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Fertility is improved within months and conception is achieved within one to six years after kidney transplantation. Pregnancy is safe and has little effect on long-term graft survival, but has increased maternal and fetal risks. Pregnancy is contraindicated in the first two years post-kidney transplantation due to increased risk of acute rejections and higher doses of immunosuppressive drugs. Poor renal function, uncontrolled diabetes mellitus and hypertension are other contraindications. Family planning and counseling, and consideration of a suitable contraceptive method are essential before transplantation. Tubal ligation and vasectomy are permanent contraceptives with the least failure results. Combined pills are highly effective and are among the lowest failure rate contraceptives, but they interact with cyclosporine, and are contraindicated in patients with thromboembolism and deep vein thrombosis. Progesterone-only minipill has the advantage of avoiding the risks associated with estrogen, but has a higher failure rate than the combined pills. The barrier methods (condom and diaphragm) are effective and safe contraceptives and can prevent sexually transmitted diseases, but require motivated couples. Intra uterine devices are convenient contraceptives, but have higher failure rate and are associated with increased incidence of pelvic infection. Pregnancy in renal transplant recipients should be managed by a multidisciplinary approach in a tertiary centre.
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Saudi J Kidney Dis Transpl 2008;19(2):165-173 Saudi Journal
of Kidney Diseases
and Transplantation
© 2008 Saudi Center for Organ Transplantation
Pregnancy and Contraceptive Issues in Renal Transplant Recipients
Ayman Karkar
Kanoo Kidney Centre, Dammam Central Hospital, Dammam, Saudi Arabia
ABSTRACT. Fertility is improved within months and conception is achieved within one to six
years after kidney transplantation. Pregnancy is safe and has little effect on long-term graft
survival, but has increased maternal and fetal risks. Pregnancy is contraindicated in the first two
years post-kidney transplantation due to increased risk of acute rejections and higher doses of
immunosuppressive drugs. Poor renal function, uncontrolled diabetes mellitus and hypertension
are other contraindications. Family planning and counseling, and consideration of a suitable
contraceptive method are essential before transplantation. Tubal ligation and vasectomy are
permanent contraceptives with the least failure results. Combined pills are highly effective and
are among the lowest failure rate contraceptives, but they interact with cyclosporine, and are
contraindicated in patients with thromboembolism and deep vein thrombosis. Progesterone-only
minipill has the advantage of avoiding the risks associated with estrogen, but has a higher failure
rate than the combined pills. The barrier methods (condom and diaphragm) are effective and safe
contraceptives and can prevent sexually transmitted diseases, but require motivated couples. Intra
uterine devices are convenient contraceptives, but have higher failure rate and are associated with
increased incidence of pelvic infection. Pregnancy in renal transplant recipients should be
managed by a multidisciplinary approach in a tertiary centre.
Keywords: Pregnancy, Contraception, Fertility, Renal recipient, Kidney transplantation
Pregnancy in renal transplant recipients
Reprints request and correspondence to:
Dr. Ayman Karkar
Department of Nephrology
Kanoo Kidney Centre
Dammam Central Hospital
P.O. Box 11825, Dammam 31463
Kingdom of Saudi Arabia
It is always a dream for patients with chronic
renal failure (CRF) on regular dialysis to get
transplanted, not only to improve their health
status and social conditions but also to enable
them to have children. In fact, patients with
CRF, and in particular those on dialysis for
prolonged periods, suffer from many
166 Karkar A
complications, which affect fertility and their
ability to conceive. These include compromised
immunity, psychological and social distur-
bance, nutritional deficiencies, anemia, secon-
dary hyperparathyroidism and hypothalamic-
gonadal dysfunction with alterations in serum
levels of reproductive hormones1 such as
follicle stimulating hormone (FSH),
luteinizing hormone (LH) and testosterone.
Furthermore, patients with CRF suffer from
ovarian dysfunction, anovulatory vaginal
bleeding, amenorrhea, high prolactin (PRL)
levels and loss of libido.2 However, improve-
ment in dialysis quality have lessened hormonal
dysfunction, and unwanted or unexpected
pregnancies may occur in women under-
going dialysis,3 though most remain infertile.4
After renal transplantation, males achieve
improvement in libido and an increase in
sperm count and serum testosterone concen-
trations, whereas females attain similar con-
centrations of FSH, LH and PRL to that of
healthy women.1,5 In fact, females resume
ovulatory cycles within 1-2 months and
achieve fertility within an average of six
months following kidney transplantation.2
The mean interval between transplantation
and conception is three years.6 Therefore,
renal transplantation offers the best hope for
patients with end-stage renal disease, at
least for those who wish to have children.
Although pregnancy after kidney transplan-
tation is safe and has little, if any, effect on
long-term graft survival,7-11 it is associated
with increased maternal and fetal morbidity.10,12
Maternal risks include hypertension, ectopic
pregnancy, pre-eclampsia, infection and the
need for delivery by cesarean section,11-16
whereas fetal complications include abortion
(spontaneous or therapeutic), intrauterine fetal
death, pre-term delivery and low birth
weight.13,17,18 There is a 12% rate of sponta-
neous abortion among kidney transplant reci-
pients, a rate similar to that in the general
population.19 The mean gestational age for
infants born to kidney recipients is less than 37
weeks, with a mean birth weight of less than
2500 gm.19
The possible effects of post-renal transplant
immunosuppressive medications on maternal
and fetal outcome have not been fully inves-
tigated.20 All medications used to prevent
rejection of transplanted kidney cross the
maternal-placental-fetal interface.21 The varied
structural defects of immunosuppressive
drugs in animal models suggest that terato-
genicity may be species-dependent and may
not always be applicable in human beings.22
Previous studies in humans have shown that
pregnancies after renal transplantation are
associated with an increased risk for both the
mother and the fetus.12 There is, however,
very little information available on neonatal
and long-term pediatric follow-up of babies
born to mothers who have undergone renal
transplantation and have been exposed to
immunosuppressive medications.22 Recent
reports, with a reasonable period of expe-
rience, have shown that corticosteroids,
cyclosporine, tacrolimus and azathioprine
are, in general, safe drugs during pregnancy
in renal transplant recipients.19,23-27 In compa-
rison, mycophenolate mofetil and sirolimus
may not be as safe as other conventional
immunosuppressive drugs.28 Pergola et al,29
reported the first case of living related-
donor kidney transplantation who received
mycophenolate mofetil, together with tacro-
limus and prednisone, during the first tri-
mester and throughout the entire pregnancy.
The mother did well, except for mild pre-
eclampsia and mild renal insufficiency at
term. The baby girl was born prematurely at
week 35. The only possible teratogenic effects
detected included hypoplastic nails and short
fifth fingers. No chromosomal abnormalities
were found. The child has been growing
and developing normally. In another study,
and contrace
tives in renal trans
lant 167
no structural malformations were noted among
offspring exposed to mycophenolate mofetil,
although the exposure was limited (5 mothers,
29 fathers).24 Recent reports indicate that
mycophenolate mofetil and sirolimus may
impose maternal and fetal risks.16,30 In
contrast, some longer term studies (2 months
to 13 years) show that despite the increased
incidence of spontaneous abortion, preterm
delivery and low birth weight newborns in
association with these immunosuppressive
drugs, there were no congenital defects noted
and their development was normal.14,17 How-
ever, Sgro et al,25 reported on a follow-up
study (from 3 months to 11 years of age)
that there was one child with insulin-
dependent diabetes mellitus, two children with
asthma and one child with recurrent otitis
media. Developmental follow-up revealed
one child with moderate to severe sensori-
neural hearing loss, one child with a learning
disability and one child with pervasive
developmental disorder. In none of these
cases were there signs of perinatal asphyxia,
and most pregnancies in the study group
went well and their offspring had normal
postnatal growth and development. In fact,
the frequency of birth defects in infants
born to women receiving immunosuppressive
agents is not statistically different from that
in general population.20,23 The European Best
Practice Guidelines for renal transplantation
state that immunosuppressive therapy based
on cyclosporine or tacrolimus with or without
steroids and azathioprine may be continued in
renal transplant women during pregnancy.14
Other drugs, such as mycophenolate mofetil
and sirolimus, are not recommended based
on current information available20 and these
guidelines recommend that women receiving
mycophenolate mofetil should be changed
to another agent and then wait for six weeks
before they attempt to conceive.14 As there are
significantly more stillbirths, preterm deli-
veries and increased incidence of low birth
weight in the transplant group, further studies
with long-term follow-up of the children are
needed to delineate their outcome and rule out
possible long-term effects of the immuno-
suppressive medication on their growth, deve-
lopment, reproduction and general health.
Contraception in the general population
In the general population, there has been a
wide variation in the use of different types
of contraceptive methods over the years. These
include coitus interruptus, postcoital douching,
postcoital estrogens, condom, spermicidal
contraceptive agents, vaginal diaphragm, the
rhythm method, oral contraceptives, intra-
uterine devices (IUDs), tubal ligation and
vasectomy, induced abortion, immunization
against human chorionic gonadotropin, phar-
macologic suppression of the corpus luteum,
long-acting injections of Depo-Provera (an
injectable progesterone solution which works
for up to three months), implantation of
capsules containing norgestrel, the intravaginal
ring, intracervical devices, release of contra-
ceptive steroids through an arm bracelet,
and male contraceptive agents.31,32
Earlier studies in the 1980s showed that
the most common methods of contraception
were condoms (50%), coitus interruptus (17%),
oral contraceptives (9%), IUDs (3%) and
vasectomy (2%).33 In the mid 1990s, an Italian
survey on 500 women showed that the most
common methods of contraception were coitus
interruptus (61%), oral contraceptives (49%),
condoms (45%) and, in 35% no method was
used.34 A life-history data was collected in
1986 on Australian women to derive the first
national estimates of trends in contraception
and sterilization from 1956-1986.35 This 30-
year study, where 2,547 women aged 20-59
years were interviewed, showed that the use
of traditional methods of contraception (coitus
168 Karkar A
interruptus, periodic abstinence) was most
common among the older women, whereas
the use of modern methods, such as oral
contraceptives and IUDs became the preferred
methods after their introduction in 1961. It
was also noted that the reliance on steri-
lization (tubal ligation and vasectomy), which
began in the early 1970s, surpassed the use of
oral contraceptives, while condoms and other
coitus-related methods were not found to be
very popular contraceptives. The Behavioral
Risk Factor Surveillance System data, which
represented the use of contraceptives in the
50 states in the United States (US),36 showed
variation of contraceptive use across states and
territories and among men and women. Oral
contraceptives, vasectomy, tubal ligation and
condoms were the methods most frequently
reported. Among female respondents using
birth control, the oral contraceptive pill was
the most common method reported, whereas
vasectomy was the most commonly reported
method among men. The prevalence of use for
the four most commonly reported methods
(pills, vasectomy, tubal ligation and condoms)
varied as much as six-fold among states for
vasectomy and three-to four-fold for condoms,
pills, and tubal ligation.
Contraception in renal transplant
It is advisable that women wishing to have
children should avoid conceiving in the first
two years following renal transplantation.6,37
This is due to low incidence of acute rejection
episodes, lower doses of immunosuppressive
drugs, completion of viral prophylaxis and
stabilized renal function after the first two
years following transplantation. Presence of
some degree of renal dysfunction, uncon-
trolled hypertension and diabetes mellitus are
associated with increased risk of pregnancy
complications, as some immunosuppressive
medications, like calcineurin inhibitors, are
associated with hypertension, diabetes mellitus
and nephrotoxicity.19,37-39 In addition, contra-
ception is indicated in couples who do not
wish to have more children, and/or in those
who wish to delay pregnancy in order to
improve their health status or social condi-
tions. However, if future fertility is not desired,
it should be addressed and discussed with the
patient prior to discharge from the hospital
after renal transplantation. In fact, planning of
pregnancy before kidney transplantation is
very crucial in avoiding maternal and fetal
risks, and deleterious effects on graft function
and survival rate.
There have not been many reports in the
literature studying the types of contraceptives
used, their side effects as well as indications
and success and failure rates in renal trans-
plant recipients. However, some Iranian studies
showed that coitus interruptus (56%) is the
most common method of contraception in 126
kidney transplanted women, followed by tubal
ligation (22%), condoms (14%), vasectomy
(6%) and only 2% used oral contraceptives.40
Another Iranian study that was conducted in
2005, showed that 92% of the unwanted
pregnancies among 64 kidney transplanted
recipients occurred in women using coitus
interruptus as the only method of contra-
ception.41 Our own data show that oral
combined pills, coitus interrupts and IUDs
are the most popular forms of contraceptive
methods (unpublished data).
Types of contraceptives for renal
transplant recipients
There are many types of contraceptives
available, which include the permanent and
temporarily methods. Permanent contraceptives
include tubal ligation and vasectomy. Tempo-
rarily contraceptive methods include barrier
contraceptives, oral contraceptive pills, proges-
and contrace
tives in renal trans
lant 169
Table 1. The Pearl Index Failure Rates of
Type of contraception Failure rate
Lactation for 12 months 25
Coitus interruptus 9
Symptothermal method 1.5–11
Spermicidal foam 3
Diaphragm 2
Intra uterine devices 1-3
Progesterone only
minipill 1-2
Condom 0.4-1.6
Combined pill 0.1
Vasectomy 0.1
Tubal ligation 0.04
Modified from Z. Mclure Failure rates
of contraceptive methods48
terone only minipill, IUD, coitus interruptus
and the use of symptothermal method. How-
ever, the choice of contraceptive method is
best determined by the efficacy of the method
and the likelihood of patient adherence.
Tubal ligation and vasectomy
These are permanent methods of sterili-
zation. The patient should be counseled before
kidney transplantation, and tubal ligation or
vasectomy should possibly be performed at
the time of transplantation. These procedures
have the least failure rates among all contra-
ceptive methods. Vasectomy has the advantage
of lacking the increased risk of ectopic preg-
nancy associated with tubal ligation.
Barrier methods
Barrier methods (condom, diaphragm, sponge,
spermicide, cervical cap) carry the lowest risk
of side effects. Their bactericidal properties
have the advantage of reducing transmission
of sexually transmitted diseases, and condoms
remain the only contraceptive method poten-
tially reducing the transmission of HIV.42
However, barrier methods may not provide a
very reliable way for contraception, and require
a highly motivated user.
Oral contraceptives
Oral contraceptives are pills containing
estrogen and progesterone, which are highly
effective. Following their introduction in the
early 1960s, their use has increased worldwide.
However, they interact with cyclosporine and
increase its serum concentration, and, there-
fore, require monitoring of liver and renal
functions. Oral contraceptive pills are abso-
lutely contraindicated in patients with
thromboembolism, deep vein thrombosis,
estrogen-dependent malignancy and severe
liver disease43 and are relatively contrain-
dicated in patients with high blood pressure,
uncontrolled diabetes mellitus, history of
smoking, migraine headaches and depression.32
The progesterone-only minipill has the
advantage of avoiding the risks associated with
estrogen. However, this has to be taken at the
same time daily, though the injection type can be
given at 3-month intervals. In addition, they
have a higher failure rate than combined pills.
They may cause delay in ovulation after
discontinuation, and could be a poor choice for
re-planning of pregnancy. They have frequent
side effects, which include interaction with
cyclosporine metabolism, irregular bleeding or
amenorrhea, weight gain, altered lipid meta-
bolism, hair loss, vaginal atrophy and depression.
More recently, there have been new advances
in the development of male contraceptive
pills due to limitations to current methods of
male contraception. It is known that adminis-
tration of testosterone, which down regulates
the secretion of LH and FSH in man, acts as
a partial contraceptive by marked impairment
of sperm production. Researchers have recently
combined testosterone with progestogens or
gonadotropin-releasing-hormone antagonists,
170 Karkar A
to further suppress secretion of LH and FSH
and improve suppression of spermatogenesis.
Such combinations suppress spermatogenesis
to zero without severe side effects in 80-
90% of men, with near-complete suppression
in the remainder of individuals.44
Intrauterine devices
Intrauterine devices (IUDs) are available
in two types: a copper-containing device that may
be left in place for 10 years and a progesterone-
containing device that is placed yearly. Place-
ment of IUDs is usually associated with
infection, and prophylactic antibiotics must
be used. Also, tubal occlusions have been
reported in previous IUD users.45 Previous
pelvic inflammation and ectopic pregnancy
are contraindications to use of IUDs.46 There are
few published case reports of failure of
IUDs in renal transplant patients, possibly due
to immunosuppression effect; the efficacy of
IUDs may be decreased by immunosuppressive
medications and anti-inflammatory agents
possibly because of modification of the leuco-
cytic response. However, because of the
increased risk of infection, IUDs are not a
very popular contraceptive method for renal
transplant patients.
Failure rates of contraceptive methods
Contraceptive failure, defined as use of con-
traceptive of any type at the time of intercourse
when conception most likely occurred, has
variably been reported in different studies.
In a large study group (3520 pregnant women),
52% had induced abortions, 10% had spon-
taneous abortions and 3% had ectopic preg-
nancies. Women aged 15-24 years were more
likely to have experienced contraceptive failure
in relation to use of condom and oral contra-
ception than women aged 25-34 years. In addi-
tion, contraceptive failure was found to be
associated with being single, a student, and
having given birth twice or more previously.47
McLure48 described the Pearl Index failure
rates of contraceptives, where lactation for 12
months, coitus interruptus and symptothermal
method carried the highest failure rates while
tubal ligation, vasectomy, combined pill and
condom had the least failure rates (Table 1).
Fertility greatly improves in both sexes
shortly after kidney transplantation. The mean
interval between transplantation and conception
is three years. Pregnancy is safe and has little
effect on long-term graft survival, although
there is increased maternal and fetal morbidity.
Pregnancy is preferable after the first two
years of transplantation, due to low risk of
rejection, lower doses of immunosuppressive
medications and stabilized renal function. Phy-
sicians should discuss fertility issues and
counsel their patients regarding the time of
pregnancy and the potential risks of preg-
nancy as well as the risks to the offsprings.
Post-renal transplant immunosuppressive
medications appear to be safe, but myco-
phenolate mofetil and sirolimus may impose
maternal and fetal risks. Family planning
and consideration of a suitable contraceptive
method are quite essential before kidney trans-
plantation. There are different types of contra-
ceptive methods available with variable
success and failure rates. The choice of
contraceptive method is best determined by
the efficacy of the method and the likely-
hood of patient adherence. Finally, preg-
nancy in renal transplant recipients should
be managed by a multidisciplinary approach
(obstetrician, nephrologist and pediatrician)
in a tertiary care centre.
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48. Mclure Z. Failure rates of contraceptive
methods. Fam Plann Inf Serv 1981;1(6):59-61.
... Given the pregnancy-associated risks described and the fact that fertility can be efficiently reverted within 1 to 6 months after kidney transplant; it is essential that methods of contraception are discussed before and initiated soon after transplant surgery to prevent premature, unplanned, and unadvised pregnancies. 26 These measures would reduce the possible complications and adverse events that might occur during pregnancy after kidney transplant. Other concerns include optimization of immuno suppressive agents ( Table 2) 27 and antihypertensive medications, since not all medications are safe during pregnancy. ...
... and the difficulty in achieving compliance. 26,32 Barrier success rate can reach 97% if used correctly and consistently. They have the advantage of being a convenient and easy to use method of contraception while also avoiding potential drug interactions, especially with immunosuppressive medications. ...
... All of these barrier methods can be used posttransplant but are best when combined with another method of birth control to reduce their potential failure rate. 26 Education of couples regarding this method of contraception encourages awareness and compliance and may reduce the failure rate of this method. 66 ...
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There is a misconception among transplant clinicians that contraception after a successful renal transplant is challenging. This is partly due to the complex nature of transplant patients, where immunosuppression and graft dysfunction create major concerns. In addition, good evidence regarding contraception and transplant is scarce, with most of the evidence extrapolated from observational and case-controlled studies, thus adding to the dilemma of treating these patients. In this review, we closely analyzed the different methods of contraception and critically evaluated the efficacy of the different options for contraception after kidney transplant. We conclude that contraception after renal transplant is successful with acceptable risk. A multidisciplinary team approach involving obstetricians and transplant clinicians to decide the appropriate timing for conception is recommended. Early counseling on contraception is important to reduce the risk of unplanned pregnancies, improve pregnancy outcomes, and reduce maternal complications in patients after kidney transplant. To ascertain appropriate advice on the method of contraception, individualizing the method of contraception according to a patient's individual risks and expectations is essential.
... French VA et al. demonstrated that the proportion of female organ transplant recipients using any contraception was 48% during the posttransplantation period [18]. Other studies have shown that the proportion of hormonal contraception is even lower than estimateda mere 2% [2,21]. In our study, when considering only currently sexually active women, the proportion of any contraception usage ranged from 83 to 90% in the studied groups. ...
... However, the available literature indicates that the rates of long-term effective contraception in female organ transplant recipients significantly vary. The use of female sterilization ranges from 14 to 31% and of IUDs from 0 to 14% [2,10,18,21]. Thus, the low usage rates of long-acting contraceptive methods observed within our study population are predominantly attributed to the generally low rates of female sterilization. ...
... It has various side effects such as weight gain, amenorrhoea or irregular bleeding, drug interaction with calcineurin inhibitors and glucocorticoids and alteration in lipid metabolism. [23] Progestogen-only injectable includes DMPA. It is synthetic progesterone to be given intramuscularly at every 12 weeks interval. ...
Solid-organ transplant increases the physical and mental well-being of women suffering from chronic kidney diseases. It also improves the menstrual and reproductive function of the transplant recipient, putting a woman at risk of unplanned pregnancy. Various contraceptive options are available to such women. According to the World Health Organization Medical Eligibility Criteria, almost all contraceptive methods belong to Category 2 for uncomplicated post-transplant recipients. For complicated renal-transplant patients, intra-uterine devices are Category 3/2, and combined hormonal contraceptives are Category 4. It is of paramount importance to discuss the pros and cons of each method, and this counselling should be included routinely before undergoing transplant surgery.
... Gebelik planlaması düşük rejeksiyon riski, immünsüpresif ajanların daha düşük dozlarda kullanılması ve stabilize renal fonksiyonun sağlanması nedeniyle transplantasyondan yaklaşık 2 sene sonra yapılmalıdır. [3] Doğurgan çağdaki fonksiyon gören böbreğe sahip ortalama her 50 kadından birinin gebe kalabildiği düşünülmektedir. Bununla birlikte bu hastaların çoğu kez son dönem böbrek yetersizliği ile birlikte gözlenebilen infertilitenin trans-plantasyon ile azalabileceği hakkında bilgileri mevcut değildir. ...
... Gebelik planlaması düşük rejeksiyon riski, immünsüpresif ajanların daha düşük dozlarda kullanılması ve stabilize renal fonksiyonun sağlanması nedeniyle transplantasyondan yaklaşık 2 sene sonra yapılmalıdır. [3] Doğurgan çağdaki fonksiyon gören böbreğe sahip ortalama her 50 kadından birinin gebe kalabildiği düşünülmektedir. Bununla birlikte bu hastaların çoğu kez son dönem böbrek yetersizliği ile birlikte gözlenebilen infertilitenin trans-plantasyon ile azalabileceği hakkında bilgileri mevcut değildir. ...
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Even though fertility is reduced, conception and delivery are possible in all stages of CKD. While successful planned pregnancies are increasing, an unwanted pregnancy may have long-lasting deleterious effects, hence the importance of birth control, an issue often disregarded in clinical practice. The evidence summarized in this position statement is mainly derived from the overall population, or other patient categories, in the lack of guidelines specifically addressed to CKD. Oestroprogestagents can be used in early, non-proteinuric CKD, excluding SLE and immunologic disorders, at high risk of thromboembolism and hypertension. Conversely, progestin only is generally safe and its main side effect is intramestrual spotting. Non-medicated intrauterine devices are a good alternative; their use needs to be carefully evaluated in patients at a high risk of pelvic infection, even though the degree of risk remains controversial. Barrier methods, relatively efficacious when correctly used, have few risks, and condoms are the only contraceptives that protect against sexually transmitted diseases. Surgical sterilization is rarely used also because of the risks surgery involves; it is not definitely contraindicated, and may be considered in selected cases. Emergency contraception with high-dose progestins or intrauterine devices is not contraindicated but should be avoided whenever possible, even if far preferable to abortion. Surgical abortion is invasive, but experience with medical abortion in CKD is still limited, especially in the late stages of the disease. In summary, personalized contraception is feasible, safe and should be offered to all CKD women of childbearing age who do not want to get pregnant.
Women undergoing solid organ transplantation are advised to avoid pregnancy for up to 24 months following transplant surgery. We conducted a systematic review of the literature, from database (PubMed) inception through February 2009, to evaluate evidence on the safety and effectiveness of contraceptive use among women having undergone solid organ transplantation. From 643 articles, eight articles from seven studies satisfied review inclusion criteria; six articles pertained to kidney transplant patients, and two reported on liver transplant patients. Two reports of one prospective cohort of 36 kidney transplant recipients taking combined oral contraceptives (COCs) or using the transdermal contraceptive patch reported no significant changes in biochemical measures after 18 months of use for either group, although 13 women modified antihypertensive medication, and two women discontinued the study because of serious medical complications. Four case reports of five kidney recipients using intrauterine devices reported inconsistent findings, including both beneficial health effects and contraceptive failures. One retrospective, noncomparative study of 15 liver transplant recipients using COCs or the transdermal contraceptive patch found no significant changes in any biochemical measures obtained, no discontinuations or severe complications and no pregnancies after a 12-month follow up. One case report of a liver transplant recipient on cyclosporine and prednisone documented the development of cholestasis associated with high-dose (50 mcg ethinyl estradiol) COC use as treatment for heavy uterine bleeding. Very limited evidence on COC and transdermal contraceptive patch use among kidney and liver transplant recipients indicated no pregnancies and no overall changes in biochemical measures. Excluding case reports, evidence on other contraceptive methods or contraception among other types of solid organ transplants was not identified.
EDITORIAL COMMENT: The purpose of this comment is to encourage readers to give this paper the close attention it deserves - the summary is too modest, and the important information in the tables may be overlooked if readers do not study them in conjunction with the text. It is noteworthy that of women aged 40–44 years in 1986, 35% had had a tubal ligation, another 11% had had a hysterectomy and a further 16% of these women had partners who had undergone vasectomy. In these data, which were collected in 1986, the condom made a miserable showing as a contraceptive, but as noted by the author ‘this is not to say that coitus-related methods may not gain some support if the motivation for their use is not entirely contraceptive - sexually transmitted diseases in general and AIDS in particular’. Enquiry of the manufacturers surprised the editor by revealing that total sales of condoms in Australia (2 per person per year or 34 million per year) have increased only about 50% in the last 10 years. This is in accord with the data in this paper and indicates that there has been little change since 1986. Summary: Life-history data collected in a national survey of women in 1986 are used to derive the first national estimates of trends in contraception and sterilization in Australia over the last 30 years. The pill rapidly became the method of choice after its release in 1961. The intrauterine device, the other truly modern method, has never attained the same popularity. The move toward sterilization dates from the early 1970s and has been so complete that women of 35 or older are now more likely to be protected by a ligation or laparoscopic sterilization than by the pill or, indeed, by all other methods combined. Unmarried women are now indistinguishable from married women on the basis of their use of contraception, and childless married women are now more likely to be using a reversible method than married women with children.
Renal transplantation is usually accompanied by an improvement in reproductive function. The possibility of conception in women of childbearing age emphasizes the need for counseling, and couples who want a child should be encouraged to discuss all implications, with the advice based on strict guidelines. If a recipient becomes pregnant, she must be monitored as a high-risk patient. Management requires particular attention to BP control, renal function, and all infection, as well as fetal surveillance. Just under 40% of conceptions do not go beyond the first trimester, but of those that do, greater than 90% end successfully. In most patients, renal hemodynamics improve during gestation, but permanent impairment occurs in 15% of pregnancies. Other patients may experience transient deterioration in late pregnancy (with or without proteinuria). Patients have a 30% chance of developing hypertension, preeclampsia, or both. Despite its pelvic location, the transplanted kidney rarely produces dystocia and experiences no apparent mechanical injury during vaginal delivery. Thus, cesarean section should be reserved for obstetric reasons only. Aseptic technique, bacterial prophylaxis even for trivial surgery, and steroid augmentation are necessary. Preterm deliveries occur in 45% to 60%, and intrauterine growth retardation in at least 20%, of gestations. Neonatal complications include respiratory distress syndrome, leukopenia, thrombocytopenia, adrenocortical insufficiency, and infection. No predominant or frequent developmental abnormalities have been described, and data on infancy and childhood are encouraging. Future goals should be to improve prepregnancy assessment criteria, to reassess the rationale and implications of immunosuppression during pregnancy, and to monitor the remote effects of pregnancy on both renal prognosis and the offspring.
Two women who hud developed amenorrheu during severe rcnui failure recovered ovulatory menstruui cycles, as shown by basal body temperature and endometrial biopsy findings, after kidney transplantation. The possible restoration of reproductive potential after recovery from renal failure is important knowledge for the patient’s family planning. © 1971 The American College of Obstetricians and Gynecologists.
A study was conducted in Malaysia of 148 women seeking induced abortion from doctors. The influence of socioeconomic, ethnic, religious, and educational factors on the practice of induced abortion in Malaysia was examined along with the relationship of induced abortion to the use of contraceptives. 135 of the women were married; 13 were unmarried. 22.3% of the women did not complete primary education, 51.4% of the women completed primary education, and 26.3% completed secondary education. 30.4% of the women were from rural areas, and the remaining 103 women lived in towns and suburbs. 62.2% of the women were housewives, 29.7% were unskilled workers, and 8.1% were skilled workers. 107 women were Buddhist, 31 were Muslims, 4 were Hindus, 2 were Catholics, 2 were Protestants, and 2 were free thinkers. There were 111 Chinese respondents, 28 Malay respondents, and 9 Indian respondents. There were 31 cases with less than 6 weeks of amenorrhea, 93 cases with 6-8 weeks of amenorrhea, 15 cases with between 8-10 weeks of amenorrhea, 7 cases of between 10-12 weeks of amenorrhea, and 2 cases with more than 12 weeks of amenorrhea. Only 53 patients (35.8%) practiced contraception of 1 kind or another. Of this group, the partners of 26 women used condoms, 9 practiced coitus interruptus, 5 used oral contraceptives (OCs), 2 used parenteral contraception, 2 used the traditional method, and the husband of 1 woman had had a vasectomy. The remaining 95 cases (64.2%) who did not use contraception gave the following reasons: side effects of contraception; fear of ill effects of contraception; ignorance of effective contraceptive methods; inconvenience; and husband's refusal for no apparent reason. 83 patients were practicing effective contraception at the time of the interview. Of these, 42 were using OCs, the partners of 24 used condoms, 10 used the IUD, 5 were getting parenteral contraceptives, and 2 had had a tubal ligation. 27 patients indicated at the interview their intention to use contraception after the induced abortion, but they did not indicate the contraceptive method. The remaining 38 patients were not willing nor did they use any effective contraception. Deferring childbirth and limiting family size were 85.8% of the reasons for abortion. There was no significant difference between women deferring childbirth and women limiting family size when comparing the racial, religious characteristics, the period of amenorrhea, occupation, and marital status.
Assess the pregnancies of our female renal transplant recipients and to document long term maternal and fetal outcome. Between 7 June 1972 and 31 December 1992 112 females had at least one renal transplant. Sixty-four of these 112 women were in the reproductive age and had a functioning graft. Nine women had 16 pregnancies which resulted in 11 live births and three first trimester abortions. Two unplanned pregnancies were terminated. Mean age at transplantation was 17.2 yr [range 16-22.5 yr] and mean interval from transplant to pregnancy was 6.8 yr [range 1.8-9.0 yr]. Prednisone and azathioprine were used in all patients and cyclosporin in five. For seven of the successful pregnancies plasma creatinine remained < or = 0.10 mmol/L. One of these women developed allograft nephropathy 5 years after delivery and returned to dialysis 9 years later. For the other four successful pregnancies the preconception plasma creatinine was 0.12-0.14 mmol/L. The woman with two successful pregnancies had a halving of glomerular filtration rate during the second pregnancy, but it has remained stable for 15 years; one was poorly compliant with her immunosuppressive regimen and reached endstage renal failure two years after delivery; one developed cyclosporin nephrotoxicity, but 18 months later renal function was stable after a dosage reduction. Ten infants were delivered by caesarean section, four of them urgently. Three babies were preterm and five growth retarded. One died of sudden infant death syndrome at four months. All other infants developed normally. There is no contraindication to pregnancy in female transplant recipients who have stable graft function and controlled blood pressure. Management of such pregnancies should be by shared obstetrical/nephrological/paediatric care.
The nurses' main purpose when discussing family planning with clients is to provide them with complete information about all available contraceptive methods so clients can choose the method best suited to them. Nurses should not use age or social factors to assume the client's contraceptive needs. They should not allow their perception of client's contraceptive needs to influence the information they provide to clients. Nurses need to consider the client's and family's medical history to identify and discuss contraindications. Contraindications for oral contraceptives (OCs) include deep vein thrombosis, smoking, past clotting problems, and an immediate family history of cardiovascular disease at a young age. IUD contraindications are past pelvic inflammatory disease or ectopic pregnancy. Nurses must monitor any changes in the health of their contraceptive clients and record their health status. They may need to advise a client to change their contraceptive method. Women considering OCs have 30 brands from which to choose. They may need to try several formulations to identify one that is best for them. There are also a variety of types and sizes of barrier methods. Nurses must be familiar with the primary and secondary mode of actions of each contraceptive method since women often choose a method based on how it works. In addition to effectiveness, women also consider perceived risk and religious and cultural values. Nurses should be able to discuss the client's needs and expectations openly and honestly. They must maintain confidentiality. Life events (e.g., childbirth and change in financial status) effect changes in contraceptive needs. During follow-up visits, nurses need to determine whether the chosen method is still the best option and to encourage the client to ask questions. The UK's Family Planning Association publishes leaflets and operates a helpline to provide family planning information to the public.
To study the outcome of pregnancy in renal transplant patients in Spain. A retrospective review based on two consecutive national inquiries. Departments of Obstetrics and Gynaecology and Renal Transplant Units in Spain. Pregnant women who had renal transplants between 1965 and 1989. From the preliminary inquiry the frequencies of miscarriage, therapeutic abortion, preterm birth, fetal malformation, twins, stillbirths, neonatal deaths and loss of maternal renal function were recorded. The subsequent, more detailed inquiry provided additional information including donor type, previous rejection episodes and interval between rejection and pregnancy, previous creatinine level, previous hypertension and development of hypertension in pregnancy, developments during labour and delivery and the occurrence of intra uterine growth retardation and low birth weight. The preliminary inquiry yielded information about 133 pregnancies. The miscarriage rate was 10% and the therapeutic abortion rate was 16%. Of the 99 pregnancies that continued, 46% ended before term and 53% progressed to term. The perinatal mortality rate was 107.8 per 1000 and 4% of the infants had minor congenital malformations. The second inquiry yielded more detailed data about 66 pregnancies. There were no therapeutic abortions and 12% of the pregnancies ended in miscarriage. Among the 58 pregnancies that reached > or = 28 weeks gestation, preterm birth occurred in 28 (48%) and intra uterine growth retardation occurred in 17 (29%). Among 48 women with normal renal function before pregnancy, the perinatal mortality rate was 68 per 1000, the miscarriage rate was 8% and in 10 of these women (21%) renal function was impaired after pregnancy. In contrast, among 18 women with impaired renal function before pregnancy, the perinatal mortality rate was 142 per 1000, the miscarriage rate was 22% and in six of these women (33%) renal function deteriorated after the pregnancy. Impairment of renal function was most common in women with hypertension during pregnancy or with rejection episodes during the year before conception. Women with a renal transplant can have a successful pregnancy, but there are definite risks for both mother and fetus. Pregnancy should be discussed with the woman and encouraged only if there is good renal graft function.
Because barrier methods provide protection against bacterial sexually transmitted diseases, these methods are valuable public health adjuncts irrespective of their effect on HIV. Male latex condoms offer substantial protection against HIV infection. Women at risk of sexual acquisition of HIV infection need one or more prophylactic methods that they can control. While the available spermicide products may serve this purpose, current data do not allow firm casual inferences. Large and well designed epidemiologic studies are required to examine the association between female use of barrier methods and HIV infection. These are difficult and costly to perform, however, and to date have yielded conflicting results. Finally, prospective studies in high-incidence cohorts are necessary, and the relationships between spermicide use, local irritation, the vaginal flora and HIV incidence rates must be clarified.
In order to better evaluate the link between contraceptive attitudes and induced abortion, 500 women who underwent voluntary termination of pregnancy (VTP) at the First Institute of Obstetrics and Gynaecology of the University of Rome "La Sapienza" were interviewed. They were young (median age 28 years), medium to high educated (61%), non married (52.4%), nulliparous (59.2%) women. Forty-two percent of them had the first sexual intercourse before 18 years of age and 72.6% at least five years before. Ninety-five women (19%) admitted a previous voluntary termination of pregnancy. Withdrawal (305 women), oral contraceptives (246 women) and condom (223 women) were the most widely used methods of fertility regulation, but the pill had been taken only for short periods of time, never exceeding one year. Withdrawal resulted to be the most utilized method during the cycle in which conception occurred (49.4%); no method had been employed by 34.8% of the women. The diffusion of modern methods of fertility regulation greatly influences the number of induced abortions in Italy, as clearly indicated by the progressive reduction of VIP starting from 1982 paralleled by a constant increase in OCs diffusion. Our data, although limited in number, confirm that induced abortion is the consequence of an insufficient use of modern methods of fertility regulation.
Successful pregnancy outcomes are possible after solid organ transplantation. While there are risks to mother and fetus, there has not been an increased incidence of malformations noted in the newborn of the transplant recipient. It is essential that there is closely coordinated care that involves the transplant team and an obstetrician in order to obtain a favourable outcome. Current data from the literature, as well as from reports from the National Transplantation Pregnancy Registry (NTPR), support the concept that immuno suppression be maintained at appropriate levels during pregnancy. At present, most immunosuppressive maintenance regimens include combination therapy, usually cyclosporin or tacrolimus based. Most female transplant recipients will be receiving maintenance therapy prior to and during pregnancy. For some agents, including monoclonal antibodies and mycophenolate mofetil, there is either no animal reproductive information or there are concerns about reproductive safety. The optimal (lowest risk) transplant recipient can be defined by pre-conception criteria which include good transplant graft function, no evidence of rejection, minimum 1 to 2 years post-transplant and no or well controlled hypertension. For these women pregnancy generally proceeds without significant adverse effects on mother and child. It is of note that the epidemiological data available to date on azathioprine-based regimens are favourable in the setting of a category D agent (i.e. one that can cause fetal harm). Thus, there is still much to learn regarding potential toxicities of immunosuppressive agents. The effect of improved immunosuppressive regimens which use newer or more potent (and potentially more toxic) agents will require further study.