1. United States Clinical Experience with Assisted Reproductive Technology in HIV- discordant Couples Mark V. Sauer, MD Professor Department of Obstetrics & Gynecology Columbia University New York, New York

2. Scope of the Problem  Nearly one million Americans are infected with HIV  Most HIV-seropositive individuals are of reproductive age  Heterosexual contact greatest risk factor in women  Many infected men and women desire to have biologic offspring  “Safe sex” recommended for prevention, but also prevents pregnancy CDC. HIV/AIDS Surveillance Report 2003 Family Planning Perspectives 2001; 33:144-152.

3. Changing Attitude and Outlook  HAART enhances longevity and quality of life  Compliant patients remain healthy for many years following diagnosis  Disease now considered a chronic illness rather than terminal disease  Improved awareness of epidemic  Increased social acceptance  Emphasis on maintaining productive “normal” lives of infected patients

4. Hurdles to Fertility Care  Lack of meaningful published reports defining safety  No RCTs regarding methodology, safety or efficacy  No short or long term follow-up of children or families  CDC recommendation against treatment  State laws that assign criminal penalties  Insurance contracts may preclude HIV-seropositive patients  Perceived liabilities of engaging in care  Malpractice  Discrimination lawsuits vs conscientious objectors  Patient concerns regarding cross-contamination  Civil and criminal penalties

5. Clinical and Basic Science Support  Clinical science: large series reports attesting to general safety  Over 3,000 washed insemination cycles reported without infection  Nearly 1,000 IVF cycles reported without infection  Basic science: defining relationship of virus to reproductive tract tissues  Transmission through cellular elements in semen or free virus in fluids  Viral cultures of semen commonly positive (10-20%)  Compartmentalization in reproductive tract tissues may occur  Sperm lack CD4 receptor and may not harbor virus  HIV rarely if ever detected from the most motile washed fraction used in ART  Sperm surface membrane may allow alternative pathway for HIV gp120 binding (GalAAG pathway) but remains unsubstantiated Reprod Biomed Online 2005; 10:135-140.

6. Programs Reportedly Accepting HIV Infected Patients  Columbia University, New York, NY  Eastern Virginia Medical College, Norfolk, VA  Albert Einstein Medical College, Bronx, NY  Washington University, St. Louis, MO  University of Colorado, Denver, CO  UMDNJ-New Jersey Medical Center, Newark, NJ

7. Published Clinical U.S. Experience  Abstracts presented at scientific meetings  3 of 822 abstracts at ASRM related to HIV in 2002  4 of 913 abstracts at ASRM related to HIV in 2004  Peer reviewed CU manuscripts since 2002  13 papers in print  2 papers in press

8. Applying Essential Principles of Medical Ethics  Autonomy  Informed rationale decisions  Alternatives to treatment offered  Individuals may participate or withdraw  Non-maleficence  No evidence of needless harm  Harm may result from “omission” of care  Beneficence  Protects women and children  Enhances quality of life  Justice  Fair distribution of accessible services Am. J. Bioethics 2003; 3:33-40.

9. Columbia University Experience  Consultants providing interdisciplinary support  Dr. Mark Sauer- Reproductive Endocrinology  Dr. Scott Hammer- Infectious Disease  Dr. Jane Pitt- Infectious Disease  Dr. Shreedhar Gaddipatti- Maternal Fetal Medicine  Dr. Kenneth Prager- Medical Ethics  Initiation of fertility treatment of HIV-seropositive males 1997  Initiation of fertility treatment of HIV-seropositive females 2002

10. Columbia University IVF/ICSI Program Goals  To provide HIV serodiscordant couples an opportunity to safely have a child through assisted reproduction using IVF/ICSI  Access to a common procedure available throughout the U.S.  Provide a therapy that doesn’t cross legal boundries of “insemination”  Decrease the time to pregnancy, and number of needed exposures by ART  To gather data to further understand the needs of HIV seropositive patients seeking fertility assistance  Social, demographic, medical and reproductive database  Follow up of families and individuals treated  To report ongoing experience to patients and professional peers in hope of changing attitudes and reducing prejudice  Encourage development of new programs  Seek professional collaboration within REI and other disciplines

11. Columbia University Experience  Enrollment Criteria  Men under active medical care and surveillance  Demonstration of stable viral loads and CD4 status  Individuals with viral counts > 30K cps/mL required to begin HAART  Semen analysis with a total motile count > 1,000,000  Female partners reproductively competent to undergo IVF therapy  COH using standard GnRH-analogues and injectable gonadotropins  Cycle monitoring using serial transvaginal ultrasound and serum E2 levels  Egg retrieval under anesthesia by transvaginal ultrasound guided needle aspiration  Transcervical embryo transfer on day 3 or day 5 post aspiration

12. Columbia University Experience  Laboratory: Sperm Processing and IVF-ICSI  Fresh samples with 2 day abstinence  Class II biologic hood outside embryology lab for processing  Double wash technique following centrifugation with discontinuous density gradient  45-60 minute swim up  Only most motile fraction selected for ICSI  ICSI 4-6 hours post aspiration  Separate incubators  ETs days 3 or 5  Cryopreserve extra embryos  Separate cryotanks

13. Post-transfer Surveillance  Serum pregnancy test 12 days post ET  HIV-RNA testing each trimester in pregnant patients and at delivery and 3 months postpartum  HIV-RNA or HIV-DNA tests at delivery and 3 months in newborns  Non-pregnant patients tested with HIV-EIA or HIV-RNA 3 and 6 months post- embryo transfer

14. Published Early Experience  Couples treated61  Initiated cycles 113  Retrievals performed100 (88.5%)  Clinical pregnancy rate per ET44.8%  Delivery rate per ET36.5%  Delivery rate per couple (inc. fresh and frozen ET)54.1%  Seroconversions in treated patients0  Seropositive newborns0 Am J Obstet Gynecol 2002; 186:627-633. Fertil Steril 2003; 80:356-362.

15. Columbia University Results  195 couples evaluated from 1998-2005  178 male HIV-seropositive  12 female HIV-seropositive  5 both partners HIV-seropositive  150 couples accepted into care  135 HIV-seropositive male  12 HIV-seropositive female  3 both partners HIV-seropositive  Variety of referral  50% from infectious disease specialist  35% self referred through internet or friends  15% from obstetrics/gynecology  Increasing number of cases with increased knowledge of availability  1997-2002 total of 50 cycles initiated of IVF-ICSI  2002-2005 total of 189 cycles initiated of IVF-ICSI

16. Columbia University Results

17. Patient Demographics for HIV-seropositive Males Age (years)37.2 + 5.6 (22 - 49) Time from HIV diagnosis (years)8.3 + 5.6 (1 - 20) Undetectable viral load48.9% Detectable viral load (cps/mL)3,381.5 + 6,130.9 (53 – 28,424) CD4 T-cell counts (cells/mm3) 589.0 + 309.4 (13-1,810) Route of presumed infection Sexual37.8% Transfusions20.0% Drug use 5.2% Unknown37.0%

18. Columbia University Results Through 4/2005 Number couples reaching retrieval 135 Number of retrievals 217 Cycle cancellation rate 9.2% Oocytes per retrieval16.1 + 9.4 (2-63) Fertilized oocytes/retrieval 9.1 + 5.2 (0-32) Embryos per ET 3.2 + 1.1 (1-8) Clinical pregnancy per retrieval48.3% Ongoing/delivered pregnancy rate43.3% Ongoing/delivered per couple (includes FETs) 69.0%

19. Columbia University Results: 4/2005  Obstetrical outcomes (113 deliveries; 12 ongoing pregnancies)  Pregnancies from IVF-ICSI  Singletons65.5%  Twins32.1%  Triplets13.0%  Quadruplets1.1%  Multiple gestations46.4%  Delivery data  Vaginal births42.2%  Cesarean section57.8%  Term Deliveries68.4%  Gestational age38.9 + 1.1 (37-41 wks)  Birth weights3501.2 + 491.1 (2550-4396 grams)  Preterm Deliveries31.6%  Gestational age33.4 + 3.0 (26-36 wks)  Birth weights2072 + 944.4 (785-2940 grams)

20. Projecting Efficacy: Female Age Matters  Life Table Analysis of 164 consecutive fresh treatment cycles  Best prognosis in women < 34 yrs.  Majority of pregnancies in 3 cycles  Delivery rate 2-times better in younger patients Reprod Biomed Online 2005; 10:130-134.

21. HCV Co-infected Patients with HIV  Clinical outcomes for men co-infected with hepatitis C not different from general population of infertile couples or from couples with HIV infection  28 of 106 HIV seropositive men also co-infected with HCV  54 cycles of ART performed using IVF-ICSI  Delivered pregnancy rate 40% per ET  20 of 28 couples (71%) achieved at least one successful pregnancy  No HIV or HCV seroconversions in patients or offspring Arch Gynecol Obstet 2005; In press ASRM Annual Meeting, 2004

22. Understanding Attitudes and Motivations  Survey of initial 50 couples regarding demographics, attitudes and motives for seeking care  9 couples experienced a previous birth; 3 after knowledge of HIV infection  12% would attempt pregnancy through intercourse in help unavailable  48% prefer donor sperm insemination if fertility care unavailable  46% seek continued assistance even if partner died (posthumous therapy)  90% had openly discussed possibility for single parenting  66% hoped to have multiple children through continued ART usage Obstet Gynecol 2003; 101:987-994.

23. Columbia University: HIV and Donor Egg  Experience with oocyte donation  From 8/97-2/02 53 couples enrolled for IVF-ICSI  21% deemed ineligible due to advanced reproductive age or lack of ovarian response to COH  5 couples elected to pursue oocyte donation with HIV-seropositive partner  3 of 5 couples delivered following 6 fresh attempts  2 singleton birth; 1 twin birth Arch Gynecol Obstet 2003; 268:202-205.

24. Building Families Through ART  Greater than 2/3 of couples expressed desire for further attempts after delivery of a child or children  5 of 5 couples previously successful were again pregnant following a subsequent attempt Fertil Steril 2002; 78:421-423.

25. Complications Related to ART  4.6% initiated cycles treated for OHSS  47% pregnancies multiple gestation  14% pregnancies higher order multiples  3 triplet  1 quadruplet Arch Gynecol Obstet 2003; 268:198-201.

26. HIV: Still a Deadly Disease  LM 38-y/o: died sepsis and liver failure  PC 42-y/o: died cardiomyopathy and pulmonary hypertension  MS 47-y/o: died ruptured cerebral aneurysm  PR 32-y/o: died aseptic meningitis  MK 31-y/o: died liver failure ASRM Annual Meeting, 2003.

27. Importance of Advanced Directives  Written and witnessed consent for the disposition of fresh and cryopreserved specimens and embryos  Clear and convincing evidence of intent of the deceased party in the absence of a written directive. Such evidence must be personally witnessed by the physician involved with the procurement of the gametes or embryos. Ethics Committee Columbia Presbyterian Medical Center 2002

28. Columbia University Results  Interesting case reports  Reversible iatrogenic azospermia secondary to prescribed androgen use  Posthumous reproduction following the death of a life-partner Obstet Gynecol 2003; 101:1073-1075. Am J Obstet Gynecol 2002; 185:252-253.

29. Initiating a Program for Women with HIV  Opportunity for HIV seropositive women to access fertility care  Pre-cycle testing the same as conventional infertility patients  Additional requirements  MFM and ID medical clearance  Maintain minimally detectable titers  Initiate HAART prior to pregnancy and maintain throughout pregnancy  Patent tubes: COH and IUI  Failed IUI or women with tubal obstruction: IVF/ICSI

30. Initiating a Program for Women with HIV  Clinical activity began in 2002  IUI of patients with patent fallopian tubes  IVF request initially turned down by CPMC ethics committee  Initial 3 patients treated with COH/IUI  All 3 women pregnant within 4 treatment cycles  All newborns HIV seronegative  IVF-ICSI initiated 2004  3 patients treated; 2 ongoing pregnancies  7 patients screened and preparing to begin therapy

31. A Role for Assisted Reproduction?  Persons with HIV cannot be refused medical treatment unless objective scientific evidence demonstrates a significant risk of infection.  Americans with Disabilities Act  ART should not be denied to HIV-infected couples solely on the basis of their positive status  ACOG Committee Opinion 235, 2001

32. Summation: American Experience  Although various techniques using washed insemination methods are available, predominant ART used in U.S. has been IVF-ICSI  Few centers are currently offering ART to HIV seropositive patients  Multidisciplinary approach best for providing integrated care by internists, reproductive endocrinologists, maternal fetal medicine specialists, social workers and skilled laboratory personnel  Despite endorsement for treatment by ASRM and ACOG, the CDC continues to recommend against insemination methods

33. Conclusion: American Experience  A slow but growing clinical experience and published literature by U.S. centers has emerged regarding reproductive care for HIV infected patients  State laws and concerns related to civil, professional and criminal liability have hindered wide-spread introduction of methods of treatment  Studies needed to address the growing needs of HIV infected patients  Uniformity of approach to care  Criteria for treatment  Outcome tracking  Multicenter collaboration both nationally and internationally