HIV

1
HIV Subfertility

• Leila C G Frodsham
• Clinical Research Fellow
• Assisted Conception Unit
• Chelsea and Westminster

Talk to UK-CAB (UK-Community Advisory Board)25
October, 2002HIV I-Basehttp//www.I-base.org.uk
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Our Team

• Leila CG Frodsham
• Research Fellow
• Bronwen Tamberlin
• Sperm washing Coordinator
• Carole Gilling-Smith
• Consultant GynaecologistDirector
• Assisted Conception Unit
• Chelsea and Westminster Hospital

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Who we treat

• HIV positive males
• with negative partners
• HIV positive females
• with negative partners
• Couples where both partners are positive

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What treatments do we offer?

• IUI
• (intrauterine insemination)
• IVF
• (in vitro fertilization)
• ICSI
• (intracytoplasmic sperm injection)
• Donor Insemination

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IUI

• In couples with normal/unexplained infertility
• Ovulation predicted via ultrasound tracking
• Sperm washed
• Sperm injected into partners womb

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Natural cycle IUI/SWP
Day 8 Day 11
Day 13
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InVitroFertilization

• In subfertile couples
• Tubal disease/low sperm count
• Superovulation by injection
• Follicles tracked by scan
• Eggs collected

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InVitroFertilization

• Sperm washed
• Sperm and eggs mixed in the lab
• Embryos replaced in womb

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Intracytoplasmic sperm injection

• Very low sperm count
• As IVF
• Single washed sperm injected into egg

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Referral to the programmes

• We are happy to consider anyone

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Referral to the programmes

• Consider welfare of the child
• Detailed HIV history
• Recent viral load and CD4
• Drugs and resistance
• Sexual health screen
• Smear/colposcopy
• Intended obstetric care

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Referral to the programmes

• No storage of positive gametes/embryos
• Gamete donation on named basis
• Couples only will be considered

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Pre conceptual counselling HIV

• Stability of relationship
• Disease progression / health of infected parent
• High risk behaviour (drug abuse, unprotected sex)
• Social support
• Understand agree to comply with risk reduction
  treatment

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Welfare of the Child in HIV ve

• In male partner
• Transmission of HIV in sperm
• In female partner
• Vertical transmission risk (lt 1)
• Use of antiretrovirals
• Mode of delivery
• Avoidance of breastfeeding
• Effect of antiretrovirals on fetus/child
• In both
• Disease progression / health of infected parent
• High risk behaviour (drug abuse, unprotected sex)

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Sperm washing programme

• Since April 1999
• 59 Couples treated
• 11 babies born

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Sperm washing-How safe?
seminal fluid
NSC
NSC
sperm
?
sperm
NSC
NSC
NSC
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Validation of sperm washing

• sperm samples from 11 HIV ve men tested for
• HIV RNA viral load
• HIV proviral DNA (latent virus)
• expression of CD4 receptor HIV co-receptors
  CCR5
• spermatozoa had no
• HIV RNA
• HIV proviral DNA
• CD4 or CCR5 expression
• L Kim et al, AIDS 1999, 13 645-51

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sperm washing

• semen centrifuged in density gradient
• NASBA check for HIV-1 RNA
• (25 HIV-1 copies/106 sperm)
• 6 risk of positive NASBA
• cancelled cycle

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Risks of unprotected intercourse

• unprotected timed intercourse
• 1 in 500 risk of infecting partner
• series of 92 HIV ve men /HIV -ve women
• carefully timed but unprotected intercourse

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Fertility provision for HIV ve males
Initial referral info pack sent out
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Pregnancy rates

• IUI
• 36 patients91 cycles 20 pregnancy
• IVF
• 13 patients19 cycles 33.3 pregnancy
• ICSI
• 10 patients16 cycles 12.5 pregnancy

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Pregnancy monitoring

• Pregnancy test
• Serial scans from 54 weeks
• 3 monthly HIV tests during antenatal post natal
  periods

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Female positive programme

• Since April 2002
• 3 women treated
• 4 pregnancies-1 ongoing

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HIV-1 ve womenwelfare of the child

• risk of vertical transmission
• cannot wash eggs
• reduced to lt 1 with good obstetric care
• effect of antiretrovirals in utero
• health / life expectancy of parent
• persistent drug abuse in parent
• future for child if born HIV positive

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HIVve women and vertical transmission

• equal or greater risks to offspring in
• older women
• trisomy 21 and other chromosome abnormalities
• women with cardiac disease or cystic fibrosis
• diabetics
• multiple pregnancy
• severe oligoasthenospermia ICSI

HIV and infertility time to treat. Gilling-Smith
C, Smith JR, Semprini A. BMJ 2001, 322 567-8
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Mother to child HIV transmission

• HAART
• Caesarean Section
• No Breastfeeding
• lt2 Vertical transmission

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Mother to child HIV transmission

• Chelsea Westminster (since 1995)
• 50 births in HIV ve womennone of the babies
  ve
• St Marys Paddington (since 1996)78 births in
  HIV ve womentwo positive babies (in both cases
  mother did not comply and take medication
  delivered elsewhere)

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Antenatal Care

• Must be optimal
• Joint care from GU Physician
• HIV Specialist Obstetrician
• CW if insufficient locally

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Fertility provision for HIV positive females
Preconceptual counselling
Sperm washing
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Female positives

• IUI-3 cycles
• 1 pregnancy early miscarriage
• IVF-5 cycles
• 3 pregnancies-1 ongoing pregnancy
• ICSI-0 cycles

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Femaleswhen to refer

• Provided
• Negative partner
• regular cycle
• no history PID/STD or abdominal surgery
• No other known fertility factors
• gt35 years 6 months self-insemination
• lt35 years 6-12 months self-insemination

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Couples where both are positive

• Sperm washing required
• Extra counselling
• 3 couples ready for/undergoing treatment

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CREAThE

• Centres for Reproductive Assistance Techniques in
  HIV in Europe
• 7 centres in 6 countries to pool data to assess
• safety of risk reduction options
• efficacy in relation to fertility factors in this
  population
• epidemiology
• behavioural and psychosocial aspects
• draw up guidelines for counselling and treatment

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Who to contact

• Bronwen Tamberlin /Dr Leila Frodsham
• Happy to take any enquiries
• Thankyou