CDC Reversal: Sperm From HIV-Infected Men Okay for Insemination

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Natural and assisted conception between HIV-infected men and their uninfected female partners is safe as long as serodiscordant couples follow recommended risk-reduction practices, according to a report from the Centers for Disease Control and Prevention (CDC).

Jennifer F. Kawwass, MD, from the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, and the Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Emory University School of Medicine, both in Atlanta, Georgia, and colleagues published their report online June 2 in Morbidity and Mortality Weekly Report.

Previously, the CDC recommended against insemination with semen from HIV-infected men. However, updated information from laboratory and epidemiologic studies indicates that the risk for HIV transmission in these couples can be reduced significantly with the implementation of certain strategies. Those include the use of highly active antiretroviral therapy (HAART) for the man, antiretroviral preexposure prophylaxis (PrEP) for the woman, and sperm washing, the authors write.

"Use of HIV-negative donor sperm that meets Food and Drug Administration donor eligibility criteria remains the safest option for avoiding HIV infection of the female partner," the authors explain. They note, however, that "[r]ecent evidence suggests that discordant couples who wish to have their own biologic children might consider using condomless intercourse timed to coincide with ovulation, or IUI [intrauterine insemination] or IVF [in vitro fertilization] in combination with sperm washing."

In this scenario, transmission risk is reduced "when the male partner is virologically suppressed on HAART and the female partner is on PrEP," the authors stress.

The estimated risk for HIV transmission during condomless intercourse between men on HAART with undetectable semen and plasma viral loads and their uninfected partners is 0.16 per 10,000 exposures (95% confidence interval, 0.02 - 1.3), they write.

Conflicting evidence regarding correlations between plasma and semen viral loads contributes uncertainty to this estimation, however. It is possible, they explain, that "men on HAART with undetectable plasma viral loads might still be at some (albeit, very low) risk (1.2 per 100 person-years, [confidence interval], 0.9 - 1.7) for transmitting HIV-1 to their female partner through condomless sexual intercourse."

To further reduce the transmission risk, the authors advise couples to minimize exposure frequency by limiting condomless intercourse to the time of ovulation, which increases the likelihood of conception, and say uninfected women should use PrEP.

With respect to sperm washing, recent evidence suggests that newer methods of concentrating and separating the seminal fluid from the sperm before assisted insemination can significantly reduce the HIV transmission risk. The use of HAART and PrEP can presumably further reduce the transmission risk, the authors suggest.

HIV infection can reduce spermatogenesis in men; therefore, infertility testing — both for male factors and female factors, such as tubal disease or ovulatory dysfunction — "is a reasonable early step in treating all HIV-discordant couples," the authors write. IUI or IVF may be the most appropriate fertility option for these couples, they add.

Further, because IVF is more effective for achieving pregnancy than is IUI or natural conception, "IVF might afford less cumulative risk, since the number of exposures to the infected partner's sperm is likely to be fewer," the authors write. "As data regarding the safety and effectiveness of semen processing emerges, the risk profile for each treatment option will be further defined."

The authors have disclosed no relevant financial relationships.

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