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HIV And Antiretroviral Therapy May Affect Fertility

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Published: Jul 14, 2011 3:36 pm
HIV And Antiretroviral Therapy May Affect Fertility

Results of a recent review indicate that people with HIV may be at an increased risk for infertility, due to both the virus itself and the use of antiretrovirals.

The authors of the review also found that assisted reproduction options can help people with fertility problems and can be a safe choice for HIV serodiscordant couples (a couple in which one partner is HIV positive and the other is HIV negative), although the risk of HIV transmission cannot be eliminated completely.

Based on their results, the authors suggested more research into future fertility treatments designed to minimize the risk of transmission, as well as further studies to evaluate the effects of HIV and antiretroviral therapy on fertility in people with HIV.

Prior to the advent of highly active antiretroviral therapy (HAART), the prospect of parenthood raised a number of issues for people with HIV, including a high risk of transmission to a partner and to the infant before or after birth. However, the use of antiretrovirals has significantly decreased mother-to-child transmission of HIV, with rates of transmission as low as 1 percent in the United States.

HIV is most common among people of reproductive age. As a result, a growing number of people with HIV desire to have children and are planning to become pregnant (see related AIDS Beacon news).

In this review, the authors addressed the potential role of HIV and antiretrovirals in people with HIV and infertility issues, as well as treatment options and fertility procedures for infertile and serodiscordant couples.

Infertility In HIV-Positive Women And Men

Results on the causes of infertility in men and women with HIV have been conflicting, but in general appear to indicate that people with HIV, particularly people with advanced HIV infections or AIDS, are less fertile than HIV-negative men and women.

Results of a study of African women with HIV showed that they were 25 percent to 40 percent less fertile than HIV-negative women. In addition, some studies have shown decreased fertility rates in HIV-positive women in the United States.

However, according to the review authors, it is still unclear whether HIV itself causes infertility or whether the problem is due to other conditions that women with HIV are more prone to. For example, additional factors that may result in infertility in HIV-infected women include stress, weakened immune systems, weight loss, drug abuse, and the presence of other sexually transmitted diseases.

Attempts to determine the role of HIV itself in infertility have had mixed results. HIV-positive women are more likely to have an anovulatory cycle, a common cause of infertility in which a woman has a menstrual cycle without the ovaries releasing an egg. HIV-positive women are also more likely to have amenorrhea, or a complete absence of a menstrual cycle in a woman of reproductive age.

However, the causes of anovulation and amenorrhea in HIV-positive women are unknown, and recent studies suggest that HIV infection itself is not linked to amenorrhea once other factors, such as weight and age, are taken into account.

Some studies have also suggested a link between HIV infection and ovarian failure in HIV-infected women. For example, researchers in one small study found that 8 percent of HIV-positive female participants had levels of the follicle-stimulating hormone, a hormone required for growth and development in the ovaries, similar to those in menopausal women. However, a larger study found no such link between the hormone and HIV, and another found no evidence of premature ovarian aging in HIV-positive women.

For women who are not on antiretroviral therapy, complications with pregnancy may occur more often. In one study, almost 19 percent of HIV-positive women experienced pregnancy loss compared to 12 percent of uninfected women. However, more recent studies have shown that HAART reduces pregnancy loss in women with HIV.

In men, studies have shown that several sexual problems that affect fertility are more common with HIV infection. Men infected with HIV, particularly men with advanced HIV, are more likely to have inflammation of the testicles and are more likely to produce insufficient testosterone levels.

Also, men with HIV are more likely to experience decreased sex drive and an estimated 60 percent experience erectile or ejaculatory dysfunction.

Sperm function also appears to be affected by HIV, with healthier men having fewer problems with their sperm. According to the review authors, men with higher CD4 (white blood cell) counts tend to have better semen volume, sperm motility, and sperm counts, all of which affect fertility, than men with lower CD4 counts.

Effects Of Antiretroviral Therapy On Fertility

The effects of antiretrovirals on fertility have also been unclear. Since advanced HIV infection tends to decrease fertility, starting HAART can improve the likelihood of pregnancy. However, there are also indications that the drugs can have negative effects on fertility.

Researchers from a study in Africa found that the use of antiretroviral therapy increased fertility in HIV-positive women (see related AIDS Beacon news). A study in the U.S., however, found that women on therapy were less likely to conceive. The reason for the difference in results is not clear.

In addition, according to the review authors, the use of some antiretrovirals, particularly zidovudine (Retrovir) and other older nucleoside reverse transcriptase inhibitors (NRTIs), may affect fertility in people with HIV.

Previous studies have shown that NRTIs, particularly older NRTIs, may cause damage to mitochondria, which are small structures within cells that supply cellular energy. In particular, NRTI use may damage the mitochondria in sperm and eggs, leading to infertility.

Other studies have shown that HIV-positive men on HAART may have damaged sperm, decreased sperm count, and decreased sperm motility.

Fertility Treatment Options For People With HIV

For people with HIV who have fertility problems or who have an HIV-negative partner and are worried about transmitting the virus, assisted reproductive technology can achieve pregnancy by artificial or partially artificial means.

Three common assisted reproduction techniques include intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection.

Intrauterine insemination is a procedure where the sperm is placed directly in the woman’s uterus. In vitro fertilization, another technique, involves fertilizing eggs with sperm outside the body and then transplanting the embryos into the uterus. Finally, intracytoplasmic sperm injection is an in vitro fertilization process in which a single sperm cell is injected directly into an egg. For men who are HIV-positive, these procedures are combined with sperm washing, which separates virus and infected immune cells from the sperm.

All three techniques have been used successfully in people with HIV, and none of the studies reviewed by the authors had any instances of transmission in serodiscordant couples. However, the authors noted that before trying to conceive, patients should reduce the risk as much as possible using HAART to suppress levels of the virus.

The authors also noted that people with HIV can face many difficulties in accessing reproductive health care. Currently, fewer than 3 percent of U.S. fertility practices provide assisted reproductive services to HIV-positive patients.

In addition, the Centers for Disease Control and Prevention have not endorsed in vitro fertilization or intracytoplasmic injection for people with HIV, and many states outlaw placing bodily fluids from an HIV-positive person into a patient.

However, the review also highlighted a report from the American Society of Reproductive Medicine that suggested that discriminating against HIV-positive patients may be illegal under the federal Americans with Disabilities Act, since HIV and AIDS are considered disabilities by the government.

For more information, please see the study in Fertility and Sterility (abstract).

Photo by karindalziel on Flickr – some rights reserved.
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One Comment »

  • Jacobeth said:

    Im understand now. But what can be done to increase the chance of falling pregnat,invitro it’s expensive.