by summarizing the available evidence on the postinsemination HIV status of the women; and to evaluate the correlates of the missing HIV status.
A Student t test and χ 2 statistics evaluated the significance of differences in means and frequency distributions. Ninety-five percent confidence intervals (CIs) for rates and proportions were computed using exact binomial or Poisson distribution tests, as appropriate. Logistic regression was used to evaluate multiple potential determinants of missing HIV status in the retrospective analysis and to compare follow-up participants with untraced women. Odds ratios (ORs) and their CI were computed from the estimates of the logistic regression coefficients and their variances.
Results
Among the 811 couples who participated in the program during 1989-2005 and were not undergoing treatment at the time of this research project, 635 eligible couples who underwent 2113 SW-IUI cycles contributed data for the retrospective analysis ( Figure 2 ). Of 472 eligible couples, 367 couples who underwent 1365 SW-IUI cycles participated in the follow-up study.
In the retrospective analysis, the average age was 31 and 34 years for the men and women, respectively ( Table 1 ). Of 635 couples, 525 (83%) resided in Italy. Male partners had acquired HIV mainly through injection drug use (70%) or unprotected intercourse (18%). The average number of SW-IUI cycles was 3.3 (range, 1–17). Many couples (53%) reported unsafe sex before entering the program, even after the partner was diagnosed with HIV (25%); 15% had pregnancies and 6% had children with their HIV-positive partner. Low CD4 counts at program entry (<200 cell/mm 3 ) were reported in 14% of the male partners, and only 23% were on highly active antiretroviral treatment (HAART) at the time of the last SW-IUI cycle ( Table 1 ).
| Characteristic | Women in retrospective analysis (n = 635) Mean (median) | Follow-up participants (n = 367) Mean (median) | Untraced women (n = 72) Mean (median) | P value a |
|---|---|---|---|---|
| Age, y | ||||
| Woman | 34 (33) | 34 (33) | 33 (33) | .21 |
| Male partner | 31 (31) | 31 (31) | 29 (29) | |
| Italian resident | ||||
| Yes | 525 (83%) | 367 (100%) | 72 (100%) | |
| No | 110 (17%) | N/A | N/A | |
| Mode of HIV acquisition by male partner | ||||
| Injection drug use | 440 (70%) | 236 (64%) | 52 (72%) | .01 |
| Sexual | 116 (18%) | 46 (13%) | 15 (21%) | |
| Other | 34 (5%) | 10 (3%) | 1 (1%) | |
| Missing/not specified | 45 (7%) | 75 (20%) | 4 (6%) | |
| Year of entry to program | < .001 | |||
| Prior to 1995 | 198 (31%) | 115 (31%) | 37 (51%) | |
| 1995-1999 | 329 (52%) | 182 (50%) | 32 (44%) | |
| After 1999 | 108 (17%) | 70 (19%) | 3 (4%) | |
| Year of last SW-IUI | < .001 | |||
| Prior to 1995 | 96 (15%) | 55 (15%) | 16 (22%) | |
| 1995-1999 | 329 (52%) | 172 (47%) | 44 (61%) | |
| After 1999 | 210 (33%) | 140 (38%) | 12 (17%) | |
| SW-IUI cycles | 3.3 (range, 1–17) | 3.8 (range, 1–14) | 3.4 (range, 1–17) | .05 |
| 1 | 176 (28%) | 80 (22%) | 23 (32%) | |
| 2 | 120 (19%) | 64 (17%) | 10 (14%) | |
| 3-4 | 167 (26%) | 91 (25%) | 22 (31%) | |
| ≥5 | 172 (27%) | 128 (35%) | 17 (24%) | |
| Missing | 4 (1%) | |||
| Treatment regimen | .36 | |||
| SW-IUI only | 544 (86%) | 311 (85%) | 64 (89%) | |
| SW-IUI plus ART | 91 (14%) | 56 (15%) | 8 (11%) | |
| Unprotected intercourse before program entry | .76 | |||
| Never | 255 (40%) | 147 (40%) | 30 (42%) | |
| Never after HIV diagnosis | 180 (28%) | 89 (24%) | 20 (28%) | |
| Some after HIV diagnosis | 159 (25%) | 94 (26%) | 21 (29%) | |
| Always | 4 (0.2%) | 11 (3%) | 0 (0%) | |
| Unknown | 40 (6%) | 26 (7%) | 1 (1%) | |
| Pregnancy before program entry | ||||
| 0 | 367 (58%) | 209 (57%) | N/A | |
| ≥1 with HIV-positive partner | 97 (15%) | 47 (13%) | ||
| Only with other partner(s) | 130 (20%) | 71 (19%) | ||
| Unknown | 41 (6%) | 40 (11%) | ||
| Children born before program entry | ||||
| 0 | 537 (85%) | 300 (82%) | N/A | |
| ≥1 with HIV-positive partner | 40 (6%) | 19 (5%) | ||
| Only with other partner(s) | 17 (3%) | 8 (2%) | ||
| Missing | 41 (6%) | 40 (11%) | ||
| Male partner’s CD4 count at entry | .56 | |||
| <200 cell/mm 3 | 92 (14%) | 45 (12%) | 10 (14%) | |
| 200-500 cell/mm 3 | 229 (36%) | 115 (31%) | 25 (35%) | |
| >500 cell/mm 3 | 144 (23%) | 69 (19%) | 19 (26%) | |
| Missing | 170 (27%) | 138 (38%) | 18 (25%) | |
| Male partner on HAART at last SW-IUI cycle | .01 | |||
| Yes | 144 (23%) | 84 (23%) | 9 (13%) | |
| No | 368 (58%) | 181 (49%) | 49 (68%) | |
| Missing | 123 (19%) | 102 (28%) | 14 (19%) |
Follow-up participants were similar to the subjects in the retrospective analysis but were only Italian residents (by design); had more SW-IUIs (mean, 3.8; range, 1–14); and were more often lacking information on the man’s HIV acquisition, baseline CD4 count, and HAART at the last SW-IUI cycle ( Table 1 ). As compared with follow-up participants, untraced women joined the program in earlier years ( P < .001), left it earlier ( P ≤ .001), were more likely to have male partners who acquired HIV mainly through injection drug use ( P = .01), had fewer SW-IUI cycles (average 3.4 vs 3.8) ( P = .05), and were less likely to have had a male partner on HAART at last SW-IUI cycle ( P = .01) ( Table 1 ).
In the retrospective analysis, 16% of the SW-IUI cycles resulted in pregnancy (95% CI, 15–18%), and 13% resulted in a live birth (95% CI, 11–14%) ( Table 2 ). The cumulative per-woman pregnancy and live-birth rates were 48% (95% CI, 44–52%) and 41% (95% CI, 37–45%), respectively. The multiple delivery rate was 8% (95% CI, 5–12%). In the follow-up study, the pregnancy and live birth rates among SW-IUI cycles were 17% (95% CI, 15–19%) and 14% (95% CI, 12–16%); the cumulative per-woman pregnancy and live-birth rates were 53% (95% CI, 48–59%) and 47% (95% CI, 42–52%), respectively; and the multiple delivery rate was 5% (95% CI, 3–9%).
| Variable Outcome | Retrospective analysis | Follow-up study | ||||||
|---|---|---|---|---|---|---|---|---|
| SW-IUI cycles (n = 2113) | Women (n = 635) | SW-IUI cycles (n = 1365) | Women (n = 367) | |||||
| n | (%) | n | (%) | n | (%) | n | (%) | |
| No pregnancy | 1676 | (84) a | 308 | (52) a | 1134 | (83) a | 168 | (47) a |
| Early pregnancy loss | 62 | (3) a | 41 | (7) a | 41 | (3) a | 22 | (6) a |
| Live birth delivery | 255 | (13) a | 238 | (41) a | 185 | (14) a | 172 | (47) a |
| Multiple delivery | 20 | (8) b | 20 | (8) c | 9 | (5) b | 9 | (5) c |
| Live infants | 285 | d | 285 | d | 196 | d | 196 | d |
| Missing data | 120 | (6) | 48 | (8) | 5 | (0) | 1 | (0) |
a As a percent of cycles/women with known outcomes;
b As a percent of all deliveries;
c As a percent of women who had at least 1 delivery;
d Not applicable as a percent because it includes multiple deliveries.
No cases of HIV seroconversion were recorded among women included in the retrospective analysis. Evidence of negative HIV status was available for 1899 (90%) SW-IUI cycles (test result on file: 68%; clinician’s notation in chart: 18%, other: 4%) (HIV status was unknown 90 days after 214 SW-IUI cycles [10%] performed in 162 women [26%]). On the basis of the cycles with known postinsemination HIV status, the estimate of the HIV transmission rate was zero, and its upper 95% confidence limit was 1.8 per 1000 cycles.
The strongest predictor of missing HIV status in the retrospective analysis was the country of residence: the evidence was missing in 71% of non-Italian residents and 16% of Italian residents ( P < .001; OR, 9.2; 95% CI, 5.2–16.3) ( Table 3 ). HIV status was missing more often among couples who had less than 5 SW-IUI cycles than among couples who had 5 or more cycles ( P ≤ .01; OR, 2.3; 95% CI, 1.2–4.2). HIV status was missing for 90% of women whose pregnancy status was unknown after the last SW-IUI cycle, 23-32% of women who did not achieve a pregnancy or had a biochemical pregnancy/early pregnancy loss, and 15% of women who had 1 live birth or more ( P = .004).
