Couples infected with HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) are increasingly seeking assisted conception. These couples avoid unprotected intercourse and use condoms at all times in order to minimize the risk of infecting their partner. As this practice inhibits pregnancy, assisted procreation is generally required for safe conception. For many couples, access to such services is restricted on ethical, geographical and financial grounds.
The aim of the study was to assess the fertility needs, geographical origin and state funding of patients with blood-borne viral infection.
A retrospective review of the medical records of couples referred for fertility treatment between January 1999 and December 2006, where one or both partners were infected with HIV, HBV and/or HCV, was carried out.
Of the 205 couples included in the study, 44% lived in London, 51% came from elsewhere in the United Kingdom and 5% travelled from outside the United Kingdom to seek treatment. Genitourinary medicine clinics were the main source of referral. 85.8% of couples had HIV infection, 15.1% were infected with HBV and 13.6% had HCV infection. Fertility screening identified a high incidence of male factor infertility (33.3%) in HIV-infected men and tubal disease (40.8%) in HIV-infected women. Only 23.6% of HIV-infected couples, 20% of HBV-infected couples and 12.5% of HCV-infected couples obtained state funding for assisted conception.
Fertility screening identified a high incidence of male and tubal factor subfertility among couples living with HIV, HBV and HCV. Limited access to specialist clinics equipped to cater for these couples and restricted funding may impact negatively on couples obtaining risk-reducing assisted reproduction treatment. This may have long-term public health implications as individuals attempt to conceive through unprotected intercourse.
Over the years, we have seen an increasing number of couples with blood-borne viral infection, such as infection with HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV), seeking assisted conception to treat fertility issues or to reduce the risk of viral transmission to their uninfected partner. In the case of HIV-infected couples, this increased desire to start a family is driven in part by the significant reduction in the mortality and morbidity associated with the advent of highly active antiretroviral therapy (HAART). As life expectancy increases and their quality of life improves, more of these couples are now seeking assistance to start a family . For many couples, access to such services is restricted on ethical, geographical and financial grounds. In the United Kingdom, only a few Human Fertilisation and Embryology Authority (HFEA) licensed fertility centres offer treatment to virally infected patients  as they do not have dedicated facilities to meet the requirements of such a service. The Assisted Conception Unit (ACU) at Chelsea & Westminster Hospital has been the principal centre offering treatment to virally infected patients since 1999 as it has specialised facilities. In this retrospective study, we assessed the fertility needs, geographical origin and state funding of patients with blood-borne viral infection seen in our clinic to determine whether their needs were being met. There is currently no information on funding of fertility treatment for this cohort of patients in the United Kingdom.
A retrospective analysis was conducted of the medical records of 205 couples where one or both partners were infected with HIV, HBV and/or HCV who were referred to Chelsea & Westminster ACU between January 1999 and December 2006 for fertility treatment. The results of fertility screening carried out on all patients were noted, irrespective of whether their subfertility was voluntary (consistent condom use to avoid the risk of viral transmission to their partner) or not. The initial screen included assessment of early follicular phase serum follicle-stimulating hormone (FSH), luteinizing hormone (LH) and oestradiol, and midluteal phase progesterone. Hysterosalpingogram was chosen as the first-line test for tubal patency as it is least invasive. Laparoscopy and a dye test were performed where there was comorbidity . Semen analysis was performed in all cases and results interpreted based on World Health Organization (WHO) reference values . The availability of state funding for the couples and their geographical origins were also recorded.
Information on funding was obtained from the unit accounts department and by reviewing invoices.
In 176 of the 205 couples (85.8%), at least one partner was infected with HIV (127 serodiscordant HIV-positive men, 29 serodiscordant HIV-positive women and 20 HIV-concordant couples). Of these 176 couples, 88.6% (156 of 176) were ‘voluntarily’ infertile. A male factor was identified in 33.3% (49 of 147) of HIV-positive men and tubal disease in 40.8% (20 of 49) of HIV-positive women. Among the HIV-positive couples who proceeded to assisted reproduction treatment, state funding was obtained in 23.6% of cases (38 of 161).
In 31 of the 205 couples, at least one partner was infected with HBV (20 serodiscordant HBV-positive men, 10 serodiscordant HBV-positive women and one HBV-concordant couple). Of these couples, 58% (18 of 31) were voluntarily infertile. A male factor was identified in 47.6% (10 of 21) of infected men and tubal disease in 45.5% (five of 11) of infected women. Of the 20 HBV-infected patients who proceeded to assisted reproduction treatment, 20% (four of 20) received state funding.
In 28 of 205 couples (13.6%) at least one partner was infected with HCV (24 serodiscordant HCV-positive men, three serodiscordant HCV-positive women and one HCV-concordant couple). Eighteen men were coinfected with HIV and four were coinfected with both HIV and HBV. Of the couples, 92.8% (26 of 28) were ‘voluntarily’ infertile to prevent viral transmission to their partner. A male factor was identified in 28% (seven of 25) of infected men and tubal disease in 25% (one of four) of infected women. Of the 24 HCV-infected couples who proceeded to assisted reproduction treatment, 12.5% (three of 24) received state funding.
Geographical origin of patients and source referral
Of the 205 couples analysed, 44% (90 of 205) lived in London, 51% (104 of 205) came from elsewhere in the United Kingdom and 5% (11 of 205) travelled from outside the United Kingdom to seek treatment because of their viral status.
Genitourinary medicine clinics were the main source of referral (63.2%). Other sources of referral included fertility clinics (13.3%), General Practitioners (GP) (6.6%), gynaecology clinics (5.1%), self referrals (5.1%), haemophilia clinics (4.6%) and chest clinics (2.1%) (Fig. 1).
Our study demonstrates that a high percentage of couples living with HIV, HBV and HCV are voluntarily infertile. This cohort of patients avoid unprotected intercourse and use condoms at all times in order to minimize the risk of infecting their partner. As this practice inhibits pregnancy, assisted procreation is generally required for the safe realization of conception. Although voluntary use of condoms is a major inhibitor of conception, co-existing factors that compromise fertility were frequently encountered during assessment of these couples. Fertility screening identified a high incidence of male factor infertility among infected men and tubal disease in HIV-infected women, necessitating in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).
The higher incidence of male factor infertility among HIV-positive men has been reported [5,6]. Nicopoullos et al.  showed that HIV-positive men were about 1.5-times more likely to have abnormal semen parameters than HIV-negative men. That series also showed a positive correlation between total sperm concentration and CD4 cell count. A similar finding was reported by Dulisoust et al. .
The pathogenesis of male factor infertility in HIV-positive men may be multifactorial. A direct effect of HIV on the hypothalamo-pituitary-gonadal axis has been suggested . Advanced HIV infection has been associated with low serum testosterone levels . It is also possible that concomitant sexually transmitted infection may contribute to the pathogenesis of male factor infertility among HIV-positive men.
There was also a high incidence of tubal factor infertility in this series (40.8% of HIV-positive women). Irwin et al.  studied the effect of HIV infection on pelvic inflammatory disease (PID) and reported an increase in the prevalence and severity of PID among HIV-positive women with consequent tubal damage.
State funding for virally infected patients was highest in HIV-infected patients, comparable to national levels for uninfected patients , but much lower in those with HBV and HCV infection. We have seen a steady rise in the number of couples seeking risk-reduction fertility treatment (Fig. 2). Risk-reduction treatment options for couples living with viral infection have been described elsewhere . These couples seek assisted conception, mainly as a preventive measure to minimize the risk of infecting their partner. The fact that half of all couples had to travel long distances from other parts of the UK to attend our clinics indicates restricted access. State funding for assisted conception treatment among couples living with blood-borne viruses should be considered a public health measure to minimize the risk of spread of the virus to partners and offspring. The last few years have seen an increase in the proportion of HIV-infected couples who received state funding for assisted conception (Fig. 3). Although this trend could be an attempt to implement National Institute for Health and Clinical Excellence (NICE) guidelines, the increase in funding is only modest and way below NICE recommendations.
Assessing the availability of state funding for assisted conception for these couples is not, however, straightforward. For instance, HIV infection is still fraught with secrecy and extreme confidentiality. The stigma associated with the condition means that most couples would rather not disclose their status even to their GP. This may explain why only 6% of our referrals came from GPs. This tendency to secrecy means that some couples may not wish to disclose their status to the funding authorities and therefore fail to access available funds. A possible solution to this problem may be the allocation of funds to specialist centres where these couples are treated, so that couples may access the funds directly without needing to disclose their status to a third party. In this way, funding will still be controlled by the stake-holders through the service providers, and couples will receive risk-reduction treatment with the utmost confidentiality that they desire.
Although a high percentage of couples with HIV, HBV and HCV infection are voluntarily infertile and elect to have assisted conception with or without sperm washing to minimize the risk of viral infection of their partner and offspring, fertility screening identified a high incidence of other factors that compromise fertility. Limited access to specialist clinics equipped to cater for these couples as well as restricted funding may impact negatively on couples obtaining risk-reducing assisted reproduction treatment. This will inevitably have long-term public health implications as individuals attempt to conceive through unprotected intercourse.