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Thinking about having a baby? Preconception Counseling for HIV Discordant Couples Erika Aaron, MSN, CRNP Marin Mercurius, MS-IV Drexel University College.

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Presentation on theme: "Thinking about having a baby? Preconception Counseling for HIV Discordant Couples Erika Aaron, MSN, CRNP Marin Mercurius, MS-IV Drexel University College."— Presentation transcript:

1 Thinking about having a baby? Preconception Counseling for HIV Discordant Couples Erika Aaron, MSN, CRNP Marin Mercurius, MS-IV Drexel University College of Medicine Phila Pa 215-762-6826 © 2005 Erika Aaron

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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 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 STD’s, 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

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

6 Why start with a genital exam?  The diagnosis and treatment of inflammatory conditions of the genital tract before pregnancy helps to decrease transmission of the virus  STDs increase the risk of HIV transmission.  This is a good time to talk about what you are doing to avoid STDs

7 The Lower the Viral Load the Better  A lower viral load decreases HIV transmission to your partner and baby— you may decide that you want to start HIV meds to lower your viral load to undetectable levels before trying to get pregnant  If your partner is HIV+ this may be a time for him/her to start HIV meds also

8 What next?  Next we recommend use of ovulation kits, basal body charts, and cervical mucus evaluation to identify ovulation (fertile period)

9 Ovulation 101  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

10 Ovulation 101 cont.  Since most people start ovulating on the 14 th day of their cycle, start using the ovulation kit on day 11 to increase your window of fertility  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

11 Indicators of fertility  Waking temperature  Cervical mucus changes  Changes on the cervix  Calculation of menstrual cycle length cycles vary from 23 days to 35 days Ovulation occurs 12-16 days before menstruation

12 When is the first day of your cycle??  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 or when you can expect to start your next menstrual cycle

13 Question???????  What day is the first day of your menstrual cycle???

14 Answer… YYES!!! TThe first day of your period is the first day of your menstrual cycle

15 Basal Body Temperature  Take temperature first thing in the morning when you wake up  Repeat daily for 15 days starting on the first day of your cycle  Enter temperature on a graph, join the numbers to make a curve  Enter comments on the graph to indicate days of period and other notable events

16 Basal body temperature cont.  The temperature remains low until the time of ovulation, when a rise occurs. The temperature usually spikes & remains high when your period begins.  The egg can be fertilized for up to 12 hours after ovulation.  Your chances of getting pregnant after the 3 rd high temperature has been recorded are greatly lowered.

17 Question????  TRUE OR FALSE…  An egg can be fertilized for up to 12 hours after you ovulate

18 Answer… TTRUE!!! AAn egg can be fertilized for up to 12 hours after ovulation!!!

19 Life cycle of cervical mucus

20 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 TestAppearance Moist or Sticky Early Mucus Scanty Thick White Sticky Holds its shape

21 Transitional phase Wetter Transitional Mucus Increasing Amounts Thinner Cloudy Slightly Stretchy

22 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)

23 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

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

25 Answer… BB. Slippery and Stretchy

26 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)

27 Life of an egg  Infertile phase I - controlled by FSH and estrogen The pituitary gland secretes FSH, a hormone which stimulates follicles in the ovary.  The follicles produce increasing amounts of estrogen. The lining of the uterus becomes thicker The cervix becomes higher and softer and open Cervical mucus thick, white, sticky The temperature remains on the lower level  Ovulation The most mature follicle ruptures and releases the egg

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

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

30 HIV + Female and HIV - Partner  If you are an HIV+ female and your partner is HIV- you can use self insemination during ovulation

31 Self-insemination: HIV+ female and an HIV- partner  Self-insemination is when the female inserts the HIV negative 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

32 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

33 HIV + Male and HIV- Female  If you are an HIV- female with an HIV+ 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

34 Timed Conception For an HIV+ male and 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 is essential to prevent development of resistance

35 HIV + Female and 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.

36 HIV + Female and 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

37 Timed Conception For an HIV+ male and 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 is essential to prevent development of resistance

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

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

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

41 Answer…  A. OVULATION !!!

42 Seeking help from a fertility specialist  Intrauterine insemination  IVF/ICSI  Sperm evaluation

43 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

44 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

45 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

46 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

47 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

48 Treatment of infected partner  Decrease viral load BEFORE time of conception  The lower the viral load in the infected partner, the lower the risk of transmission of HIV to the partner or the baby

49 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

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

51 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

52 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

53 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

54 Question????  TRUE OR FALSE…  Multi vitamins before you get pregnant is recommeded.

55 Answer… TTrue!! TTaking vitamins with Folic Acid before pregnancy will protect your baby from developing defects.

56 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

57 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 and drug and alcohol use  Partner and friends  Family

58 Isn’t planning for baby worth it?

59 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 eaaron@drexelmed.edu


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