Fertility guidelines
published last year have opened the door to more sero-discordant couples using
sperm washing to start a family. Martine Gallie reports
Deciding to have children is a big step for any couple. But when one of you
is HIV positive, the whole thing gets a lot more complicated. How do you make
the decision to try for a baby when you know there’s a risk that you
could infect your partner and possibly your child?
Despite the risks, some sero-discordant couples choose to have unprotected
intercourse to conceive. Risk of transmission can be lowered slightly by having
limited unprotected intercourse when the female partner is at the most fertile
point of her cycle. But it’s still a risky business. In one study involving
92 couples where the male partner was HIV positive and the female wasn’t,
four women became infected following timed unprotected sex.
How sperm washing works
If you’re an HIV positive man, one low risk way to start your family
is through a technique called sperm washing, pioneered in Italy during the
late Eighties. It’s based on the fact that, while the HIV virus is found
in semen, it can’t actually attach itself to the sperm cells themselves.
This means that doctors can remove the virus from semen by separating sperm
cells from the other components of semen, in effect ‘washing’
them.
‘Clean’ sperm is then placed into the female partner’s womb
when she is fertile using intra-uterine insemination (IUI). Alternatively,
if the female partner is found to have fertility problems, doctors can use
the sperm to carry out in vitro fertilisation (IVF). Here the egg and sperm
are combined to make an embryo, which is then transferred to the womb. Where
there is a problem with the male partner’s sperm, doctor may use intracytoplasmic
sperm injection (ICSI), in which the sperm is injected directly into the egg
to make an embryo.
Some groups still excluded
“To be eligible for sperm washing you need to be a heterosexual couple
who have been in a committed relationship for at least a year, and who are
either HIV discordant or who are both positive,” says Ms Carole Gilling-Smith,
director of the Assisted Conception unit at the Chelsea and Westminster Hospital,
London. “We would also expect you to be on medication and for your disease
to be stable. Currently, we are not allowed to treat gay men.”
Couples considering sperm washing are also assessed to check that the welfare
of any future children is not at risk. “If we found that someone was
actively taking drugs, for example, that would be an issue,” says Ms
Gilling-Smith.
Funding - the big issue
Until now, a big barrier to couples using sperm washing has been lack of NHS
funding. Between 2000 and 2003, only nine per cent of couples who wanted the
procedure managed to get funding. Another 40 per cent gave up after failing
to get funding, while the rest managed to finance the treatment themselves.
But this all changed with new fertility guidelines published in 2004 which
actively promoted sperm washing as a way to reduce HIV transmission rates.
“After that we began to see a rise in the number of primary care trusts
(PCTs) willing to provide funding for sperm washing,” says Ms Gilling-Smith.
“Now I’d estimate that approximately 30 per cent of the couples
we see have funding. It’s very encouraging and we are working hard towards
universal funding.”
So far, 31 children have been born following sperm washing in the UK, 516
in Europe as a whole, and although there is a small theoretical risk of HIV
transmission, none of the women or their children have so far become HIV positive.
“I expect to see a lot more couples coming forward in future as more
funding becomes available,” says Ms Gilling-Smith.
Currently the technique is not available privately in the UK, so couples are
either expected to seek funding from their local PCT or fund themselves through
NHS treatment. One cycle of IUI at the Chelsea and Westminster costs £625,
one cycle of IVF costs £2,080 while a cycle of ICSI costs £2,726.
If you do find you need to self-fund, don’t forget to factor in travel
costs and loss of earnings.
According to Ms Gilling-Smith, the best way of obtaining NHS funding for sperm
washing is to ask your GU consultant to approach your local PCT, presenting
sperm washing as a means of reducing the risk of HIV transmission, rather
than as a fertility technique. “There is a lot more money available
for preventing the spread of HIV than there is for fertility treatment,”
she says. “Some PCTs will fund up to three cycles.”
This may all sound too good to be true, but there are several issues you need
to consider carefully before you rush off to talk to your doctor.
And the small print...
The most important thing to remember is that sperm washing doesn’t completely
remove the risk of HIV transmission. It’s estimated that five per cent
of washed sperm samples still contain the HIV virus (in numbers too small
to show up in tests). So there is still a small risk that your partner, and
possibly your child, may be infected.
You may also have to travel long distances for treatment. At present, Chelsea
and Westminster’s assisted conception unit is the only place offering
sperm washing to sero-discordant or HIV positive couples in the UK. More centres
are planned for the north of England, Scotland and Northern Ireland over the
next few years.
Also, bear in mind, having a child through sperm washing is a long, drawn-out
process - about three months from start to finish - with no guarantee of success
at the end. Chelsea and Westminster’s live birth rate is 12.2 per cent
for IUI, 22.6 per cent for IVF and 16.7 per cent for ICSI. This is roughly
comparable with other centres offering routine fertility treatment.
If you decide to go ahead, you will both be screened for sexually transmitted
infections, including HIV, and undergo fertility tests. For the man, this
just means a sperm test. The woman, meanwhile, will have to undergo blood
tests to check that she is producing eggs, an ultrasound examination of the
pelvic area and tests to check that her fallopian tubes are clear. All of
these tests can be done at your local hospital if you far from London.
Couples seen at the Chelsea and Westminster are offered counselling before
treatment starts so that they can think through all the issues. How do you
feel about being a parent and managing a chronic disease at the same time?
How would you feel if your partner did become infected? And are you prepared
for the possibility that you might not conceive?
Other options
There are other options open to sero-discordant or HIV positive couples besides
sperm washing. It is possible to have a child through sperm donation. This
means the female partner’s egg is fertilised using sperm from a donor.
But after the government removes anonymity for sperm donors later this year,
the number of men willing to donate sperm may drop. You may also feel that
you can’t face the prospect of your child looking up his or her biological
father later in life.
Another possibility is adoption, but some couples may feel that adopting a
child at the same time as managing a chronic illness is simply too much to
take on. “It also removes the genetic element of parenting and, if you
are HIV positive, you may feel it is important to have a part of yourself
that lives beyond you,” says Ms Gilling-Smith.
So there are still no perfect solutions for couples living with HIV who want
a family. But one thing is for sure: with sperm washing rapidly becoming more
affordable and more widely available over the next few years, there’s
cause for optimism at last.
• For an information pack about sperm washing phone the assisted conception
unit at the Chelsea & Westminster, tel: 0208 746 8585.
• PN would like to hear from any gay men or former IV drugs users who
have tried but failed to access sperm washing. Contact editor@positivenation.co.uk
Sperm washing factfile
• About 30 per cent of couples who undergo sperm washing now get NHS
funding.
• Some PCTs will fund up to three cycles of fertility treatment following
sperm washing.
• Ask your GU to apply for funding on the basis that sperm washing reduces
the risk of HIV transmission.
• Sperm washing does not remove the risk of HIV transmission completely
- an estimated five per cent of sperm samples remain infected after washing.
• At present Chelsea and Westminster Hospital ACU is the only place
offering sperm washing in the UK.
• Sperm washing is only available to heterosexual couples in a stable
relationship.
• So far 31 babies have been born to sero-discordant or HIV positive
couples following sperm washing in the UK - none of the mothers or babies
were infected.
CHRIS’S STORY
itting in a cubby hole, on the fourth floor of Chelsea and Westminster Hospital
I survey the surroundings. There are some ‘it’s-not-like-an-NHS-hospital-really’
soft furnishing and casually placed glossy magazines; not Hello or Vogue this
time but Big ‘n’ Busty and Fiesta. Above the wall hatch is a sign
that says ‘please place samples here’. Beyond lies the mysterious
process known as sperm washing.
I could have done the deed at home and sprinted across town, but was put off
by visions of the jar spinning across the floor of the number 360 bus and
landing just below the boot of a fellow-travelling OAP. No, it was going to
be freshly, if not romantically, produced sperm.
So how did we get here? I have been living with HIV for ten years, my partner
is HIV negative. We wanted to get pregnant with the minimum risk. Suffice
to say questions of mortality, morality, security - you name it - had been
dredged up, wept over and resolved as much as we could. We are both well,
fertile and fecund and we want a baby more than anything else, and will do
everything we can - with a little help from Chelsea and Westminster’s
Assisted Conception Unit (ACU).
The funding process was a big unknown. Would the PCT pay? “Who knows?
It’s a new one to me,” said our GP. Eventually we got the PCT
go ahead. But even then we had to go through the “show us the money,”
ritual during hospital visits. We even paid for a couple of procedures but
the fees were eventually refunded. The moral is: always get it in writing.
The first ‘consultation’ induced mild paranoia. We imagined the
door bell ringing; booting the wine bottles and curry cartons under the settee
and assuming ‘Mr and Mrs Responsible’ faces. We would invite them
in and they would give a casual glance at the mess, run a surreptitious finger
along the worktop and then utter “you two want to be parents?”.
Cue cruel laughter.
Not so. Our lifestyle and my positive status were given a cursory glance.
I had good CD4 counts and undetectable viral loads and my consultant at St
Thomas’, Babu Kulasegaram, was fully behind us. ACU staff were brilliant,
totally professional without being cold; a rare talent. They clearly spelt
out the processes to pass through and all the difficulties everybody faces
getting pregnant.
Then came a full sexual health screen, followed by the fertility tests. My
partner’s tests were more invasive, but everything went well. All she
needed was an injection to bring forward ovulation as sperm washing is a Monday
to Friday job. Eventually I’m in the cubby hole with a sample bottle
in my hand.
We were fortunate. The first treatment hit the spot. Even so, two weeks later
(six months from our first discussion with my consultant) the two of us staring
at the blue line on the pregnancy kit was an incredible feeling. For so long
we had closed out of our lives the possibility of having a child. Then we
had hope. Now we had a lot more than that.
