Transcript HIV and Subfertility - UK-CAB

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, 2002
HIV I-Base:
http://www.I-base.org.uk
Our Team

Leila CG Frodsham
Research Fellow

Bronwen Tamberlin
Sperm washing Coordinator

Carole Gilling-Smith
Consultant Gynaecologist+Director
Assisted Conception Unit
Chelsea and Westminster Hospital
Talk to UK-CAB 25.10.02
Who we treat

HIV positive males
with negative partners

HIV positive females
with negative partners

Couples where both partners are positive
Talk to UK-CAB 25.10.02
What treatments do we offer?
 IUI
(intrauterine insemination)

IVF
(in vitro fertilization)

ICSI
(intracytoplasmic sperm injection)

Donor Insemination
Talk to UK-CAB 25.10.02
IUI

In couples with normal/unexplained infertility

Ovulation predicted via ultrasound tracking

Sperm washed

Sperm injected into partners womb
Talk to UK-CAB 25.10.02
Natural cycle IUI/SWP
18mm
Day 8
Day 11
Day 13
Talk to UK-CAB 25.10.02
InVitroFertilization

In subfertile couples
Tubal disease/low sperm count

Superovulation by injection

Follicles tracked by scan

Eggs collected
Talk to UK-CAB 25.10.02
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
Talk to UK-CAB 25.10.02
Referral to the programmes

We are happy to consider anyone
Talk to UK-CAB 25.10.02
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
Talk to UK-CAB 25.10.02
Referral to the programmes

No storage of positive gametes/embryos

Gamete donation on named basis

Couples only will be considered
Talk to UK-CAB 25.10.02
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
Talk to UK-CAB 25.10.02
Welfare of the Child in HIV
+ve

In male partner:
– Transmission of HIV in sperm

In female partner:
– Vertical transmission risk (< 1%)



Use of antiretrovirals
Mode of delivery
Avoidance of breastfeeding
– Effect of antiretrovirals on fetus/child

In both:
– Disease progression / health of infected parent
to UK-CAB 25.10.02
– High risk behaviour (drug abuse, Talk
unprotected
Sperm washing programme

Since April 1999

59 Couples treated

11 babies born
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Sperm washing-How safe?
sperm
NSC
?
sperm
NSC
seminal fluid
NSC
NSC
NSC
Talk to UK-CAB 25.10.02
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
Talk to UK-CAB 25.10.02
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
Talk to UK-CAB 25.10.02
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
4 seroconversions
•2 during pregnancy
•2 postpartum
Mandlebrot et al, Lancet 1997; 349:850-851Talk to UK-CAB 25.10.02
Fertility provision for HIV +ve
males
Initial referral
info pack sent out
1st appointment (GUM)
sexual health screen
Counselling
2 sessions
2nd appointment (ACU)
fertility screen
IVF or ICSI
3rd appointment (ACU)
treatment planned
IUI
Talk to UK-CAB 25.10.02
Pregnancy rates

IUI
36 patients=91 cycles: 20%

pregnancy
IVF
13 patients=19 cycles: 33.3%

pregnancy
ICSI
10 patients=16 cycles: 12.5%
pregnancy
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Pregnancy monitoring

Pregnancy test

Serial scans from 5+4 weeks

3 monthly HIV tests during antenatal + post
natal periods
Talk to UK-CAB 25.10.02
Female positive programme

Since April 2002

3 women treated

4 pregnancies-1 ongoing
Talk to UK-CAB 25.10.02
HIV-1 +ve women:welfare of the
child

risk of vertical transmission
– cannot ‘wash eggs’
– reduced to < 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
Talk to UK-CAB 25.10.02
HIV+ve 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
&JR,
ICSI
HIV and infertility:
timeoligoasthenospermia
to treat. Gilling-Smith C, Smith
Semprini A. BMJ 2001,
322: 567-8
Talk to UK-CAB 25.10.02
Mother to child HIV
transmission
HAART
+
Caesarean Section
+
No Breastfeeding
=
<2% Vertical transmission
Talk to UK-CAB 25.10.02
Mother to child HIV
transmission
Chelsea &Westminster (since 1995)
50 births in HIV +ve women
none of the babies +ve
St Mary’s Paddington (since 1996)
78 births in HIV +ve women
two positive babies (in both cases mother did not comply and take
medication & delivered elsewhere)
Talk to UK-CAB 25.10.02
Antenatal Care

Must be optimal

Joint care from GU Physician
& HIV Specialist Obstetrician

C+W if insufficient locally
Talk to UK-CAB 25.10.02
Fertility provision for HIV positive
females
1st appointment (GUM)
sexual health screen
Preconceptual
counselling
2nd appointment (ACU)
fertility screen
IUI
3rd appointment (ACU)
treatment planned
Sperm
washing
IVF or ICSI
pregnant
Obstetric
monitoring
•HAART
•LSCS
Talk to UK-CAB 25.10.02
•no breast feeding
Female positives

IUI-3 cycles
1 pregnancy; early miscarriage

IVF-5 cycles
3 pregnancies-1 ongoing pregnancy

ICSI-0 cycles
Talk to UK-CAB 25.10.02
Females:when to refer

Provided




Negative partner
regular cycle
no history PID/STD or abdominal surgery
No other known fertility factors
>35 years: 6 months self-insemination
<35 years: 6-12 months self-insemination
Talk to UK-CAB 25.10.02
Couples where both are
positive

Sperm washing required

Extra counselling

3 couples ready for/undergoing treatment
Talk to UK-CAB 25.10.02
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
Talk to UK-CAB 25.10.02
Who to contact

Bronwen Tamberlin /Dr Leila Frodsham
Happy to take any enquiries
Thankyou
Talk to UK-CAB 25.10.02