1. Thinking about having a baby?
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
© 2010 Erika Aaron

3. 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

4. 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)

5. 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

6. 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

7. Where do we begin?
We recommend beginning with a genital examination of both partners prior to attempting pregnancy.

8. 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.

9. 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

10. 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

11. Answer…
A. When viral load is lowest!!
Remember…it is always best to decrease viral load BEFORE becoming pregnant!

12. 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

13. 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.

14. 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

15. 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

16. 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 days before menstruation

17. Question???????
What day is the first day of your menstrual cycle???

18. Answer…
YES!!!
The first day of your period is the first day of your menstrual cycle

19. 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.

20. Example of a Basal Body Temperature Chart

21. 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

22. Life cycle of cervical mucus

23. Infertile phase I After your period; dryness, no visible mucus.
May be absent in short cycles and numerous in long cycles
Sensation at Vulva
Finger Test
Appearance
Moist or Sticky
                                                                  
Early Mucus
Scanty
Thick
White
Sticky Holds its shape

24. Transitional phase Transitional Mucus Increasing Amounts Wetter
                                                                  
Transitional Mucus
Increasing Amounts
Thinner
Cloudy
Slightly Stretchy

25. 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)

26. 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

27. Question???? During your most fertile phase, is your cervical mucus…
A. dry and sticky
B. slippery and stretchy
C. dry and thick

28. Answer…
B. slippery and stretchy

29. 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)

30. Question???
Can you still get pregnant even if it has been 2 days since you had intercourse?

31. Answer… ABSOLUTELY YES!!!
Remember, sperm survives 3-5 days or longer in a woman’s cervix in the presence of fertile mucus!!!

32. 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

33. 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

34. 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

35. 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

36. 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”

37. 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

38. 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.

39. 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

40. 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

41. Question????
Is it alright to have unprotected intercourse at any time of the month if you are trying to get pregnant?

42. Answer… ABSOLUTELY NOT!!!
If you are trying to get pregnant, only introduce sperm to cervix during your fertile time of the month!!

43. Question???? What is another name for your fertile time of the month?
A. Ovulation
B. Menstruation
C. Temptation

44. Answer…
A. OVULATION !!!

45. More about seeking help from a fertility specialist
Intrauterine insemination
IVF/ICSI
Sperm evaluation

46. 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

47. 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

48. 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

49. 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

50. So if you become pregnant what are the recommended goals:
To have a healthy pregnancy
Eat a well balanced diet
Prevent transmission to baby

51. 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

52. 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

53. 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

54. 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

55. Question???? TRUE OR FALSE…
Multi vitamins before you get pregnant are recommended.

56. Answer…
True!!
Taking vitamins with folic acid before pregnancy will protect your baby from developing defects.

57. 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

58. 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

59. Isn’t planning for baby worth it?

60. 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