Unprotected vaginal intercourse. If the man's positive and the woman's negative—or vice versa—there's a risk of HIV transmission if unprotected vaginal intercourse is the conception method of choice. But if the positive partner is on antiretroviral treatment and his or her viral load is undetectable, the risk of transmission decreases. Other ways to reduce the chance of transmission include pre-exposure prophylaxis (PrEP), a short course of HIV drugs given to the negative partner before intercourse to help prevent infection. There's also timed intercourse—engaging in unprotected vaginal sex only during times of peak ovulation.
When both partners are positive, there is a risk of reinfection (also called "superinfection"). However, very little is known about this risk. And when both partners have undetectable viral loads, this risk of reinfection is reduced.
Assisted reproduction. Assisted reproduction involves the use of technology, usually at a fertility clinic, to achieve fertilization without vaginal intercourse. In the past, fertility clinics were generally unwilling to help out HIV-positive or HIV-serodiscordant couples wanting to become pregnant. Today, several clinics across the United States are offering a full range of reproductive services to HIV-positive couples. While assisted reproduction technologies are changing all the time, there are a few "standard" approaches to know about:
- Oligospermia cup insemination (OGI): This is perhaps the least invasive procedure offered by assisted reproduction clinics. It involves placing sperm in a cup that is securely fastened to the cervix, similar to a diaphragm, to coax the sperm to enter the uterus and fertilize an egg released by the ovaries.
- In utero fertilization (IUF): This procedure involves placing sperm deep within the uterus to promote fertilization.
- In vitro fertilization (IVF): Using this method, the woman takes fertility drugs to stimulate her ovaries to produce more eggs. The eggs are then retrieved and combined, in a petri dish, with sperm from the male partner (or sperm donor). Once fertilization occurs, the embryo is then implanted in the lining of the woman's uterus using a thin plastic tube.
- Intracytoplasmic sperm insertion (ICSI): With this technique, a single sperm is injected into the egg and the embryo is placed in the fallopian tubes or uterus.
Regardless of which procedure is selected, it is important for the HIV-positive partner to be on antiretroviral treatment and to have an undetectable viral load before attempting fertilization. However, even if a male's HIV is undetectable in his blood, it is still possible for HIV to be present in his sperm. To further reduce the risk of transmission, some clinics offer a procedure called "sperm washing." Sperm washing involves placing collected semen in a test tube and mixing it with a solution that is denser than the seminal fluid (where HIV can be found) but less dense than sperm. The test tube is then placed in a centrifuge and spun at a high speed, causing the seminal fluid to rise to the top and the sperm to sink to the bottom. The seminal fluid is then then skimmed off and the remaining sperm sample is tested for HIV using ultrasensitive tests. If no HIV is found, the sperm is then used to fertilize the egg using one of the procedures described above.
To learn more about assisted reproduction for HIV-positive couples, consider getting in touch with the Special Program for Assisted Reproduction (SPAR) at the Bedford Research Foundation in Bedford, Massachusetts. SPAR has a national network consisting of more than 25 fertility centers throughout the U.S.