**3.3. Social factors**

can result in cell injury.[46] The degree of mitochondrial toxicity is specific to each NRTI. Theoretically, an HIV-infected person's fertility may be affected by NRTI use via the damage

in sperm and oocytes of HIV-infected patients taking NRTIs and in low oocyte mtDNA in patients with ovarian insufficiency.[47-49] Data from epidemiologic studies are conflicting regarding the impact of cART on fertility. A prospective cohort from the United States reported the lower likelihood of conception associated with antiretroviral therapy among HIV-infected women,[5] whereas a more recent study from Africa demonstrated significantly higher pregnancy rates among HIV-infected women on cART compared to those not on cART.[50] However, these two studies were conducted in different settings and time, and specific behavioral and biological mechanisms were not explored. Zidovudine (azidothymidine, AZT) is the NRTI drug that has been studied the most. In animal studies, AZT has been shown to suppress cell division in the preimplantation mouse embryo, causing reduction in inner cell mass proliferation, greater number of resorptions, and fewer fetuses.[51, 52] A previous study demonstrated that exposure to NRTI transplacentally caused significant fetal mitochondrial damage in experimental monkeys.[53] Unfortunately, there have been no studies examining

Decrease in sexual activity after a new diagnosis of HIV infection is usually observed and may be accompanied by the feeling of guilt and shame and aggravated by the stigma related to HIV infection.[54] Individuals recently diagnosed with HIV infection reported to have decreased desire for or interest in sex relations. They also reported to use condom more consistently during sexual intercourse to avoid transmission of HIV to their partners.[55] Previous studies indicated that HIV-infected women often chose to avoid pregnancy.[56, 57] However, another study revealed that high-risk behaviors, unplanned pregnancies, and pregnancy termination remain prevalent among this population.[58] In the pre–cART era, there was a significant increase in the pregnancy termination rate from 3.5 to 6.3 per 100 women-years following a new HIV diagnosis in the United Kingdom and Ireland[56] and 47% of pregnancies were voluntarily terminated following a new HIV diagnosis in an Australian study.[57] The reasons for pregnancy termination may include challenges of pregnancy, birth and parenting in the context of HIV infection, concerns about increased risks of complications related to pregnancy and delivery, and risk of HIV transmission to the newborn. A previous study reported that unplanned pregnancy, lower CD4 cell count, and having an HIV-infected current partner were factors associated with the decision to terminate a pregnancy.[59] Following the introduction of cART with overall improvement in health and immune status of HIV-infected women, the rates of elective pregnancy termination after a HIV diagnosis were 22%-26% decreased from the pre–cART period.[60, 61] With the success of cART in preventing mother-to-child HIV transmission, HIV infection was reported to have no effect on desire for pregnancy among young urban African Americans aged 15–24 years.[62] Reproductive desire among PLWHIV may now be associated with personal health, cART, concern about HIV transmission, and

This is supported by the mtDNA depletion observed

to mitochondrial biogenesis of gametes.3

184 Genital Infections and Infertility

fertility effect of NRTIs in humans.

**3.2. Psychological factors**

The HIV/AIDS epidemic has a significant impact on the economic and political stability of a nation. Awareness of HIV/AIDS at the population level may affect the age of sexual debut, frequency of sexual intercourse, safer sex and contraceptive practices, perceived value of marriage, social norms, and fertility intentions and choices of PLWHIV.3 The dramatic improvement in the life expectancy of PLWHIV and reduction in HIV transmission rates following treatment of the infected partner have changed ethical considerations regarding childbearing in HIV-infected individuals. Early in the HIV/AIDS epidemic, pregnancy in HIVinfected women was considered morally problematic, whereas recently, the Ethics Committee of the American Society for Reproductive Medicine stated that it is ethical for health care providers to assist PLWHIV who seek pregnancy when optimal precautions to prevent HIV transmission are utilized.[66] Despite more opportunities for access to reproductive care, PLWHIV still face multiple obstacles. First, the severity of their disease, level of immunosup‐ pression, presence of OIs, and other comorbid diseases may impair their fertility. Second, their HIV provider may have limited knowledge to counsel them on reproductive health issues, and infertility specialists may have limited expertise in providing care for HIV-infected persons. Third, HIV stigmatization could potentially preclude them from establishing reproductive care. Finally, assisted fertility therapy (AFT) is technically complicated in regard to HIV transmission prevention and costliness and may not be available in all settings.[3]
