Folic acid is a supplementation that is recommended before and during pregnancy to help make sure the neural tube (which becomes the spine) in the fetus develops properly. It can be started as soon as you start thinking about pregnancy, but you definitely should be on it at least 3 months before pregnancy. If you are not actively preventing pregnancy (i.e., regularly using some form of birth control method) and there is a chance you might become pregnant, you should be taking folic acid. Many people only realise that they are pregnant 4 weeks into their pregnancy (when they have a late period). By then, the neural tube in the fetus is already almost formed. So starting to take folic acid before pregnancy is really important. The recommended dose is 0.4 – 1 mg per day and it is continued throughout pregnancy. Folic acid can be purchased at a drug store without a prescription and is usually found behind the pharmacy counter. Prenatal vitamins also contain folic acid, so some people planning pregnancy simply take a prenatal vitamin every day. If there is a family history of neural tube defects or a high risk of neural tube defects, the dosage can be increased up to 5 mg per day. Speak to a healthcare professional if you have specific questions about folic acid.
After some concerns about the risk of dolutegravir increasing neural tube defects, the current recommendation is that when taken at the time of conception, dolutegravir likely slightly (<1%) increases the risk for neural tube defects. But dolutegravir remains a preferred first-line antiretroviral because of its high efficacy, ease of administration, infrequent side effects, and high barrier to resistance, even during pregnancy. Many clinicians and researchers say the benefits of dolutegravir outweigh the risks. If you are taking dolutegravir and considering getting pregnant, you should speak to your HIV care provider and discuss that there is data that taking a higher dose of folic acid (5 mg per day) should be started before conception/pregnancy.
Yes. Studies have shown that people with viral loads of less than 1500/ml cannot pass the virus to their sexual partners because the virus is not in the body fluids. The most important aspect is that people with undetectable viral loads continue to take their medication and maintain a suppressed viral load. So as long as you have an undetectable viral load, for at least 3 but preferably 6 months, you #cantpassiton.
It does not need to be complicated. If either you or your partner are living with HIV and are taking effective HIV medication and have an undetectable viral load, you can go ahead and have sex without a condom. If you or your partner or both of you are taking effective HIV medication and your viral load is undetectable, you cannot transmit the virus sexually (remember U=U). The Canadian HIV Pregnancy Planning Guidelines (CHPPG) recommend avoiding condomless sex until the person(s) with HIV has had an undetectable viral load for at least 3 months, but preferably 6 months, with at least two viral load measurements at least one month apart below the limit of detection. You may also want to time the condomless sex with peak fertility (i.e. ovulation). For more information on timing ovulation see the FAQ below, "Do we have to time ovulation?".
If, however, you are in a sero-discordant relationship (i.e., one partner is positive, the other is negative) with a non supressed viral load, and still want to get pregnant, it is highly recommended that you use condoms and the partner with HIV work with their HIV care team to achieve an undetectable viral load before trying to have sex without a condom. If this is not possible, it is essential that the negative partner take something called pre-exposure prophylaxis (PrEP), which is one pill per day to prevent HIV. Speak to a healthcare professional if you have specific questions about conception options (and see some of the FAQs below).
PrEP is the use of anti-HIV medication (the same kind of medication people living with HIV take to fight the virus inside their body) that keeps HIV negative people from becoming infected. Specifically, the anti-HIV medication consists of two antiretroviral drugs in a combination pill known as Truvada® and is taken as one pill per day. PrEP stops HIV from taking hold and spreading throughout your body. When taken daily, PrEP is highly effective for preventing HIV. PrEP is much less effective when it is not taken consistently.
The reason for this is NOT to reduce the risk of HIV transmission by reducing the number of times you have sex without a condom. Instead, the CHPPG recommends timing condomless sex with peak fertility because that will increase the chances of conception (getting pregnant). The timing of sex has to be around the time of ovulation or else pregnancy will not happen.
There are a number of ways you can monitor when you are ovulating. We have created a great resource that you can easily download and print (see this great OVULATION 101 Tool).
No. Timing ovulation is a personal choice, but it may increase your chance of conceiving. Some people find this stressful and just like the idea of ‘seeing what happens’. If that is what you prefer or believe in, you don’t need to time ovulation when you first start trying. Over time, it may be recommended if you have not conceived.
In individual cases, timing ovulation may be recommended. It is always best to speak to a healthcare provider about your plans to try and conceive before starting to make sure you can make an informed decision about things like whether or not to time ovulation.
The likelihood of getting pregnant varies from person to person. What is important to know is that getting pregnant usually takes time. Even timing condomless sex with peak fertility (ovulation) doesn’t guarantee you will become pregnant. Even for a person with ‘typical’ fertility it can sometimes take as long as one year of home-based methods to become pregnant. It is said that the approximate chance of getting pregnant for each attempted cycle is approximately 10%. If you have specific concerns about your chances of becoming pregnant speak to your healthcare professional.
Unless you are known to have previous infertility or a risk of having fertility issues, or you are single/in a relationship that might require a fertility clinic, it is not recommended that you go straight to a fertility clinic. If you are concerned about your fertility, speak to a healthcare professional to see if a referral to a fertility expert is necessary.
No. As stated above, unless you (or your partner) are known to have previous infertility or a risk of having fertility issues, it is not recommended that you go straight to a fertility clinic. If you are concerned about your fertility, speak to a healthcare professional to see if a referral to a fertility expert is necessary.
The general recommendation is that conception should be attempted for 12 months without success prior to fertility investigation. Working with experts across Canada, the CHPPG recommends referral to a gynecologist or fertility specialist after as little as 6 months of failed conception with home-based conception attempts. This is because some studies have suggested there may be a connection between HIV and infertility. More importantly, if you acquired HIV sexually, you may be at risk of infertility caused by other STIs in the past. In some cases the CHPPG recommends referral sooner than 6 months if your healthcare provider suspects you may have decreased fertility.
Age is also a very important consideration for the person intending pregnancy (e.g., a woman or trans man). It is generally recommended that people under 35 years of age who have no known risk factors try for 12 months, those over age 35 years but less than 40 years of age try for 6 months, and anyone over age 40 years be referred immediately, or 3 months after, initiating home-based conception attempts.
The chance of getting pregnant goes down with age and becomes less likely once people are in their early or mid 40s. However, there are cases of pregnancy even into one’s 50s. Therefore, it is a personal decision to decide when one is too old to try to get pregnant. Trying does not mean you will be able to get pregnant.
For the person planning to become pregnant, blood tests can be done to see if your body is still ovulating and if you can become pregnant. You don’t necessarily need to see a fertility specialist for these tests. Speak to your healthcare professional about blood testing options. Note that some are covered by various forms of insurance and some you may have to pay for. For the person providing sperm (e.g., man or trans woman), age does not impact fertility the same way. If you have any concerns about the impact of your age on sperm quality, speak to your healthcare provider. Most sperm testing does require referral to a fertility specialist.
The good news is that there are plenty of options. Options that other GBTQ+ men and single men have used are:
Raising foster children or adoption. For people living with HIV domestic adoption is the best option. However, international adoption of family members may be possible. For more about adoption, see ‘ADOPTION’ on page 108 of the CHPPG.
Various forms of surrogacy are possible also. Surrogacy is when a person carries a pregnancy for another person or couple. Sometimes the egg(s) come from the pregnant person and other times they are donor egg(s). The sperm would be provided by you or your partner. Surrogacy is possible for men living with HIV in Canada. Because of the different options, if you are interested in surrogacy it is recommended that you speak to a fertility specialist and a surrogacy agency to learn more.
Co-parenting (a planned, platonic parenting relationship). This would involve conceiving a biological child to parent with someone that you are not in an intimate relationship with. Decisions around conception would be based on the preference of the co-parents and should be based on the viral load of the person living with HIV (if applicable as in cases of two men, an HIV-negative partner may decide to be the biological parent). Canada is recognized as a very inclusive country for multi-parented families. Based on Children’s Law Reform Act, up to 4 parents can be listed on a birth certificate if a pre-conception parentage agreement is in place. If you are considering co-parenting in this way, you may want to speak to a lawyer before trying to conceive.
The good news is that there are plenty of options. Common options that other LGBTQ+ women and single women have used are:
Raising foster children or adoption. For people living with HIV domestic adoption is the best option. Also, international adoption of family members is another option. For more about adoption, see ‘ADOPTION’ on page 108 of the CHPPG.
Insemination with donor sperm. Donor inseminations are performed using either anonymous donor sperm from a bank, or sperm from a known individual of your choosing. This can be done using a home-based method or in a fertility clinic. Donor sperm from a sperm bank costs money as do some fertility treatments if needed. To learn more about donor sperm and insemination speak to your healthcare professional.
Reciprocal IVF (i.e., in vitro fertilization) (for lesbian couples; one partner carries the pregnancy, the other is the egg donor).
Co-parenting (a planned, platonic parenting relationship). This would involve conceiving a biological child to parent with someone that you are not in an intimate relationship with. Decisions around conception would be based on the preference of the co-parents and should be based on the viral load of the person living with HIV (if applicable an HIV-negative partner may decide to be the biological parent). Canada is recognized as a very inclusive country for multi-parented families. Based on Children’s Law Reform Act, up to 4 parents can be listed on a birth certificate if a pre-conception parentage agreement is in place. If you are considering co-parenting in this way, you may want to speak to a lawyer before trying to conceive.
Infertility does affect about 10 percent of the general population, and people with HIV might be at higher risk of infertility. The reasons for this are not clear but might include previous genital tract infections from STIs and HIV may cause sperm problems. If you have had previous STIs or a specific concern about your chances of becoming pregnant speak to your healthcare professional.
Every fertility clinic is a little different. It is good to learn as much as you can about a clinic before you decide which one might be the best fit for you.
Once you start going to the clinic, they will collect a very full history related to your health and any reproductive history. Physical exams and various tests will be done depending on why you are seeing a fertility specialist. Common tests include blood tests to look at hormone levels. The person intending pregnancy may have several different types of ultrasounds. The person providing sperm (if not using an anonymous donor) will have their semen analyzed. The fertility specialist will then make recommendations on the ways you might successfully conceive. Some services within fertility clinics cost money that public and/or private insurance doesn’t fully cover. The fertility clinic will have people who can review these costs with you. However, being aware of these costs beforehand and considering what is affordable for you is important before visiting a fertility clinic.
Sperm washing is a routine part of sperm preparation within fertility clinics. In the era of U=U, it is not related to you or your partner’s status or viral load. The sperm washing is done to allow the collection of the best and most concentrated sperm. Also, as the sperm is most commonly inserted into the uterus, it has to be free of a protein found in the semen, prostaglandin, which would induce spasms of the uterus which would be very painful.
There are many different services that have fees at fertility clinics. The costs vary somewhat from clinic to clinic and province to province. Most clinics can offer you a fees schedule at your first appointment. This will be the most accurate information about costs.
The largest costs are for people pursing IVF (i.e., in vitro fertilization). In Canada, IVF treatments can cost $10,000 to $15,000 per cycle. In some cases, the cost of fertility drugs and other tests and consultations can push that cost up to around $20,000. Different provinces in Canada have different public coverage plans, and these change over time. Check out your provincial and/or territory coverage for more information. Many private health plans offered by employers can also assist in lightening the financial burden.
Yes. Sadly, there are still fertility clinics in Canada that do not see patients affected by HIV and other blood-borne viral infections, like hepatitis B and C. We are working constantly to try and eliminate this barrier. If you are in need of a fertility expert, reach out to your doctor (family doctor and/or HIV specialist) and/or our project lead.
If you are in need of a fertility clinic, feel free to explore the options in your area. If you are concerned and would like support in choosing a fertility clinic, reach out to your doctor (family doctor and/or HIV specialist) and/or our project lead.
Many people are confused about the changes and how they may/may not positively impact people and couples affected by HIV. These changes came into effect on February 4th, 2020. The major changes relate to the registration of fertility clinics and doctors and to known donors.
The good news is that the new regulations will also allow people to use known donors who are living with HIV. Previously, known donors and commercial donors had to meet the same standards and HIV-infection was an exclusion. Doctors who want to offer this service now have to register with Health Canada, the same way commercial sperm banks currently do. The new regulations do not change the options for people living with HIV who want to access fertility care when they are partnered in a heterosexual relationship.
There are NO changes in the Health Canada Act that impact HIV handling in fertility clinics. The act ONLY addresses provision of donor gametes and surrogates. The new law allows intended parents to choose donors or surrogates/carriers who are HIV positive.
The best plan is to work with your HIV care provider to make any necessary changes to your HIV medications before pregnancy (this is part of the planning).
In terms of changing HIV medications, in most cases the answer is no but this depends on the regimen you are currently on. Most current first line medications are relatively safe in pregnancy including Dolutegravir. If you are virally suppressed on the current regimen, then it is not likely that you will have to change. However, if you are not virally supressed, drugs may be changed if treatment failure is suspected.
There are obstetricians (doctors who look after pregnant people) in most major cities in Canada who have some expertise in managing HIV in pregnancy. The CHPPG recommends working with your HIV provider to find the obstetrician in your region with the most experience.
If there is no expert in your area, your HIV care provider can help you find someone to manage your pregnancy. Family doctors who do prenatal care are also an option. At this time, midwives in independent practice cannot manage a pregnancy in a person living with HIV as this is outside their scope of practice.
Whether you plan a visit with a pregnancy care provider or your HIV care provider, it is always a good idea to meet with someone before you start planning to become pregnant to discuss any questions you might have; this will help you make a plan, and even do some baseline tests to make sure your body is ready for pregnancy.
Most people living with HIV in Canada can have vaginal deliveries because their viral loads are undetectable. If you have a detectable viral load, working with your HIV care provider to become undetectable is important for your delivery and your baby. A caesarean section may be necessary if you continue to have a detectable viral load as you approach delivery.
Remember – caesarean sections are required for a number of reasons. So just because you have an undetectable viral load does not mean you won’t need a caesarean section for another reason. Work with your pregnancy care provider to determine the safest delivery option for you and your baby.
Breastfeeding is not recommended for people living with HIV in Canada. The recommendation for infant feeding is to use formula. Most provinces offer subsidized formula programs for people living with HIV where the formula is given for free for up to a year. For information about provincial formula funding or other ways to access formula, speak with your HIV care provider or the pediatric HIV expert that will follow your baby after birth.
Many people have thoughts and desires related to breastfeeding. If you are feeling like you may want to breastfeed, or even that you want to talk about it, speak to a member of your HIV care team, or your future child’s HIV care team about breastfeeding and HIV. They can offer you a lot of information to help support you and your family in making this decision. The most important thing is to be open about your feelings and plans so that your healthcare team, and your future child’s healthcare team, can support you in the best way possible.
All newborns who were delivered to a person living with HIV will be given 1-3 HIV drugs to reduce the risk of transmission of HIV. The medications are started within 6 to 12 hours after birth. A newborn’s HIV drugs will be determined based on several factors from your health and pregnancy and infant factors that influence the risk of perinatal transmission of HIV. A 4-week course of liquid zidovudine (ZDV) is the most common regimen used in most newborns when there was an undetectable load during pregnancy.
In Canada we can safely say that if you start HIV medications and have an undetectable viral load before pregnancy, stay undetectable throughout your pregnancy, and formula feed your baby there is ZERO risk of HIV transmission to your baby. Under these conditions there has never been a case of perinatal HIV transmission.
Globally, with HIV medications being taken in pregnancy, the risk is usually reported as less than 1 or 2%.
Your care will be routine after pregnancy. You may see your HIV care provider soon after but the rest of your follow up will be routine.
What is different is that your baby will have follow up appointments with the pediatric HIV team. These appointments start out more frequently but by a few months of age really space out. Each clinic may be slightly different with their follow up schedule, so it is best to speak to the pediatric HIV team in your region to answer your questions about the follow up for your newborn.
Birth control is an important consideration after pregnancy. Remember that even if your period hasn’t returned you can get pregnant. All forms of birth control that were available to you before pregnancy are still available postpartum (i.e., after birth). For a quick reference about birth control options for people living with HIV check out this Infographic from AIDSInfo.
Deciding the timing and frequency of pregnancies is your right. If you want to get pregnant again soon after this pregnancy, speak to your healthcare team about any considerations you might want to take into your decision making. It is generally recommended that the time between pregnancies be enough to allow the body to heal, for vitamin and mineral stores in the body to build up, and so on. There is also a recommendation about waiting between pregnancies when the delivery required a caesarean section.