Introduction to HIV Discordant CoupleInsemination
Deborah J. Anderson, Ph.D.
Dept Medicine and Center for AIDS ResearchHarvard Medical School and
Department of Obstetrics & Gynecology Boston University School of Medicine
Boston, MA
1987
• HIV/AIDS: a poorly understood lethal sexually transmitted disease
• Stewart et. (1985): seroconversion in 4 women following AI with semen from an HIV+ donor
• Published reports of HIV attachment to sperm
• High fetal maternal transmission rate
Dr. Enrico Semprini proposed to establish a protocol to reduce the risk
of HIV transmission in HIV-1 discordant couples desiring a child
Gradient Sperm Separation Method
Seminal Plasma
47% Separation Medium
90% Separation Medium
Motile Sperm
Nonmotile Sperm,Immature Germ CellsWBCs
DiscontinuousDensity Gradient
HIV p24
++++
++
++
+/-
Swim-up Method
Sw
im-u
p
Motile Sperm for Insemination
Sperm Wash Medium
Swim-up
HIV p24
+/-
++
Gradient/Swim-up Method
Sw
im-u
p
Wash Pellet
Seminal Plasma
47% Separation Medium
90% Separation Medium
Motile Sperm
Nonmotile Sperm,Immature Germ CellsWBCs
HIV p24
undetectable
Additional elements in Semprini protocol:
• Reduce exposure by maximizing fertility and optimal timing of fertilization
• Reduce transmission risk by treating STDs and reducing HIV viral load
1990
Chiasson MA, Stoneburner RL, et al. Human Immunodeficiency Type 1 virus transmission through artificial insemination. JAIDS 3:69-72, 1990
131 women in New York inseminated with fresh semen from 6 HIV+ donors. One seroconverted.
Centers for Disease Control.
HIV-1 infection and artificial insemination with processed sperm.
MMWR 39: 249-56, 1990.
Recommendation: Do not used processed semen from HIV+ donors for artificial insemination
1990
Semprini AE, Levi-Setti P, Bozzo M, Ravizza M, Pardi G.
Insemination of HIV-negative women with processed semen of HIV-positive partners.
Lancet 340:1317-9, 1992.
1992
1993
American Society for Reproductive Medicine Guidelines: ART services should be withheld from HIV-infected individuals or couples.
Fertility and Sterility 59 (Suppl 1): 1-39, 1993.
1997
Mandelbrot L, Heard I, et al. Natural conception in HIV-negative women with HIV infected partners. Lancet 349:850-1; 1997.
5% seroconversion rate in 92 HIV-discordant couples that practiced unprotected intercourse to conceive a child.
1998
Marina S, et al.
Human immunodeficiency virus type-1 serodiscordant couples can bear healthy children after undergoing intrauterine insemination .
Fertil. Steril. 70: 35-39, 1998.
2000
CreaThe is established: a consortium of 11 clinics in Europe that provide assisted reproductive technology services to HIV-1 infected couples.
•Forum for discussion
•Guidelines and protocols
•European database
2002
Antiretroviral therapy has changed the perception of HIV-1 disease (chronic but manageable) and reduced the maternal-fetal transmission rate to <5%.
HIV-1 infected individuals protected against medical discrimination by the Americans with disability act.
2002
Recommendations of the ASRM Ethics Committee on Human Immunodeficiency Virus and Infertility Treatment.
Fertility and Sterility 77: 218-222, 2002.
Fertility services cannot be reasonably withheld from individuals with chronic viral infections including HIV-1.
Sauer MV.
Providing fertility care to those with HIV: time to re-examine healthcare policy.
AJOB 2003; 3: 3-40.
ICSI procedure for insemination with HIV+ sperm
US Experience
00002-E-4 – 1 December 2002
Adults and children estimated to be living Adults and children estimated to be living with HIV/AIDS as of end 2002with HIV/AIDS as of end 2002
Total: 42 million
Western Europe570 000570 000
North Africa& Middle East
550 000550 000Sub-Saharan
Africa29.4 million29.4 million
Eastern Europe & Central Asia
1.2 million1.2 million
South & South-East Asia
6 million6 million
Australia & New Zealand
15 00015 000
North America980 000980 000
Caribbean
440 000440 000
Latin America1.5 million1.5 million
East Asia & Pacific
1.2 million1.2 million
Resource Poor Settings
Should timed inseminations be recommended for HIV discordant couples that want to have children?
• Fertility work-up
• Treatment of STIs
Under development: sperm-friendly vaginal microbicides.
