Preconception Counseling for HIV Discordant Couples
Erika Aaron, MSN, CRNP
Obehi A Asemota MD
Marin Mercurius, MS-IV
Drexel University College of Medicine
Phila Pa 215-762-6826
© 2010 Erika Aaron
Why come for preconception
counseling?
 To learn how to make informed decisions about
your future reproductive choices
 To learn about the risks and benefits of HIV meds
both to mom and baby
 To learn how to avoid transmission of HIV to your
partner and baby
 To help mentally prepare you as a parent for all
that is about to come
Others reasons why you should
come to preconception counseling
 To learn how to maintain your health before,
during and after pregnancy
 To learn how to prevent superinfection (passing a
more virulent strain of HIV to another HIV
positive partner)
Before thinking of having children
you need to be aware of:
 Having a child is a lot of work: monetary,
emotional and time commitment.
 Having HIV may impair your fertility.
 So consider alternatives if you are not able to have
children, such as adoption
How do we hope to assist you in
preparing for your baby?
 Assist with pregnancy planning
 Inform you about reproductive & general health
 Help you enter pregnancy in good health, with a
healthy immune system, and as few risk factors as
possible
 Screen for STDs, advise about good nutrition, and the
harms of drugs, alcohol and cigarettes
 Help you to become fully informed about HIV meds
to prevent HIV transmission
 Begin HIV meds early to prevent transmission
Where do we begin?
 We recommend beginning with a genital
examination of both partners prior to
attempting pregnancy.
Why start with a genital exam?
 The diagnosis and treatment of genital tract
infections such as gonorrhea and Chlamydia
before pregnancy helps to decrease transmission of
the virus
 STDs increase the risk of HIV transmission.
Next we check your HIV status
 We check you CD4 count and viral load
 A lower viral load decreases HIV transmission to your
partner and baby—so you may decide that you want to
start HIV meds to lower your viral load to undetectable
levels before trying to get pregnant
 But note, not all HIV medications are appropriate during
pregnancy, some may cause abnormalities in babies so you
medications may need to be switched when you get pregnant.
 If your partner is HIV+ this may be a time for him/her to
start HIV meds also
Question????
 When is the best time to try to get pregnant?
A. When viral load is lowest
B. When viral load is medium
C. When viral load is highest
Answer…
A. When viral load is lowest!!
Remember…it is always best to decrease viral
load BEFORE becoming pregnant!
So how do you plan on getting
pregnant?
 We recommend use of:
 Ovulation kits (LH kits)
 Basal body charts
 Cervical mucus evaluation to identify ovulation
(fertile period)
 Noting when you have midcycle lower
abdominal pain
Ovulation 101
 Ovulation is when an egg is released from
the ovary
 To get pregnant you must have intercourse
when this egg is release, this is your fertile
window. Usually this is one to two days
before and one day after you ovulate.
So how do you know when you are
ovulating? By using ovulation kits
 Ovulation is your most
fertile time of the month
 Ovulation kits allow you
to track ovulation each
month to identify the best
time of the month to get
pregnant
 Testing should be done
every morning before
getting out of bed
Ovulation kits cont.
 Since most people start ovulating on the 14th day of
their cycle, start using the ovulation kit on day 11 to
determine your fertile window
 Two-three days immediately after a positive test is
the best time to introduce sperm into uterus. This
will increase your chances to become pregnant
 You can also use an ovulation calculator to predict
when you will be fertile. These can be found for
free on fertility websites online
Quick review of menstrual cycle
(average of 28 days)
 The first day of your cycle is the first day that you
begin your period
 You always count from the first day of your period
to know when you ovulate, which is usually day 14,
or when you can expect to start your next
menstrual cycle
 Cycles vary from 23 days to 35 days
 Ovulation occurs 12-16 days before menstruation
Question???????
 What day is the first day of your
menstrual cycle???
Answer…
YES!!!
 The first day of your period is the first day of
your menstrual cycle
Basal Body Temperature Charting
 Take your temperature first thing in the morning when you
wake up from the first day of your menstrual cycle.
 Enter temperature on a graph, join the numbers to make a
curve
 You will notice following ovulation, your temperature can
increase by 0.4 to 1.0 degrees.
 You won't feel the shift, but you can detect it by using a basal
body temperature (BBT) thermometer.
Example of a Basal Body
Temperature Chart
Basal Body Temperature cont’d
 You're most fertile in the two or three days before your
temperature hits its high point
 By the time you temperature increases, it's too late to get
pregnant
 However by charting your temperature by taking it each
morning for a few months, you can detect a pattern and
pinpoint your likely ovulatory date.
 Then you can plan to have sex during the two to three days
preceding the day your temperature normally rises
Life cycle of cervical mucus
Infertile phase I
 After your period; dryness, no visible mucus.
 May be absent in short cycles and numerous in long cycles
Sensation
at Vulva
Moist
or
Sticky
Finger Test
Appearance
Early Mucus
• Scanty
• Thick
• White
• Sticky
Holds its shape
Transitional phase
Wetter
Transitional Mucus
• Increasing Amounts
• Thinner
• Cloudy
• Slightly Stretchy
Fertile Phase
 Increase in secretion of cloudy mucus discharge,
slipperiness at the vulva which is moist or sticky in scant
amounts - white or creamy-colored.
 On finger-testing this highly fertile mucus may stretch
for several inches before it breaks.
Slippery
Highly Fertile Mucus
• Profuse
• Thin
• Transparent
• Stretchy
(like raw egg white)
Infertile Phase II
 Completely infertile phase
 A return to stickiness or dryness
 The mucus is now thick and acts as a physical
barrier to sperm
Question????
 During your most fertile phase, is your
cervical mucus…
A. dry and sticky
B. slippery and stretchy
C. dry and thick
Answer…
B. slippery and stretchy
Life of a sperm
 Sperm survives 3-5 days or longer in a woman‘s
cervix in the presence of fertile mucus (thin,
watery mucus)
Question???
 Can you still get pregnant even if it has been
2 days since you had intercourse?
Answer…
 ABSOLUTELY YES!!!
 Remember, sperm survives 3-5 days or longer in
a woman’s cervix in the presence of fertile
mucus!!!
Midcycle lower abdominal pain
(mittelschmerz)
 Some women actually feel ovulatory activity,
which can range from mild achiness to
twinges of pain in the abdomen (called
mittelschmerz) This may last a few minutes
to a few hours
 This could alert you that you are ovulating
and will be a good time to have intercourse
For HIV+ female & HIV- partners
another option is self insemination
 If you are an HIV+ female and your partner
is HIV- you can use self insemination during
ovulation
Self-insemination:
HIV+ female & HIV- male partner
 Self-insemination is when the female inserts the
HIV- partner’s semen into close contact with the
cervix at the time of ovulation.
 This can be done at home or in a gynecologist office
 Methods include:
 Syringe
 Turkey baster
 Cervical cap
Self-insemination cont.
 Self insemination is placing the non-HIV-infected
sperm into the tool of choice and introducing it
near the cervix at the fertile time of the cycle
 This increases the chance of becoming pregnant
without risking transmission of HIV to the
negative partner
 Use condoms during intercourse
HIV+ male & HIV- female:
Fertility clinic or timed intercourse
 If you are an HIV- female with an HIV+ male
partner the safest option is a fertility clinic where
sperm washing is performed on the HIV+ male’s
sperm
 After the sperm is washed it is placed into the
uterus by intrauterine insemination in the office
 If this is not an option for you unprotected
intercourse only at the time of ovulation is called
“timed conception”
Timed conception for an
HIV+ male & an HIV- female
 Timed conception is unprotected intercourse only during
times of ovulation for the purpose of becoming pregnant
and NEVER AT ANY OTHER TIME
 There is a risk of transmission whenever you have
unprotected intercourse
 It is advisable for the HIV infected partner to start HIV meds
in order to lower the viral load. A low viral load will decrease
the chances of transmission during this process.
 Strict adherence to HIV medication is essential to prevent
development of resistance
HIV+ female & HIV+ male
 Unprotected intercourse risks the chance of
“Superinfection.”
 “Superinfection” is when a more virulent
(stronger) HIV strained or a resistant strain is
passed from one infected person to another
infected person.
HIV+ female & HIV+ male
 The safest option is a fertility clinic where sperm
washing is performed on the HIV+ male’s sperm
 After the sperm is washed it is placed into the
uterus by intrauterine insemination in the office
 If this is not an option for you unprotected
intercourse only at the time of ovulation is called
timed conception
Timed conception for
an HIV+ male & HIV+ female
 Timed conception is unprotected intercourse only
during times of ovulation for the purpose of becoming
pregnant and NEVER AT ANY OTHER TIME
 There is a risk of “superinfection” whenever you have
unprotected intercourse
 It is advisable for both partners to start HIV meds in
order to lower the viral load.
 Strict adherence to HIV medication is essential to prevent
development of resistance
Question????
 Is it alright to have unprotected intercourse
at any time of the month if you are trying to
get pregnant?
Answer…
ABSOLUTELY NOT!!!
 If you are trying to get pregnant, only introduce
sperm to cervix during your fertile time of the
month!!
Question????
 What is another name for your fertile time
of the month?
A. Ovulation
B. Menstruation
C. Temptation
Answer…
A. OVULATION !!!
More about seeking help from a
fertility specialist
 Intrauterine insemination
 IVF/ICSI
 Sperm evaluation
Intrauterine insemination
 Direct placement of sperm into cervix and
up into uterus--done by a physician
 Sperm from an HIV+ male is first prepared
via “sperm washing” to reduce the amount
of virus in the fluid around the sperm
 The sperm is then introduced into the cervix
and into uterine cavity
IVF/ICSI
 In vitro fertilization (IVF) is when the egg and the
“washed” sperm are put together in the same dish
and then the resulting fertilized embryo is
reinserted into the uterine cavity
 ICSI is when the sperm alone without any
surrounding fluid is injected into the egg resulting
in a fertilized embryo that is reinserted into the
uterine cavity through the cervix
Fertility specialists cont.
 These methods often result in successful
pregnancy with least risk of transmission
 Unfortunately these procedures are very expensive
and not covered by most insurances
 Another option for having a baby is using an HIV
negative sperm donor
 Adoption is a great option for having a baby
Sperm evaluation for fertility:
When couples are having difficulty
getting pregnant
 Semen specimens are collected by masturbation into a
sterile wide-mouth container after 2-5 days of having no
sex and then analyzed within 2 hr of collection
 Two to three testing cycles, separated by at least a
month, are required for a meaningful evaluation
 Doctors test the total number of sperm, the shape of
sperm, how well the sperm move, & the strength of the
sperm
So if you become pregnant what are
the recommended goals:
 To have a healthy pregnancy
 Eat a well balanced diet
 Prevent transmission to baby
Healthy pregnancy outcomes
 Begin antiretroviral treatment early and maintain a
low viral load
 Eliminate exposure to cigarette smoke, street drugs,
alcohol
 Increase vitamin intake via folic acid and iron
supplements
 Begin a balanced diet
 All these things should be started BEFORE
becoming pregnant to help ensure the best possible
outcome
Folic Acid
 Folic acid- 400 micrograms daily- is important in
preventing defects in the development of the
baby’s brain & spine
 It’s best if you begin taking folic acid supplements
in a multivitamin daily before pregnancy occurs.
Most birth defects occur when the pregnancy is in
the very early stages
 Folic acid can be found in green leafy vegetables,
citrus fruits, nuts, whole grains, and prenatal
vitamins
Balanced diet
 Begin eating a healthy
diet now, and at least 3
months before getting
pregnant
 Eating a balanced diet
helps get important
vitamins and nutrients
to the developing baby
Avoid alcohol, drugs, & cigarettes
 Drugs and alcohol (even marijuana-weed or
beer) can hurt you and your baby, especially
when you are pregnant
 Smoking can cause babies to be born too
early & too small
 Go to a “stop smoking” class if you are
thinking about getting pregnant
Question????
 TRUE OR FALSE…
 Multi vitamins before you get pregnant are
recommended.
Answer…
True!!
 Taking vitamins with folic acid before
pregnancy will protect your baby from
developing defects.
Get baby here safely…
 Help prevent transmission of HIV from
mom to baby…
 Lower viral load via HIV meds
 AZT (an HIV med) during labor
 C-section delivery if necessary
 AZT for baby up to 6 weeks old
 NO BREASTFEEDING—FORMULA ONLY
Support throughout this process
 Peer counselors/other
HIV+ persons
 Social workers/Case
managers
 HIV & OB nurses
& doctors
 Childbirth classes
 Nutritionists
 Therapists for mental
health issues & drug &
alcohol use
 Partner & friends
 Family
Isn’t planning for baby worth it?
Created by:
 Marin Mercurius, MS-IV,
Drexel University College of Medicine, and
 Erika Aaron, MSN, CRNP
Partnership Comprehensive Care Practice
Drexel University College of Medicine
1427 Vine St MS 595
Phila. Pa. 19102
215-762-6826
[email protected]
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So you want to have a baby?