Prof Athula Kaluarachchi
MBBS,MS,MRCPI.FRCOG,FSLCOG Faculty Of Medicine,University of Colombo
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This Presentation covers only fertility management of HIV positive discordant or concordant couples and not on comprehensive management of infertile couples
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HIV/AIDS patients are now living with a manageable chronic condition because of the efficacy of therapy. As a result, reproductive desires have emerged as clinically important in patients with HIV/AIDS.
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Do we need to address their fertility issues Do the HIV/AIDS patients have desire to have children Does HIV/AIDS have an impact male and Female infertility What safe options are available What can we offer in Sri Lanka as at present and what can we do
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Currently, fewer then 3% of U.S. fertility practices provide assisted reproductive services to HIV-infected patients.
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Awareness of HIV/AIDS affects the age of sexual debut, coital frequency, use of barrier contraceptives, and rates of remarriage. Systemic illness, stress, weight loss, and drug abuse may impact reproductive potential. A direct effect of HIV leading to gonadal failure has been proposed in both men and women; however, proof of this hypothesis remains elusive.
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Decreased fertility rates in HIV-infected women have been described in the United States in more recent studies. 
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The incidence of tubal occlusion on hysterosalpingogram has been demonstrated as high as 27.8% among HIV-infected women HIV-infected women are more likely to have protracted anovulation and amenorrhea
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In clinical studies, pregnancy loss is more common among HIV-infected women than uninfected women (18.5% vs. 12.2%) . HIV-infected women terminate pregnancies in light of the challenges that pregnancy, birth, and parenting in the presence of HIV infection. Termination rates as high as 47% has been described. This has decreased after introduction of HAART.
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Men tend to have normal testosterone levels early in the course of HIV disease. As the disease progresses to AIDS, testosterone levels decline. Hypogonadism, diminished libido, and impotence are major issues in HIV-infected men. Erectile and ejaculatory dysfunction is estimated to affect 60% of men with advanced disease.
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Orchitis and acute epididymitis in HIVpositive men has been reported involving opportunistic infections including cytomegalovirus (CMV), salmonella, toxoplasmosis, Ureaplasma urealyticum, Corynebacterium sp., Mycoplasma sp., and Mima polymorpha, fungi, and mycobacteria. Kaposi sarcoma and lymphoma involving the testes have also been described.
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Sperm parameters that reflect fertility are significantly impaired in HIV infected men. The standard measurements are adversely affected, including semen volume and sperm motility, concentration, and morphology. Recent data indicate that HAART significantly decreases total sperm count, progressive motility, and post preparation count while significantly increasing the proportion of abnormal sperm forms. 12/3/2013
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Obtain a detailed HIV history that includes recent viral load and CD4, drugs and resistance, disease progression, 2. Suppressing viraemia before treatment 3. Any sexually transmitted infections should be treated before fertility treatment 4. High-risk behaviour, 5. Complete infertility evaluation, 6. Establishment of a social support structure. Patients must understand the importance of riskreduction treatment and be willing to take reasonable steps toward this goal. 1.
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Unprotected timed intercourse Intrauterine insemination (IUI) with partner or donor sperm In vitro fertilization with intracytoplasmic sperm injection (IVF/ICSI) Embryo donation Adoption.
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The rate of HIV heterosexual transmission is relatively low (approximately one per 1,000 acts of unprotected intercourse) The rate of HIV transmission is associated highly with peripheral blood viral load and is lowest in individuals with peripheral viral loads <10,000 copies/mL . The seminal HIV viral load correlates with plasma viral load but is much more variable. Individuals with undetectable circulating viral loads still can have infectious HIV in their semen, especially if they have a coexisting STI or genital tract inflammation .
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Risk factors for transmission Genital tract infections, Trauma with sex Elevated peripheral blood viral loads. In a series of 104 natural conceptions with timed intercourse in HIV-serodiscordant couples, there was a 4.3% seroconversion rate in female partners.
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HIV is present in the semen of infected men as free HIV RNA particles in the seminal plasma and as cell-associated virus in nonspermatozoal cells . HIV should not have a direct impact on the human oocyte because no receptors for HIV have been described on either the cumulus cells or on the surface of the oocyte (Baccetti et al., 1998).
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Sperm washing to reduce HIV levels before insemination involves a three-step process. First, the liquefied semen is filtered through a Percoll gradient. Next, the recovered spermatozoa are washed to eliminate seminal plasma and hyperosmotic gradient media. Last, a modified swim-up method recovers highly motile spermatozoa free from leukocytes.
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Quantitative assessment of HIV in semen before and after the sperm-wash procedure indicates that >99% of HIV is removed. Virologic testing of the sperm fraction for the presence of residual detectable HIV prior to its use for insemination can provide an added measure of safety, as up to 5% to 10% of samples may contain residual virus after this procedure . References
12.Politch JA, Xu C, Tucker L, Anderson DJ. Separation of human immunodeficiency virus type 1 from motile sperm by the double tube gradient method vsother methods. Fertil Steril 2004;81:440–7. 13.Marina S, Marina F, Alcolea R, Exposito R, Huguet J, Nadal J, et al. Human immunodeficiency virus type 1—serodiscordant couples can bear healthy children after undergoing intrauterine insemination. Fertil Steril 1998;70: 35–9.
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Options after sperm washing IUI IVF ICSI
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Conventional IVF
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ICSI
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The Centre for Reproductive Assisted Techniques for HIV in Europe has reported outcomes from eight centers of 3,390 ART cycles (2,840 IUI, 107 IVF, 394 ICSI, and 49 FET) using sperm washing; there was no evidence of seroconversion in any uninfected partner or child on follow-up evaluation. Investigators at Columbia University recently published their 10 year experience involving 420 ICSI cycles with HIV-positive men. The ongoing pregnancy rate per embryo transfer was 37%. The obstetric outcomes included 41% multiple gestation rate, 5% high-order multiples, and 43% premature infants. There were no maternal or neonatal HIV infections.
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To date, the cumulative number of reproductive techniques is 3215 couples treated, 6220 with IUI and 1686 with IVF-ICSI, leading to 1320 children born. No seroconversion has been reported using sperm washing, so neither women nor children were infected.
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IUI Donor Insemination Self Insemination Pre exposure Prophylaxis
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Conception under HAART To reduce the risk of fetal neural tube defects, folic acid should be supplemented pre conceptionally. Nevertheless, during the conceptional period, HAART regimens should only include drugs with known safety. Currently, there is no evidence of a significantly increased risk of birth defects associated with antiretroviral treatment before conception or during the first trimester but changes into safer therapy may be required (Coll et al., 2008).
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Self Insemination If the man is uninfected, the woman should undergo self- insemination around the time of ovulation. This procedure is simple, inexpensive and available for all couples. The male provides a fresh semen sample into a collection cup and the semen is then inserted in the vagina using a needleless syringe.
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Antiretroviral agent like tenofovir disoproxil fumarate (TDF), a nucleoside reverse transcriptase inhibitor (NRTI), alone or coformulated with another NRTI, emtricitabine. These drugs have a long intracellular and plasma half-life providing the pharmacokineticâ&#x20AC;&#x201C;pharmacodynamic rationale for once-daily dosing and achieve higher concentrations in genital tract secretions than in blood (Wang et al., 2004; Dumond et al., 2007).
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Donor Insemination IUI IVF/ICSI Need separate facilities to avoid cross contamination
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