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.