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Serdiscordant couple seeks advise about conception

Aufgrund gehäufter Anfragen aus dem angelsächsischen Bereich publizieren wir für einmal einen Beitrag in Englisch.

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Quite often, we have been approached by serodiscordant couples wishing to conceive a child. Our presentation at the IAS-conference in Sydney (July 2007) did receive a lot of attention, in particular in the America HIV-field. In agreement with our mail-contact we therefor decided to publish one of our recent mail-requests for further information. We assume, that this will be of interest to a large group of affected couples worldwide.

Mail from Dorothe (name changed)
Von: Dorothe
Gesendet: Mittwoch, 26. September 2007 07:33
An: Vernazza Pietro HCARE-KSSG-INFEKT
Betreff: Serdiscordant couple seeks advise about conception

Hello Professor Vernazza,
Recently, I read an article posted on The Body.com. about your studies of serodiscordant couples and conception My partner and I would very much like to conceive a child naturally but until we read your article, we were not considering this as an alternative to sperm washing. As my partner and I live in California, the option of sperm washing was just recently made available and the practice is not widely accepted in our state or even within our country due to liability risk. After reading your article, I feel that with the necessary precautions, we would be able to conceive naturally and without harm to myself or our child.
My fiance is a hemophiliac and contracted HIV from clotting factor when he was 8 years of age. He is now 30 years old, is in good health and has an undetectable viral load. His medication regiment changed 6 months ago from Combivir to Atripla, 1 time per day. He changed for convenience reasons and has no known drug resistance.
Norman, my fiance is afraid to attempt natural conception as he does not want to hurt me in any way. He has contacted his doctors to discuss options but I fear that due to liability issues, they will not encourage us to conceive without IUI. I feel confident that we could conceive without incident following the plan that your study follows. Would you be willing to share more information with us so that we can make an appropriate decision?
We both appreciate the work that you and your colleagues are doing.
Thank you
Dorothe

(IUI stands for intrauterine Inseminatin, a procedure where [processed] semen is injected into the uterus)

Response to Dorothe

Subject: AW: Serdiscordant couple seeks advise about conception
Date: Wed, 26 Sep 2007 12:40:33 +0200
From: pietro.vernazza@kssg.ch
To: …
Dear Dorothe
Thanks for your request. There are thousands of couples in your situation in the US. And there are another several thousands of couples that have unprotected sex without telling anybody. I do consider it unethically to withhold information to those couples, how to do it safer. All we do is to give you an advice how to make unprotected sex safer.
As you know from the literature, the risk of sexual transmission in your case is in the range of mounting an airplane. No single documented case so far and a lot of circumstances supporting low risk of transmission.

What we suggest:
You and your partner (not your doctor) should make a decision whether you consider the risk of transmission for yourself as acceptable or not. You will be able to find lots of arguments that support a very limited risk. As I said, it is in the range of usual risks like driving a car etc.. Nobody tells you whether you are allowed to use a car or not. It is your own decision. That would mean that you have to decide, whether using a condom is something you want to forget as long as your partner is well suppressed. If, at this point, you do not consider the risk as low as making you confident to have unprotected sex each time youhave sex, then there are several options, to reduce this theoretically low risk

  1. You could check for sexually transmitted diseases, make sure, both of you have no other sexual relations that you do not inform your partner about. Always use condoms in such relations.
  2. You could limit the number of unprotected sex acts to the minimum required to get pregnant. For that purpose, I suggest you use a urine test for LH. LH is a hormone that can be detected in the urine. It gets positive around day 14 of your cycle. If you test your urine every morning starting day 12, you can expect a positive result within 1-4 days. When the result is positive, wait 36 hours (the other evening) and then have your “timed” unprotected intercourse. The Urine test can be purchased in pharmacies. In Europe, they call them Clearplan or similar names. The cost is in the range of 1-2 boxes of pampers. Not cheap, but affordable.
  3. You could further limit the chance of transmission by taking an HIV drug before having unprotected sex. We suggest tenofovir due to its long intracellular action. In the animal model with rectal virus challenge, truvada (combination tenofovir and FTC) worked even better). You may also use truvada. Since the risk is so low, I would stick to tenofovir. Take 1 pill the morning of the positive LH-urin-test. A second dose, the next moring, i.e. the same day, when you will have sex in the evening.
  4. You might consider to check your fertility and the fertility of your partner. The easiest part is to have a semen sample analysed. However, don’t get frustrated if it’s not 100% normal. Women still get pregnant with suboptimal sperm quality. You would need a specialist for advice. I suggest to try 2-4 cycles. If you are not pregnant by then, get a sperm test. If that is ok and you still don’t get pregnant after a total of 5-7 cycles check with a gynaecologist and ask him about further exams for fertility tests in your case.

Few other considereations:

  • Semen quality is best, if the last ejaculation is more than 2 but less than 7 days back. So you need some practice… For simplicity, you might consider to take your partner’s atripla.
  • In general, I suggest to have as little drug as possible in a pregnancy. Efavirenz, which is part of atripla could be toxic to the fetus. I am not very concerned at this very early stage, but I would still avoid it. So, your partner could split his regimen to truvada and sustiva (efavirenz). So you could steel two tablets of truvada from him. Maybe you find a doctor that prescribes the truvada or tenofovir for your pre-exposure prophylaxis.
  • If you get pregnant, please remember, that many pregnancies (probably more than 50%) result in early abortion. This is a normal selection process of mother nature. So don’t get frustrated. Take it as an indication that both of you are fertile. Try again.
  • If you get pregnant, and give birth to a baby, please send us a picture of the baby!

    Kind regards
    Pietro Vernazza

    Further Information in English

  • Read our Poster-Presentation at IAS-Sydney
  • Read the feedback the presentation had on US-sites TheBodyPro: (Podcast)  (End of report)
  • AIDSmap News (very well written, extensive report)
  • Presentation: HIV in semen – Is it as infectious as patients may think? (given at the Stockholm Regional HIV-meeting on May 31, 2007)
  • Interview: with Pietro Vernazza by Benny Goldman for TheBodyPro (15 Min)
  • POZ: http://www.poz.com/articles/761_12611.shtml?rss=true
  • REUTERS health information

Prof. em. Dr. med. Pietro Vernazza

Prof. Pietro Vernazza war bis zu seiner Emeritierung Chefarzt der Infektiologie und seit 1985 beim Kantonsspital St. Gallen tätig. Vor seiner Arbeit am Kantonsspital hat er folgende Ausbildungen absolviert: Studium Humanmedizin, Universität Zürich 1976 -1982 / Klinische Ausbildung Innere Medizin ...  Mehr