3Why come for preconception counseling? To learn how to make informed decisions about your future reproductive choicesTo learn about the risks and benefits of HIV meds both to mom and babyTo learn how to avoid transmission of HIV to your partner and babyTo help mentally prepare you as a parent for all that is about to come
4Others reasons why you should come to preconception counseling To learn how to maintain your health before, during and after pregnancyTo learn how to prevent superinfection (passing a more virulent strain of HIV to another HIV positive partner)
5Before 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
6How do we hope to assist you in preparing for your baby? Assist with pregnancy planningInform you about reproductive & general healthHelp you enter pregnancy in good health, with a healthy immune system, and as few risk factors as possibleScreen for STDs, advise about good nutrition, and the harms of drugs, alcohol and cigarettesHelp you to become fully informed about HIV meds to prevent HIV transmissionBegin HIV meds early to prevent transmission
7Where do we begin?We recommend beginning with a genital examination of both partners prior to attempting pregnancy.
8Why 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 virusSTDs increase the risk of HIV transmission.
9Next we check your HIV status We check you CD4 count and viral loadA 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 pregnantBut 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
10Question???? When is the best time to try to get pregnant? A. When viral load is lowestB. When viral load is mediumC. When viral load is highest
11Answer…A. When viral load is lowest!!Remember…it is always best to decrease viral load BEFORE becoming pregnant!
12So how do you plan on getting pregnant? We recommend use of:Ovulation kits (LH kits)Basal body chartsCervical mucus evaluation to identify ovulation (fertile period)Noting when you have midcycle lower abdominal pain
13Ovulation 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.
14So how do you know when you are ovulating? By using ovulation kits Ovulation is your most fertile time of the monthOvulation kits allow you to track ovulation each month to identify the best time of the month to get pregnantTesting should be done every morning before getting out of bed
15Ovulation 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 windowTwo-three days immediately after a positive test is the best time to introduce sperm into uterus. This will increase your chances to become pregnantYou can also use an ovulation calculator to predict when you will be fertile. These can be found for free on fertility websites online
16Quick review of menstrual cycle (average of 28 days) The first day of your cycle is the first day that you begin your periodYou 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 cycleCycles vary from 23 days to 35 daysOvulation occurs days before menstruation
17Question???????What day is the first day of your menstrual cycle???
18Answer…YES!!!The first day of your period is the first day of your menstrual cycle
19Basal 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 curveYou 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.
21Basal Body Temperature cont’d You're most fertile in the two or three days before your temperature hits its high pointBy the time you temperature increases, it's too late to get pregnantHowever 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
23Infertile phase I After your period; dryness, no visible mucus. May be absent in short cycles and numerous in long cyclesSensation at VulvaFinger TestAppearanceMoist or StickyEarly MucusScantyThickWhiteSticky Holds its shape
25Fertile PhaseIncrease 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.SlipperyHighly Fertile MucusProfuseThinTransparentStretchy (like raw egg white)
26Infertile Phase II Completely infertile phase A return to stickiness or drynessThe mucus is now thick and acts as a physical barrier to sperm
27Question???? During your most fertile phase, is your cervical mucus… A. dry and stickyB. slippery and stretchyC. dry and thick
29Life of a spermSperm survives 3-5 days or longer in a woman‘s cervix in the presence of fertile mucus (thin, watery mucus)
30Question???Can you still get pregnant even if it has been 2 days since you had intercourse?
31Answer… ABSOLUTELY YES!!! Remember, sperm survives 3-5 days or longer in a woman’s cervix in the presence of fertile mucus!!!
32Midcycle 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 hoursThis could alert you that you are ovulating and will be a good time to have intercourse
33For 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
34Self-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 officeMethods include:SyringeTurkey basterCervical cap
35Self-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 cycleThis increases the chance of becoming pregnant without risking transmission of HIV to the negative partnerUse condoms during intercourse
36HIV+ 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 spermAfter the sperm is washed it is placed into the uterus by intrauterine insemination in the officeIf this is not an option for you unprotected intercourse only at the time of ovulation is called “timed conception”
37Timed 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 TIMEThere is a risk of transmission whenever you have unprotected intercourseIt 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
38HIV+ female & HIV+ maleUnprotected 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.
39HIV+ female & HIV+ maleThe safest option is a fertility clinic where sperm washing is performed on the HIV+ male’s spermAfter the sperm is washed it is placed into the uterus by intrauterine insemination in the officeIf this is not an option for you unprotected intercourse only at the time of ovulation is called timed conception
40Timed 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 TIMEThere is a risk of “superinfection” whenever you have unprotected intercourseIt 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
41Question????Is it alright to have unprotected intercourse at any time of the month if you are trying to get pregnant?
42Answer… ABSOLUTELY NOT!!! If you are trying to get pregnant, only introduce sperm to cervix during your fertile time of the month!!
43Question???? What is another name for your fertile time of the month? A. OvulationB. MenstruationC. Temptation
45More about seeking help from a fertility specialist Intrauterine inseminationIVF/ICSISperm evaluation
46Intrauterine insemination Direct placement of sperm into cervix and up into uterus--done by a physicianSperm from an HIV+ male is first prepared via “sperm washing” to reduce the amount of virus in the fluid around the spermThe sperm is then introduced into the cervix and into uterine cavity
47IVF/ICSIIn 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 cavityICSI 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
48Fertility specialists cont. These methods often result in successful pregnancy with least risk of transmissionUnfortunately these procedures are very expensive and not covered by most insurancesAnother option for having a baby is using an HIV negative sperm donorAdoption is a great option for having a baby
49Sperm 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 collectionTwo to three testing cycles, separated by at least a month, are required for a meaningful evaluationDoctors test the total number of sperm, the shape of sperm, how well the sperm move, & the strength of the sperm
50So if you become pregnant what are the recommended goals: To have a healthy pregnancyEat a well balanced dietPrevent transmission to baby
51Healthy pregnancy outcomes Begin antiretroviral treatment early and maintain a low viral loadEliminate exposure to cigarette smoke, street drugs, alcoholIncrease vitamin intake via folic acid and iron supplementsBegin a balanced dietAll these things should be started BEFORE becoming pregnant to help ensure the best possible outcome
52Folic AcidFolic acid- 400 micrograms daily- is important in preventing defects in the development of the baby’s brain & spineIt’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 stagesFolic acid can be found in green leafy vegetables, citrus fruits, nuts, whole grains, and prenatal vitamins
53Balanced dietBegin eating a healthy diet now, and at least 3 months before getting pregnantEating a balanced diet helps get important vitamins and nutrients to the developing baby
54Avoid alcohol, drugs, & cigarettes Drugs and alcohol (even marijuana-weed or beer) can hurt you and your baby, especially when you are pregnantSmoking can cause babies to be born too early & too smallGo to a “stop smoking” class if you are thinking about getting pregnant
55Question???? TRUE OR FALSE… Multi vitamins before you get pregnant are recommended.
56Answer…True!!Taking vitamins with folic acid before pregnancy will protect your baby from developing defects.
57Get baby here safely…Help prevent transmission of HIV from mom to baby…Lower viral load via HIV medsAZT (an HIV med) during laborC-section delivery if necessaryAZT for baby up to 6 weeks oldNO BREASTFEEDING—FORMULA ONLY
58Support throughout this process Peer counselors/other HIV+ personsSocial workers/Case managersHIV & OB nurses & doctorsChildbirth classesNutritionistsTherapists for mental health issues & drug & alcohol usePartner & friendsFamily
60Created by: Marin Mercurius, MS-IV, Drexel University College of Medicine, andErika Aaron, MSN, CRNPPartnership Comprehensive Care PracticeDrexel University College of Medicine1427 Vine St MS 595Phila. Pa