Guidance for Preconception Counseling and Prevention of Sexual Transmission

CDC is updating its guidance on timing of conception after possible Zika virus exposure and prevention of sexual transmission of Zika virus. CDC continues to evaluate all available evidence and update recommendations as new data become available. Most of the recommendations for preconception counseling and prevention of sexual transmission are dependent on whether persons live in or travel to areas of active Zika virus transmission.¶ As of September 26, 2016, 59 countries and U.S. territories reported active Zika virus transmission. The Florida Department of Health identified two areas of Miami-Dade County with active local mosquito-borne Zika virus transmission; as of September 20, 2016, only one remains an area of active transmission (37). Updates on areas with active Zika virus transmission are available online at http://www.cdc.gov/zika/geo/index.html.

For Couples Planning to Conceive Who Do Not Live in Areas with Active Zika Virus Transmission. Health care providers should discuss couples’ travel plans in preconception counseling. Women and men who are planning to conceive in the near future should consider avoiding nonessential travel to areas with active Zika virus transmission.

Women who have had possible Zika virus exposure through travel or sexual contact and do not have ongoing risks for exposure should wait at least 8 weeks from symptom onset (if symptomatic) or last possible exposure (if asymptomatic) to attempt conception. Women who wait at least 8 weeks to conceive might have an increased likelihood that Zika virus no longer presents a risk for maternal-fetal transmission.

CDC now recommends that men with possible Zika virus exposure, regardless of symptom status, wait at least 6 months from symptom onset (if symptomatic) or last possible exposure (if asymptomatic) before attempting conception with their partner. CDC previously recommended that men with possible Zika virus exposure who were asymptomatic wait at least 8 weeks from last possible exposure. The updated recommendation minimizes the likelihood that periconceptional sexual transmission will result in fetal exposure to Zika virus. The recommendation to wait at least 6 months for asymptomatic men is based on the range of time after symptom onset that Zika virus RNA has been detected in semen of symptomatic men and the absence of definitive data that the risk for sexual transmission differs between symptomatic and asymptomatic men. Zika virus has not been definitively cultured from semen more than 3 months after symptom onset. It is unknown whether detection of Zika virus RNA in semen indicates presence of infectious virus and the potential for transmission. Current recommendations provide couples planning to conceive with periods that, based on existing data, are expected to minimize risk for Zika virus transmission to an uninfected partner. Studies are underway to better understand the persistence of infectious Zika virus in semen and the associated risk for sexual transmission of the virus. Given that limited data are available, some couples in whom a partner had possible Zika virus exposure might choose to wait longer or shorter than the recommended period to conceive, depending on individual circumstances (e.g., age, fertility, details of possible exposure) and risk tolerance. For example, after consultation with their health care provider, symptomatic persons with negative test results who received testing in the appropriate time window and in accordance with the testing algorithm (38) might choose not to wait to conceive.

For Couples Who Want to Conceive, in Which One or Both Partners Live in Areas with Active Zika Virus Transmission. Women and men who reside in areas with active Zika virus transmission and who experience symptoms of Zika virus disease should be tested for Zika virus infection (38). Men with results that indicate recent Zika virus or unspecified flavivirus infection should wait at least 6 months from symptom onset to attempt conception with their partner; women with results that indicate recent Zika virus or unspecified flavivirus infection should wait at least 8 weeks from symptom onset to attempt conception. Persons who have had symptoms of Zika virus disease with negative Zika virus test results should talk with their health care provider about timing of conception in the setting of ongoing risk for possible exposure.

Persons living in an area with active Zika virus transmission should be counseled on the possible risk for Zika virus infection during the periconception period. CDC has developed tools to assist health care providers with preconception counseling (39). Health care providers should provide counseling about the potential consequences to the fetus associated with Zika virus infection during pregnancy, such as microcephaly and other serious brain abnormalities. Women and men should discuss their reproductive life plans** with their health care provider, in the context of potential and ongoing Zika virus exposure. Health care providers should review factors that might influence pregnancy timing (e.g., unknown duration of Zika virus outbreak, fertility, age, reproductive history, medical history, personal values and preferences). For couples who choose to conceive, health care providers should stress use of mosquito bite prevention strategies†† while attempting pregnancy and during pregnancy. Health care providers should counsel couples who decide to wait to attempt conception about strategies to prevent unintended pregnancy, including the most effective contraceptive methods (i.e., long-acting reversible contraception) and provide contraception or referral to appropriate providers for contraception care (40).

Special Considerations for Women Undergoing Fertility Treatment. Zika virus transmission through assisted reproductive technology has not been reported. However, transmission through gametes or embryos is theoretically possible. Recommendations for sexually intimate couples with Zika virus infection or possible Zika virus exposure undergoing fertility treatment with their own gametes and embryos should follow the testing and timing recommendations as described above; recommendations might need to be adjusted depending on individual circumstances. The Food and Drug Administration has issued guidance to reduce the risk for Zika virus transmission by donated human cells, tissues, and cellular and tissue-based products, including reproductive tissues (41).

For Couples Who Are Not Pregnant and Are Not Planning to Become Pregnant in the Near Future. Couples in whom the man or woman has had possible Zika virus exposure who want to maximally reduce their risk for sexually transmitting Zika virus to the uninfected partner should use condoms consistently and correctly or abstain from sex for at least 6 months for men or 8 weeks for women after symptom onset (if symptomatic) or last possible Zika virus exposure (if asymptomatic). Some couples might choose to use condoms or abstain from sex for a shorter or longer period than recommended depending on individual circumstances and risk tolerance. Couples should be advised that correct and consistent use of condoms reduces the risk for other sexually transmitted infections.

Health care providers should discuss strategies to prevent unintended pregnancy with couples who do not want to become pregnant. Safety, effectiveness, availability, and acceptability should be considered when choosing a contraceptive method (42). Patients should be counseled to use the most effective contraceptive method that can be used correctly and consistently. Long-acting reversible contraception, including contraceptive implants and intrauterine devices, provide highly effective reversible options.

For Pregnant Women and Their Partners. Pregnant women living in areas without active Zika virus transmission should be advised to avoid nonessential travel to areas with active transmission. Persons who have traveled to or live in an area with active Zika virus transmission and whose partner is pregnant should be advised to consistently and correctly use condoms during sex or abstain from sex for the duration of the pregnancy. These actions reduce the risk for sexual transmission of Zika virus during pregnancy. Health care providers should ask pregnant women about their own and their sex partner’s history of travel to areas with active Zika virus transmission. Pregnant women with possible Zika virus exposure, either through sex or through traveling to or living in an area with active Zika virus transmission, should be tested for Zika virus infection in accordance with CDC’s “Updated Interim Pregnancy Guidance: Testing and Interpretation Recommendations for a Pregnant Women with Possible Exposure to Zika Virus” (http://www.cdc.gov/zika/pdfs/testing_algorithm.pdfpdf icon), including pregnant women with possible sexual exposure whose sex partner has had no symptoms of Zika virus disease. Further guidance for care of pregnant women with possible Zika virus exposure has been published (3).