Hysteroscopic Sterilization in an Immunosuppressed Patient

Post-Transplant Pregnancy and Contraception

Placed in a historical context, this overview focuses on post-transpant pregnancy, fatherhood, and contraception in women and men. The critical importance of early reproductive counseling because of improved sexual function and the early return of ovulation and menses post-transplant is emphasized. We explain the decision making regarding contraception choices. The available data on the safety of immunosuppressive drugs in pregnancy, and for men desiring fatherhood, are detailed. The risk of maternal ingestion of mycophenolate products on the in utero fetus is considered and contrasted with the lack of concern for their use by men fathering children. Pregnancy risks to the allograft, baby, and mother are discussed. An infant's exposure to specific immunosuppressant medications through breastfeeding is reviewed. The ethics and realities of post-transplant parenthood are explored.

Hysteroscopic sterilization in immunocompromised patients who have intrauterine devices in place: two case reports

Introduction

The micro-inserts used in the hysteroscopic sterilization procedure elicit a benign occlusive tissue response leading to permanent tubal occlusion. Little is known about whether immunosuppressed patients mount the immunological response necessary to ensure tubal occlusion. Theoretical concern for non-occlusion has limited the use of hysteroscopic sterilization in patients on immunosuppressive therapies.

In all patient populations, if an intrauterine device is in place, it is usually removed at the time of hysteroscopic sterilization. Little is known about maintaining intrauterine devices during the 3-month period to tubal occlusion.

Case presentation

Our patient in case 1 was a 35-year-old Hispanic woman, gravida 2, para 2002, with a history of a living donor kidney transplant. Our patient in case 2 was a 32-year-old Hispanic woman, gravida 3, para 2103, diagnosed with undifferentiated autoimmune disease. Both patients underwent hysteroscopic sterilization. In both cases, a levonorgestrel intrauterine device was in place for contraception. At the time of micro-insert placement, our patients were both on daily immunosuppressive medications, including long-term glucocorticoids. Three months after the hysteroscopic procedure, both patients had successful tubal occlusion, demonstrated by a hysterosalpingogram.

Conclusion

Hysteroscopic sterilization in an outpatient setting is a reasonable option for sterilization in immunocompromised patients on immunosuppressive therapies. Intrauterine devices can be maintained during the procedure and during the 3-month period to tubal occlusion.