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 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 Finger Test Appearance Moist or Sticky                                                                    Early Mucus Scanty Thick White Sticky Holds its shape

Transitional phase Transitional Mucus Increasing Amounts 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 eaaron@drexelmed.edu