Women and transplantation: fertility, sexuality, pregnancy, contraception

Contraception in Medically Complex Adolescents and Young Adults

Contraception is a significant part of comprehensive sexual and reproductive health (SRH) care for adolescents and young adults (AYA). While providers may assume that AYA with chronic illness are not sexually active, studies have shown that there are no differences in their sexual practices compared to their counterparts without an illness. This assumption may result in less SRH screening, preventative services, and counseling by providers resulting in decreased basic sexual knowledge, increased risk of unplanned pregnancy, and other health disparities. Sexually active AYA with medical complexity are particularly in need of contraception for a variety of reasons. A better understanding of the complexities around contraception counseling can help increase utilization rates, improve shared-decision making around family planning, and reduce the stigma around sexual health counseling in this population. We have included three sections. First, a general overview of contraception methods. Next, an overview of contraceptive methods currently available, their efficacy, and medical eligibility criteria for their use in AYA who have certain characteristics or medical conditions. Finally, cases adapted from real clinical scenarios to highlight specific recommendations for contraception in AYA women living HIV, autoimmune conditions, and those who have received a solid organ transplant. This information will help providers to consider the multiple factors that influence contraception decision-making (including clinical status, thrombosis risk, medication interactions, safety), and optimize care for AYA living with chronic illness.

Prevalence of infertility and pregnancy loss among individuals with kidney disease in the Hispanic Community Health Study/Study of Latinos

BACKGROUND

Hispanic/Latino individuals are less likely to receive optimal treatment for chronic kidney disease than non-Hispanic whites. This may be particularly detrimental for women of reproductive age as chronic kidney disease increases risk for infertility, menstrual irregularities, and pregnancy loss. While these maternal outcomes have been associated with advanced chronic kidney disease, their occurrence in early chronic kidney disease is unclear.

OBJECTIVES/DESIGN

Using baseline (2008-2011) and second study visit (2014-2017) data from the Hispanic Community Health Study/Study of Latinos, we retrospectively assessed the prevalence of chronic kidney disease as well as the association between chronic kidney disease and self-reported infertility, cessation of menses, hysterectomy, and nonviable pregnancy loss (experienced at less than 24 weeks gestation) in women of reproductive age (18-45 years).

METHODS

Multivariable survey logistic regression analyses determined the unadjusted and multivariable-adjusted prevalence odds ratios with 95% confidence intervals between chronic kidney disease and the separate outcomes.

RESULTS

Among 2589 Hispanic/Latino women included (mean age = 31.4 years), 4.6% were considered to have chronic kidney disease. In adjusted analyses, women with chronic kidney disease did not have a significantly increased odds of infertility (odds ratio = 1.02, 95% confidence interval = 0.42-2.49), cessation of menses (odds ratio = 1.25, 95% confidence interval = 0.52-3.04), or hysterectomy (odds ratio = 1.17, 95% confidence interval = 0.61-2.25) compared to those without chronic kidney disease. In those with chronic kidney disease, the adjusted odds of a nonviable pregnancy loss occurring after baseline visit were increased (odds ratio = 2.11, 95% confidence interval = 0.63-7.02) but not statistically significance.

CONCLUSION

The presence of early stage chronic kidney disease did not confer a significant risk of infertility, cessation of menses, or nonviable pregnancy loss.

Associations of Reproductive Health Concerns, Health-Related Quality of Life, and Stress Among Adolescents and Young Adults with Chronic Illness

OBJECTIVE

Adolescents and young adults (AYA) living with chronic illness are as sexually active and interested in having children as healthy peers. Few studies have examined the intersection of managing chronic illness and concerns about realizing reproductive goals, including fertility, pregnancy, childbirth, and parenting. Even less is understood regarding how these concerns might be associated with psychological distress. This study examines associations between the reproductive health concerns (RHC) and health-related stress of AYA patients living with chronic conditions including rheumatologic, cardiac, pulmonology, gastrointestinal disorders, and solid organ transplant.

METHODS

A total of 140 patients aged 15 to 20 years (68% female; 81% Hispanic/Latinx) recruited from a transition program located at a safety-net pediatric institution completed surveys examining multiple dimensions of RHC and health-related quality of life (life satisfaction, illness burden, and illness-related anxiety) and condition-related stress. Exploratory factor analyses of RHC variables yielded 3 factors used in regression analyses to identify convergent validity of RHC factors with health-related mental health measures.

RESULTS

Three RHC factor loadings emerged: concern about availability to raise children (timing/future), impact of condition/medication on fertility and childbearing (pregnancy/fertility), and impact of condition on motivation to have children (motivation/decision-making). Positive associations were found between all RHC factors and illness-related anxiety; condition-related stress was associated with motivation/decision-making.

CONCLUSION

RHC, health-related anxiety, and stress can impede healthy sexual and reproductive health and development of AYA living with chronic conditions. Providers' proactive exploration of patients' concerns about their reproductive future can offer critical support as they navigate the unique existential challenges of early adulthood.

The Quality of Sex Life Among Patients Before and After Lung Transplantation: A Single-Center Study

BACKGROUND

Lung transplantation (LTx) is the only effective method of treatment for patients with end-stage lung diseases; LTx prolongs and increases the quality of life (QoL). An important aspect of QoL that changes in the course of severe diseases is the quality of sex life. This aspect is yet to be discussed in relationship to LTx. We aim to compare patients' quality of sex life at the qualification process with patients' who underwent LTx.

METHODS

The studied group consisted of 100 patients (24 women before and 16 after LTx, 39 men before and 21 after LTX) who were admitted to the lung transplantology department for qualification or to control the function after LTx. To assess the patients' quality of sex life, we used The Changes in Sexual Functioning Questionnaire (CSFQ) and World Health Organization (WHO) QoL-BREF. To assess lung function, patients underwent a 6-Minute-Walk-Test (6MWT).

RESULTS

Patients after LTx obtained higher results-compared to patients qualified for LTx-in the WHO QoL-BREF in every domain (somatic, psychological, social, and environment). Men after LTx got more points in every domain and better total score (53 ± 5.62 vs 44.23 ± 10.28 point; P < .05) in CSFQ. Women before and after LTx obtained comparable results in CSFQ. Results of 6-Minute-Walk-Test were better among patients after LTx than in qualified patients (523.62 ± 95.71 vs 333.14 ± 145.38 and 524.12 ± 56.17 vs 317.20 ± 141.6, respectively for men and women).

CONCLUSIONS

Patients after LTx show better pulmonary function and quality of sex life than qualified. Preliminary results encourage us to conduct research on a larger group.

Parenthood with kidney failure: Answering questions patients ask about pregnancy

Achieving parenthood can be an important priority for women and men with kidney failure. In recent decades, the paradigm has shifted toward greater support of parenthood, with advances in our understanding of risks related to pregnancy and improvements in obstetrical and perinatal care. This review, codesigned by people with personal experience of kidney disease, provides guidance for nephrologists on how to answer the questions most asked by patients when planning for parenthood. We focus on important issues that arise in preconception counseling for women receiving dialysis and postkidney transplant. We summarize recent studies reflecting pregnancy outcomes in the modern era of nephrology, obstetrical, and perinatal care in developed countries. We present visual aids to help clinicians and women navigate pregnancy planning and risk assessment. Key principles of pregnancy management are outlined. Finally, we explore outcomes of fatherhood in males with kidney failure.

Pregnancy, Contraception, and Menopause in Advanced Chronic Kidney Disease and Kidney Transplant

Background: Reproductive health is an essential part of the care of women with kidney disease. However, the self-reported patient experience of reproductive issues has been underexplored.

Materials and Methods: We identified a cohort of women ages 18 to 44 at the time of kidney transplant from 1996 to 2014 at our 3-site program (n = 816). We sent each woman a survey on her reproductive lifespan, characterizing features from menarche to menopause.

Results: We received survey responses from 190 patients (27%). One third of respondents reported amenorrhea before transplant, and 61.5% of these women reported resumption of menses post-transplant. The average age of menopause was 45.5 years, earlier than the general population (51.3 years). There were 204 pregnancies pretransplant and 52 pregnancies post-transplant. Pregnancies post-transplant were more likely to be complicated by preeclampsia, preterm delivery, and small for gestational age babies than pregnancies that occurred >5 years before transplant. Pregnancies <5 years before transplant were similar to post-transplant pregnancies with respect to complications. Forty-two percent of women were advised to avoid pregnancy after transplant, most often by a nephrology provider.

Conclusions: In our cohort of kidney transplant recipients, women report increased pregnancy-related complications post-transplant and in the 5 years before transplant, compared with pregnancies that occurred greater than 5 years before transplant. They were often counseled to avoid pregnancy altogether. Women reported a younger age of menopause relative to the general population. This should be considered when counseling patients with chronic kidney disease regarding optimal pregnancy timing.

Usage of Tacrolimus and Mycophenolic Acid During Conception, Pregnancy, and Lactation, and Its Implications for Therapeutic Drug Monitoring: A Systematic Critical Review

BACKGROUND

Conception, pregnancy, and lactation following solid organ transplantation require appropriate management. The most frequently used immunosuppressive drug combination after solid organ transplantation consists of tacrolimus (Tac) plus mycophenolic acid (MPA). Here, the effects of Tac and MPA on fertility, pregnancy, and lactation are systematically reviewed, and their implications for therapeutic drug monitoring (TDM) are discussed.

METHODS

A systematic literature search was performed (August 19, 2019) using Ovid MEDLINE, EMBASE, the Cochrane Central Register of controlled trials, Google Scholar, and Web of Science, and 102 studies were included. Another 60 were included from the reference list of the published articles.

RESULTS

As MPA is teratogenic, women who are trying to conceive are strongly recommended to switch from MPA to azathioprine. MPA treatment in men during conception seems to have no adverse effect on pregnancy outcomes. Nevertheless, in 2015, the drug label was updated with additional risk minimization measures in a pregnancy prevention program. Data on MPA pharmacokinetics during pregnancy and lactation are limited. Tac treatment during conception, pregnancy, and lactation seems to be safe in terms of the health of the mother, (unborn) child, and allograft. However, Tac may increase the risk of hypertension, preeclampsia, preterm birth, and low birth weight. Infants will ingest very small amounts of Tac via breast milk from mothers treated with Tac. However, no adverse outcomes have been reported in children exposed to Tac during lactation. During pregnancy, changes in Tac pharmacokinetics result in increased unbound to whole-blood Tac concentration ratio. To maintain Tac concentrations within the target range, increased Tac dose and intensified TDM may be required. However, it is unclear if dose adjustments during pregnancy are necessary, considering the higher concentration of (active) unbound Tac.

CONCLUSIONS

Tac treatment during conception, pregnancy and lactation seems to be relatively safe. Due to pharmacokinetic changes during pregnancy, a higher Tac dose might be indicated to maintain target concentrations. However, more evidence is needed to make recommendations on both Tac dose adjustments and alternative matrices than whole-blood for TDM of Tac during pregnancy. MPA treatment in men during conception seems to have no adverse effect on pregnancy outcomes, whereas MPA use in women during conception and pregnancy is strongly discouraged.

Sexual dysfunction and activity avoidance in female kidney transplant patients

Sexual dysfunction is common after kidney transplantation and has an adverse effect on patients' quality of life. This paper aims to evaluate the female sexual function, activity avoidance, and kidney function among a convenience sample of patients who had a kidney transplant. A cross-sectional study was conducted that included 250 patients had undergone a kidney transplant procedure >3 months ago, from multiple transplant centers and answered a self-reported sociodemographic questionnaire, the female version of the Arizona Sexual Experience Scale, and the Tampa Scale for Kinesiophobia-13. A correlation was found between sexual function and activity avoidance (r = .361, p < .001, n = 250) as well as between activity avoidance and kidney function (r = .198, p = .012, n = 250). Less education, having no child, post-transplant time for <36 months, and smoking (active and passive) were risk factors for female sexual dysfunction after kidney transplantation. The results suggest that physicians that the importance of recognize the relationship between fear of sexual activity and sexual function and that they should provide patients with more education and guidance on post-transplant sexual behaviors.

Chronic Kidney Disease and Pregnancy

Women with chronic kidney disease (CKD) are at high risk for adverse outcomes in pregnancy. In the United States, pregnancy rates in women with risk factors for CKD such as obesity and advanced maternal age are increasing; thus, more pregnancies are likely to be affected by CKD. Strategies that involve coordinated multidisciplinary care to optimize preconception health, perform meticulous antenatal monitoring, and provide continued care in the postpartum "fourth trimester" appear to be most beneficial for both the mother and baby. Discussions surrounding preconception risk stratification should be individualized based on CKD stage/serum creatinine level, degree of hypertension and proteinuria, and comorbid conditions. Preparation for pregnancy should include optimization of comorbidities and medication adjustments to those compatible with pregnancy. Unless contraindicated, all women with CKD should be prescribed low-dose aspirin in pregnancy to reduce risk of preeclampsia. After delivery, women with CKD may benefit from an early postpartum visit (within 7-10 days) for blood pressure check and may require serial monitoring of serum creatinine and proteinuria as appropriate. Breastfeeding is safe and can be recommended for most women with CKD. A contraceptive plan that includes patients' preferences, feasibility, medical eligibility, duration, and effectiveness of the contraceptive method should be implemented.

Contraception in chronic kidney disease: a best practice position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology

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.

Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases

Pregnancy is possible in all phases of chronic kidney disease (CKD), but its management may be difficult and the outcomes are not the same as in the overall population. The prevalence of CKD in pregnancy is estimated at about 3%, as high as that of pre-eclampsia (PE), a better-acknowledged risk for adverse pregnancy outcomes. When CKD is known, pregnancy should be considered as high risk and followed accordingly; furthermore, since CKD is often asymptomatic, pregnant women should be screened for the presence of CKD, allowing better management of pregnancy, and timely treatment after pregnancy. The differential diagnosis between CKD and PE is sometimes difficult, but making it may be important for pregnancy management. Pregnancy is possible, even if at high risk for complications, including preterm delivery and intrauterine growth restriction, superimposed PE, and pregnancy-induced hypertension. Results in all phases are strictly dependent upon the socio-sanitary system and the availability of renal and obstetric care and, especially for preterm children, of intensive care units. Women on dialysis should be aware of the possibility of conceiving and having a successful pregnancy, and intensive dialysis (up to daily, long-hours dialysis) is the clinical choice allowing the best results. Such a choice may, however, need adaptation where access to dialysis is limited or distances are prohibitive. After kidney transplantation, pregnancies should be followed up with great attention, to minimize the risks for mother, child, and for the graft. A research agenda supporting international comparisons is highly needed to ameliorate or provide knowledge on specific kidney diseases and to develop context-adapted treatment strategies to improve pregnancy outcomes in CKD women.

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes “normal” or “good” kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1–2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage “non-ideal” situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial “third element”.

Fertility, Contraception, and Novel Reproductive Technologies in Chronic Kidney Disease

Chronic kidney disease (CKD) affects hypothalamic-pituitary-gonadal axis function, leading to menstrual abnormalities, sexual dysfunction, functional menopause, and loss of fertility. Pregnancy in a patient with CKD is associated with a higher risk of complications to both the mother and the fetus, highlighting the importance of contraceptive counseling at all stages of CKD. There has been limited research on the safety and efficacy of different contraceptive methods in the CKD population, and it is important to tailor the choice of contraception to the patient's lifestyle and comorbidity status. Cyclophosphamide is a commonly used immunosuppressive agent that impairs fertility in a dose-dependent fashion, with greater impact in older women of child-bearing age. Strategies to reduce the impact of cyclophosphamide on ovarian reserve as well as fertility preservation technologies are options to consider when treating immune-mediated CKD. A multidisciplinary approach in counseling the woman with CKD who wishes to contemplate or avoid pregnancy is necessary to optimize outcomes. Further research in this important area is required.

[Sexuality, fertility and pregnancy after kidney transplantation]

AIMS

To describe sexuality and fertility alterations secondary to chronic kidney disease and their outcomes after renal transplantation.

MATERIAL AND METHODS

An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords: erectile dysfunction; impotence; sexuality; pregnancy; fertility; renal transplantation. Publications obtained were selected based on methodology, language, date of publication (last 10 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 706 articles. After reading titles and abstracts, 76 were included in the text, based on their relevance.

RESULTS

The observed prevalence of erectile dysfunction is high in men with chronic kidney disease. The causes of erectile dysfunction are numbers and its origin is often multifactorial. Most of the time, kidney transplantation improves sexuality and the management of erectile dysfunction in transplanted men is similar to the general population. Improvement in sexuality in men and women after kidney transplantation may conduct to pregnancy. The outcomes of pregnancy after transplantation are quite good in absence of risk factors such as time to pregnancy less than 1 year after transplantation, uncontrolled high blood pressure, and decreased renal function of the graft. Adaptation of immunosuppression may be required to avoid any teratogenicity for the fetus.

CONCLUSION

Kidney transplantation improves sexuality and fertility in men and women with chronic kidney disease.

Managing pregnancy in chronic kidney disease: improving outcomes for mother and baby

Parenthood is a central focus for women with chronic kidney disease, but raises important fears and uncertainties about risks to their own and their baby’s health. Pregnancy in women with background kidney disease, women receiving dialysis, or those with a functioning kidney transplant poses a challenging clinical scenario, associated with high maternal–fetal morbidity and potential impact on maternal renal health. Improvements in care over recent decades have led to a paradigm shift with cautious optimism and growing interest regarding pregnancies in women with chronic kidney disease. In this review, we discuss obstetric and renal outcomes, and practical aspects of management of pregnancy in this complex cohort.

Pregnancy outcomes among renal transplant recipients and patients with end-stage renal disease on dialysis

AIM

The purpose of our study is to compare pregnancy outcomes between women with a functioning renal transplant and women with end-stage renal disease (ESRD).

METHODS

We carried out a population-based retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from 2006 to 2011. Logistic regression analysis was used to estimate the age-adjusted effect of functioning renal transplant vs. ESRD requiring dialysis on pregnancy outcomes.

RESULTS

We identified 264 birth records to women with a functional renal transplant and 267 birth records to women with ESRD on dialysis among 5,245,452 births. As compared to women with ESRD on dialysis, renal transplant recipients were less likely to have placental abruption [odds ratio, OR 0.23 (95% confidence interval, CI 0.08-0.70)], to receive blood transfusions [OR 0.17 (95% CI 0.09-0.30)], and to have growth-restricted and small-for-gestational-age babies [OR 0.45 (95% CI 0.23-0.85)]. Renal transplant recipients were more likely to have an instrumental delivery [OR 15.38 (95% CI 1.92-123.3)]. Among renal transplant women, there was a trend towards delivery by cesarean section as compared to patients with ESRD [OR 1.31 (95% CI 0.93-1.85)]. However, these results were not statistically significant. Fetal deaths were less likely to occur in women with a renal transplant [OR 0.41 (95% CI 0.17-0.96)]. There were four maternal deaths among patients with ESRD on dialysis and no maternal deaths among renal transplant patients.

CONCLUSION

Patients with a functional renal graft had an overall lower rate of morbidity and adverse pregnancy complications when compared to patients with ESRD on dialysis.

Perspectives on Pregnancy in Women With CKD: A Semistructured Interview Study

BACKGROUND

Women with chronic kidney disease (CKD) often have difficulty achieving pregnancy and are at increased risk for adverse pregnancy outcomes. Given the medical, ethical, and emotional complexities of pregnancy in CKD, the clinical approach should involve explicit consideration of women's values, for which there are sparse data. This study aims to describe the beliefs, values, and experiences of pregnancy in women with CKD to inform prepregnancy counseling and pregnancy care.

STUDY DESIGN

Qualitative study.

SETTING & PARTICIPANTS

41 women (95% response rate) aged 22 to 56 years with CKD stages 3 to 5 (n=5), receiving dialysis (n=5), or received a kidney transplant (n=31) from 2 renal units in Australia.

METHODOLOGY

Semistructured interviews.

ANALYTICAL APPROACH

Transcripts were analyzed thematically.

RESULTS

6 themes were identified: bodily failure (conscious of fragility, noxious self, critical timing, and suspended in limbo), devastating loss (denied motherhood, disempowered by medical catastrophizing, resolving grief, barriers to parenthood alternatives, and social jealousy), intransigent guilt (disappointing partners, fear of genetic transmission, respecting donor sacrifice, and medical judgment), rationalizing consequential risks (choosing survival, avoiding fetal harm, responding to family protectiveness, compromising health, decisional ownership, and unjustifiable gamble), strengthening resolve (hope and opportunity, medical assurance, resolute determination, and reticent hope), and reorientating focus (valuing life and gratitude in hindsight).

LIMITATIONS

Only English-speaking women were recruited, which may limit transferability of the findings.

CONCLUSIONS

Decisions surrounding pregnancy in the context of CKD require women to confront uncertainties about their own survival, disease progression, guilt toward their family and kidney donor, the outcomes of their offspring, and genetic transmission. Communicating the medical risks of pregnancy to women with CKD must be carefully balanced with their values of autonomy, hope, security, and family. Informed and shared decision making that addresses women's priorities as identified in this study may help contribute to improved pregnancy, health, and psychosocial outcomes in this vulnerable population.

Reproductive health care after transplantation

Contraception, cervical cancer screening, human papillomavirus (HPV) vaccination, sexually transmitted infection (STI) screening, and menstrual disorders are issues that need to be addressed in all reproductive-aged women, including those with a history of solid organ transplantation. There are specific considerations that may alter routine care in this population. Due to teratogenic immunosuppressive medications, highly effective contraception is important to planning or appropriately timing pregnancy. Estrogen-containing methods (pill, patch, and ring) may be contraindicated. Immunosuppression is also a consideration when screening for and treating STIs including precancerous conditions of the cervix. This chapter will provide a framework to address the specific gynecologic needs of women with a history of solid organ transplantation.

Sexually transmitted infections in pediatric renal transplant recipients: Time to take notice!

We sought to assess the prevalence of STIs, contraception use, and unintentional pregnancy in our pediatric renal transplant recipients. We performed a retrospective chart review. Forty-nine of 65 patients in our program are currently in the high-risk age window of 13 yr or older (34 men, 15 women; mean age 17 yr old, range 13-23 yr old). There was a disproportionate difference in sexual behavior among the men and women, such that while only 15% of the men reported being sexually active, 53% of the women were sexually active. Among high-risk age-group women, 40% were on hormonal contraception. This increased to 75% in sexually active women. There were no cases of unintentional pregnancy. Thirty percent of sexually active recipients had at least one STI. This was higher among sexually active women (37.5%) compared to men (20%). STIs identified included gonococcal and chlamydial urethritis/cervicitis, Trichomonas vaginitis, HSV-2 genital sores, pelvic inflammatory disease, and HIV. In conclusion, STIs are a realistic public health concern in our pediatric renal transplant recipients. Consensus guidelines on STI screening and reproductive health counseling are needed to address this understudied problem.

Best practices on pregnancy on dialysis: the Italian Study Group on Kidney and Pregnancy

BACKGROUND

Pregnancy during dialysis is increasingly being reported and represents a debated point in Nephrology. The small number of cases available in the literature makes evidence-based counselling difficult, also given the cultural sensitivity of this issue. Hence, the need for position statements to highlight the state of the art and propose the unresolved issues for general discussion.

METHODS

A systematic analysis of the literature (MESH, Emtree and free terms on pregnancy and dialysis) was conducted and expert opinions examined (Study Group on Kidney and Pregnancy; experts involved in the management of pregnancy in dialysis in Italy 2000-2013). Questions regarded: timing of dialysis start in pregnancy; mode of treatment, i.e. peritoneal dialysis (PD) versus haemodialysis (HD); treatment schedules (for both modes); obstetric surveillance; main support therapies (anaemia, calcium-phosphate parathormone; acidosis); counselling tips.

MAIN RESULTS

Timing of dialysis start is not clear, considering also the different support therapies; successful pregnancy is possible in both PD and HD; high efficiency and strict integration with residual kidney function are pivotal in both treatments, the blood urea nitrogen test being perhaps a useful marker in this context. To date, long-hour HD has provided the best results. Strict, personalized obstetric surveillance is warranted; therapies should be aimed at avoiding vitamin B12, folate and iron deficits, and at correcting anaemia; vitamin D and calcium administration is safe and recommended. Women on dialysis should be advised that pregnancy is possible, albeit rare, with both types of dialysis treatment, and that a success rate of over 75% may be achieved. High dialysis efficiency and frequent controls are needed to optimize outcomes.

Sexual dysfunction in inflammatory bowel disease

Sexual health is a broad term that encompasses a variety of functions including sexual thoughts, desire, arousal, intercourse, orgasm, and the impact of body image. Sexual dysfunction in individuals with inflammatory bowel disease is multifactorial including the impact of psychosocial factors, disease activity, medical therapies, surgical interventions, body image perceptions and changes, hypogonadism, and pelvic floor disorders. Providers caring for patients with inflammatory bowel disease should be cognizant of these concerns and develop management plans and techniques for earlier diagnosis and treatment.

Contraceptive use in female recipients of a solid-organ transplant

CONTEXT

Women of reproductive age account for more than one-third of all solid-organ transplant recipients and are advised against becoming pregnant for 1 to 2 years after their surgeries. The risks posed to the woman, the transplanted organ, and the fetus underscore the importance of systems to ensure that patients receive counseling on family planning, including return to fertility, contraceptive use, and when pregnancy can be safely considered, and highly effective methods of contraception.

OBJECTIVE

To investigate use of contraceptives among women after solid-organ transplant and to identify opportunities to improve care.

DESIGN

A cross-sectional survey study.

SETTING

An urban academic medical center.

PATIENTS

Women 18 to 50 years old who have received a kidney, pancreas, and/or liver transplant within the past 1 to 24 months.

INTERVENTION

Participants completed self-administered questionnaires regarding their menstrual pattern, pregnancy history, contraceptive use before and after transplant, and counseling on family planning issues.

MAIN OUTCOME MEASURES

Contraceptive use.

RESULTS

The most common contraceptive method used in both the year preceding transplant and the year after transplant was condoms. Participants desired more counseling on highly effective contraceptive methods, such as intrauterine devices. Participants would like to receive contraceptive counseling from an obstetrician/gynecologist or transplant care team provider.

CONCLUSION

Female recipients of solid-organ transplants want more counseling on highly effective methods of contraception.

The multidisciplinary approach

Complex pathologies associated with chronic health conditions must be dealt in a coordinated way and the 'multidisciplinary team' approach (MDTA) represents the most efficacious way of managing these patients. Over the last 25 years, the initial limited field for joint interventions by several specialists has been progressively expanded and this article reviews some of the conditions in which the MDTA has found useful application. This has been the case in fields as diverse as primary healthcare, oncology, diabetes, cardiovascular, chronic kidney diseases and high-risk pregnancy. In the latter situation, an MDTA can offer clear advantages for pregnancies in solid organ recipient women. In these patients, a close collaboration is mandatory between a series of dedicated physicians (including, but not limited to, infertility and maternal-foetal medicine specialists, obstetricians, paediatricians, transplant physicians, geneticists and psychologists). Such a team should be active before, during and after pregnancy and should cope with all their reproductive health needs.