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Reproductive counseling in the age of Zika virus

Sex, contraception, pregnancy, fear… Here’s what health care providers can do for their patients.

by Abigail Cutler, MD

published 05/13/16

*This article was updated on July 16, 2017, to reflect the most recent guidance and data.

The recent spread of the Zika virus, mainly a mosquito-borne illness, poses a possible threat to all women who may become pregnant. We now know that when contracted during pregnancy, the Zika virus causes microcephaly and other severe neurological defects in the developing fetus. It is also strongly associated with other adverse pregnancy and birth outcomes, including intrauterine growth restriction and pregnancy loss.

Recent research shows that Zika can be transmitted through sex, including vaginal, oral, and anal sex. As of this writing, 5,381 cases of Zika have been reported in the continental United States and Hawaii, including 1,997 in pregnant women. Summer mosquito season is upon us and the types of mosquito that carry the virus (genus Aedes) are now firmly established in the U.S. Mosquito-borne transmission of Zika occurred in multiple states in the past year, and travel-associated Zika cases have been reported in most states.

Guidance is here

With news of Zika virus making headlines on a daily basis, health care providers face questions from patients who understandably fear Zika’s potential impact on their current or future pregnancies. The U.S. Centers for Disease Control and Prevention (CDC) have been developing guidance for patients and providers on an ongoing basis. The Office of Population Affairs (OPA) also created a handy toolkit for health care providers based on the CDC's guidance.

What we know (and don’t) about sexual transmission of Zika

We now know that the Zika virus can be transmitted during sex by both men and women infected with Zika in the absence of barrier protection—before, during and after the onset of symptoms such as fever. We also know that the virus is found in both blood and semen and seems to persist longer in semen. In one case, it was present in semen up to 62 days after the onset of fever. We do not yet know whether men and women without symptoms can spread the virus to their partners.

Future Zika research will likely address these gaps in our knowledge. In the meantime, the CDC recommends that men who live in or have traveled to areas with active Zika virus transmission either use a condom for every sex act or abstain from sexual intercourse with their partners for a specific duration of time. (Find those specific guidelines here.)

Pregnancy planning in the age of Zika

How should we respond when a patient asks how best to think about her reproductive life plans in the setting of Zika?

The public health concerns surrounding Zika virus transmission serve to remind us that all women of reproductive age need and deserve up-to-date, evidence-based, and bias-free information on the full range of contraception and family planning services in order to exercise full autonomy over their reproductive lives. For women who wish to avoid pregnancy in the setting of a Zika outbreak, health care providers should offer counseling on and access to all contraceptive methods.

If you have a female patient who is not pregnant and has a suspected or confirmed case of Zika, you can assure her that our best evidence suggests that a Zika infection is cleared by the body on its own. The current advice is to wait at least 8 weeks after exposure or onset of symptoms before attempting to get pregnant. Men who may have been exposed to Zika or who've been diagnosed with Zika infection should wait at least 6 months before attempting pregnancy, whether or not they've shown symptoms of infection. Currently, there is no evidence that Zika virus will cause poor pregnancy or infant outcomes in pregnancies conceived after the resolution of maternal infection, though our data is limited. If she has recently had unprotected sex, you should give her full counseling on her emergency contraception options.

If your patient is pregnant and worried about Zika—whether the pregnancy is wanted, unwanted, or she feels ambiguous about it—she is likely to have lots of questions. Be prepared to provide information on the potential risks to her fetus, the types of testing you’d recommend to monitor the pregnancy, and her pregnancy options.

All women, including those with Zika, deserve quality reproductive care

Decisions about pregnancy timing and planning are personal and complex, and counseling around these topics should be individualized. Regardless of our female patients’ exposure to Zika, we must ensure that they are supported in ways that respect their right to shared decision-making and safeguard their access to comprehensive reproductive health care. The American College of Obstetricians and Gynecologists encourages comprehensive and patient-centered contraceptive and preconception counseling for all women at risk for or diagnosed with Zika infection. ACOG also offers online resources to help providers stay up-to-date with the latest evidence and guidelines.

Abigail Cutler, MD, is a resident in obstetrics and gynecology at Yale-New Haven Hospital in Connecticut. She plans to pursue a fellowship in family planning because she believes that reproductive health care is a fundamental human right. When she’s not at work, she can usually be found reading on her porch, working in her (tiny) garden, or relaxing in a bubble bath.
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