European clinical experience with assisted reproductive technology in HIV-discordant couples Augusto Enrico Semprini Research Fellow – University of Milan Medical School Honorary Research Fellow – University College of London Honorary 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%)

Males as % of all HIV/AIDS reported cases 80% 71% 79.5% 77% 70.9% 85% 75% 82% 73% 62.5% 97% 72% 66% 84% <20% 20-40% 40-60% 60-80% 80.3% 83% 61.2% 61% 76% 78% 68% 74% 64% 79% >80% 81% 70% 79% 62% 75% 75% 78% 77% 81% 80% 63% 90% 74% N/A 68% 82% Males as % of all HIV/AIDS reported cases NOTE: % of AIDS cases in countries not reporting HIV Sources: EuroHIV; national reports; 82,8%

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

REMOVAL OF p18 IMMUNOREACTIVE CELLS FROM THE SEMEN HTLV-III/LAV SEROPOSITIVE MEN Augusto E Semprini, A Vucetich, E Morandi, CL Parravicini, G Pardi and AE Beer. Colloque INSERM, Vol. 154, 1987, pp 462 A cytospin preparation of washed spermatozoa, supernatant and the second fraction of the ejaculate were tested against a monoclonal anti-p18 antibody by immunoperoxidase technique. Washed sperm of seropositive and seronegative men were non-reactive, while many mononuclear cells and those in the second fraction of seropositive males were strongly reactive. Experiments are under way to test the possibility of safe intrauterine insemination with processed semen of HIV-positive men desiring a child.

SPERM WASHING Semprini et al. – Lancet 1992 45% 90% Gradient Wash Sperm-migration Test for residual HIV Total dilution: 4 x 106

INSEMINATION OF HIV-NEGATIVE WOMEN WITH PROCESSED 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

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 CONCEPTION IN HIV-DISCORDANT COUPLES LESS RISKY THAN NATURAL CONCEPTION CLINICAL SELECTION OF ADEQUATE AND FEASIBLE REPRODUCTIVE TECHNOLOGY TO ACHIEVE PREGNANCY

Natural conception in HIV-negative women with HIV-infected partners L 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 CONCEPTION 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 DETECTED BY PCR (LOWER DETECTION LIMIT 100 COPIES/ML)

HIV-1 DNA IN SEMEN AND PBMC BY PCR ASSAY (LOWER DETECTION LIMIT 50 COPIES/ML)

CONRAD 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. In particular, when requested to grade the importance of assisted conception services from 0 to 5 (not at all important, a little important, somewhat important quite important, important, very important) not a single participant gave a vote of less than 4.

to avoid sexual transmission of HIV to overcome an infertility problem ART IN COUPLES WITH HIV to avoid sexual transmission of HIV to overcome an infertility problem

INFERTILITY IN COUPLES WITH HIV 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. Desire for children Participants described their desire for a biological child as a normal instinct. Women described renouncing parenthood as a difficult aspect of their relationship with an HIV-positive man. Couples said that having a child of their own gave them a sense of ‘normalcy’ usually lacking in the lives of families with HIV. Some mentioned stigma deriving from childlessness. Some saw the child as a continuation of their 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 - findings Decision 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 Decision making process Desire for children appeared to be first expressed by the women, but the men were strongly supportive. No woman was pressured by her partner to have children Men reported minimizing their own desire for children to avoid putting pressure on their wives. Men were more concerned about avoiding the risk of transmission and sought more information on the safety of the method. Alternatives considered or attempted by couples Couples knew of other HIV-discordant couples who pursued spontaneous conception. Some reported that their physicians had recommended they engage in unprotected sex to conceive. All were aware that adoption procedures in Italy discriminate against families with HIV and that access to donor insemination was difficult. Most couples reported that they believed assisted conception with washed sperm minimized the risk of transmission to mother and child, thereby raising their hope that they could have their own children. Experience with the program Experience with the program was very intense. Access to assisted conception was difficult because of a lack of treatment centers and of information about prevailing services. Some were forced to pay high costs for travel. Some couples cited such difficulties as reasons for leaving the program Failure or interruption of a cycle and loss of pregnancy were the most sensitive moments. Notwithstanding the tension the program into their relationship, couples found the experience highlighted their mutual solidarity. Women praised the support and care they received from their partners, while men expressed admiration for their partners’ strength and willingness to endure a treatment made necessary by the man’s disease. Information and service needs of participants Couples reported having little fear of infection during treatment. All participants reported that information was a key issue for retaining the couple in the program. While all were informed of the risk of HIV infection associated with sperm washing, awareness of the clinical aspects and chances of specific outcomes varied. Couples stated that expected treatment duration, failure rates, and other treatment information should be discussed with patients prior to starting treatment. Considering the significant psychological burden couples stated that patients should be supported both by a dedicated treating physician and by a second non medical figure for psychological and logistic support. Influences on couple relationship, risk behavior, and quality of life. Couples who had successfully conceived reported that the program had a significant positive impact on their quality of life and fulfilled their long-standing desire to be parents. Men who became fathers reported enhanced motivation to follow treatment and remain healthy for as long as possible. Independent of the outcome and their experience with the program, participants felt very strongly that reproductive assistance should be offered to HIV-discordant couples. Participants strongly argued that it was unethical to withhold assisted reproductive services from couples who wanted them or to discriminate against HIV-discordant couples seeking fertility services.

CONRAD - findings Effect 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

CREAThE CENTRES FOR REPRODUCTIVE ASSISTANCE TECHNIQUES IN hiv-INFECTED INDIVIDUALS IN EUROPE

CREAThE CREAThE is a network of centres providing assisted reproduction services to couples with HIV. The aims of the network are: To promote the availability of assisted concpetion services to couples with HIV. To increase the knowledge on reproductive health techniques for these couples For this purpose CREAThE members may be involved in training and information activities targeted at healthcare professionals, decision and policy makers, and the community of people living with HIV and AIDS.

creathe A 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 centres 1. Italy, Milano, San Paolo 2. Italy, Milano, Esman 3. UK, London, C&WS 4. France, Toulouse 5. France, Strasbourg 6. France, Paris, Cochin 7. Switzerland, St. Gallen, KSSG 8. Germany, Mannheim 9. Belgium, Brussels, Free University

Centre Cycles TOTAL 3864 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 OF SEXUAL TRANSMISSION OF HIV HAS BEEN REPORTED BY ANY CENTER IN EUROPE USING SPERM WASHING WITH SEROLOGIC FOLLOW-UP RATES 75 -100%

“I am glad I had a chance to have my child this way, but I would have gone on and had it anyway… because in our case, what keeps you from having children is fear. And what pushes you to have them is life itself… … and life is always stronger than fear”