European clinical experienceEuropean clinical experience

with assisted reproductive technology with assisted reproductive technology

in HIV-discordant couplesin HIV-discordant couples

Augusto Enrico SempriniAugusto Enrico SempriniResearch Fellow – University of Milan Medical SchoolResearch Fellow – University of Milan Medical School

Honorary Research Fellow – University College of LondonHonorary Research Fellow – University College of London

Honorary Consultant – Chelsea and Westminster Hospital of LondonHonorary Consultant – Chelsea and Westminster Hospital of London

HIV/AIDS epidemic in Europe

WHO/UNAIDS estimates, end of 2004:

PLWHA: 2,010,000 (1.40 – 2.86m)

Estimated prevalence: 0.4% (range: 0.2-0.6%)

80%

71%

80%

79.5%

77%

70.9%

85%

75%

82%

73%

62.5%

85%

97% 72%

66%

84%

<20%

20-40%

40-60%

60-80%

80.3%

83%61.2%

61%

76%

78%

68%72%

74%

71%

80%

64%

79%

>80%

81%

77%

79%72%

70%

82,8%

78%

68%

77%

81%

75%

79%

80%

90%74%

63%

82%

75%

N/A

Males as % of all HIV/AIDS reported casesNOTE: % of AIDS cases in countries not reporting HIVSources: EuroHIV; national reports;

62%

Historical scenario of the HIV epidemic in Italy

• From the eighties on there was an epidemy of HIV and HCV infections among drug users with 75% acquiring both infections

• In the drug addicted population there is a four to one ratio of males to females• Less than 5% of drug addicted males admits also homosexual behaviour• A large reservoir of HIV-infected young heterosexual males was formed• Couples formed by HIV-infected male and uninfected female adamant to

conceive• The sperm washing method was developed as a “harm reduction” measure to

avoid sexual transmission of HIV to healthy females

““we do not help them have babies…we do not help them have babies…

… … we help preventing sexual transmission to their healthy female partners and we help preventing sexual transmission to their healthy female partners and possibily to the child”possibily to the child”

REMOVAL OF p18 IMMUNOREACTIVE CELLS FROM THE SEMEN REMOVAL OF p18 IMMUNOREACTIVE CELLS FROM THE SEMEN HTLV-III/LAV SEROPOSITIVE MENHTLV-III/LAV SEROPOSITIVE MENAugusto E Semprini, A Vucetich, E Morandi, CL Parravicini, G Pardi and AE Augusto E Semprini, A Vucetich, E Morandi, CL Parravicini, G Pardi and AE Beer. Colloque INSERM, Vol. 154, 1987, pp 462Beer. Colloque INSERM, Vol. 154, 1987, pp 462

A cytospin preparation of washed spermatozoa, supernatant and the second A cytospin preparation of washed spermatozoa, supernatant and the second

fraction of the ejaculate were tested against a monoclonal anti-p18 antibody fraction of the ejaculate were tested against a monoclonal anti-p18 antibody

by immunoperoxidase technique. Washed sperm of seropositive and by immunoperoxidase technique. Washed sperm of seropositive and

seronegative men were non-reactive, while many mononuclear cells and seronegative men were non-reactive, while many mononuclear cells and

those in the second fraction of seropositive males were strongly reactive. those in the second fraction of seropositive males were strongly reactive.

Experiments are under way to test the possibility of safe intrauterine Experiments are under way to test the possibility of safe intrauterine

insemination with processed semen of HIV-positive men desiring a child.insemination with processed semen of HIV-positive men desiring a child.

45%

90%

Gradient Sperm-migration Wash

Test for residual HIV

SPERM WASHINGSPERM WASHINGSemprini et al. – Lancet 1992Semprini et al. – Lancet 1992

Total dilution: 4 x 106

INSEMINATION OF HIV-NEGATIVE WOMEN WITH INSEMINATION OF HIV-NEGATIVE WOMEN WITH PROCESSED SEMEN OF HIV-POSITIVE PARTNERSPROCESSED SEMEN OF HIV-POSITIVE PARTNERS

85 HIV-discordant couples were screened for fertility; 29

women were found suitable for a timed insemination course

with the processed semen of their HIV-positive partner. None

of the inseminated women seroconverted and 17

pregnancies were achieved in 15 women. All 10 infants born

to these mothers remain HIV seronegative. The eldest child

is now three years old, healthy and uninfected. (Semprini et al. - Lancet 1992; 340: 1317-19)

AMOUNT OF HIV-1 IN SPERM FRACTION AFTER SPERM PROCESSING TECHNIQUES (normal semen

spiked with 106 pg as by Abbot HIV-Ag ELISA)Anderson and Semprini, Fertil Steril 1993, abstract

TECHNIQUE AMOUNT REDUCTION

Simple cell wash 80 pg 10.000-fold

Gradient centrifugation Undetectable >100.000-fold

Swim-up Undetectable >100.000-fold

SPERM WASHING AND REPRODUCTIVE ASSISTANCE IN ITALY (1989 -2005)

• 2506 cycles of assisted conception

• 732 women treated

• 2210 IUI

• 73 IVFET

• 173 ICSI

• 41 ET

• 6 ICSI with donor egg

KEY ISSUES FOR ASSISTED KEY ISSUES FOR ASSISTED CONCEPTION IN HIV-DISCORDANT CONCEPTION IN HIV-DISCORDANT

COUPLESCOUPLES

• LESS RISKY THAN NATURAL CONCEPTION

• CLINICAL SELECTION OF ADEQUATE AND FEASIBLE

REPRODUCTIVE TECHNOLOGY TO ACHIEVE PREGNANCY

Natural conception in HIV-negative women with Natural conception in HIV-negative women with HIV-infected partnersHIV-infected partnersL Mandelbrot, I Heard, E Henrion-Geant, R Henrion (Lancet 1997; 349: 850)

We followed 104 consecutive pregnancies in 92 HIV-negative

women with HIV-positive partners. Couples were advised to

pinpoint ovulation in order to reduce possible exposure.

Seroconversion was observed in two women at 7 months of

pregnancy and in two others post partum. Some authors advocate

intrauterine insemination with semen from the HIV-infected males,

but the risk of this must be measured against the low background

risk of natural conception. Stringent standard of safety must be

required before inseminating potentially infected semen.

NATURAL CONCEPTION AND HIV

• In 56 HIV-discordant couples trying for a pregnancy on

their own after failing to achieve gestation trough

sperm washing and ART there was one documented

case of HIV transmission to the uninfected woman

CAVEATS ABOUT NATURAL CAVEATS ABOUT NATURAL CONCEPTIONCONCEPTION

• Presence of infertility factors in the couple

• Assessment of transmissibility of HIV in the couple

• Ruling out gential infections

• 10% of males without detectable blood viraemia have

significant concentration of HIV in their semen

• Availability of infertility services if pregnancy does not occur

• Long-term effect of discontinuing the use of condoms

TESTING SEMEN FOR THE

PRESENCE OF

HIV DNA AND RNA

HIV-1 RNA IN SEMEN AND BLOOD PLASMA AS HIV-1 RNA IN SEMEN AND BLOOD PLASMA AS DETECTED BY PCRDETECTED BY PCR

(LOWER DETECTION LIMIT 100 COPIES/ML)(LOWER DETECTION LIMIT 100 COPIES/ML)

Plasma(blood)

N 50

WholeSemen

N 48

SeminalPlasma

N 46

NSCs

N 38

Spermatozoabefore

migration

N 38

FinalSpermatozoa

fraction

N 46

21(42%)

0 4(8.7%)

1(2.6%)

0 0

HIV-1 DNA IN SEMEN AND PBMC BY PCR HIV-1 DNA IN SEMEN AND PBMC BY PCR ASSAYASSAY

(LOWER DETECTION LIMIT 50 COPIES/ML)(LOWER DETECTION LIMIT 50 COPIES/ML)

PBMC

n 50

Wholesemen

n 49

NSCs

n 48

Spermatozoabefore

migration

n 46

Finalspermatozoa

fraction

n 40

50 0 7(14.6%)

0 0

CONRAD Main study – quantitative analysisCONRAD Main study – quantitative analysis

• 811 couples in original clinical dataset

• 243 excluded, 80 lost to follow up

• 488 contacted

• 369 women and 293 men consented to phone survey

• 646 conducted (365 and 281)

CONRAD - findings

• 223 (46%) couples achieved pregnancy.

• Of the 264 couples who failed to conceive 67 (26%)

attempted spontaneous conception.

• In these couples we had reports of pregnancy in 56

women and one documented HIV infection.

• Survey findings corroborated pilot results.

ART IN COUPLES WITH HIVART IN COUPLES WITH HIV

to avoid sexual transmission of HIV

to overcome an infertility problem

INFERTILITY IN COUPLES WITH INFERTILITY IN COUPLES WITH HIVHIV

Couples with HIV suffer an increased

prevalence of infertility factors:

•GENITAL INFECTIONS (up to 50%)

•TUBAL DAMAGE (up to 10%)

•ANOVULATION (up to 10%)

•DYSPERMIA?

PSICHOLOGICAL ASPECTS OF

ACHIEVING PREGNANCY BY

ASSISTED CONCEPTION IN HIV-

DISCORDANT COUPLES

CONRAD - findings

• Desire for children• desire for a biological child described as a normal instinct.• Women: renouncing parenthood is a difficult aspect of

relationship with an HIV-positive man.• Having a child gives a sense of ‘normalcy’.• Stigma deriving from childlessness. • Child as a continuation of the family and love relationship once

the man was gone. • Men and women described learning about assisted

conception as opening a door that was closed to them before.

CONRAD - findingsDecision making process

• No woman was pressured by her partner to have children

• Men were more concerned about avoiding the risk of transmission

• Physicians had recommended unprotected sex to conceive

Experience with program

• Very intense

• Access was difficult: no info, treatment centers

• Failure or interruption of a cycle and loss of pregnancy were the most sensitive

moments

• Information and psychological suppport - key issues for retaining couples in the

program

CONRAD - findingsEffect on quality of life

• Families are stable (28 separated of 488)

• Notwithstanding the tension, the experience highlighted mutual solidarity

• Successful outcome had a significant positive impact on quality of life

• Men who became fathers: enhanced motivation to follow treatment and

remain healthy

• Treatment enhanced attention to safe sex behavior

• Independent of the outcome, participants felt very strongly that reproductive

assistance should be offered.

• Participants strongly argued that it was unethical to withhold assisted

reproductive services from couples who wanted them

CREAThECREAThE

CCENTRES FOR ENTRES FOR REREPRODUCTIVEPRODUCTIVE

AASSISTANCE SSISTANCE TTECHNIQUES IN ECHNIQUES IN

hivhiv-INFECTED INDIVIDUALS IN -INFECTED INDIVIDUALS IN

EEUROPEUROPE

CREAThECREAThE

creathecreatheA non profit organization founded by all European

centres providing reproductive assistance to

couples with HIV aiming at:

• Establishing a forum for collaboration

• Establishing a common database

• Standardisation of protocols of assistance

• Training and support for new centers

Creathe network for assisted conception in couples with HIV

• 9 European centres1. Italy, Milano, San Paolo2. Italy, Milano, Esman3. UK, London, C&WS4. France, Toulouse5. France, Strasbourg6. France, Paris, Cochin7. Switzerland, St. Gallen, KSSG8. Germany, Mannheim9. Belgium, Brussels, Free University

Centre Cycles

Milan 2506

London 153

Paris, Cochin 394

Toulouse 299

St. Gallen 230

Mannheim 119

Strasbourg 121

Brussels 43

TOTAL 3864

IN SIXTEEN YEARS NOT A SINGLE CASE IN SIXTEEN YEARS NOT A SINGLE CASE

OF SEXUAL TRANSMISSION OF HIV HAS OF SEXUAL TRANSMISSION OF HIV HAS

BEEN REPORTED BY ANY CENTER IN BEEN REPORTED BY ANY CENTER IN

EUROPE USING SPERM WASHING WITH EUROPE USING SPERM WASHING WITH

SEROLOGIC FOLLOW-UP RATES 75 -SEROLOGIC FOLLOW-UP RATES 75 -

100%100%

““I am glad I had a chance to have my child I am glad I had a chance to have my child this way, but I would have gone on and had this way, but I would have gone on and had

it anyway…it anyway…

because in our case, what keeps you from because in our case, what keeps you from having children is fear. And what pushes having children is fear. And what pushes

you to have them is life itself…you to have them is life itself…

… and life is always stronger than fear”… and life is always stronger than fear”