Interpretation
Our participants had questions and worries about the presence of HPV in
the semen and the impact of HPV infection upon male fertility. Concern
over subfertility in HPV-positive men has received far less attention in
previous qualitative studies. The data support the presence of HPV in
semen and its proposed role in decreased fertility
(20, 21).
Other studies indicated that HPV infection of semen represents a risk
factor for male fertility abnormality (1,
3). A study found the most common HPV
genotype among couples undergoing IVF treatment was 52
(1). Interestingly two of our participants
(numbers 10 and 8) who were extremely concerns over infertility had
genotype 52. Although this is not a correlational study, it can be
suggested as an area for more research.
In line with our findings, various other studies also indicated
HPV-positive women have concerns about female fertility impairment and
the effects of HPV on childbearing and pregnancy outcomes
(9, 10,
13,
22-24).
It is worth mentioning that HPV DNA has been detected in endometrium and
ovaries (25). In a cohort study conducted
in Denmark, no association had been found between high-risk HPV and the
risk of female infertility (26). In a
review, alluded to a relationship HPV had with alterations in fertility
and ART outcomes (27). Accordingly, HPV
detection and genotyping in both men and women are suggested in
infertility diagnosis, at least in idiopathic infertility cases, before
IVF procedures (27).
Two participants expressed worries about the relationship between
infecting with HPV and the failure of ART. It is worth mentioning that
in a study conducted in Belgium, indicated that HPV positivity is
associated with a negative IUI outcome. HPV-positive women were six
times less likely to become pregnant after IUI
(28). Other studies found the detection
of HPV at the time of fertility treatment has been adversely affected
IVF outcomes, including lower pregnancy rates and increased risk of
early pregnancy loss (29,
30). Since their concerns do not seem to
be unfounded, it is suggested health care providers take these concerns
seriously and consider referring them to specialists.
Our participants expressed their fear of losing fertility due to getting
HPV-associated cancers in the future. Another study also reported
similar concerns (9). In line with our
findings, fertility concerns surrounding the HPV vaccine were reported
in another study (12). It can be due to
considerable media attention to the safety of the HPV vaccine. World
Health Organization (WHO) indicated to a systematic review concluded no
causal relationship between HPV vaccination and infertility
(31). Caregivers can reassure women with
these concerns by citing to the WHO.
As indicated by some other studies, fertility concerns surrounding
conservative treatment for CIN have also mentioned by our participants
(9, 12,
23). Women expressed fears about whether
their fertility would be affected by HPV diagnostic and therapeutic
procedures like LEEP and conization. Research has yielded mixed results,
but at least one study indicates that fertility is not affected by a
LEEP (32).
Pregnancy concerns were another main category extracted from the
interview data. Women mentioned that worrying about the adverse effects
of pregnancy on their health was the main reason they decided not to get
pregnant. In a mixed-method study conducted in the United States, 30 of
94 women who planned on getting pregnant indicated that their HPV test
results would change their future pregnancy plans
(33). Physiological changes during
pregnancy and a decline in the functions of the immune system may
stimulate the progression of the HPV infection
(34). Women infected with HPV needed to
know what they need to do to have a healthy pregnancy. They may also
face barriers seeking and obtaining information to address their
reproductive concerns.
In the present study, the participants feared that the accidental
injection of the HPV vaccine during pregnancy would cause harm to the
fetus or adverse pregnancy outcomes. This fear surrounding the HPV
vaccine may stem from the fact that drugs and medications theoretically
might be damaging, especially in the first pregnancy trimester
(35). Pregnancy testing before
vaccination is not necessary although the vaccine manufacturers and WHO
recommend avoiding HPV vaccination during pregnancy
(35). Since no HPV vaccine-associated
adverse events has been observed in pregnancy or immediately
post-conception, in cases of unintentional immunization of pregnant
women no intervention is needed (35).
Unexpectedly, for protection against HPV, the vaccination of women is
preferable before or eventually during pregnancy
(25), but in a meta-analysis indicated
that the association between peri-conceptional or pregnancy exposure of
HPV vaccine and spontaneous abortion is still uncertain
(36).
In line with our findings, two studies also indicated concerns about the
association between HPV infection and adverse pregnancy outcomes such as
spontaneous abortion and preterm delivery
(9, 12).
Scientific literature states that HPV infection in females is associated
with spontaneous abortion and preterm birth
(3, 27,
28, 37).
Adequately, HPV positivity in pregnant women or their partners can be
considered as a risk of miscarriages and premature rupture of membrane
(3, 27).
Two studies indicated that the cervical conization and a LEEP do not
necessarily increase the risk of preterm delivery in a subsequent
pregnancy (38,
39).
Women interviewed thought natural childbirth may pose a transmission
risk to a newborn. Another qualitative study reported this concern
(12). Tseng et al. found the overall
frequency of HPV transmission from mothers to neonates was 39.7%, and a
meaningfully higher rate of infection was observed when infants were
delivered vaginally compared with cesarean
(40).
Most participants reported being highly concerned about the safety of
wart-removing medications and diagnostic and therapeutic interventions
for cervical cell changes during pregnancy. They asked about the safest
way to remove GWs. In a study, CO2 laser vaporization has been suggested
as a safe, simple treatment for warts during pregnancy
(41).
In line with Pourmohsen, maternal-to-fetal HPV transmission was a common
concern, especially among married who had the pregnancy plans. There is
still much controversy about the precise mode of and the clinical
effects of infection on the child. Detection of HPV DNA in semen,
endometrium, and ovaries indicates the possibility of transmission even
before conception. It raises the possibility of a child’s parents as the
potential sources of HPV infection (25,
42). Another possible route of infection
is intrauterine or prenatal transmission; because of the reported
presence of HPV DNA in the amniotic fluid, placenta, and cord blood
samples. Close contact of the fetus with the infected cervical and
vaginal tracts of the mother during delivery can cause perinatal
transmission. Maternal history of genital warts in pregnancy was
associated with a higher risk of respiratory papillomatosis in the child
(43). Horizontal HPV transmission during
breastfeeding or early nursing has also been considered as a significant
contributor toward the infant’s contagion. Two participants expressed
such concerns. Inconsistent results have been found in terms of breast
milk as a potential reservoir of viruses
(25). In light of lifelong HPV
protection, considering the vaccination of infants is suggested
(25).
Almost all interviewed women had been recommended to use a condom. Most
married reported that they (or their husbands) are reluctant to use a
condom. They wanted to know why constantly using condoms is essential
while they already are HPV-infected. Caregivers should also explain why
they recommend using a condom.
Some women with a history of taking hormonal contraceptives pointed out
they have been recommended to stop taking combined hormonal pills.
HPV-positive women raise some concerns about choosing their
contraceptive method. Long-term use of birth control pills increases
cervical cancer risk, importantly for women with persistent HPV
infection. However, users of combined oral contraceptives (COCs) have a
decrease in immune cells providing a favorable environment for the
appearance of HPV lesions (44). Although,
to conclude causality, more studies are needed
(44), particular attention should be
given to discuss contraception methods with HPV-positive women.
Such richness from the interviews revealed unexpected concerns such as
fear of having an ovarian tumor and getting cancer because of a family
history of cancer. They considered HPV to be a familial carcinogen
factor. Similar concerns indicated by another study
(8).
The only context-specific finding was the fear of cervical cancer in
single virgin women. To reassure these women, doctors take a so-called
”Girly Pap smear” from the upper part of the vagina with a cotton swab.