1 / 51

Reproductive Technologies & Counseling

This article discusses the transmission risks of HIV, pregnancy options for HIV-positive individuals, infertility, and treatment options. It provides insights on transmission rates, vertical transmission, viral load in body fluids, and reproductive decisions.

gradyn
Download Presentation

Reproductive Technologies & Counseling

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Reproductive Technologies & Counseling Patricia Kloser, MD, MPH, FACP Professor of Medicine Professor of Public Health June 2006 UMDNJ, a Local Performance Site of the NY/NJ AETC

  2. Objectives • Transmission risks • Pregnancy options • Infertility • Treatment options

  3. Transmission Risks • Heterosexual • Vertical

  4. Risk of Transmission • Unprotected vaginal intercourse • Male to female = 3% to .01% per contact • Female to male = 10% to 17% less efficient

  5. HIV in Body Fluids • Blood • Semen • Cervical secretions • Breast milk • Spinal fluid

  6. HIV in Semen • Higher in acute HIV infection in men • Correlation between viral levels of HIV in blood and semen • Men hyperinfectious before symptoms of HIV infection occur (lasts 6 weeks) • Could infect 7 to 24% of partners during first 2 months of infection • STD would increase this rate (in either partner) JID 2004; 189:1785-1792

  7. U.S. • HIV-1 RNA in Cervical Secretions • Varies in menstrual cycle (due to hormone variation) • Highest just before menses start • Risk of transmission riskiest as menses approach • Lowest level at mid-cycle • Explains increase of HIV in cervical secretions in women on oral contraceptives • No increase of cervical shedding in menses • Less variation in serum than genital secretions • Less virus in vaginal than cervical in secretions

  8. Heterosexual Transmission Risks Increase With • Genital ulcer or STD • Cervical ectopy • Male partner not circumcised • Sex during menses • Bleeding during intercourse • Receptive anal intercourse • Partner with high viral load

  9. Risk of Vertical-Transmission • Mother - cigarette smoking - older maternal age - high viral load - low CD4 - vaginal delivery - prolonged rupture of membranes >4hrs - acute HIV infection • Baby - prematurity - breastfeeding

  10. Vertical Transmission • In utero - <10% • Peripartum – 40 – 70% • Breastfeeding – 0.5% per month risk • Most important factor is viral load

  11. Vertical Transmission Rate • Total rate – 13% to 60% • U.S. – 25% to 30% • Europe – as low as 13% • Africa – 50% to 60%

  12. Treatment None AZT HAART HAART Transmission 24.5% (WITS 1993) 7.6% (ACTG 076 1994) <1% (2006) 7 cases NJ (2004) MTCT with ARV (U.S.)

  13. Mother’s viral load <1000 1000 to 10,000 10,000 to 50,000 50,000 to 100,000 More than 100,000 Garcia, et al NEJM 1990;341:394 Transmission rate 0% 16.5% 21.3% 30.9% 40.6% Viral load and MTCT (U.S.)

  14. Vertical Transmission with Treatment • U.S. – with HAART <1% • Developing Countries • PMTCT reduces transmission by 50% • Nevirapine – 200mg to mother - 6ml to baby • Or equivalent AZT dose

  15. Viral load in Genital Secretions & MTCT (Thailand)

  16. Cesarean Delivery

  17. Cesarean Section • Elective cesarean section before rupture of membranes or onset of labor usually at 37-39 weeks may further decrease vertical transmission • Not routinely done unless mother requests or if the viral load is high

  18. Pregnancy Options

  19. Pregnancy • Does not affect disease progression • Lowers CD4 count • Should not use Stavudine and ddi together • No Efavirenz in the first trimester

  20. In unprotected vaginal intercourse leading to pregnancy the risks are twofold: • Partner’s risk of infection • Baby’s risk of infection

  21. Risk to Partners • Expense (depending on method) • Possibility of HIV infection (depending on method used) • Possibility of passing “resistant” HIV to infected partner • Time consuming (depending on method used)

  22. Negative FemalePositive Male • Timed unprotected intercourse (as above) not recommended • Intrauterine insemination (IUI) after “sperm washing” • Intracytoplasmic sperm injection (ICSI) one sperm-one egg with zygote implanted in uterus (aliquots tested for cell free virus) via laser manipulation

  23. Negative MalePositive Female • Timed unprotected intercourse (using basal body temperature monitoring) • “Turkey baster” method self insemination • Ovarian stimulation with artificial insemination (partner/donor) • In vitro fertilization (ova harvested and fertilized outside of body and then implanted in hormonally stimulated uterus)

  24. Positive MalePositive Female • Remember undetectable viral load in serum does not mean undetectable genital viral load • It may be possible to impart resistant virus from one partner to the other

  25. Superinfection • Controversial • 5 published verified cases • Appears to occur but difficult to verify • Usually occurs shortly after initial infection less likely later on • Positive partners study on-going • HIV positive people prefer other HIV positive people

  26. Reproductive Decisions • Artificial insemination • Invitro fertilization • Intracytoplasmic sperm injection – most expensive • Self insemination • Timed intercourse • Transmission rates MTCT <1% in women with VL <1000 copies in U.S.

  27. U.S. • Timed intercourse: • Condoms at all times • No condom during fertile times • 4% transmission rate (for female if male HIV+) • Men – semen sample – count motility, progression, morphology • Women – ultrasound during follicular phase and endocrine profile

  28. U.S. • Self insemination • Women inseminate themselves with fresh semen using syringe (without needle) or disposable Pasteur pipette (cheap, safe)

  29. U.S. • IVF – for infected male for uninfected female sperm processed and single sperm used to fertilize egg of HIV infected woman • No seroconversion and no HIV+ infants • (intracytoplasmic sperm injection) $$$$

  30. Sperm Washing • Infected male followed by intrauterine insemination • 29% success rate for pregnancy • No seroconversion of females

  31. Sperm Washing • For use in cases where male is HIV+ • Ejaculate is processed in laboratory separating semen from sperm cells • These cells are then reinserted into female (in vivo) or inserted into ovum (in vitro) for fertilization • This process will reduce possibility of infecting HIV negative woman • This process will reduce chance of re-infection of HIV positive woman with resistant viral strain • Problems – expense, technical availability, needs cooperative couple and committed obstetrician

  32. Patient Considerations • Healthy • No active OI • CD4 >350 • VL <50,000 • Woman must have normal PAP or normal colposcopy • If Hepatitis C must have normal liver enzymes and hepatology consult • Been on HAART for 1 year • Male semen sample • No unprotected sex during this time

  33. Laboratory Considerations • Cross contamination is a concern • Must have separate freezers and storage for samples • May be difficult regarding food facilities • Milan, Italy criteria and Columbia University in NYC doing this work

  34. U.S. • Assisted reproductive techniques • Expensive $10,000 to $17,000 per cycle • Many (most) cannot afford this expense • VL undetectable • CD4 >400

  35. Goals of these Reproductive Options • Achieve pregnancy • Avoid transmission of HIV to mother, father or baby • Give woman choice regarding pregnancy

  36. Risk to Fetus • Multiple fetuses • Low birth weight • Pre-term delivery

  37. Infertility

  38. Infertility • HIV positive and HIV negative workup is no different

  39. Infertility • One year of unprotected intercourse • History/sexual practices • Sperm evaluation • Urologic evaluation • GYN evaluation • Appropriate treatment

  40. Infertility Treatment • Based on problem • Many have no particular medical issue and diagnosis of etiology can’t be determined

  41. Male Infertility Male causes • Sperm - poor quality - poor quantity - poor motility • Semen - poor quality - poor quantity

  42. Male Infertility • Anatomical - obstruction - hypospadia - varicocele - injury - retrograde ejaculation • Endocrine - low testosterone • Genetic - Klinefelters, etc. • Psychiatric - depression - low libido

  43. Male Infertility Suggestions • Stop smoking • Avoid tight fitting pants (male), bicycle riders • Timing of intercourse • Appropriate weight • Healthy life style

  44. Female Infertility • Endocrine - thyroid, pituitary, adrenal insufficiency • Genetic - polycystic ovaries, Turners • Psychiatric - depression - low libido

  45. Female Infertility Female causes • Ova - poor quantity - poor quality – age, nutrition, injury, illness • Anatomical - obstructed fallopian tubes - poor motility of cilia in fallopian tubes - uterine lining abnormality fibroid - endometriosis - uterine anatomy

  46. Treatment Options

  47. Minimal MTCT Risk • With serum VL <1000 • No breastfeeding • Woman on HAART

  48. Factors Associated with Vertical Transmission • High viral load • Acute HIV infection • Older maternal age • Cigarette smoking • Prolonged rupture of membranes

  49. U.S. • Pregnancy • Lopinavir with Ritonavir– levels 50% lower in third trimester • Levels still adequate but study needed • Efavirenz – not in 1st trimester • Nevirapine – watch liver function • D4T/DDI – do not combine – lactic acidosis

  50. Counsel Woman • Importance of adherence to care • Importance to take every pill every day • Seek care of experienced OBS/ID team for the best result • Obtain all laboratory tests on schedule • Follow up immediately for any new symptoms or signs

More Related