The first pregnancy in kidney transplanted patient was reported in 1967. Kidney transplantation leads to increase rate of conception in kidney transplant recipients with good allograft function. Ovulation may initiate as soon as 1-month post-transplantation. Thus, consultation and planning for timely pregnancy is crucial in kidney transplant recipients. It is suggested that a period of 1 year after transplant appears to be sufficient to minimize the risk of fetal and maternal adverse events due to pregnancy as well as risk of acute rejection and graft loss. Adequate kidney function before kidney transplantation is the most important factor, predicting the outcomes of pregnancy. Major complications to the fetus in pregnant transplant recipients include prematurity, intrauterine growth retardation, and low birth weight. Preeclampsia (in 30% of kidney transplanted patients), hypertension and graft dysfunction are important maternal complications. Pretransplant education about the risk of unplanned pregnancy and choosing the method of contraception is important in kidney transplanted patients. Utilization of contraceptive methods should be started soon after transplantation to avoid unplanned high-risk pregnancy. Optimization of immunosuppressive agents and using safe drugs are other concerns during pregnancy. Contraception after kidney transplantation There are two principal contraception methods: permanent and temporary methods Permanent methods consist of female tubal ligation and male vasectomy. Temporary methods include the use of combined hormonal oral contraception, intrauterine devices, vaginal rings, subcutaneous implants, barriers, and natural methods like coitus interruptus. Combined hormonal contraceptives are commonly used and are associated with some adverse effects attributed to estrogen component such as headache, hypertension, and increase the risk of thromboembolic events. Combined hormonal contraceptives are primarily metabolized by the cytochrome P4503A4 system. consequently, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important. These are not recommended in patients with the history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have active liver disease or hepatic adenoma. Depot medroxyprogesterone acetate (DMPA), a synthetic progestin with slow release over 3 months, is a highly effective and safe method. Reversible decrease in bone density and the increased risk of thromboembolism are its use concern. The main advantage of this drug is the absence of interaction with immunosuppressive agents. Hence it is good choice for kidney transplant recipients. It is not recommended in patients with active liver disease. The etonogestrel implant, implanted subcutaneously in the upper arm, and protection lasts for 3 years. It has risk-benefit features as the same as DMPA with lesser decrease in bone density, and can be safely advised. Transdermal contraceptive patches deliver estrogen and progesterone in the patch placed on the abdomen. Its use is associated with at least similar to two-fold increase risk of thromboembolism events compared to combined humoral contraceptives. Progestin-only pills have the advantages of avoidance of estrogen-related risks. Incidence of amenorrhea and relatively high risk of failure is main concern of its utilization. In addition, it should be avoided in patients with liver disease. The CNI level monitoring is advised because of interaction with these pills. Lipid profile and weight gain should be monitored. In patients with high cardiovascular risk , progesterone-only pills are better choice compared to combined contraceptives. Intrauterine devices (IUDs) are categorized as category 2 contraceptives in transplanted patients. It is suggested that kidney transplanted women are not at higher risk of developing pelvic infections. IUDs have advantages include easy insertion, long lasting, and low failure rate, reversible, no interaction with immunosuppression drugs, and no increased risk of thromboembolism, but it probably is accompanied by higher risk of infection early after insertion in immunosuppressed patients. Copper IUD and the levonorgestrel-releasing IUDs are both effective and safe to use after kidney transplant. They are long-time methods for kidney transplanted women. The vaginal ring, contains etonogestrel and ethinyl estradiol, and is associated with reduced adverse events related to ethinyl estradiol.
Alshymaa Eltahan
2 years ago
Contraception methods are generally classified into14:
I. Permanent:
1. Male vasectomy.
2. Female tube ligation: Risk of ectopic pregnancy.
II. Temporary:
1.Hormonal:
A. Combined pills: classified as class 4 medications, may interfere with immunosuppressant medications so careful monitoring is required, and may be associated with exacerbated migraine episodes, thromboembolic events, and uncontrolled hypertension.
B. Depot medroxyprogesterone acetate: A synthetic progestin, with a release form over 3 months, effective with a failure rate of 2%, not interfering with medication metabolism, but still there are some concerns regarding thromboembolism.
C. Etonogestrel implant: A subcutaneous implant, with a high success rate of > 99%, lasts for 3 years. Generally safe, but may be associated with some bleeding irregularities.
D. Transdermal patch: Deliver both estrogen and progesterone, which have similar effects to COPs.
E. Progestin-only pills: Delivered orally, failure rate about 5%, undergo first hepatic metabolism so may interfere with CNIs metabolism.
F. The vaginal ring: Are a silastic ring of etonogestrel and Ethinyl estradiol. Controls the menstrual cycle and delivers a lower concentration of estradiol thus minimizing its side effects.
2.Intrauterine device: Classified as category 2 compared to COPs, and category 4 in complicated transplants. There is a theoretical risk for pelvic inflammatory diseases which has not proven by studies. The major advantages of IUDs are they’re easily inserted and safe, and there is no risk of thromboembolism nor drug interaction with immunosuppressant medications. The copper IUD is effective for 10 years and the levonoregesterl-releasing for 5 years duration. Theoretically, an immunosuppression state may reduce the effectiveness of the IUDs due to reduced leucocytic reaction, but again no solid evidence supports this hypothesis.
3. Barrier methods: Have the advantages of being safe, reversible, easy to use, and with no drug interaction. But have a high failure rate and requires high compliance. Better to be combined with other contraception methods.
Nasrin Esfandiar
2 years ago
This article summarizes the type and the effectiveness of the various methods of contraception after kidney transplantation.
Fertility can be return after one month after kidney transplantation.
So, to avoid unplanned and complicated pregnancy it is necessary to discuss about contraceptive methods even before TX.
These methods may be temporary or permanent.
Permanent methods are female tubal ligation and male vasectomy.
Vasectomy is irreversible but has lower risk for ectopic pregnancy comparing to tubal ligation.
Temporary methods include:
1- Combined hormonal contraceptive: this method carries high risk due to estrogen component that induce migraine, thromboembolism and hypertension. But the rate of pregnancy is near zero (0.1%) and they reduce ovarian cyst and menorrhagia. They can deteriorate liver function and affect CNIs metabolism. They can only use when there is no contraindication.
2- Depot medroxyprogesterone acetate injection. It is highly effective and safe method with failure rate of 20%. So it very effective.
Concerns: higher risk of thromboembolic events and reversible decrease in bone density which will be normalized after stopping it. It has liver metabolism and is not recommended in liver diseases.
Advantages: No interaction with immunosuppression drugs.
3- Etonogestrel implant: completely effective method (>99%)with 3years protection.
Adverse effect: bleeding irregularity, low effect in bone mineral density
Advantages: highly effective and rapidly reversible.
4- Transdermal contraceptive patch:
High level of circulating estrogen with 2- fold increase in the risk of thromboembolism.
So, although is an effective method, it is not safe.
5- Progesterone – only pills: They are effective method (1-2% failure rate) if used correctly and constantly. Their liver metabolism could be troublesome in liver disease and CNIs interaction. They have risk of weight gain but cane be used in female kidney TX and are not contraindication in this group.
6- IUDs: Their usage is relatively safe (category2) in female kidney TX recipients. They are effective contraceptive method with low failure rate (~1%)
Advantages: Reversible after removal, no interaction with immunosuppression drugs .no risk of thromboembolic events.
Contraindication: History of ectopic pregnancy and pelvic inflammation.
7- Vaginal rings: Lower rate of exposure to ethinyl estradiol comparing combined pills or patches.
8- Barrier methods: These include condoms spermicides, diaphragm, cervical cap, and sponges.
9- They are less effective methods with high failure rate and difficulty in compliance
Advantages: Easy to use avoid drug interactions.
Dalia Eltahir
2 years ago
Contraception post kidney transplant : After transplantation fertility return in 6 month , so pregnancy should be planned stabilization of the graft function is very important so the women in child bearing age should used contraception .There are two type of contraception permanent or temporal , methods which can be used after transplantation :1- condom are safe but have high failure rate but when it used in aright way the protection rate is 97% .It is good method to avoid drug interaction .2-combined pills , contain progesterone and estrogen metabolize by CYTP450 it may lead to drug interaction .Used with caution in women with high blood presser also there is tendency to form aclot .3- Trans-dermal patch also contain progesterone and estrogen so it’s the same as combined pills .
4-DMPA {Depot Medroxy Progesterone Acetate } it is more safe no drug interaction but it can cause loss of bone density this become more worse with used of steroid .
5-Etonogestrel Implant : implanted subcutaneously can be used for 3 years it is effective and safe it contain progesterone only , it can affect bone density but less than DMPA . 6-Progesterone only pill it has high failure rate more than 5% .6-Intrauterine devices : two type 1- copper – T give protection for ten year Levonorgestrol IUCD coated hormone give protection for 5 year .Contraindication infection and history of ectopic pregnancy .
7- Vaginal ring also effective and can be used .
Assafi Mohammed
2 years ago
Methods of contraception
there are 2 principal methods:
· Permanent methods; include female tubal ligation and male vasectomy. Male vasectomy is invasive and non-reversible and has the advantage of having less associated risks of ectopic pregnancy than tubal ligation.
· Temporary methods;involve the use of combined hormonal oral contraception, intrauterine devices, vaginal rings, subcutaneous implants, barriers, and natural methods like coitus interruptus.
Combined hormonal contraceptives
· classified as category 4 in complicated transplant.
· Contraceptives containing estrogen and progestin are commonly used in daily practice as they are highly effective and with minimal failure rate. Estrogen is associated with exacerbation of migraine, headaches, risk of thromboembolism, and worsening hypertension control.
· primarily metabolized by the cytochrome P4503A4 system; so attention regarding drug-drug interaction should be kept in mind.
· Not advisable in patients with history of MI, DVT, migraine, uncontrolled HTN, active liver disease or hepatic adenoma.
Depot medroxyprogesterone acetate
· Depot medroxyprogesterone acetate is a synthetic progestin with slow release over 3 months.
· It is a highly effective and safe method with failure rate of 2% due to delay in repeat injection.
· Adverse events; decrease in bone density and thromboembolic risk.
· Advantage; no drug interactions with immunosuppressive medications.
· Not advisable in active liver disease.
Etonogestrel implant
· It’s is a single silastic rod implanted subcutaneously in the upper arm.
· The effectiveness is > 99%, and the protection lasts for 3 years. On removal, the etonogestrel drops rapidly, with most patients ovulating after 3 weeks.
· The adverse effect; bleeding irregularity and fewer decreases in bone mineral density. Transdermal contraceptive patch
· It delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen.
· The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives.
· Adverse events; venous thromboembolism. Progestin-only pills
· The advantage; no estrogen-related risks.
· Disadvantage; Not advisable in active liver disease,having drug interaction with CNI and causes weight gain. Intrauterine devices
· Classified as category 2 compared with combined pills.
· The advantages of the IUD; easy insertion, long lasting, and low failure rate beside reversible effect. No risk of VTE and drug interaction.
· levonorgestrel-releasing intrauterine system is effective and safe to use after kidney transplantwith effective duration of 5 to 10 years according to manufacturer.
· Theoretically; Posttransplant immunosuppressive medications may decrease the efficacy of IUDs.
The vaginal ring
· It is a silastic ring that is impregnated with etonogestrel and ethinyl estradiol.
· Advantage; lower concentration of ethinyl estradiol compared with combined pills,
Barrier methods of contraception
· Barriers (condoms, spermicides, diaphragm, cervical cap, sponges).
· Less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate.
· Barrier success rate can reach 97% if used correctly and consistently.
· Better to be combined with another method of contraception.
· Having the advantage of being a convenient and easy to use.
Mohamed Ghanem
2 years ago
As Fertility is reverted within the first 6 months after transplantation contraception is mandatory in the first year post kidney transplantation to avoid unplanned and not advisable pregnancy to minimize the risk of acute rejection and risk of graft loss and to maintain adequate renal allograft functions (no proteinuria and well-controlled blood pressure) in the first year post-transplantation.
Methods of contraception may be temporary or permanent
Permanent methods include vasectomy of males and tubal ligation of females. Temporary methods include: A-Combined oral contraceptives:
they contain both estrogen and progesterone with high efficacy with minimal failure rate But with some adverse effects of estrogen component with increased risk of thromboembolism, hypertension, frequencies of migraine and also interfere with the metabolism of CNI so levels of CNI should be carefully assessed. B- Depot medroxyprogesterone acetate :
It is synthetic progesterone with high efficacy and a low failure rate of 2 % despite some adverse effects such as the increased risk of thromboembolism and osteoporosis, there are no associated drug interactions with other immunosuppressants. C-Transdermal patch :
the patch contains both estrogen and progesterone with the same risk of potential hazards like combined oral contraceptives. D-Progesterone only pills :
Despite the avoidance of adverse effects of estrogen, there is an increased incidence of failure rate in addition to the rate of amenorrhea by 5%. E-Intrauterine devices :
two types were identified Copper and progestin IUDs with many advantages high success rate, no drug interaction, long-lasting, easy insertion, and reversible fertility after removal of IUD. F- The vaginal ring :
It is a ring containing both etonogestrel and low concentrations of Ethinyl estradiol so minimal adverse effects of estrogen showed in patches and the combined pills. G- Barrier methods:
They are less effective with high failure rates and include Condoms, sponge , cervical cap, and spermicidal gel.
Wael Jebur
2 years ago
This article addresses the current concerns about the fertility post transplantation , the outcome of pregnancy post transplantation, anti natal complications ,and contraception recommendations.
The fertility of end stage kidney disease patients is usually reversed swiftly after transplantation and the women regained normal hormonal cycles , menstruation and ovulation with restoration of libido and vaginal lubrication as early as 1 to 6 months with a high chance of getting pregnancy thereafter.
However, the pregnancy post transplantation is quite unsafe in the first year as it was reported to be associated with increasing maternal and fetal shortcomings along with allograft complications including allograft rejection. Furthermore, the medications commonly used as anti rejection and antihypertensives are highly unsafe with teratogenicity and fetotoxicity. Therefore prior contemplation of contraception earlier to transplantation is of a prime importance.
Its recommended as per CDC to avoid conception in the first year due to the high risk associated with it.
The allograft function has to be stable with constant anti rejection blood level and no proteinuria.
Medications to be avoided include MMF and mTORi, ACEi and ARBs have to be replaced with safer medications.
All contraceptives are safe and effective in controlling the contraception with its varied potential of causing drawbacks,
As per the general recommendation of CDC in complicated transplant patients {those with acute or chronic rejection and allograft dysfunction and allograft failure}combined hormonal contraceptives are category 4, mainly because of the heightened risk of thrombosis. Similarly IUD is category 3 in the complicated transplant patient , however preinserted device is permitted to continue, but no new IUD is advisable.
Its inherent that estrogen based contraceptive is associated with increased incidence of thrombosis, migraine headache and worsening hypertension control. furthermore , its metabolized via cytochrome p4503A2 bearing the potential interaction with CNi, necessitating close observation of CNi blood level. Similarly its use is not advocated in patients with chronic liver disease.
Depo Medroxyprogesteron:
is injection every 3 months highly effective with main advantage of no drug-drug interaction with immunosuppressants. Main shortcomings are osteoporosis and the increased risk of thromboembolism. Its metabolized in liver , therefore its not used in patients with liver disease.
Etonogestrel implant:
Its effective sub cutaneous contraceptive implant, that last effectively for 3 years, It has similar profile to depo medroxyprogesteron but lesser effect on bone density which is usually impacted secondary to the use of cortisone .
Transdermal patch:
It delivers estrogen and progestron through the skin. Some studies reported higher Thromboembolic risks than combined contraceptive pills.
Progestin only pills:
Main advantage is the avoidance of estrogen, the drawbacks are amenorrhea and failure rate of 5% which can drop to 0.5% if used correctly.Its metabolized in the liver with interaction with CNi. Its quite helpful in patients with hypertension and hypertension and cardiac disease.Silmilarly , its causing hyperlipidemia
IUD:
Either copper or levonorgestrel based, advantages, are no increase in thromboembolism, no drug-drug interaction and no bone effect. Side effect reported by some studies is increased local infection
mai shawky
2 years ago
Types and effectiveness of various types of contraception
Counseling of transplant recipients regarding pregnancy and contraception after successful kidney transplantation is essential. Females can regain their ovulatory cycles and fertility as soon as one-month post-transplant, so effective contraceptive method is essential to guard against unplanned pregnancy which can eventually lead to various maternal and fetal complications.
It is proven from available evidence that delay in conception for at least one-year post-transplantation and ensuring adequate graft function, GFR > 60 ml/min/1.73 m2, proteinuria less than 0.5 gm/day and well controlled blood pressure are associated with good pregnancy and graft outcomes. So effective contraception till that target is crucial.
Contraceptive methods are mainly 2 groups, permanent and temporary as shown in table 1 and 2 respectively.
table 1, 2 of contraceptive methods, advantages and adverse effects of each
Fatima AlTaher
2 years ago
Pregnancy after kidney transplantation is possible as most causes of infertility caused by renal failure are corrected. But pregnancy must be planned well as it’s still considered high risk pregnancy as associated with adverse events on mother, fetus and graft. Thus pregnancy should be postponed till the graft is stable to avoid harmful interaction between pregnancy and the graft.
Almost all contraceptive methods can be used post transplantation with variable failure rates and interaction with IS drugs.
Contraceptive methods are classified into
1- perminant as tuballigation in females and vasectomy in males
Very effective method but irreversible.
2- Temporary methods including
a- Barrier methods (safe but high failure rates) :
– male and female condums.
– Diaphragm or cervical cap with spermicides.
– Contraceptive spongs.
b- Hormonal methods : low failure rate but may interfere with IS e.g.
– Compined contraceptive pills
– Progesterone dermal patches
The safest and best methods for kidney recipients is IUD and transdermal progesterone as they have low failure rates, cheap and no interaction with IS
while other hormonal methods are effective but can interfere with IS as they are metabolized by CYP 450 A30 , also they may increase thrombotic tendency so better to be avoided in patients with previous VTE , stroke and antiphospholipid Antibodies syndrome.
Abdullah Raoof
2 years ago
the education of patients and their partners about the risks of unplanned pregnancy is avital point , as both of them are involved in choosing the method of contraception and the timing of pregnancy.
to avoid premature , unplanned pregnancy the methods of contraception should be educated before kidney transplantation .
Other important point include choosing of safe immunosuppressive medication and safe antihypertensive drugs .
Temporary Permanent
Copper and progestin intrauterine devices – Female tubal ligation
– Male vasectomy
Hormone methods
Estrogen and progesterone
Oral contraceptive pill
Transdermal patch
Vaginal ring
Progesterone only
Implant Barrier methods
Diaphragm with spermicide
Cervical cap with spermicide
Contraceptive sponge
Male condom
Female condom
Regarding the effectiveness of various types of contraceptive methods
devices
Failure Rates of Different Contraceptive Methods (Pearl Index)
Type of Contraception Failure Rate (Pearl Index)
Lactation for 12 mo 25
Coitus interruptus 9
Symptothermal method 1.5–11
Spermicidal foam 3
Diaphragm 2
Intrauterine device 1-3
Progesterone-only pill 1-2
Condom 0.4-1.6
Combined pill 0.1
Vasectomy 0.1
Tubal ligation 0.04
1- Combined hormonal contraceptives ( COCP )
COCP are considered ascategory 4.
Usually they are very effective with low failure rate , therefore they are in common use .
The most common side effect of this drug are due to the presence of estrogen, which include
· Worsening of migraine headaches,
· thromboembolism, and
· exacerbation of hypertension control.
COCP are metabolized by the cytochrome P4503A4 enzyme ; therefore drug drug interaction with CNI could be a problem .
Failure rate : 0.1 (Pearl Index)
It is contra indicated in
· a history of MI ,
· CVA
· DVT
· Migraine
· Poorly controlled hypertension
· active liver disease or liver adenoma .
2- Depot medroxyprogesterone acetate
Depot medroxyprogesterone acetate (Depo- Provera) is slow released (3month) a synthetic
Progestin it is very effective and safe method . failure rate = 2% because of poor drug adherence (delaying of injection ) .
Side effects : reversible osteoporosis , thromboembolisim .
Precaution in liver disease .
Advantage : no drug-drug interactions with immune suppressive drug .
It is a good choice .
3- Etonogestrel implant (E I )
E I T IS implanted subcutaneously in the upper arm.
Very effective ( 99% ) , duration of effect is 41 The effectiveness is > 99%, and the protection is 3 years.
It has temporary effect , the normal cycle restart ( within 3 weeks ) once it is stoped .
Side effect : bleeding irregularity .
The risk-benefit characteristic is like that of depo- provera.
it is safely advised, very effective and reversible effect.
4 – Transdermal contraceptive patch .
It is a cutaneous patch that release estrogen and progesterone. The blood level of these hormones are higher than that of COCP .
The risk of thromboembolism is similar to ( in one study it is twice higher than) COCP . 5-Progestin-only pills.
It contains only progestin (no estrogen ) therefore there is no estrogen related side effect .
Side effects : risk of amenorrhea with 5% failure rate, high first-pass liver , there is drug -drug interaction, weight gain, dyslipidemia .
Contraindicated in liver disease.
Failure Rate (Pearl Index) is 1-2 .
6-Intrauterine devices.
Intrauterine devices (IUDs) are category 2 .this method carry no additional risk of pelvic infection .
Advantages : easy insertion, long lasting, low failure rate (Pearl index, 1-3), no drug – drug interaction, No thromboembolism , ] cost-effective , long-lasting methods .
Contraindications : history of ectopic pregnancy and pelvic inflammatory condition.
Copper IUD and the levonorgestrel-releasing IUD has both effectivity and safety.
Although there is no good evidence , the immunosuppressive medication may decrease the efficacy of IUD .
7-The vaginal ring
The vaginal ring is a silastic ring that is impregnated with etonogestrel and ethinyl estradiol. It is effective (Pearl index, 1-3), controls the menstruation , has a lower blood level ( lower exposure )of ethinyl estradiol in comparison with COCP.
8-Barrier methods of contraception
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective with high failure rate (Pearl index, 0.4-1.6) and usually with poor compliance.
Success rate can reach 97% if used correctly and consistently.
Advantage : convenient and easy to use, no drug drug interaction.
Can be used in kidney transplant recipient , but is better when it is combined with other methods.
Education regarding this method enhance \ awareness and compliance and reduce the failure rate .
AMAL Anan
2 years ago
Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation
-The risk of rejection with invention of modern immunosuppressive on is reduced resulting in increasing number of women with reproductive age with good graft functions.
-Ovulation may start as soon as 1 month after transplant thereafter it is crucial to plan for a timely safe conception and effective maternity care .
the period of 1 year after transplant appears to be sufficient to minimise the risk of adverse events of pregnancy.
-Adequate graft function before conception ( no proteinuria and well controlled blood pressure) is key factor for safe pregnancy as both conditions associated with poor outcomes to foetus and pregnant mother after kidney transplant.
Methods of contraception must discussed before and soon after transplant surgery as fertility reversed 1-6 months after transplant.
Methods of contraceptions after kidney transplant:
either permenant or temporary
Permanent methods
female tubal ligation or male vasectomy but vasectomy associated with decreased risk of ectopic pregnancy but it is irreversible and invasive procedure.
Temporary methods…
* combined hormonal contraceptions:
– classified as category 4 in complicated transplant.
– contraceptive containing estrogen and progestin are commenly used in daily practice due to their effectiveness and minimal failure rates.
– studies showed low dose of oral contraceptives there were no pregnancy for at least 18 months.
– combined contraception is the main contraceptive methods in 58%.of women in study population.
– 42% of women used combined contraceptives for reducing menonhagia and reducing development of ovarian cysts.
– combined oral contraception metabolized by cytochrome p 450 , these drugs interact with calcineurin inhibitors in female kidney transplant.
– combined oral contraceptives are contraindicated :
1-history of myocardial infarction.
2- stroke or deep vein thrombosis.
3- migraine or uncontrolled hypertension.
4- active liver diseases or hepatic adenoma. *Depot medroxyprogesterone acetate : – synthetic progestin with slow release over three months.
– high effective and safe I failure rate 2%..
– reversible decrease in bone density due to normalize of DMPA acetate.
– risk of thrombo-embolism.
– No interaction with immune-suppression.
-good choice as motivated as patients adhere to injections sequdule.
– metabolise through liver so contra-indicated with active liver diseases.
ETONOGESTREL IMPLANT : –single silastic rod implanted subcutaneously in the upper arm.
-effectiveness is 97% and the protection lasts for 3 years .
-on removal, the etonogestrol drops rapidly and most patient ovulate after 3 weeks .
-adverse effects bleeding irregularities in minority of patients.
-affect bone density especially with using of steroids after transplan.
– safely advice, highly effective and reversible. transdermal contraceptives pathches: _ patch was placed transdermal through abdomen which delivers estrogen and progesterone, but level of ear roger higher than combined contraceptives.
– carry risk of thrombo-embolism like contraceptive methods by about 2 folds more.
Intrauterine devices :
-classified as category 2.
– studies showed that immune-compromised women at great risk of developing pelvic infections.
-but risk of infection significant increase after IUD insertion s but no benefit to use prophylactic antibiotics after IUD insertion.
-advantages:.
*effect reversible after removal.
* long lasting, low failure rate and easy insertions.
* not interact with immenosuppression.
* no risk of thrombo-embolism.
– contraindicated:-
* pelvic ectopic pregnancy.
* history of pelvic inflammation.
-copper IUD effective and safe for 10 years, while levonorgestrel-releasing intrauterine device lasts for 5 years.
-post-transplant immenosuppession decrease efficacy of IUD because modify lencoeyte response.
The vaginal ring :
silastic ring impregnated with etonogestrel and ethinyl estradiol
-effective and control of menstrual cycle .
-low side effects as compared to combined contraceptive due to low concentration of of ethinyl estradiol .
-serum ethinyl estradiol is lower compared to patch or combined contraceptive. BARRIER METHODS OF CONTRACEPTION
Less effective due to high failure rate and non-compliance.
if used correctly can be successful up to 97%.
*advantages :
easy method
convient
not interact with immunosuppressive
better with use with another methods of birth control
Wee Leng Gan
2 years ago
Contraception after kidney transplantation
Temporary method
Type 1) IUCD
PRO
Reversible contraception after IUCD removal.
Easy insertion method.
Long lasting.
Low failure rate.
No drug-drug interaction especially with immunosuppressant.
CONS
Risk of pelvic infection dispute view.
Contraindicated in history of ectopic pregnancy and pelvic inflammation.
2) Combined hormonal contraceptives
PRO
Regulate menstrual cycle and may protect from ovarian cysts.
Highly effective with low failure rate.
Estrogen component of OCP precipitated migraine , thromboembolism, and worsening hypertension control.
CONS
Worsening liver disease.
Drug-drug interaction with immunosuppressant.
3) Depot medroxyprogesterone acetate PRO
Highly effective with low failure rate.
No drug-drug interaction especially with immunosuppressant.
CONS
Risk of thromboembolism.
Aggravate active liver disease.
Decrease bone density.
4) Etonogestrel implant
PRO
Highly effective.
Long lasting at least 3 years.
Rapidly reversible.
CONS
Irregular menses.
Decrease bone mineral density however lower then Depot medroxyprogesterone acetate.
5) Transdermal contraceptive patch
PRO
Regulate menses.
Highly effective with low failure rate.
CONS
Two fold increase in the risk of venous thromboembolism.
6) Progestin-only pills
PRO
No estrogen related risk.
CONS
significant incidence of amenorrhea and the 5% failure rate.
Weight gained.
Drug-drug interaction especially with CNI.
Poor BP control precipitated CVS risks.
Not suitable for active liver diseases.
7) The vaginal ring.
PRO
Highly effective.
lower concentration of ethinyl estradiol.
CONS
Local irritation.
8) Barrier methods of contraception.
PRO
Convenient and easy to use.
No drug-drug interaction.
CONS
Less effective.
Compliance issue.
Permanent method
Type
Female tubal ligation.
PRO
Highly effective.
low failure rate.
No drug-drug interaction.
CONS
Ectopic pregnancy.
Irreversible.
Invasive procedure.
2.Male vasectomy
PRO
Highly effective.
low failure rate.
No drug-drug interaction.
CONS
Irreversible.
Invasive procedure.
In conclusion pregnancy following renal transplant has higher risk as compare to general population. However, pregnancy generally permitted after 2 years of renal transplant in uncomplicated condition. Proper counseling regarding risks and benefits of each contraception method is essential before renal transplant.
Tahani Hadi
2 years ago
Methods of contraception should be taken in consideration for kidney recipient women due to maternal and fetal complications that occur in higher rate than in general population.
Each one of these methods has it’s risk, side effects and effectiveness all should be discussed with the family to prevent unplanned pregnancy.
There are 2 main methods of contraception Permanent and temporary.
Permenant method consists of 2 main types female tubal ligation and male vasectomy,tubal ligation carries risk of ectopic pregnancy while vasectomy has no this risk and it’s non reversible.
Temporary method subdivided into different methods like:
Combined hormonal contraceptives
Depot medroxyprogestrone acetate
Etonogestrel implant
Transdermal patch
Progestin only pills
Intrauterine devices
Vaginal ring
Barrier methods of contraception
Combined hormonal contraceptives are widely used ,highly effective with minimum failure rate also used to regulate menstrual bleeding and protect from ovarian cysts.
Depot medroxyprogesteone acetate is synthetic progestin slow release over 3 months it’s highly effective and safe with no drug interactions with IS medications.
Etonogestrel implant is implanted subcutaneous in the upper arm effective and last for 3 years and if removed ovulation can occur after 3 wks so it’s rapidly reversible.
Transdermal contraceptives patch by using patch placed on the abdomen .
Progestin only pills are used to avoid estrogen related risks .
Intrauterine devices have low failure rate ,easily inserted , can be used for long duration,reversible, no IS drug interactions and no risk of thromboembolism.
The vaginal ring has advantage of low concentration of ethinyl estradiol.
Barrier methods like condoms,spermicides,,diaphragm,cervical cap and spongs all are less affective than other methods but they are easy to use and have no drug interactions.
CARLOS TADEU LEONIDIO
2 years ago
Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation
THESE METHODS ARE CLASSIFICADES IN:
A – PERMANENTS :
-Female tubal ligation: reversible surgical method, but there is a risk of tubal pregnancy.
– Male vasectomy: less risk of ectopic pregnancy, but is a invasive and irreversible procedure.
B – TEMPORARY:
– COMBINED HORMONAL ORAL CONTRACEPTIVES:
Contraceptives containing estrogen and progestin – in a study of 26 women who used combined low-dose oral contraceptives after renal transplant for at least 18 months, no pregnancy was reported.
Depot medroxyprogesterone acetate (DMPA) is a synthetic progestin with slow release over 3 months. It is a highly effective and safe contraceptive method. The failure rate is only 2% due to delay in repeat injections.
– INTRAUTERINE DEVICES :
Currently available data suggest that immunocompromised women are not at greater risk of developing pelvic infections and no differences in infectious morbidity. However, many studies indicated that the risk of infection is significantly increased immediately after IUD insertion in immunocompromised patients. The advantages of the IUD include easy insertion, long lasting, and low failure rate. Previous ectopic pregnancy and history of pelvic inflammation are contraindications to the use of IUDs.
Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years, are both effective and safe to use after kidney transplant
– VAGINAL RINGS:
It is effective controls the menstrual cycles and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
– SUBCUTANEOUS IMPLANTS : the effectiveness is > 99%, and the protection lasts for 3 years.
– BARRIERS METHODS
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate and the difficulty in achieving compliance. But, barrier success rate can reach 97% if used correctly and consistently. 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.
Ofonime Udoh
2 years ago
A] Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation
Contraception is important after transplantation, as pregnancy post- trabsplant has to be planned and timed. Fertility returns within months following a renal transplant, and so pregnancy can occur., However pregnancy in one who has had a renal transplant is asscociated with some increased risks, and the immunosuppresants are mostly teratogenic.
There are two main methods of contraception: permamnent and temporary. The permanent methods include tubal ligation and vasectomy. Vasectomy is preferred as its less likely to increase the risk of ectopic pregnancies [in the female] assocuated with tubal ligation.
The temporary forms of contraception include
the combined hormonal contraceptives,[ tablets], which have a mixtur of estrogen and pregesterone. Oestrogen is known to cause an increase in migraines,formation of clots, and a rise in blood pressure so is used with caution.It is also metabolized by the CYTP450 system aso may interact wioth some of the immunosuppresants.
the transdermal contraceptive patch contains a mix of estrogen and preogesterone, but more of estrogen. This patch is placed on the abdominal wall. It has the same risks as the combind pill discussed above
the Depot MedroxyProgesterone Acetate [DMPA] has progesterone and is given once in three months. It is quite safe, has the advantage of no drug interaction with the immunosupresants. It however can causea reversible loss of bone density which can be made worse by the steroids that alo caue bone density loss.
the Etonogestrel implant which is placed subcutaneouly and can alst up to three years. It is also a pregaterone based medicine, and causes less bone density loss than DMPA. It is safe, effective, rapidly reversible and advised for use in females post transplant for contraception.
the Pregestin-only pills: this has progesterone only in it thus avoiding the risks assocuated with Estrogem. It however has a failure rate of 5% in the first year. Just like the DMPA, adhering strictly to the medication is important in ensuring effectiveness. Thsi medication can also interact with Calcineurin inhibitors, and is not to be used inn cases of liver failure.
Intrauterine devices: the Copper-T which can protect up to 10 years and the levonorgesterol impregnanted device which lasts 5 years. These are alsosafe in women post transplant; are contrindicated in those with a history of pelvic inflammationn and ectopic pregnancy; are not associated with an increased risk of infection post insertion; and there is solid evidence that immunosuppresants affect its efficacy.
the Vaginal ring, a silastic ring impregnanted with ethinyl estradiol and etonorgestrel. The rin is effective, controls the menstrual cycles, and has siignificantly less levels of estrogen than the combined pills or patch, thus the patients are exposed to less amounts of estrogen.
barrier methods: condoms [male and female], spermicides, sponges, cervical caps. These, if used the right way, may give up to 97% siccees rate, but are known to have a high failure rate. They are convenient to use and avoid interactions with drugs being taken.
In summary, pregnancy must be planned post transplant: so contraception must be discussed before the transplant is doneand also post transplant. The available types opf contraceptives have been discussed above. The permanent form of contraception is safe, so is the IUD and the combined hormone contraceptives. The patient must be wholly infomed about the risks associated with pregnancy, the different types of copntraception and their associated risks, and will use this knowledge to make an informed decision about the type of contraceptive she will use.
MICHAEL Farag
2 years ago
I) permanent methods A) tubal ligation B) male vasectomy Permanent methods the most effective Male vasectomy has advantage over tubal ligation in avoidance of ectopic pregnancy but it is invasive and irreversible II) temporary methods A) Combined hormonal contraceptives they are highly effective and with minimal failure rate The risks with combined hormonal contraceptives are attributed to the estrogen component of these formulations, including exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control. Therefore; Patients who have a history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have active liver disease or hepatic adenoma are advised not to use combined hormonal contraceptives, as they may aggravate these conditions Note: COCs are metabolized by cytochrome P450 so may have interaction with some Is medications like CNIs B) Depot medroxyprogesterone acetate (synthetic progestin with slow release over 3 months) DMPA It is a highly effective and safe contraceptive method. The failure rate is only 2% due to delay in repeat injections. SE: – decrease bone density but it is reversible once it is stopped – Thromboembolic complications and this is the main risk factor – Not used for patients with liver affection as it is metabolized in liver Adv.: + no drug interaction + more compliance as only one injection every 3 months but needs adherence to the time of injection C) Etonogestrel implant The etonogestrel implant is a single silastic rod implanted subcutaneously in the upper arm.41 The effectiveness is > 99%, and the protection lasts for 3 years. On removal, the etonogestrel drops rapidly, with most patients ovulating after 3 weeks. So it can be safely advised to kidney transplant female recipient , because it is highly effective, and is rapidly reversible Etonogestrel implant has risk-benefit features similar to DMPA but has been shown to cause fewer decreases in bone mineral density D)Transdermal contraceptive patch Same mechanism, efficacy and side effects of COCs but it deliver estrogen and progesterone from a patch inserted subcutaneously; mainly in the abdomen with higher level of estrogen which may contribute to higher risks than COCs E)Progestin-only pills 5% failure rate during the first year are the major concerns; this rate drops to < 0.5% if used correctly and constantly. Progestin-only pills require ensured compliance to reduce failure rates It spares the risks of estrogen containing methods Interactions with medications that are metabolized by the liver can occur especially with CNI medications whiche requires careful monitoring of CNI levels progestin-only pills should be avoided in patients with liver disease. Progestin-only pills increase the risk of weight gain. F) Intrauterine devices Copper IUD and the levonorgestrel-releasing intrauterine system are both effective and safe to use after kidney transplant. Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years Adv.: + easy insertion, + long lasting, and + low failure rate + reversible after IUD removal + no drug interaction + no risk of thromboembolism Disdv.: the risk of pelvic infection G) The vaginal ring impregnated with etonogestrel and ethinyl estradiol. It is effective and works by controlling the menstrual cycles and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol H)Barrier methods of contraception Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate. 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
Ramy Elshahat
2 years ago
the pregnancy-associated risks described and the fact that fertility can be efficiently reverted within
1 to 6 months after a 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.
These measures would reduce the possible complications and adverse events that might occur during
pregnancy after a kidney transplant. Other concerns include the optimization of immunosuppressive agents
and antihypertensive medications.
There are 2 principal methods of permanent contraception and several temporary methods.
1. Permanent methods include
· female tubal ligation
· male vasectomy.
Vasectomy has the advantage of having fewer associated risks of ectopic pregnancy than tubal ligation, but it is a nonreversible and invasive procedure.
2. Temporary methods involve the use of
· combined hormonal oral contraception,
· intrauterine devices
· vaginal rings
· subcutaneous implants
· barriers, and natural methods like coitus interruptus. Combined hormonal contraceptives are commonly used in daily practice as they are highly effective and
with a minimal failure rate. The risks with combined hormonal contraceptives are attributed to the estrogen component of these formulations, including
· exacerbation of migraine
· headaches, the risk of thromboembolism, and
· worsening hypertension control
· Combined hormonal contraceptives are primarily metabolized by the cytochromeP4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients. Depot medroxyprogesterone acetate is a synthetic progestin with a slow-release over 3 months. It is a
highly effective and safe contraceptive method. The failure rate is only 2% due to delays in repeat
injections. The reversible decrease in bone density and concern about thromboembolic are the main causes of DMPA cessation. Etonogestrel implant is a single silastic rod implanted subcutaneously in the upperarm. The effectiveness is > 99%, and the protectionlasts for 3 years. On removal, the etonogestrel dropsrapidly, with most patients ovulating after 3 weeks.
The adverse effect of this method is the bleeding irregularity and decreases in bone mineral density encountered in a minority of patients. A transdermal contraceptive patch that delivers estrogen and progesterone through the transcutaneous on the abdomen but unfortunately the circulating levels of estrogen are substantially higher than with combined hormonal contraceptives which explains why Some studies have shown more than a 2-fold increase in the risk of venous thromboembolism associated with this method. Progestin-only pills: The advantage of progestin-only pills is the avoidance of estrogen-related but with an increase in the incidence of amenorrhea, the risk of weight gain, and a 5% failure rate during the first year. Progestin-only pills require ensured compliance to reduce failure rates Interactions with medications that are metabolized by the liver can occur with progestin-only pills, and they should be avoided in patients with liver disease. Intrauterine devices are classified as a category
2 compared with combined pills, which are classified as category 4 in complicated transplants. we have always been concerned regarding the development of pelvic infections but currently available data suggest that immunocompromised women are not at greater risk of developing pelvic infections.
Also, the risk of Previous ectopic pregnancy and a history of pelvic inflammation is considered contraindications to the use of IUDs.
Copper IUD and the levonorgestrel-releasing intrauterine system are both effective and safe to use after kidney transplants. Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years.
Theoretically, posttransplant immunosuppressive medications may decrease the efficacy of IUDs, possibly because they modify the leucocyte response. However, there is no solid evidence suggesting that the safety and effectiveness of the IUD would be compromised in the transplant patient. The vaginal ring is a silastic ring that is impregnated with etonogestrel and Ethinylestradiol. It is effective controls the menstrual cycles, and has the advantage of a lower concentration of Ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to Ethinyl estradiol Barrier methods of contraception Like condoms, spermicides, diaphragm, cervical
cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the
relatively high failure rate and difficulty in achieving compliance. The 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.
Education of couples regarding this method of contraception encourages awareness and compliance
and may reduce the failure rate of this method.
In conclusion
Early counseling, ideally before transplant, to discuss the methods of contraception and to allow women to make an informed choice regarding contraception and subsequent pregnancy is of paramount importance.
It sounds logical that patients must be made aware of the benefits and risks of each method used after transplant through proper education. Effective and suitable contraception is important to reduce the risk of unplanned pregnancy A multidisciplinary team approach involving obstetricians and nephrologists should be adopted to decide the appropriate timing for conception, ascertain appropriate follow-up, and advise on methods of contraception that suit the patient.
There is no ideal contraceptive method; the best is to individualize the method of contraception according to a patient’s individual risk.
kumar avijeet
3 years ago
Restoration of fertility post-transplant can be seen in 1 to 6mnth of transplant and post-transplant counselling regarding various methods of contraception is very important.
Various method of contraception-
I) Permanent methods: These can be utilized in patients not willing for further child-bearing.
1) Female tubal ligation: Associated with risk of ectopic pregnancy and has failure rates of 0.5%.
2) Male vasectomy: Invasive and non-reversible.
II) Temporary methods:
1)Combined hormonal contraceptives: These include contraceptives containing estrogen and progestin. The failure rate associated with their use is 0.3%. But the estrogen component can cause migraine headache exacerbation, increased blood pressures and thromboembolic events, hence are contraindicated in patients with history of stroke, myocardial infarction, deep vein thrombosis, migraine and uncontrolled hypertension as well as active liver disease and hepatic adenoma.
2) Depot Medroxy Progesterone Acetate (DMPA): It is long acting (3 months) with failure rate of 6% (due to delayed repeat injection). Its use has been associated with decreased bone mineral density.
3) Etonorgesterol implant: It is a very long-acting form of contraception with protection for 3 years, implanted in the upper arm subcutaneously and fertility reversal is achieved in 3 weeks post-removal with a failure rate of less than 1%.
4) Transdermal contraceptive patch: It delivers estrogen and progesterone, has 2 times increased risk of venous thromboembolism and has low failure rates (0.3%).
5) Progestin only pills: These avoid risks associated with estrogen but have failure rate of 5% initially which decreases to less than 0.5% later. They are useful in patients with high blood pressures but should be avoided in active liver disease and close monitoring of calcineurin inhibitor drug levels is required. They are associated with weight gain and altered lipid profile.
6) Intrauterine devices (IUD): They are long acting, cost-effective, easily inserted and have low failure rates (0.6-0.8%) with absence of increased risk of thromboembolism, immunosuppression drug interaction or associated increased pelvic infection rates. They should not be used in patients with history of pid.
i.Copper IUD:
ii. Levonorgesterol releasing IUD:
7) The vaginal ring: It is impregnated with etonorgesterol and ethinyl estradiol in lower concentration with low failure rates (1-3%)
8) Barrier methods of contraception: These include condoms, spermicides, diaphragm, cervical cap and sponges. They are easy to use, have no drug interactions but have relative high failure rates (12-23%) and associated with compliance issues. They are useful as an adjunct to other forms of contraception
Theepa Mariamutu
3 years ago
Improvement of fertility post-transplant can be seen in 1-6 months. Therefore, the role of pre-transplant and post-transplant counselling regarding methods of contraception is essential.
Several methods of contraception available post-transplantation:
I) Permanent methods: Patients not willing for further childbearing.
· Female tubal ligation: Associated with risk of ectopic pregnancy and failure rates of 0.5%.
· Male vasectomy: Invasive and non-reversible, but decreases the risk of ectopic pregnancy and has failure rate of 0.5%
II) Temporary methods:
1) Combined hormonal contraceptives: include contraceptives containing oestrogen and progestin
a. failure rate is 0.3%.
b. oestrogen component can cause migraine headache exacerbation, increased blood pressures and thromboembolic events, so contraindicated in patients with history of stroke, myocardial infarction, deep vein thrombosis, migraine, and uncontrolled hypertension as well as active liver disease and hepatic adenoma. Drug interactions with calcineurin inhibitors needs to be considered.
2) Depot Medroxy Progesterone Acetate (DMPA):
a. long acting (3 months) with failure rate of 6% (due to delayed repeat injection).
b. has no drug interactions but should not be used in patients with active liver disease and risks of thromboembolic events.
c. associated with decreased bone mineral density.
3) Etonorgesterol implant:
a. long-acting form (for 3 years)
b. implanted in the upper arm subcutaneously and fertility reversal is achieved in 3 weeks post-removal
c. failure rate of less than 1%.
4) Transdermal contraceptive patch:
a. delivers oestrogen and progesterone
b. 2 times increased risk of venous thromboembolism
c. has low failure rates (0.3%).
5) Progestin only pills:
a. These avoid risks associated with oestrogen
b. failure rate of 5% initially which decreases to less than 0.5% later
c. useful in patients with high blood pressures
d. should be avoided in active liver disease
e. close monitoring of calcineurin inhibitor drug levels is required.
f. associated with weight gain and altered lipid profile.
6) Intrauterine devices (IUD):
a. long acting, cost-effective, easily inserted
b. low failure rates (0.6-0.8%)
c. absence of increased risk of thromboembolism, immunosuppression drug interaction or associated increased pelvic infection rates.
d. should not be used in patients with history of previous ectopic pregnancy or pelvic inflammation.
e. Copper IUD: have long life of 10 years
f. Levonorgesterol releasing IUD:
life of 5 years
associated with less menstrual blood loss
very low failure rates (0.2%)
7) The vaginal ring
a. impregnated with etonorgesterol and ethinyl oestradiol in lower concentration
b. low failure rates (1-3%)
8) Barrier methods of contraception:
a. such as condoms, spermicides, diaphragm, cervical cap and sponges.
b. easy to use
c. have no drug interactions
d. relative high failure rates (12-23%)
e. associated with compliance issues.
f. useful as an adjunct to other forms of contraception
9) Other methods: These are very unreliable
a) Lactation amenorrhea:
b) Coitus interruptus: 20% failure rate
c) Symptothermal methods: 15-24% failure rate.
Various method of contraception-
I) Permanent methods:
*Female tubal ligation: Associated with risk of ectopic pregnancy and has failure rates of 0.5%.
*Male vasectomy: Invasive and non-reversible.
II) Temporary methods:
1-Combined hormonal contraceptives:
Are containing estrogen and progestin.
The failure rate is 0.3%.
Side effects:
migraine headache exacerbation
increased blood pressures
thromboembolic events,
contraindications:
in patients with history of stroke, myocardial infarction, deep vein thrombosis, migraine and uncontrolled hypertension as well as active liver disease and hepatic adenoma.
2-Depot Medroxy Progesterone Acetate (DMPA):
It is long acting (3 months) with failure rate of 6%
Side effect:
decrease bone mineral density.
3- Etonorgesterol implant:
It is a very long-acting form of contraception with protection for 3 years, implanted in the upper arm subcutaneously and fertility reversal is achieved in 3 weeks post-removal with a failure rate of less than 1%.
4-Transdermal contraceptive patch:
It delivers estrogen and progesterone,has low failure rates (0.3%)
Side effects :
has 2 times increased risk of venous thromboembolism.
5- Progestin only pills:
These avoid risks associated with estrogen but have failure rate of 5% initially which decreases to less than 0.5% later.
Side effects:
weight gain
altered lipid profile.
6 -Intrauterine devices (IUD):
Advantages
They are long acting ,easily inserted, and have low failure rates (0.6-0.8%) with absence of increased risk of thromboembolism, immunosuppression drug interaction.
i.Copper IUD:
ii. Levonorgesterol releasing IUD:
7- The vaginal ring: It is impregnated with etonorgesterol and ethinyl estradiol in lower concentration with low failure rates (1-3%)
8- Barrier methods of contraception:
These include condoms, spermicides, diaphragm, cervical cap and sponges.
They are easy to use, have no drug interactions but have relative high failure rates (12-23%) .
They are useful as an adjunct to other forms of contraception
Asmaa Khudhur
3 years ago
Evidence suggests that a period of 1 year after transplant appears to be sufficient to minimize the risk of adverse events due to pregnancy, as possible risks of acute rejection and graft loss and prematurity will be less after this time.Adequate graft function before conception (no proteinuria and well- controlled blood pressure) is the key factor toward a safe pregnancy because these 2 conditions are associated with poor outcomes to fetus and pregnant mothers after kidney transplant. Major complications to the fetus in pregnant transplant recipients include prematurity, intrauterine growth retardation, and low birth weight.The preterm delivery rate is 40% to 60% (whereas it is 5%-15% in the general population)
Complications and Pregnancy Outcomes in Female Patients After Kidney Transplantation:
Hypertension
Preeclampsia
Type 2 diabetes mellitus
Rejection
Graft loss within 2 y
Pregnancy Outcomes
Spontaneous abortion
Live birth
Prematurity ( 99%, and the protection lasts for 3 years.
On removal, the etonogestrel drops rapidly, with most patients ovulating after 3 weeks.
The adverse effect of this method is the bleeding irregularity encountered in a minority of patients.Etonogestrel implant has risk-benefit features similar to DMPA but has been shown to cause fewer decreases in bone mineral density.
It is safely advised, is highly effective, and is rapidly reversible.
Transdermal contraceptive patch
This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen.
The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives. events of nonfatal venous thromboembolism for the contraceptive patch, have a similar risk to combined hormonal contraceptives.
Combined hormonal contraceptives:
Combined hormonal contraceptives are classified as category 4 in complicated transplant.Contraceptives containing estrogen and progestin are commonly used in daily practice as they are highly effective and with minimal failure rate.
The risks with combined hormonal contraceptives are attributed to the estrogen component of these formulations, including exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control.
combined hormonal contraceptives were additionally used for reducing the development of ovarian cysts and menorrhagia. These drugs were found to regulate menstrual bleeding patterns and may protect from ovarian cysts.
Combined hormonal contraceptives are primarily metabolized by the cytochrome P4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients. Patients who have a history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have active liver disease or hepatic adenoma are advised not to use combined hormonal contraceptives, as they may aggravate these conditions.
Progestin-only pills
The advantage of progestin-only pills is the avoidance of estrogen-related risks.
The significant incidence of amenorrhea and the 5% failure rate during the first year are the major concerns.
Progestin-only pills require ensured compliance to reduce failure rates.
Progestin-only pills are orally administered, and, unlike DMPA and etonogestrel implant, they undergo the first-pass metabolism through the liver.
Interactions with medications that are metabolized by the liver can occur with progestin-only pills, and they should be avoided in patients with liver disease.
Their interaction with calcineurin inhibitors requires proper calcineurin inhibitor monitoring posttransplant.
Progestin-only pills increase the risk of weight gain, and both progestin-only pills and calcineurin inhibitors alter the metabolism of lipids in female kidney recipients.
Female kidney recipients who smoke or are at risk for cardiovascular problems such as high blood pressure may be able to use progestin-only pills since combined hormonal contraceptives are usually contraindicated for them.
Intrauterine devices
are classified as category 2
The advantages of the IUD include easy insertion, long lasting, and low failure rate.
The major advantage of using IUDs is that the effect is reversible after IUD removal, and immunosuppression drug interaction is not a concern in women with kidney transplants. In addition, it is not associated with increased risk of thromboembolism.
Previous ectopic pregnancy and history of pelvic inflammation are contraindications to the use of IUD.
Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years
Vaginal ring
impregnated with etonogestrel and ethinyl estradiol.It is effective ,controls the menstrual cycles, and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
Progesterone only Implant
Barrier methods
Diaphragm with spermicide
Cervical cap with spermicide
Contraceptive sponge
Male condom
Female condom
are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate and the difficulty in achieving compliance.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.
Permanent
Female tubal ligation
Male vasectomy
Vasectomy has the advantages of having less associated risks of ectopic pregnancy than tubal ligation, but it is a nonreversible and invasive procedure.
fakhriya Alalawi
3 years ago
Kidney transplant recipients are advised to delay pregnancy for a minimum of 1 year after transplant to reduce potential neonatal and maternal complications. An effective and suitable contraception is important to reduce the risk of unplanned pregnancy.
Temporary contraception methods involve the use of combined hormonal oral contraception, intrauterine devices, vaginal rings, subcutaneous implants, barriers, and natural methods like coitus interruptus.
· Combined hormonal contraceptives: Contraceptives containing estrogen and progestin are commonly used in daily practice as they are highly effective and with minimal failure rate. Risks includes: exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control. Combined hormonal contraceptives are primarily metabolized by the cytochrome P4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients.
· Depot medroxyprogesterone acetate is a synthetic progestin with slow release over 3 months. It is a highly effective and safe contraceptive method. The major concern of DMPA is the thromboembolic risk. Depot medroxyprogesterone acetate has the advantage of no drug interactions with immuno – suppressive medications of transplant patients and is a good choice as long as patients are motivated to adhere to the injection schedule.
· Etonogestrel implant: The effectiveness is > 99%, and the protection lasts for 3 years. The adverse effect of this method is the bleeding irregularity encountered in a minority of patients. This implant, a new method of contraception for female kidney recipients, can be safely advised, is highly effective, and is rapidly reversible.
· Transdermal contraceptive patch: This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen. The risk with this method is similar to that shown with combined hormonal contraceptives.
· Progestin-only pills: The advantage of progestin-only pills is the avoidance of estrogen-related risks. Progestin-only pills are orally administered, and, unlike DMPA and etonogestrel implant, they undergo the first-pass metabolism through the liver. Interactions with medications that are metabolized by the liver can occur with progestin-only pills, and they should be avoided in patients with liver disease. Their interaction with calcineurin inhibitors requires proper calcineurin inhibitor monitoring posttransplant. Progestin-only pills increase the risk of weight gain, and both progestin-only pills and calcineurin inhibitors alter the metabolism of lipids in female kidney recipients.
· Intrauterine devices Intrauterine devices (IUDs): Currently available data suggest that immunocompromised women are not at greater risk of developing pelvic infections. The major advantage of using IUDs is that the effect is reversible after IUD removal, and immunosuppression drug interaction is not a concern in women with kidney transplants. Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years, rendering these cost-effective and long-lasting methods of contraception for women with kidney transplants.
· The vaginal ring: It is effective, controls the menstrual cycles, and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
· Barrier methods of contraception Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate and the difficulty in achieving compliance. 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.
· Permanent methods include female tubal ligation and male vasectomy.
nawaf yehia
3 years ago
Methods of contraception after kidney transplantation:
There are 2 principal methods of permanent contraception and several temporary methods . Permanent methods include female tubal ligation and male vasectomy.
Temporary methods involve the use of combined hormonal oral contraception, intrauterine devices, vaginal rings, subcutaneous implants, barriers, and natural methods like coitus interruptus
Combined hormonal contraceptives
The risks with combined hormonal contraceptives are attributed to the estrogen component of these formulations, including exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control.
In a study of 26 women who used combined low-dose oral contraceptives after renal transplant for at least 18 months, no pregnancy was reported.
These drugs were found to regulate menstrual bleeding patterns and may protect from ovarian cysts.
Combined hormonal contraceptives are primarily metabolized by the cytochrome P4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients.
Patients who have a history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have active liver disease or hepatic adenoma are advised not to use combined hormonal contraceptives
Depot medroxyprogesterone acetate
Depot medroxyprogesterone acetate (DMPA; DepoProvera, Pfizer, New York, NY, USA)
Acts slowly , failure rate about 2% , The reversible decrease in bone density is a concern that normalizes on DMPA cessation
medroxyprogesterone acetate has the advantage of no drug interactions with immuno – suppressive medications of transplant patients and is a good choice as long as patients are motivated to adhere to the injection schedule. The metabolism of DMPA is through the liver; therefore, it is not recommended for those with active liver diseas
Etonogestrel implant
The etonogestrel implant is a single silastic rod implanted subcutaneously in the upper arm. The effectiveness is > 99%, and the protection lasts for 3 years. The adverse effect of this method is the bleeding irregularity encountered in a minority of patients.41 Etonogestrel implant has risk-benefit features similar to DMPA but has been shown to cause fewer decreases in bone mineral density, a concern that is also commonly encountered after transplant due to the effect of steroids on can be safely advised .
It is highly effective, and is rapidly reversible can be safely advised for transplanted females .
Transdermal contraceptive patch
This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen , its effectiveness and adverse effects profile is as for combined hormonal contraceptive pills .
Progestin-only pills
The advantage of progestin-only pills is the avoidance of estrogen-related risks.48 The significant incidence of amenorrhea and the 5% failure rate during the first year are the major concerns; this rate drops to < 0.5% if used correctly and constantly
they undergo the first-pass metabolism through the liver. Interactions with medications that are metabolized by the liver can occur with progestin-only pills, and they should be avoided in patients with liver disease. Their interaction with calcineurin inhibitors requires proper calcineurin inhibitor monitoring posttransplant. Progestin-only pills increase the risk of weight gain, and both progestin-only pills and calcineurin inhibitors alter the metabolism of lipids in female kidney recipients.
Intrauterine Devices
Currently available data suggest that immunocompromised women are not at greater risk of developing pelvic infections
The advantages of the IUD include:
1- easy insertion, long lasting , cost effective and low failure rate
2-the effect is reversible after IUD removal
3- immunosuppression drug interaction is not a concern in women with kidney transplants.
4-It is not associated with increased risk of thromboembolism
The vaginal ring
The vaginal ring (NuvaRing is a silastic ring that is impregnated with etonogestrel and ethinyl estradiol. controls the menstrual cycles, and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
Barrier methods of contraception
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate and the difficulty in achieving compliance. Barrier success rate can reach 97% if used correctly and consistently.
They have the advantage of being a 1)convenient and easy to use method of contraception while also 2) 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.
Radwa Ellisy
3 years ago
Fertility is shortly regained (1-6 months after transplantation)
Unplanned pregnancy must be avoided in transplant recipients to avoid pregnancy-associated risks and to optimize immunosuppression and antihypertensive agents
Methods of contraception should be discussed before transplantation
manal jamid
3 years ago
There are different methods of contraception and their efficacy critically evaluated after kidney transplant and they are successful with acceptable risk.
individualizing the method of contraception according to a patient’s individual risks and expectations is essential.
There are 2 principal methods
A. permanent contraception such as female tubal ligation and male vasectomy.
B. several temporary methods such as
1. intrauterine devices (Copper and progestin)
2. Hormone methods Estrogen and progesterone e.g.: Oral contraceptive pill, Transdermal patch Vaginal Ring Progesterone Only Implant
3. Barrier methods Diaphragm with spermicide, Cervical cap with spermicide Contraceptive sponge, Male condom, Female condom — Combined hormonal contraceptives
Are highly effective and with minimal failure rate. The risks are attributed to the estrogen component, including exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control.
As they metabolized by the cytochrome P4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors.
It’s not advice for women who have a history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and active liver disease or hepatic adenoma, as they may aggravate these conditions. — Depot medroxyprogesterone acetate
Is a synthetic progestin with slow release over 3 months, highly effective and safe, failure rate is only 2% due to delay in repeat injections, the reversible decrease in bone density has the thromboembolic risk. no drug interactions (IS). The metabolism of DMPA is through the live therefore, it is not recommended for those with active liver disease –Etonogestrel implant
Effectiveness is > 99%, and the protection lasts for 3 years is a single silastic rod implanted subcutaneously in the upper arm. side effect is the bleeding irregularity. fewer decreases in bone mineral density, transplant due to the effect of steroids on bones. –Transdermal contraceptive patch
This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen. ▪︎The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives
—Progestin-only pills
The advantage of progestin-only pills is the avoidance of estrogen-related risks. the major concerns are amenorrhea and the 5% failure rate during the first year this rate drops to < 0.5% if used correctly and constantly▪︎ Interactions with medications that are metabolized by the liver can occur, and they should be avoided in patients with liver disease. Their interaction with calcineurin inhibitors requires proper calcineurin inhibitor monitoring post-transplant. Female kidney recipients who smoke or are at risk for cardiovascular problems such as high blood pressure may be able to use progestin-only pills.
–-IUCD
The major advantage of IUDs is that the effect is reversible after removal, . Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years and has no drug interaction with (IS)., it is not associated with increased risk of thromboembolism. Copper IUD and the levonorgestrel-releasing intrauterine system are both effective and safe to use after kidney transplant. –The vaginal ring
Has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol
▪︎Serum ethinyl estradiol levels of patients showed much lower variations with the vaginal ring than with the patch or combined hormonal contraceptives. —Barrier methods of contraception:
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the
relatively high failure rate and difficulty in achieving compliance.
– 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 post-transplant but are best when combined with another method of birth control to reduce their potential failure rate.
.
Mohammed Sobair
3 years ago
Contraception After Kidney Transplantation, From Myth to Reality:
A Comprehensive Review of the Current Evidence.
Summarize the types and the effectiveness of the various methods of
contraception after kidney transplantation.
Ovulation may start as soon as 1 month after transplant; therefore, it is crucial to plan for
a timely, safe conception and effective maternity care.
Education of patients and counseling with her partner during workup forkidney
transplant, decision of choosing the method of contraception that is appropriate for
them and the timing of pregnancy.
A multidisciplinary team approach involving obstetricians and transplant clinicians to
decide the appropriate timing for conception is recommended.
Methods of contraception after kidney transplantation:
(1) Permanent :
Female tubal ligation devices Male vasectomy.
May be used if couple complete their families or if they do not want children.
Advantage:
Less risk of ectopic pregnancy, low failure rate.
Disadvantage:
Nonreversible and invasive procedure.
(2)Temporary:
Combined hormonal contraceptives:
Estrogen and progesterone Oral contraceptive pill.
Transdermal patch.
The risk with this method is similar to that shown with combined hormonal
contraceptives.
Vaginal ring:
Impregnated with etonogestrel and ethinyl estradiol.
Controls the menstrual cycles.
Advantage of a lower concentration of ethinyl estradiol compared with combined
hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
Advantage:
Highly effective and with minimal failure rate 0.1%.
Disadvantage:
Exacerbation of migraine headaches, the risk of thromboembolism, and worsening
hypertension control. Venous thrombosis.
Drugs’ interactions with CNI.
Contraindication:
Myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled
hypertension and p active liver disease or hepatic adenoma.
Progesterone only Implant:
Depot medroxyprogesterone acetate:
Progestin with slow release over 3 months.
Advantage:
Effective a good choice and safe method.
No drug interactions with immunosuppressive medications.
Disadvantage:
The failure rate is 2%.
Thromboembolic risk.
Decrease in bone density.
Contraindication:
Active liver disease.
Etonogestrel implant:
The effectiveness is > 99%, and the protection lasts for 3 years.
Rapidly reversible.
Less bone effect on bone density.
Disadvantage:
Bleeding irregularity.
Progestin-only pills:
Advantage of progestin-only pills is the avoidance of estrogen-related risks.
Disadvantage:
Amenorrhea and the 5% failure.
Interactions with medications that are metabolized by the liver.
Interaction with CNI requires proper monitoring.
Weight gain.
Contraindication:
Active liver disease.
Intrauterine devices:
Copper and progestin intrauterine device both effective in posttransplant.
Classified as category 2.
Advantage:
Easy insertion, long lasting, and low failure rate 1-3.
Copper IUD has an effective duration of 10 years, and the Levonorgestrel-releasing
intrauterine system lasts for 5 years.
Contraindications:
Previous ectopic pregnancy and history of pelvic inflammation.
Barrier methods of contraception:
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective
contraceptive methods for organ transplant recipients due to the relatively high failure
rate 0.4-1.6.
Advantage of being a convenient and easy to use method of contraception while also
avoiding potential drug interact.
Barrier methods can be used posttransplant but are best when combined with another
method of birth control to reduce their potential failure rate.
Though OCP most commonly used in posttransplant patient, long-acting reversible
contraception is an ideal method of contraception for women with transplants because
they are highly effective, require a single office visit for initiation, and do not require daily
adherence.
As the findings of the Contraceptive CHOICE project recently established that long-
acting reversible contraception, including intrauterine devices and contraceptive
implants, provides the most effective contraception and decreases the rate of unplanned
pregnancies in general.(1)
The benefits generally outweigh the risks for most contraceptive methods (including
intrauterine devices) in an uncomplicated solid organ transplantation patient (2).
References:
1-Winner B, Peipert JF, Zhao Q, Buckel C, Madden T, Allsworth JE, et al. Effectiveness
Of long-acting reversible contraception. N Engl J Med. 2012; 366:1998–2007.
2-Centers for Disease Control and Prevention (CDC) U S. medical eligibility criteria
For contraceptive use, 2010. MMWR Recomm Rep. 2010; 59(RR-4):1–86.
Zahid Nabi
3 years ago
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 and it should be individualized. This review has addressed this issue which sometimes is ignored by transplant teams.
Considering pregnancy-associated risks 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.
Methods of contraception after kidney trans- plantation
There are 2 principal methods of permanent contraception and several temporary methods. Permanent methods include female tubal ligation and male vasectomy.
Vasectomy has the advantage of having less associated risks of ectopic pregnancy than tubal ligation, but it is a nonreversible and invasive procedure.
Combined hormonal contraceptives
Contraceptives containing estrogen and progestin are commonly used in daily practice as they are highly effective and with minimal failure rate .
The risks with combined hormonal contraceptives are attributed to the estrogen component of these formulations, including exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control.
Depot medroxyprogesterone acetate
It is a highly effective and safe contraceptive method. The failure rate is only 2% due to delay in repeat injections.
The major concern of DMPA is the thromboembolic risk and reversible decrease in bone density.
It has advantage of no drug interaction with immunosupressives commonly used in kidney transplant patients.
Etonogestrel implant
The etonogestrel implant is a single silastic rod implanted subcutaneously in the upper arm. The effectiveness is > 99%, and the protection lasts for 3 years.
The adverse effect of this method is the bleeding irregularity encountered in a minority of patients
Transdermal contraceptive patch
Some studies have shown more than 2-fold increase in the risk of venous thromboembolism associated with this method.
Progestin-only pills
The advantage of progestin-only pills is the avoidance of estrogen-related risks.
The significant incidence of amenorrhea and the 5% failure rate during the first year are the major concerns; this rate drops to < 0.5% if used correctly and constantly.
Should be avoided in patients of liver disease
Intrauterine devices
Currently available data suggest that immunocompromised
women are not at greater risk of developing pelvic infections.
The advantages of the IUD include easy insertion, long lasting, and low failure rate and the fact that the effect is reversible after IUD removal, and immunosuppression drug interaction is not a concern in women with kidney transplants.
The vaginal ring
The vaginal ring is impregnated with etonogestrel and ethinyl estradiol.
The advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives is lower risk of complications related to ethinyl estradiol
Barrier methods of contraception
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate
They have the advantage of being a convenient and easy to use method of contraception while also avoiding potential drug interactions.
Ahmed Abd El Razek
3 years ago
Permanent:
Female Tubal ligation (risk of ectopic pregnancy) and male vasectomy. nonreversible and invasive procedure.
Temporary:
Combined hormonal contraceptives and Transdermal contraceptive patch:
They are highly effective and with minimal failure rate.
Side effects: exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control.
N.B. Combined hormonal contraceptives are primarily metabolized by the cytochromeP4503A4, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important.
Contraindicated in: history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have active liver disease or hepatic adenoma.
Depot medroxyprogesterone acetate:
Highly effective and safe contraceptive method.
Side effect: Thromboembolic risk, alteration in bone density.
Advantages: no drug interactions with immuno -suppressive medications of transplant patients and is a good choice as long as patients are motivated to adhere to the injection schedule.
Contraindicated in: active liver disease.
Etonogestrel implant:
The effectiveness is > 99%, and the protection lasts for 3 years. Adverse effect: may be associated with bleeding irregularity.
Progestin-only pills:
5% failure rate during the first year.
Side effect: Amenorrhea, weight gain.
Disadvantages:
Require ensured compliance, orally administered (undergo the first-pass metabolism),drug interactions.
Contraindicated in liver diseases.
Intrauterine devices:
Highly effective (category 2)
Advantages:
Easy insertion, long lasting, and low failure rate, the effect is reversible after IUD removal, no drug interactions, no risk of thromboembolism. Cost-effective and long-lasting.
Contraindications:
Previous ectopic pregnancy and history of pelvic inflammation.
The vaginal ring:
Effective
Barrier methods of contraception:
Less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate, and the difficulty in achieving compliance.
Advantages: convenient and easy to use method of contraception, no potential drug interactions.
Mahmud Islam
3 years ago
Menstrual functions and fertility improve shortly after successful kidney transplantation. Ovulation may improve as early as 1-month post-transplantation. An unplanned pregnancy can cause severe problems for the mother and fetus. For that, couples should e educated regarding protection, especially at least for the first year. Close monitoring is also essential for optimal pregnancy outcomes with optimized renal function, controlled blood pressure, and proteinuria.
Contraception methods differ in terms of effectiveness and reversibility. Male vasectomy and tubal ligation are permanent with lowest failure rates 0.1 and 0.04, respectively. Other reversible methods vary in efficacy and duration. Natural methods include timing and lactation with failure rate of 25 compared to 9 for coitus interrupts. A summary is provided in the table below:
(please see attached photo ; as table could not be pasted)
Ahmed Omran
3 years ago
Role of pre-transplant and post-transplant counselling regarding various methods of contraception is highly important.as restoration of fertility can be seen in 1-6 months following Tr
Different methods of contraception include:
Permanent methods; indicated when not willing for further child-bearing including tubal ligation: with risk of ectopic pregnancy and failure rates of 0.5% and including male vasectomy It is Invasive and irreversible, but decreases risk of ectopic pregnancy ;its failure rate 0.5%
Temporary methods include :
* Combined hormonal contraceptive: containing estrogen and progestin. Failure rate is 0.3%. Estrogen component can cause migraine exacerbation, increased blood pressures and thromboembolic events; contraindicated in patients with history of stroke, myocardial infarction, DVT, migraine and uncontrolled hypertension & active liver disease and hepatic adenoma. Drug interactions with calcineurin inhibitors is to be considered.
* DEPO MEDROXY PROGESTERONE ACETATE (DMPA): long acting (3 months) with failure rate of 6% (related delayed repeat injection). No drug interactions but contraindicated in patients with active liver disease and those risks of thromboembolic events. It has side effects decreased bone mineral density.
* Etonoregesterol : an implant with very long-acting form of contraception for 3 years, implanted in the upper arm subcutaneously and fertility reversal is achieved in 3 weeks post-removal ;its failure rate of less than 1%.
*Transdermal contraceptive patch: ( estrogen and progesterone), has 2 fold increased risk of venous thromboembolism and low failure rates (0.3%).
* Progestin pills: avoiding risks associated with estrogen but with failure rate of 5% initially which decreases to less than 0.5% later. It has advantage in patients with high blood pressures ;to be avoided in active liver disease with close monitoring of calcineurin inhibitor. They are associated with weight gain and dyslipidemia. *Intrauterine device; long acting ,easily inserted cost-effective, and have low failure rates (0.6-0.8%) without increased risk of thromboembolism, immunosuppression drug interaction or increased pelvic infection rates. They are contraindicated in patients with history of previous ectopic pregnancy or pelvic inflammation.
*Vaginal ring;impregnated with etonorgesterol and ethinyl estradiol with lower concentration ; low failure rates (1-3%)
Barrier methods: condoms, spermicides, diaphragm, cervical cap and sponges; easy to use, no drug interactions but with relative high failure rates (12-23%) and associated with compliance issues. They are useful as an adjunct methods.
* Others : These are very unreliable including lactation amenorrhea, coitus interruptus: 20% ;failure rate & Sympto thermal methods;15-24% failure rate; all considered unreliable.
Hinda Hassan
3 years ago
There are 2 principal methods of permanent contraception and several temporary methods. It is better to use combined methods and provide education to enhance compliance.
Permanent methods include female tubal ligation and male vasectomy. Vasectomy has the advantage of having less associated risks of ectopic pregnancy than tubal ligation, but it is a nonreversible and invasive procedure. Temporary methods involve the use of the following: Combined hormonal contraceptives:
Combined hormonal contraceptives are classified as category 4 in complicated transplant. Contraceptives containing estrogen and progestin are commonly used in daily practice as they are highly effective and have minimal failure rate Disadvantages:
Ø exacerbation of migraine headaches
Ø the risk of thromboembolism
Ø worsening hypertension control
Ø drug interaction with CNI Advantages:
Ø effective in preventing pregnancy by 100%
Ø reducing the development of ovarian cysts and menorrhagia. Contraindications
Ø History of myocardial infarction, stroke, deep venous thrombosis, migraine and uncontrolled hypertension.
Ø Patients who have active liver disease or hepatic adenoma. Depot medroxyprogesterone acetate:
This is a synthetic progestin with slow release over 3 months. It is a highly effective and safe contraceptive method. The failure rate is only 2% due to delay in repeat injections. Disadvantages:
Reversible decrease in bone density
thromboembolic risk Advantage:
No drug interactions with immuno – suppressive medications Contraindications:
Active liver disease
Etonogestrel implant
This is a single silastic rod implanted subcutaneously in the upper arm. The effectiveness is > 99%, and the protection lasts for 3 years. On removal, the etonogestrel drops rapidly, with most patients ovulating after 3 weeks. Disadvantages:
Ø Bleeding irregularity in a minority of patients.
Ø Fewer decreases in bone mineral density than the previous method
Transdermal contraceptive patch
Trans-dermal patch is placed on the abdomen. The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives. Disadvantages:
Nonfatal venous thromboembolism events
Progestin-only pills Advantage:
Ø Avoidance of estrogen-related risks.
Ø Can be used in those who smoke or are at risk for cardiovascular problems such as high blood pressure.
Disadvantages:
Ø amenorrhea
Ø 5% failure rate during the first year which drops to < 0.5% if used correctly and constantly require ensured compliance to reduce failure rates.
Ø interaction with calcineurin inhibitors
Ø Interactions with medications that are metabolized by the liver Contraindications:
Ø Liver disease.
Ø weight gain
Ø alter the metabolism of lipids Intrauterine devices
Those are classified as category 2 in complicated transplants. Copper IUD and the levonorgestrel-releasing intrauterine system are both effective and safe to use after kidney transplant. Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years. Currently available data suggest that immunocompromised women are not at greater risk of developing pelvic infections as shown in a study in 649 women with human immunodeficiency virus infection. Other studies indicated that the risk of infection is significantly increased immediately after IUD insertion in immunocompromised patients. Grimes and associates studied the use of antibiotic prophylaxis for IUD insertion but found this conferred little benefit. Advantages:
Ø easy insertion
Ø long lasting
Ø low failure rate
Ø reversible effect after IUD removal
Ø no immunosuppression drug interaction
Ø Not associated with increased risk of thromboembolism.
Ø Levonorgestrel-releasing intrauterine system was shown to reduce menstrual blood loss.
A study in 649 patients showed no increase in overall complications in women regardless of immune status. Another study in 599 participants showed no differences in infectious morbidity. Contraindications:
Previous ectopic pregnancy and history of pelvic inflammation
Theoretically, posttransplant immunosuppressive medications may decrease the efficacy of IUDs, possibly because they modify the leucocyte response but there is no solid evidence . The vaginal ring
The vaginal ring is a silastic ring that is impregnated with etonogestrel and ethinyl estradiol. Advantage:
Ø controls the menstrual cycles
Ø lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
Ø In a trial, the vaginal ring group showed that exposure to ethinyl estradiol was significantly 3.4 times lower than in the patch group and 2.1 times lower than in the combined hormonal contraception group. Serum ethinyl estradiol levels of patients showed much lower variations with the vaginal ring than with the patch or combined hormonal contraceptives.
Barrier methods of contraception
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate and the difficulty in achieving compliance. Barrier success rate can reach 97% if used correctly and consistently. Advantages:
Ø Convenient and easy to use method of contraception
Ø Avoiding potential drug interactions.
Shereen Yousef
3 years ago
▪︎Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation.
Transplantation Improves fertility in women ,
Ovulation may starts about 1 month after transplant; therefore, it is crucial to plan for a timely, safe conception and effective maternity.
Evidence suggests that a period of 1 year after transplant appears to be sufficient to minimize the risk of adverse events due to pregnancy.
risks includes
acute rejection and graft loss.
prematurity will be less after 1 year .
Hypertension and DM.
Adequate graft function before conception (no proteinuria and well-controlled blood pressure) is the key factor toward a safe pregnancy .
▪︎Methods of contraception after kidney transplantation
There are 2 principal methods of permanent contraception and several temporary methods
*Permanent methods
Permanent methods include female tubal ligation ,high risk of ectopic pregnancies.
and male vasectomy which is invasive and permanent.
*Temporary methods:
*Hormone methods
Using Hormonal estrogen or progesteron alone or combined .
It is provided in different forms ( pills ,patches,implants ,injection)
Main side effects are related to estrogen, including exacerbation of migraines, the risk of thromboembolism, and worsening hypertension control.
it is also metabolised by the cytochrome P450 with possibility of interaction with CNI.
Progesterone only methods avoids the side effects of estrogen but still can cause thromboembolism.
* intrauterine devices is long acting, cost-effective, low failure rates ,with no risk of thromboembolism,no effect on CNI metabolism.
* Barrier methods( male or female condoms ,vaginal ring )
These are safe regarding drug interactions but high failure rates .
Last edited 3 years ago by Shereen Yousef
ahmed saleeh
3 years ago
Ovulation may start as soon as 1 month after transplant; therefore, it is crucial to plan for a timely, safe conception and effective maternity care.
period of 1 year after transplant appears to be sufficient to minimize the risk of adverse events due to pregnancy
Adequate graft function before conception (no proteinuria and wellcontrolled blood pressure)
methods of contraception are discussed before and initiated soon after transplant surgery to prevent premature, unplanned, and unadvised pregnancies.
Contraception methods :
Permanent methods include female tubal ligation and male vasectomy
Temporary methods :
OCPs: side effects increase migrane , thrombosis and HTN
careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients.
DMPA : The major concern of DMPA is the thromboembolic risk. But benefit from no drug interaction with immunosuppressive drugs . Not used in hepatic patients.
Etonogestrel implant has risk-benefit features similar to DMPA but has been shown to cause fewer decreases in bone mineral density but 99 % success percent.
advantage of progestin-only pills is the avoidance of estrogen-related risks
IUD : category 2 while OCP category 4
The advantages of the IUD include easy insertion, long lasting, and low failure rate and reversible with immunosuppression drug interaction .
Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years,
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate
minimum of 1 year after transplant to reduce potential neonatal and maternal complications.
Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation
There are two principal methods of permanent contraception and several temporary methods.
Permanent methods:
female tubal ligation.
male vasectomy: less risk of ectopic pregnancy but is irreversible and invasive.
Temporary methods:
Intrauterine devices
Hormone methods
Barrier methods
Hormone methods:
Combined hormonal contraceptives:
They are highly effective with a minimal failure rate.
The risks are attributed to the estrogen component of these formulations, including exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control.
They are primarily metabolised by the cytochrome P450 and hence the possibility of interaction with CNI.
Depot medroxyprogesterone acetate:
Is synthetic progesterone with a slow release over 3 months.
It is highly effective, and safe, with a low failure rate.
The major concern about it is the risk of thromboembolism.
There is no interaction with IS medication.
Metabolised in the liver, so it is not recommended in cases of liver disease.
Etonogestrel implant:
A single silastic rod is implanted subcutaneously in the upper arm.
It is more than 99% effective and the protection lasts for 3 years with a fewer decrease in BMD.
The adverse effect is irregular bleeding.
In general, it is safe, highly effective, and rapidly reversible.
Transdermal contraceptive patch:
This method delivers estrogen and progesterone through a transdermal patch placed on the abdomen. The risk is similar to that of combined oral contraceptive pills.
Progestin-only pills:
The advantage of this method is the avoidance of estrogen and its problems.
Amenorrhea and 5% failure rate in the first year are the major concerns.
Requires compliance.
Metabolised in the liver and has an interaction with CNI.
Increases the risk of weight gain through altering lipid metabolism.
May be useful in females with high cardiovascular risk.
Intrauterine devices:
Classified as category 2.
There is a controversy about the risk of PID in immunocompromised woman.
Some suggested the use of prophylactic AB but then it was found to be of little benefit.
The major advantage is that the effect is reversible.
other advantages:
easy insertion
low failure rate
no interaction with IS medications
no risk of thromboembolism
copper IUD and levonorgestrel-releasing IUD are safe, cost-effective, and long lasting in KTx.
The vaginal ring:
has an advantage of lower concentration of ethinyl estradiol compared to combined oral contraceptive pills and is effective.
Barrier methods of contraception:
Less effective due to the relatively high failure rate and the difficulty in achieving compliance.
The advantage of them is being a convenient and easy to use and the avoidance of drug interaction.
They should be combined with other method to reduce their potential failure rate.
Sahar elkharraz
3 years ago
Fertility rate improved after kidney transplant within months and there’s high risk effects of pregnancy on graft and may lead to graft loss due to increase incidence of uncontrolled hypertension and develops of preeclampsia; also evidence of teratogenic effects of immunosuppressive drug on foetus with high risk of prematurity.
So ladies with kidney transplant should counselling regarding conception from one to two years after transplant to avoid unplanned pregnancy and should monitoring her blood pressure and her medication 3 months before pregnancy to avoid teratogenic effects of immunosuppressive agents.
Methods of contraception:
Permanent by tubal ligation but still history of ectopic pregnancy.
Another permanent option is male vasectomy
Temporary method is combined oral hormonal therapy (oestrogen & progesterone ); but there is risk of hypertension and arterial and venous thrombosis and exacerbation of migraines.
Progesterone only pills but still risk of thrombosis
vaginal ring
intrauterine contraception device (IUCD) safe and effective method but there’s risk of infection and bleeding.
Male and female condoms but high risk of failure rate
it’s not safe and not effective.
Lactation:
All immunosuppressive agents excreted in breast milk in small level and not side effects on babies.
But cellcept should shift to azathioprine during pregnancy and lactation because it’s effects on foetus
Sirolimus contraindicated in pregnancy and lactation.
Rituximab should be avoiding in pregnancy and lactation.
References:
Mina Al-Badri, MBCHB, Juliana M. Kling, MD, MPH and Suneela Vegunta, MD; Reproductiveplanning for women after solid-organ transplant:Cleveland Clinic Journal of Medicine September 2017, 84 (9) 719-728; DOI: https://doi.org/10.3949/ccjm.84a.16116
Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation :
there has been a long-standing misconception that contraception in patients with renal transplantation is a challenge. this misconception originates from the possible interaction with immunosuppressive medicines and possible graft dysfunction. also, the good evidence regarding pregnancy with transplantation is lacking and most data are derived from observational and case-controlled studies.
this review discussed different methods of contraception in these patients. the conclusion was as following :
1- pregnancy after renal transplantation is normal and encountered. however, both maternal and fetal complications rates are higher if compared with non-transplant patients.
2- pregnancy affects graft functions. therefore, it is advised to delay pregnancy to be at least 1 year post-transplantation to ensure stable and satisfactory graft functions.
3-effective and suitable contraception is important as it decreases the risks of unplanned pregnancy with its complications.
4- different methods can be used for contraception. each method has its own benefits and risks. also, no ideal method is the best. the decision should be individualized.
5- early counseling by a multidisciplinary team is important. this team will negotiate with the patient the best timing of pregnancy and the suitable method of contraception.
6- combined oral contraceptive pills can be used safely in stable graft function.
7- IUD is safe and effective with no evidence of increased infection.
8- permanent methods are valid options in some selected patients.
Counselling the female recipient pre& post-transplant about the contraception is very important , for safe pregnancy for the mother & the fetus.
Various methods of contraception available post-transplantation include:
· Permanent methods: mostly surgical method,
1-Female tubal ligation: (risk of ectopic pregnancy, failure rates of 0.5%).
2- Male vasectomy: (decreases the risk of ectopic pregnancy, failure rate of 0.5%)
· Temporary methods:
These include:
1. intrauterine devices (Copper & progestin IUD), it is long acting, cost-effective, easily inserted and have low failure rates (0.6-0.8%) with no risk of DVT , nor drug interaction
2. Hormone methods
Hormonal contraceptives are either estrogen or progesterone based or combined. They are commonly used , highly effective with minimal failure rate. It`s side effects incude exacerbation of migraines, the risk of VTE, and worsening hypertension control.
– Estrogen and progesterone
– Oral contraceptive pill
– Transdermal patch
– Vaginal ring
– Progesterone only
Implant
3. Barrier methods(they haven’t drug interactions but have relative high failure rates (12-23%) and associated with compliance issues. They are useful as an adjunct to other forms of contraception.
Contraception After Kidney Transplantation, From Myth to Reality: A Comprehensive Review of the Current Evidence
A multidisciplinary team approach involving obstetricians and transplant clinicians is needed to decide the appropriate timing for conception is recommended as its mainly individualizing. Methods of contraception after kidney trans – plantation: 1-Permenant.
Female tubal ligation 0.04 (Pearl Index).
Male vasectomy with failure rate 0.1 (Pearl Index). 2-Temporary. a-Combined hormonal contraceptives.
Highly effective and with minimal failure rate(0.1 according to (Pearl Index). b-Depot medroxyprogesterone acetate.
It is a highly effective and safe contraceptive method. The failure rate is only 2% due to delay in repeat injections. c-Etonogestrel implant.
The effectiveness is > 99%, and the protection lasts for 3 years. d-Transdermal contraceptive patch.
minimal failure rate(0.1 according to (Pearl Index) like COC. e- Progestin-only pills.
The 5% failure rate during the first year are the major concerns; this rate drops to < 0.5% if used correctly and constantly. f- Intrauterine devices.
Failure Rate (Pearl Index) 1-3. g- The vaginal ring.
It is effective (Pearl index, 1-3). h- Barrier methods of contraception.
Barrier success rate can reach 97% if used correctly and consistently with high failure rate e (Pearl index, 0.4-1.6).
Fertility in patients with end stage renal disease can be efficiently reverted within 1 to 6 months after kidney transplant; that’s why methods of contraception should be discussed before and initiated soon after transplant surgery to prevent premature, unplanned, and unadvised pregnancies.
There are 2 main methods of contraception:
Contraception is classified into temporary/reversible and permanent/irreversible.
Irreversible contraception is usually achieved by surgical procedures like vasectomy or tubal ligation and others.
Reversible contraception is achieved using intrauterine devices or drug eluting implants, or hormonal contraceptive pills/injections or patches and also male/female condoms and others.
There is no study evaluated the efficacy of different types of contraception in transplanted females, however results are extrapolated from non-transplant population.
Hormonal contraceptives
Hormonal contraceptives are either estrogen or progesterone based or combined. Hormonal contraceptives are commonly used (58% in one study). They are highly effective with minimal failure rate. Estrogen based contraceptives is associated with exacerbation of migraines, the risk of VTE, and worsening hypertension control. Hormonal contraceptives have protective effects in menstrual bleeding patterns and may protect from ovarian cysts.
Another option of hormonal therapy also include etonogestrel implant which is a single silastic rod implanted SC in the upper arm. It is highly effective and protective for 3 years. Etonogestrel risk-benefit features similar to DMPA but causes fewer decreases in BMD. On removal, the etonogestrel drops rapidly, with most patients ovulating after 3 weeks.
Transdermal contraceptive patch is also part of hormonal therapy which is a patch placed on the abdomen to deliver estrogen and progesterone.
Intrauterine devices
IUDs are easy to insert, long lasting, and has low failure rate. The effect is reversible after IUD removal. No concern of interaction with IS drugs. No increased risk of VTE. No increase in overall complications in women regardless of immune status. No differences in infectious morbidity.
The vaginal ring
It is an effective method of contraception. Vaginal ring is a silastic ring impregnated with etonogestrel and ethinyl estradiol. It is associated with lower incidence of adverse events. A lower concentration of ethinyl estradiol compared with patch or combined hormonal contraceptives.
Barrier methods include condoms, spermicides, diaphragm, cervical cap and sponges are commonly used but associated with failure rates due to compliance issues. Education of couples on its use increases the awareness, compliance and may reduce the failure rate.
Due to the era of new immunosuppresion drugs with incraesing centers of transplantion and new era of PKD programm an expanding the criteria of cadaveric donors , a lot of females in child bearing period is being transplanted.
This incresing numbers of females put the clincicans in chelleng to keep the graft and the mother and the foetous safe if she wants to get pergnant.
Fertilty of most of females can be effciently reverted from 1- 6 month after transplantion, so couselling the transplanted females about the best contraceptive method suloud be done befor trasnplantion journey starts to prevent unplanned nor premature pregnancy, since not all the immunosprreion medication nor ant hypertensive medication are safe during pregnancy.
methods of contraception after kidney transplantion
1.permnanat mtthods,like
tubAL ligation, which is unreversivle
vesectomy , more safe for the mother preventing ectpoic pregnancy
2.irrevisble methods , which can be comibened together like,
combined oral contaceptibe pills , highly effective and with minimal failure rate , but has risks of incresing VTE,excerbation of migraine , worsening of HTN .not advised in pt with active liver disases.cuatoius should be taken for tac levels after transplantion as it increse its level.
Depot medroxyprogesterone acetate ,is a synthetic progestin with slow release over 3 months ,failure rate is less than 2%,incres the risk of VTE, not advised for pt with active liver disase.
Etonogestrel implant ,implanted subcutaneously in the upper arm. The effectiveness is > 99%, and the protection lasts for 3 years. can concive after 3 weeks of removal, increase bleeding irregularity,increseas the risk of osteoprosois especially they are on steroids.
Transdermal contraceptive patch estrogen and progesterone through the transdermal route using a patch placed on the abdomen ,same like OCP, but with much higher riks of VTE ,2 more flods.
Progestin-only pills ,faliure rate is high more than 5% in the first year, needs more comapliance,incres the risk of CVS , obesity ,high blood preesure , interacts with tac so craeful monitoring of tac levels , not advise in any activeliver disases patient.
Intrauterine devices ,faliure rate is very low less than <1%, no data suggest increases the PID, easily inserted and removed , no interaction with immunsouprresant drugs.
vaginal rings, it is effective ,controls the menstrual cycles, and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol .
Barrier methods of contraception ,condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods,with high failure rate and the difficulty in achieving complianc, and should be combined with another method
Last edited 3 years ago by MOHAMMED GAFAR medi913911@gmail.com
Contraception After Kidney Transplantation, From Myth to Reality: A Comprehensive Review of the Current Evidence
¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤
☆Introduction:
▪︎It is crucial to plan for a timely, safe conception and effective maternity care because ovulation may start as soon as 1 month after transplant.
▪︎Evidence suggests that a period of 1 year after transplant appears to be sufficient to minimize the risk of adverse events due to pregnancy.
☆Methods of contraception after kidney transplantation:
_________________
A) Permanent Methods: These include:
1.Female tubal ligation
2. Male vasectomy: Has the advantage of having less associated risks of ectopic pregnancies than tubal ligation,
B) Temporary methods: These include:
1. Copper & progestin intrauterine devices
2. Hormone methods
– Estrogen and progesterone
– Oral contraceptive pill
– Transdermal patch
– Vaginal ring
– Progesterone only
Implant
3. Barrier methods
– Diaphragm with spermicide
– Cervical cap with spermicide
– Contraceptive sponge
– Male condom
– Female condom
◇Combined hormonal contraceptives:
_______________________________________
▪︎Are commonly used in daily practice as they are highly effective and with minimal failure rate.
▪︎Careful attention regarding the drugs’ interactions with calcineurin inhibitors .
◇Depot medroxyprogesterone acetate:
_______________________________________
Is a highly effective and safe contraceptive method.
▪︎The failure rate is only 2% due to delay in repeat
injection.
▪︎ It has the advantage of no drug interactions with immunosuppressive medications and is a good choice as long as patients are motivated to adhere to the injection schedule.
◇Etonogestrel implant:
_________________________
▪︎The effectiveness is > 99%, and the protection lasts for 3 years.
▪︎It is a new method of contraception for female kidney recipients, can be safely advised, is highly effective, and is rapidly reversible.
◇Transdermal contraceptive patch:
______________________________________
▪︎This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen. ▪︎The circulating levels of estrogen
are substantially higher than with combined
hormonal contraceptives.
◇Progestin-only pills:
_________________________
▪︎The significant incidence of amenorrhea and the 5% failure rate during the first year are the major concerns.
▪︎Interactions with medications that
are metabolized by the liver can occur with
progestin-only pills, and they should be avoided in patients with liver disease.
▪︎Their interaction with calcineurin inhibitors requires proper calcineurin
inhibitor monitoring posttransplant.
▪︎Alter the metabolism of lipids in female kidney recipients.
◇Intrauterine devices:
________________________
▪︎Intrauterine devices (IUDs) are classified as category 2 compared with combined pills, which are classified as category 4 in complicated transplants.
▪︎ The advantages of the IUD include easy insertion, long lasting, low failure rate, the effect is reversible after removal, and immunosuppression drug interaction
is not a concern in women with kidney transplants.
▪︎It is not associated with increased risk of
thromboembolism.
▪︎Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing
intrauterine system lasts for 5 years, rendering these cost-effective and long-lasting methods ofcontraception for women with kidney transplants.
▪︎Theoretically, posttransplant immunosuppressive medications may decrease the efficacy of IUDs, possibly because they modify the leucocyte response.
▪︎There is no solid evidence suggesting that
the safety and effectiveness of the IUD would be compromised in the transplant patient.
◇The vaginal ring:
___________________
▪︎Has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events
related to ethinyl estradiol
▪︎Serum ethinyl estradiol levels of patients showed much lower variations with the vaginal ring than with the patch or combined hormonal contraceptives.
◇Barrier methods of contraception:
______________________________________
▪︎Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the
relatively high failure rate and
the difficulty in achieving compliance.
▪︎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.
▪︎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.
▪︎Education of couples regarding this method of contraception reduce it’s failure rate.
. –One- year after transplant is sufficient to minimize the risk of adverse events due to pregnancy, as possible risks of acute rejection and graft loss, and prematurity
will be less after this time.
– Adequate graft function before conception (no proteinuria and well-controlled blood pressure) is the key factor toward a safe pregnancy because these 2 conditions are associated with poor outcomes for the fetus and pregnant mothers after kidney transplant.
-Female fertility can be efficiently reverted within 1 to 6 months after a kidney transplant; methods of contraception must be discussed before and initiated soon after transplant surgery to prevent premature, unplanned, and unadvised pregnancies. Methods of contraception after kidney transplantation:
There are 2 principal methods of permanent contraception and several temporary methods. Temporary methods: Combined hormonal contraceptives
-Combined hormonal contraceptives are classified as category 4 in complicated transplants.
-The risks with combined hormonal contraceptives are attributed to the estrogen component of these formulations, including exacerbation of migraine
headaches, the risk of thromboembolism, and worsening hypertension control.
-Combined hormonal contraceptives are primarily metabolized by the cytochrome P4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients.
-Patients who have a history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have
active liver disease or hepatic adenoma are advised not to use combined hormonal contraceptives, as they may aggravate these conditions. Depot medroxyprogesterone acetate (DMPA):
-It is a synthetic progestin with a slow-release over 3 months. It is a highly effective and safe contraceptive method. The failure rate is only 2% due to delays in repeat injections.
-The major concern of DMPA is the thromboembolic risk.
-It has the advantage of no drug interactions with immunosuppressive medications for transplant patients and is a good choice as long as patients are motivated to adhere to the injection schedule.
-The metabolism of DMPA is through the liver; therefore, it is not recommended for those with active liver disease. Etonogestrel implant:
-The etonogestrel implant is a single silastic rod implanted subcutaneously in the upper arm.
-The effectiveness is > 99%, and the protection lasts for 3 years.
-The adverse effect of this method is the bleeding irregularity encountered in a minority of patients.
-It causes fewer decreases in bone mineral density, a concern that is also commonly encountered after transplant due to the effect of steroids on bones. Transdermal contraceptive patch
-It delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen.
– The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives.
-Some studies have shown more than a 2-fold increase in the risk of venous thromboembolism associated with this method. Progestin-only pills
-The advantage of progestin-only pills is the avoidance of estrogen-related risks.
-The significant incidence of amenorrhea and the 5% failure rate during the first year are the major concerns; this rate drops to < 0.5% if used correctly and constantly.
-It undergoes the first-pass metabolism through the liver. Interactions with medications that are metabolized by the liver can occur with progestin-only pills, and they should be avoided in patients with liver disease.
-Their interaction with calcineurin inhibitors requires proper calcineurin inhibitor monitoring post-transplant.
-It increases the risk of weight gain, and both progestin-only pills and calcineurin inhibitors alter the metabolism of lipids in female kidney recipients. Intrauterine devices
-Intrauterine devices (IUDs) are classified as category 2 compared with combined pills, which are classified as category 4 in complicated transplants.
– They are not at greater risk of developing pelvic infections.
-The advantages of the IUD include easy insertion, long-lasting, low
failure rate, the effect is reversible after IUD removal, an immunosuppression drug interaction is not a concern in women with kidney transplants,and is not associated with increased risk of thromboembolism.
-The levonorgestrel-releasing intrauterine system was shown to reduce menstrual blood loss.
-Previous ectopic pregnancy and history of pelvic inflammation are contraindications to the use of IUDs.
-Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years. The vaginal ring
-The vaginal ring is impregnated with etonogestrel and ethinyl estradiol.
– It is effective, controls the menstrual cycles, and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal
contraceptives, thus minimizing the adverse events related to ethinyl estradiol. Barrier methods of contraception
-Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the
relatively high failure rate and difficulty in achieving compliance.
– 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. Permanent methods include:
-Female tubal ligation
– Male vasectomy.
–There is no ideal contraceptive method; the best is to individualize the method of contraception according to a patient’s risk
Restoration of fertility post-transplant can be seen in 1-6 months. Hence the role of pre-transplant and post-transplant counselling regarding various methods of contraception is very important.
Various methods of contraception available post-transplantation include:
I) Permanent methods: These can be utilized in patients not willing for further child-bearing.
1) Female tubal ligation: Associated with risk of ectopic pregnancy and has failure rates of 0.5%.
2) Male vasectomy: Invasive and non-reversible, but decreases the risk of ectopic pregnancy and has failure rate of 0.5%
II) Temporary methods:
1) Combined hormonal contraceptives: These include contraceptives containing estrogen and progestin. The failure rate associated with their use is 0.3%. But the estrogen component can cause migraine headache exacerbation, increased blood pressures and thromboembolic events, hence are contraindicated in patients with history of stroke, myocardial infarction, deep vein thrombosis, migraine and uncontrolled hypertension as well as active liver disease and hepatic adenoma. Drug interactions with calcineurin inhibitors needs to be assessed.
2) Depot Medroxy Progesterone Acetate (DMPA): It is long acting (3 months) with failure rate of 6% (due to delayed repeat injection). It has no drug interactions but should not be used in patients with active liver disease and risks of thromboembolic events. Its use has been associated with decreased bone mineral density.
3) Etonorgesterol implant: It is a very long-acting form of contraception with protection for 3 years, implanted in the upper arm subcutaneously and fertility reversal is achieved in 3 weeks post-removal with a failure rate of less than 1%.
4) Transdermal contraceptive patch: It delivers estrogen and progesterone, has 2 times increased risk of venous thromboembolism and has low failure rates (0.3%).
5) Progestin only pills: These avoid risks associated with estrogen but have failure rate of 5% initially which decreases to less than 0.5% later. They are useful in patients with high blood pressures but should be avoided in active liver disease and close monitoring of calcineurin inhibitor drug levels is required. They are associated with weight gain and altered lipid profile.
6) Intrauterine devices (IUD): They are long acting, cost-effective, easily inserted and have low failure rates (0.6-0.8%) with absence of increased risk of thromboembolism, immunosuppression drug interaction or associated increased pelvic infection rates. They should not be used in patients with history of previous ectopic pregnancy or pelvic inflammation. i. Copper IUD: They have long life of 10 years ii. Levonorgesterol releasing IUD: They have life of 5 years and are associated with less menstrual blood loss with very low failure rates (0.2%)
7) The vaginal ring: It is impregnated with etonorgesterol and ethinyl estradiol in lower concentration with low failure rates (1-3%)
8) Barrier methods of contraception: These include condoms, spermicides, diaphragm, cervical cap and sponges. They are easy to use, have no drug interactions but have relative high failure rates (12-23%) and associated with compliance issues. They are useful as an adjunct to other forms of contraception
9) Other methods: These are very unreliable
i. Lactation amenorrhea:
ii. Coitus interruptus: 20% failure rate
iii. Symptothermal methods: 15-24% failure rate.
Fertility after kidney transplant returns to normal with in one month and pregnancy happens within few months post transplant.
It’s should be counseling conception at least one year post transplant to avoid unplanned pregnancy and reduce risk of maternal and fetal complications and reduce risk of hypertension and preeclampsia and risk of graft loss; Also avoid teratogenic effects of immunosuppressive drug.
Method of contraception after transplant:
2 permanent contraception
– [ ] Female tubal ligation
– [ ] Male vasectomy
male vasectomy is non reversible and invasive procedure
Female tubal ligation has risk of ectopic pregnancy.
Combined hormonal contraception and effective and low failure rate and less risk of menorrhagia
It’s has risk of thromboembolic and migraines and hypertension.
It’s contraindicated in the active liver disease and MI , stroke .
Depot medroxy progesterone acetate :
It’s synthetic progestin with slow release over 3 months
It’s effective and safe and no drug interaction with immunosuppressive agents
It’s has risk of thrombosis and not give in patients with liver disease.
Etonogestrel implants:
It’s single silastic rod implanted subcutaneous in upper arm and fertility returns after 3 weeks.
Transdermal contraception patches
Progestin only pills:
It’s progestin pills
It’s has interaction with calcinurine inhibitors and drug level needs monitoring
It’s associated with weight gain and high blood pressure
It’s contraindicated in liver disease
Vaginal rings
It’s ethinyl estradiol
IUCD
It’s safe and effective and low failure rate
No evidence of thrombosis or drug interaction
No risk of infection and fertility reversible after removal of IUCD
Barrier method of contraception like male and female condoms and spermicide are less effective and it’s have higher rate of failure
Weam Elnazer
3 years ago
Summary
Even though the risk of maternal and fetal problems following kidney transplantation is greater than in the general population. pregnancy after kidney transplant is normal and regularly observed.
Preventive counselling should begin as soon as possible after the transplant, preferably before the procedure, to explain contraceptive techniques and enable women to make an educated decision about contraception and eventual pregnancy.
It is natural that patients should be made aware of the advantages and hazards associated with each procedure employed following transplantation via appropriate education. It is important to use an effective and appropriate method of contraception in order to limit the chance of unexpected pregnancy. Women should be informed of the impact of pregnancy on graft function, fetal well-being, and the risk of developing maternal problems during and after the procedure. If you do not want children, you may want to consider using a permanent form of contraception following a kidney transplant because of the dangers connected with pregnancy after a kidney transplant.
It is recommended that kidney transplant patients avoid becoming pregnant for at least one year after their transplant in order to lessen the risk of newborn and maternal problems.
– Following a kidney transplant, a variety of contraceptive techniques may be used. A prominent reason for the widespread use of combined hormonal contraceptives is their efficacy. The advantages of estrogen-based contraceptives in an uncomplicated stable transplant patient who does not have a contraindication to using combination hormonal contraceptives exceed the risks of using them, according to the evidence. Intrauterine devices are an effective means of contraception and should be regarded as a safe and effective approach following transplantation since there is no data to indicate that kidney transplant patients have a higher infection risk than the general population. 75
Permanent methods of contraception are valid\soptions for couples who decide not to have children.
In order to determine the most ideal time for conception, determine the most appropriate follow-up, and provide advice, a multidisciplinary team approach comprising obstetricians and nephrologists should be used.
-Hormonal contraceptives that work in conjunction:
Depot medroxyprogesterone acetate is a very effective and safe approach that releases medroxyprogesterone acetate gradually over a three-month period. There have been no reported drug-drug interactions with immunosuppressive drugs. It should not be used in patients with active liver disease or a history of thromboembolic events since it is reversible and has a failure rate of 2 per cent owing to the delay in repeat injection.
-Only progestin tablets have a 5 per cent failure rate, which may be reduced to 0.5 per cent when taken appropriately and continuously. Drug interaction with CNI results in weight gain, and lipid metabolism problems, and should be avoided in patients with liver disease.
-Intrauterine devices are rated as category 2 by the Centers for Disease Control and Prevention (CDC). They are an effective, reversible, and safe method of contraception that has a low failure rate, no drug-drug interaction, and is not related to an increased risk of thrombophilia.
-Transdermal contraceptive patch: The transdermal contraceptive patch is applied to the abdomen and delivers both estrogens and progesterone. The effectiveness and negative effects of combination contraception are comparable.
-Etonogestrel implant: a very successful approach with the efficacy of >99 per cent that is both safe and reversible in a short period of time. It consists of a single silastic rod implanted subcutaneously in the upper arm that has a duration of action of three years. Although it has a lower risk of osteoporosis, it is connected with bleeding and irregular menses.
Abdulrahman Ishag
3 years ago
There are 2 principal methods of permanent contraception and several temporary methods .
Permanent methods ;
Include female tubal ligation and male vasectomy. Vasectomy has the advantage of having less associated risks of ectopic pregnancy than tubal ligation, but it is a nonreversible and invasive procedure.
Temporary methods;
involve the use of combined hormonal oral contraception, intrauterine devices, vaginal rings, subcutaneous implants, barriers, and natural methods like coitus interruptus.
Combined hormonal contraceptives;
Contraceptives containing estrogen and progestin are ;
1- Highly effective and with minimal failure rate .
2- Metabolized by the cytochromeP4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients.
3-Contraindicated in patients who have a history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have active liver disease or hepatic adenoma .
Depot medroxyprogestrone acetate.
1-It is a synthetic progestin with slow release over 3 months.
2- The metabolism of DMPA is through the liver; therefore, it is not recommended for those with active liver disease.
3-It is a highly effective and safe contraceptive method and the failure rate is only 2% due to delay in repeat injections.
4- It has the advantage of no drug interactions with immunosuppressive medications of transplant patients and is a good choice as long as patients are motivated to adhere to the injection schedule.
5- It’s side effects include ;
a-Reversible decrease in bone density,which normalizes on DMPA cessation.
b- The thromboembolic risk.
Etonogestrel implant;
1-A new method of contraception for female kidney recipients, can be safely advised, is highly effective, and is rapidly reversible.
2-It is implanted subcutaneously in the upper arm.
3-The effectiveness is > 99%, and the protection lasts for 3 years.
4- The adverse effect of this method is;
a- The bleeding irregularity encountered in a minority of patients.
b- Etonogestrel implant has risk-benefit features similar to DMPA but has been shown to cause fewer decreases in bone mineral density, a concern that is also commonly encountered after transplant due to the effect of steroids on bones.
Transdermal contraceptive patch ;
1-This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen.
2-The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives.
3- Some studies have shown more than 2-fold increase in the risk of venous thromboembolism associated with this method.
Progestin-only pills;
1-The advantage of progestin-only pills is the avoidance of estrogen-related risks.
2-They are significantly effective with 5% failure rate . This rate drops to < 0.5% if used correctly and constantly.
3- Progestin-only pills require ensured compliance to reduce failure rates.
4- They undergo the first-pass metabolism through the liver.
5- Interactions with medications that are metabolized by the liver can occur with progestin-only pills, and they should be avoided in patients with liver disease. Their interaction with calcineurin inhibitors requires proper calcineurin inhibitor monitoring post transplant.
6- Progestin-only pills increase the risk of weight gain.
8-Female kidney recipients who smoke or are at risk for cardiovascular problems such as high blood pressure may be able to use progestin-only pills since combined hormonal contraceptives are usually contraindicated for them.
Intrauterine devices;
1-Intrauterine devices (IUDs) are classified as category 2 compared with combined pills, which are classified as category 4 in complicated transplants.
2-Currently available data suggest that immunocompromised women are not at greater risk of developing pelvic infections.
3-The advantages of the IUD include easy insertion, long lasting, and low failure rate .
4-The major advantage of using IUDs is that the effect is reversible after IUD removal, and immunosuppression drug interaction is not a concern in women with kidney transplants. In addition, it is not associated with increased risk of thromboembolism.
The vaginal ring;
1- It is effective controls the menstrual cycles, and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
Barrier methods of contraception;
1-Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate and the difficulty in achieving compliance.
2- Barrier success rate can reach 97% if used correctly and consistently.
3-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.
4- All of these barrier methods can be used post transplant but are best when combined with another method of birth control to reduce their potential failure rate. Conclusion;
Combined hormonal contraceptives are commonly used for their effectiveness.
The benefits of estrogen-based contraceptives in an uncomplicated stable transplant recipient who have no contraindication to use combined hormonal contraceptives likely outweigh the potential for harm.
Intrauterine devices are an effective method of contraception and should be considered as a safe and an effective method after transplant with no evidence to suggest increased infection rate in kidney transplant recipients.
Permanent methods of contraception are valid options for couples who decide not to have children.
A multidisciplinary team approach involving obstetricians and nephrologists should be adopted to decide the appropriate timing for conception, ascertain appropriate follow-up, and advise on methods of contraception that suit the patient.
There is no ideal contraceptive method; the best is to individualize the method of contraception according to a patient’s individual risk.
Mohamed Mohamed
3 years ago
Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation Introduction Contraception in post-kidney transplant women is successful with acceptable risk. It needs a multidisciplinary approach that involves obstetricians & transplant physicians to:
– reduce the risk of unplanned pregnancies.
– improve pregnancy outcomes
– reduce maternal complications
– advice on the appropriate method of contraception on individual basis.
– prevent interactions with the IS & antihypertensive medications Methods of contraception post-plantation: A. Permanent methods:
– Female tubal ligation
– Male vasectomy; is irreversible but effective & prevents risks of ectopic pregnancy associated with tubal ligation. A. Temporary methods:
– Combined hormonal oral contraception
– Intrauterine devices
– Vaginal rings
– Subcutaneous implants
– Barriers
– Coitus interruptus. Combined hormonal contraceptives:
– Are category 4 in complicated transplant according to the US CDC.
– Are commonly used(58% in one study)
– Estrogen & progestin pills are highly effective with minimal failure rate
– The risks with combined hormonal contraceptives are due to the estrogen component & include exacerbation of migraines, the risk of VTE, & worsening hypertension control.
– They may regulate menstrual bleeding patterns & may protect from ovarian cysts.
– Interaction with CNIs medications(metabolism by cytochromeP4503A4 system)
– Not to be used if there is H/O of MI, stroke, DVT, migraine, & uncontrolled hypertension.
– Depot medroxyprogesterone acetate (DMPA, a synthetic progestin with slow release over 3 months). Is highly effective & safe. Failure rate is only 2% due to delay in repeat injections. The major concern is the VTE. No interactions with IS medications. Not recommended if there is active liver disease. The etonogestrel implant:
– Is a single silastic rod implanted SC in the upper arm.
– Effectiveness is > 99%, & protection lasts for 3 years.
– On removal, the etonogestrel drops rapidly, with most patients ovulating after 3 weeks.
– Menestrual irregularity occurs in a minority.
– Risk-benefit features similar to DMPA but causes fewer decreases in BMD. Transdermal contraceptive patch:
– A patch placed on the abdomen delivers estrogen & progesterone.
– The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives
– Some studies shown >2-fold increase in the risk of VTE. Progestin-only pills:
– Advantage of avoidance of estrogen-related risks.
– Significant incidence of amenorrhea.
– 5% failure rate during the 1st year; this rate drops to < 0.5% if used correctly & constantly.
– Requires good adherence to reduce failure rates.
– Orally taken, &, unlike DMPA & etonogestrel implant, they undergo the 1st– pass metabolism in the liver. Their interaction with CNIs requires proper CNI trough monitoring post- transplant; both of them cause dyslipidemia.
– Progestin-only pills increase the risk of weight gain.
– Female kidney recipients who smoke or are at risk for CV problems such as high BP may be able to use progestin-only pills since combined hormonal contraceptives are usually contraindicated for them. Intrauterine devices (IUDs)
– Are category 2 in complicated transplants.
– No greater risk of developing pelvic infections, even in women with HIV infection. However, many studies indicated that the risk of infection is significantly increased immediately after IUD insertion in immunocompromised patients. Antibiotics prophylaxis is not useful for IUD insertion.
– IUD is easy to insert, long lasting, & has low failure rate.
– The effect is reversible after IUD removal
– No concern of interaction with IS drugs.
– No increased risk of VTE.
– No increase in overall complications in women regardless of immune status.
– No differences in infectious morbidity.
– The levonorgestrel-releasing IUD reduces menstrual blood loss.
– IUD use is contraindicated if there is previous H/O ectopic pregnancy or pelvic inflammation.
– Copper IUD & the levonorgestrel-releasing IUD are both effective & safe to use after kidney transplant.
– Copper IUD has an effective duration of 10 years.
– Levonorgestrel-releasing intrauterine system lasts for 5 years. The vaginal ring
– It is a silastic ring impregnated with etonogestrel & ethinyl estradiol.
– Effective controls of the menstrual cycles.
– A lower concentration of ethinyl estradiol compared with patch or
combined hormonal contraceptives, thus less adverse events related to ethinyl estradiol. Barrier methods (condoms, spermicides, diaphragm, cervical cap, sponges)
– Less effective methods due to the relatively high failure rate &the
difficulty in achieving compliance.
– Barrier success rate can reach 97% if used correctly & consistently.
– Are convenient & easy to use.
– Avoid potential drug interactions, especially with IS medications.
– Are best when combined with another method of birth control to
reduce their potential failure rate.
– Education of couples regarding their use encourages awareness &
compliance & may reduce the failure rate.
Abdul Rahim Khan
3 years ago
Pregnancy after transplantation was considered a challenging entity due to complex nature of patients , immunosuppression and fear of graft dysfunction. In this review authors evaluated different methods of contraception and their efficacy. A MDT approach to decide about appropriate timing of conception is recommended. early counselling and individualization according to patient risks is recommended. Contraception Methods. 1-Permanent
Female- Tubal ligation
Males-Vasectomy 2-Temporary a- Combined Hormonal contraception
It has low failure rates but can interact with CNI due t cytochrome P450. It can cause hyercoagupathy with risk of DVT , stroke and MI. It can effect liver functions and can cause hepatic adenoma b-Depot Medroxyprogesterone acetate
It is synthetic progesterone and is safe and effective . It cannot be used in liver disease and side effects are reversible. c-Etonogestril implant
Single subcutaneous implant in upper arm. efficacy around 99% d-Transdermal contraceptive patches
Efficacy similar to the combined contraceptives and deliver both estrogens and progesterone. e-Progesterone only pills
These are safe in patients with cardiovascular issues and have failure rates around 5% f-IUD
It is effective with no side effects. No interaction with immunosuppressive drugs g-Vaginal Ring
This ring is impregnated with etonogestril and Estradiol. It is effective with less side effects due to low serum levels f- Barrier Methods
These have high failure rates and include condoms, cervical cap , diaphragm, spermicides and sponges. These can be combined with other modalities.
Heba Wagdy
3 years ago
Fertility is regained effectively within 1-6 months post transplant, contraceptive methods are essential to avoid unplanned pregnancy with its associated complications and to use safe immunosuppressive agents. Permanent methods:
Female tubal ligation, associated with risk of ectopic pregnancy.
Male vasectomy.
Non reversible and invasive procedures Temporary methods: Combined hormonal contraceptives:
Contain estrogen and progesterone.
Effective with low failure rate, decrease menorrhagia and development of ovarian cysts.
Side effects: thromboembolic events, exacerbation of migraine and poor control of HTN.
metabolized by cytochrome P450 with many drug interactions
Requires close monitoring of CNI levels. Depot medroxyprogesterone acetate (DMPA):
Sustained release synthetic progestin
Highly effective and safe with no drug interaction with immunosuppressive agents
Side effects: reversible decrease in bone density, thromboembolic risk, need compliance to injection schedule. Etonogestrel implant:
Single silastic rod implanted subcutaneously
Safe, highly effective, lasts for 3 years and rapidly reversible.
Side effects: bleeding irregularity, decrease in bone density. Transdermal contraceptive patch:
Estrogen and progesterone through transdermal route.
Side effects: same as combined hormonal with 2-fold increase in risk of venous thromboembolism. Progestin only pills:
No estrogen related complications
Side effects: 5% failure rate (can be improved with compliance), significant incidence of amenorrhea, increase risk of weight gain and alter metabolism of lipids.
First pass metabolism through liver leading to potential drug interaction
Needs close monitoring of CNI. Intrauterine devices:
Easy insertion, cost-effective, long lasting, low failure rates, safe with reversible effects and no drug interactions.
Some studies showed significant increase in risk of infection after IUD insertion in immunocompromised patients while other randomized study showed no difference in infectious morbidity.
can’t be used in patients with history of ectopic pregnancy or pelvic inflammation. The vaginal ring:
Silastic ring impregnated with etonogestrel and ethinyl estradiol.
Effective, control menstrual cycles with significant lower exposure to ethinyl estradiol and lower variation in serum level. Barrier methods of contraception:
Easy to use with no potential drug interactions
Less effective with higher failure rate and difficult to achieve compliance
Better to be used with another method to decrease failure rate
amiri elaf
3 years ago
*** Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation
# This study evaluated the efficacy of the different options for contraception and it is success after kidney transplant.
# The fertility can be efficiently reverted within 1 to 6 months after KT, so early counseling for using contraception reduce the risk of unplanned pregnancies, maternal complications and improve the outcomes after KT.
# A period of 1 year after KT is sufficient to minimize the risk of :
1* Adverse events of pregnancy (prematurity, intrauterine growth
retardation, low birth weight and preeclampsia.)
2* cute rejection and graft loss
# Adequate graft function before pregnancy (no proteinuria, controlled blood pressure) is important to prevent such complications.
# # Methods of contraception after kidney trans plantation
We have two types of contraception:
A) Permanent contraception include:
1* Female tubal ligation
2* Male vasectomy ( less associated risks of ectopic pregnancy than tubal ligation, non reversible and invasive procedure.)
B) Temporary methods include:
1# Combined hormonal contraceptives
* Are classified as category 4 in complicated transplant.
*Contraceptives containing estrogen and progestin are highly effective and with minimal failure rate.
*Study reported that, use of combined low dose oral contraceptives after RT for at least 18 months, sufficient to prevent pregnancy.
*It reducing the development of ovarian cysts and menorrhagia
*The primarily metabolism of this hormones in the cytochrome P4503A4 system, so it has drug interactions with calcineurin inhibitors
*The risks with combined hormonal contraceptives are due to estrogen component, so patients with history of myocardial infarction,stroke, deep venous thrombosis, migraine, uncontrolled hypertension,active liver disease and hepatic adenoma are advised not to use combined hormonal contraceptives, because it may aggravate these conditions.
2# Depot medroxyprogesterone acetate
*Is a synthetic progestin with slow release over 3 months.
* It is a highly effective and safe contraceptive method with failure rate 2% due to delay in repeat injections.
* DMPA has advantage of no drug interactions with immuno suppressive medications and is a good choice as long as patients are motivated to adhere to the injection schedule.
*The metabolism through the liver, so not recommended in active liver disease also there is risk of reversible decrease in bone density and thromboembolic effect.
3# Etonogestrel implant
*It is a single silastic rod implanted subcutaneously in the upper arm.
*The effectiveness is > 99%, and the protection lasts for 3 years.
*After removal the etonogestrel drops rapidly and ovulation occur after 3 weeks.
*The adverse effect is the irregular bleeding in few patients
*IT has risk benefit features like DMPA, but cause fewer decreases in bone mineral density, so commonly encountered after transplant due to the effect of steroids on bones
4# Transdermal contraceptive patch
*This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen.
* The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives.
*The risk with this method is similar to combined hormonal contraceptives.
*Some studies showed the risk of venous thromboembolism more than 2-fold
associated with this method.
5# Progestin-only pills
*The advantage of progestin only pills is the avoidance of estrogen related risks.
*The adverse effect is amenorrhea and there is 5% failure rate during the first year this, but it can drops to < 0.5% if used correctly and constantly so it need good compliance
* Interactions with medications that are metabolized by the liver can occur, they should be avoided in liver disease, and due to interaction with calcineurin inhibitors the later requires proper monitoring posttransplant.
*The main S/E is weight gain, and both Progestin only pills and calcineurin inhibitors alter the metabolism of lipids in female kidney recipients.
*Female kidney recipients who smoke, cardiovascular disease and hypertension can use progestin only pills since combined hormonal contraceptives are contraindicated
6# Intrauterine devices
* (IUDs) are classified as category 2
*Immunocompromised women are not at greater risk of developing pelvic infections.
* However, many studies indicated that the risk of infection is significantly increased immediately after IUD insertion in immunocompromised patients.
*The use of antibiotic prophylaxis for IUD insertion with little benefit.
* The advantages:
Easy insertion, long lasting, low failure rate, the effect is reversible after removal, no immunosuppression drug interaction and not associated with increased risk of thromboembolism.
* A prospective study showed no increase in overall complications in women regardless of immune status.
*levonorgestrel releasing intrauterine system reduce menstrual blood loss.
* Previous ectopic pregnancy and history of pelvic inflammation are contraindications to the use of IUDs.
* Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years rendering.
.
7# The vaginal ring
*The vaginal ring is a silastic ring that is impregnated with etonogestrel and
ethinyl estradiol.
* It is effective in controls the menstrual cycles and lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, so can reduce the adverse events.
8# Barrier methods of contraception
*Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods due to the high failure rate.
*The advantage: easy to use, no drug interactions with immunosuppressive medications.
*All of these barrier methods can be used posttransplant ,and to reduce the failure rate better to combined with another method of Contraception and education the couples for good compliance.
.
Jamila Elamouri
3 years ago
Pregnancy after a kidney transplant is normal and common. As fertility is expected to return efficiently within 1 to 6 months. The risk of maternal and fetal complications is higher than in the general population. therefore; it is important to discuss with the patient the method of contraception before transplantation to avoid unplanned pregnancy and give the proper education that helps her to make an informed choice.
Women with kidney transplants should be advised to delay pregnancy for 1 year after transplant, in order to minimize the risk of pregnancy adverse events. Good graft function before conception with no proteinuria and well-controlled blood pressure is the most determined point for pregnancy outcome. There is no ideal method, and the best is to individualize the method according to the patient’s risk. Methods of contraception after kidney transplantation: 1- Combined hormonal contraceptives:
It is considered category 4 in complicated transplants. Combined pills containing estrogen and progestin are commonly used on a daily base. It is highly effective with a minimal failure rate. It can exacerbate migraine and hypertension and can cause venous thrombosis and deterioration of liver function. It is metabolized by the cytochrome P4503A4 system so; it has interaction with calcineurin inhibitors. Nevertheless; the benefit of them outweigh the harm and their use should be advised. a- Depot medroxyprogesterone acetate:
It’s a slowly released, injectable form, with a low failure rate. It has no drug interactions, its adverse effects include a decrease in bone density and thromboembolic risk. It is not recommended for liver disease.
b- Etonogestrel implant:
It is implanted subcutaneously in the upper arm. Highly effective with protection lasts for 3 years and is rapidly reversible. Its adverse effect includes bleeding irregularity and decreases bone density.
c- Transdermal contraceptive patch:
Transdermal patch placed on the abdomen. The main side effect is the thromboembolic event.
2- Progestin-only pills
It has a higher failure rate than the combined hormonal contraceptive, and to increase its effectiveness compliance with the pills is required. It has first-pass metabolism in the liver, so it interacts with calcineurin inhibitors. It can cause weight gain, and alter lipid metabolism.
3- Vaginal ring:
It is a silastic ring contains etonogestrel and ethinyl estradiol. It is effective with fewer adverse effects if compared to combined hormonal contraceptives.
4- Intrauterine devices (IUDs)
IUDs are considered category 2. Data suggest that immunosuppressant women are not at increased risk of developing a pelvic infection. The advantages of the IUD include easy insertion, long-lasting, and low failure rate, as well, their effect is reversible after IUD removal and no drug interaction with the immunosuppressive medications. No thromboembolic event risk. Copper IUD and levonorgestrel-releasing IUD are both effective. IUDs are cost-effective and long-lasting methods for kidney transplants.
5- Barrier methods of contraception:
They are less effective methods as they have a high failure rate and difficulty in achieving compliance.
6- Permanent methods of contraceptive
a- female tubal ligation
b- male vasectomy.
They are a valid option for couples who decide not to have children.
The first pregnancy in kidney transplanted patient was reported in 1967. Kidney transplantation leads to increase rate of conception in kidney transplant recipients with good allograft function.
Ovulation may initiate as soon as 1-month post-transplantation. Thus, consultation and planning for timely pregnancy is crucial in kidney transplant recipients.
It is suggested that a period of 1 year after transplant appears to be sufficient to minimize the risk of fetal and maternal adverse events due to pregnancy as well as risk of acute rejection and graft loss.
Adequate kidney function before kidney transplantation is the most important factor, predicting the outcomes of pregnancy.
Major complications to the fetus in pregnant transplant recipients include prematurity, intrauterine growth retardation, and low birth weight. Preeclampsia (in 30% of kidney transplanted patients), hypertension and graft dysfunction are important maternal complications.
Pretransplant education about the risk of unplanned pregnancy and choosing the method of contraception is important in kidney transplanted patients.
Utilization of contraceptive methods should be started soon after transplantation to avoid unplanned high-risk pregnancy. Optimization of immunosuppressive agents and using safe drugs are other concerns during pregnancy.
Contraception after kidney transplantation
There are two principal contraception methods: permanent and temporary methods
Permanent methods consist of female tubal ligation and male vasectomy.
Temporary methods include the use of combined hormonal oral contraception, intrauterine devices, vaginal rings, subcutaneous implants, barriers, and natural methods like coitus interruptus. Combined hormonal contraceptives are commonly used and are associated with some adverse effects attributed to estrogen component such as headache, hypertension, and increase the risk of thromboembolic events.
Combined hormonal contraceptives are primarily metabolized by the cytochrome P4503A4 system. consequently, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important.
These are not recommended in patients with the history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have active liver disease or hepatic adenoma.
Depot medroxyprogesterone acetate (DMPA), a synthetic progestin with slow release over 3 months, is a highly effective and safe method. Reversible decrease in bone density and the increased risk of thromboembolism are its use concern. The main advantage of this drug is the absence of interaction with immunosuppressive agents. Hence it is good choice for kidney transplant recipients. It is not recommended in patients with active liver disease.
The etonogestrel implant, implanted subcutaneously in the upper arm, and protection lasts for 3 years.
It has risk-benefit features as the same as DMPA with lesser decrease in bone density, and can be safely advised.
Transdermal contraceptive patches deliver estrogen and progesterone in the patch placed on the abdomen. Its use is associated with at least similar to two-fold increase risk of thromboembolism events compared to combined humoral contraceptives.
Progestin-only pills have the advantages of avoidance of estrogen-related risks. Incidence of amenorrhea and relatively high risk of failure is main concern of its utilization. In addition, it should be avoided in patients with liver disease. The CNI level monitoring is advised because of interaction with these pills. Lipid profile and weight gain should be monitored. In patients with high cardiovascular risk , progesterone-only pills are better choice compared to combined contraceptives.
Intrauterine devices (IUDs) are categorized as category 2 contraceptives in transplanted patients. It is suggested that kidney transplanted women are not at higher risk of developing pelvic infections.
IUDs have advantages include easy insertion, long lasting, and low failure rate, reversible, no interaction with immunosuppression drugs, and no increased risk of thromboembolism, but it probably is accompanied by higher risk of infection early after insertion in immunosuppressed patients. Copper IUD and the levonorgestrel-releasing IUDs are both effective and safe to use after kidney transplant. They are long-time methods for kidney transplanted women.
The vaginal ring, contains etonogestrel and ethinyl estradiol, and is associated with reduced adverse events related to ethinyl estradiol.
Contraception methods are generally classified into14:
I. Permanent:
1. Male vasectomy.
2. Female tube ligation: Risk of ectopic pregnancy.
II. Temporary:
1.Hormonal:
A. Combined pills: classified as class 4 medications, may interfere with immunosuppressant medications so careful monitoring is required, and may be associated with exacerbated migraine episodes, thromboembolic events, and uncontrolled hypertension.
B. Depot medroxyprogesterone acetate: A synthetic progestin, with a release form over 3 months, effective with a failure rate of 2%, not interfering with medication metabolism, but still there are some concerns regarding thromboembolism.
C. Etonogestrel implant: A subcutaneous implant, with a high success rate of > 99%, lasts for 3 years. Generally safe, but may be associated with some bleeding irregularities.
D. Transdermal patch: Deliver both estrogen and progesterone, which have similar effects to COPs.
E. Progestin-only pills: Delivered orally, failure rate about 5%, undergo first hepatic metabolism so may interfere with CNIs metabolism.
F. The vaginal ring: Are a silastic ring of etonogestrel and Ethinyl estradiol. Controls the menstrual cycle and delivers a lower concentration of estradiol thus minimizing its side effects.
2.Intrauterine device: Classified as category 2 compared to COPs, and category 4 in complicated transplants. There is a theoretical risk for pelvic inflammatory diseases which has not proven by studies. The major advantages of IUDs are they’re easily inserted and safe, and there is no risk of thromboembolism nor drug interaction with immunosuppressant medications. The copper IUD is effective for 10 years and the levonoregesterl-releasing for 5 years duration. Theoretically, an immunosuppression state may reduce the effectiveness of the IUDs due to reduced leucocytic reaction, but again no solid evidence supports this hypothesis.
3. Barrier methods: Have the advantages of being safe, reversible, easy to use, and with no drug interaction. But have a high failure rate and requires high compliance. Better to be combined with other contraception methods.
This article summarizes the type and the effectiveness of the various methods of contraception after kidney transplantation.
Fertility can be return after one month after kidney transplantation.
So, to avoid unplanned and complicated pregnancy it is necessary to discuss about contraceptive methods even before TX.
These methods may be temporary or permanent.
Permanent methods are female tubal ligation and male vasectomy.
Vasectomy is irreversible but has lower risk for ectopic pregnancy comparing to tubal ligation.
Temporary methods include:
1- Combined hormonal contraceptive: this method carries high risk due to estrogen component that induce migraine, thromboembolism and hypertension. But the rate of pregnancy is near zero (0.1%) and they reduce ovarian cyst and menorrhagia. They can deteriorate liver function and affect CNIs metabolism. They can only use when there is no contraindication.
2- Depot medroxyprogesterone acetate injection. It is highly effective and safe method with failure rate of 20%. So it very effective.
Concerns: higher risk of thromboembolic events and reversible decrease in bone density which will be normalized after stopping it. It has liver metabolism and is not recommended in liver diseases.
Advantages: No interaction with immunosuppression drugs.
3- Etonogestrel implant: completely effective method (>99%)with 3years protection.
Adverse effect: bleeding irregularity, low effect in bone mineral density
Advantages: highly effective and rapidly reversible.
4- Transdermal contraceptive patch:
High level of circulating estrogen with 2- fold increase in the risk of thromboembolism.
So, although is an effective method, it is not safe.
5- Progesterone – only pills: They are effective method (1-2% failure rate) if used correctly and constantly. Their liver metabolism could be troublesome in liver disease and CNIs interaction. They have risk of weight gain but cane be used in female kidney TX and are not contraindication in this group.
6- IUDs: Their usage is relatively safe (category2) in female kidney TX recipients. They are effective contraceptive method with low failure rate (~1%)
Advantages: Reversible after removal, no interaction with immunosuppression drugs .no risk of thromboembolic events.
Contraindication: History of ectopic pregnancy and pelvic inflammation.
7- Vaginal rings: Lower rate of exposure to ethinyl estradiol comparing combined pills or patches.
8- Barrier methods: These include condoms spermicides, diaphragm, cervical cap, and sponges.
9- They are less effective methods with high failure rate and difficulty in compliance
Advantages: Easy to use avoid drug interactions.
Contraception post kidney transplant : After transplantation fertility return in 6 month , so pregnancy should be planned stabilization of the graft function is very important so the women in child bearing age should used contraception .There are two type of contraception permanent or temporal , methods which can be used after transplantation :1- condom are safe but have high failure rate but when it used in aright way the protection rate is 97% .It is good method to avoid drug interaction .2-combined pills , contain progesterone and estrogen metabolize by CYTP450 it may lead to drug interaction .Used with caution in women with high blood presser also there is tendency to form aclot .3- Trans-dermal patch also contain progesterone and estrogen so it’s the same as combined pills .
4-DMPA {Depot Medroxy Progesterone Acetate } it is more safe no drug interaction but it can cause loss of bone density this become more worse with used of steroid .
5-Etonogestrel Implant : implanted subcutaneously can be used for 3 years it is effective and safe it contain progesterone only , it can affect bone density but less than DMPA . 6-Progesterone only pill it has high failure rate more than 5% .6-Intrauterine devices : two type 1- copper – T give protection for ten year Levonorgestrol IUCD coated hormone give protection for 5 year .Contraindication infection and history of ectopic pregnancy .
7- Vaginal ring also effective and can be used .
Methods of contraception
there are 2 principal methods:
· Permanent methods; include female tubal ligation and male vasectomy. Male vasectomy is invasive and non-reversible and has the advantage of having less associated risks of ectopic pregnancy than tubal ligation.
· Temporary methods; involve the use of combined hormonal oral contraception, intrauterine devices, vaginal rings, subcutaneous implants, barriers, and natural methods like coitus interruptus.
Combined hormonal contraceptives
· classified as category 4 in complicated transplant.
· Contraceptives containing estrogen and progestin are commonly used in daily practice as they are highly effective and with minimal failure rate. Estrogen is associated with exacerbation of migraine, headaches, risk of thromboembolism, and worsening hypertension control.
· primarily metabolized by the cytochrome P4503A4 system; so attention regarding drug-drug interaction should be kept in mind.
· Not advisable in patients with history of MI, DVT, migraine, uncontrolled HTN, active liver disease or hepatic adenoma.
Depot medroxyprogesterone acetate
· Depot medroxyprogesterone acetate is a synthetic progestin with slow release over 3 months.
· It is a highly effective and safe method with failure rate of 2% due to delay in repeat injection.
· Adverse events; decrease in bone density and thromboembolic risk.
· Advantage; no drug interactions with immunosuppressive medications.
· Not advisable in active liver disease.
Etonogestrel implant
· It’s is a single silastic rod implanted subcutaneously in the upper arm.
· The effectiveness is > 99%, and the protection lasts for 3 years. On removal, the etonogestrel drops rapidly, with most patients ovulating after 3 weeks.
· The adverse effect; bleeding irregularity and fewer decreases in bone mineral density.
Transdermal contraceptive patch
· It delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen.
· The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives.
· Adverse events; venous thromboembolism.
Progestin-only pills
· The advantage; no estrogen-related risks.
· Disadvantage; Not advisable in active liver disease,having drug interaction with CNI and causes weight gain.
Intrauterine devices
· Classified as category 2 compared with combined pills.
· The advantages of the IUD; easy insertion, long lasting, and low failure rate beside reversible effect. No risk of VTE and drug interaction.
· levonorgestrel-releasing intrauterine system is effective and safe to use after kidney transplantwith effective duration of 5 to 10 years according to manufacturer.
· Theoretically; Posttransplant immunosuppressive medications may decrease the efficacy of IUDs.
The vaginal ring
· It is a silastic ring that is impregnated with etonogestrel and ethinyl estradiol.
· Advantage; lower concentration of ethinyl estradiol compared with combined pills,
Barrier methods of contraception
· Barriers (condoms, spermicides, diaphragm, cervical cap, sponges).
· Less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate.
· Barrier success rate can reach 97% if used correctly and consistently.
· Better to be combined with another method of contraception.
· Having the advantage of being a convenient and easy to use.
As Fertility is reverted within the first 6 months after transplantation contraception is mandatory in the first year post kidney transplantation to avoid unplanned and not advisable pregnancy to minimize the risk of acute rejection and risk of graft loss and to maintain adequate renal allograft functions (no proteinuria and well-controlled blood pressure) in the first year post-transplantation.
Methods of contraception may be temporary or permanent
Permanent methods include vasectomy of males and tubal ligation of females.
Temporary methods include:
A-Combined oral contraceptives:
they contain both estrogen and progesterone with high efficacy with minimal failure rate But with some adverse effects of estrogen component with increased risk of thromboembolism, hypertension, frequencies of migraine and also interfere with the metabolism of CNI so levels of CNI should be carefully assessed.
B- Depot medroxyprogesterone acetate :
It is synthetic progesterone with high efficacy and a low failure rate of 2 % despite some adverse effects such as the increased risk of thromboembolism and osteoporosis, there are no associated drug interactions with other immunosuppressants.
C-Transdermal patch :
the patch contains both estrogen and progesterone with the same risk of potential hazards like combined oral contraceptives.
D-Progesterone only pills :
Despite the avoidance of adverse effects of estrogen, there is an increased incidence of failure rate in addition to the rate of amenorrhea by 5%.
E-Intrauterine devices :
two types were identified Copper and progestin IUDs with many advantages high success rate, no drug interaction, long-lasting, easy insertion, and reversible fertility after removal of IUD.
F- The vaginal ring :
It is a ring containing both etonogestrel and low concentrations of Ethinyl estradiol so minimal adverse effects of estrogen showed in patches and the combined pills.
G- Barrier methods:
They are less effective with high failure rates and include Condoms, sponge , cervical cap, and spermicidal gel.
This article addresses the current concerns about the fertility post transplantation , the outcome of pregnancy post transplantation, anti natal complications ,and contraception recommendations.
The fertility of end stage kidney disease patients is usually reversed swiftly after transplantation and the women regained normal hormonal cycles , menstruation and ovulation with restoration of libido and vaginal lubrication as early as 1 to 6 months with a high chance of getting pregnancy thereafter.
However, the pregnancy post transplantation is quite unsafe in the first year as it was reported to be associated with increasing maternal and fetal shortcomings along with allograft complications including allograft rejection. Furthermore, the medications commonly used as anti rejection and antihypertensives are highly unsafe with teratogenicity and fetotoxicity. Therefore prior contemplation of contraception earlier to transplantation is of a prime importance.
Its recommended as per CDC to avoid conception in the first year due to the high risk associated with it.
The allograft function has to be stable with constant anti rejection blood level and no proteinuria.
Medications to be avoided include MMF and mTORi, ACEi and ARBs have to be replaced with safer medications.
All contraceptives are safe and effective in controlling the contraception with its varied potential of causing drawbacks,
As per the general recommendation of CDC in complicated transplant patients {those with acute or chronic rejection and allograft dysfunction and allograft failure}combined hormonal contraceptives are category 4, mainly because of the heightened risk of thrombosis. Similarly IUD is category 3 in the complicated transplant patient , however preinserted device is permitted to continue, but no new IUD is advisable.
Its inherent that estrogen based contraceptive is associated with increased incidence of thrombosis, migraine headache and worsening hypertension control. furthermore , its metabolized via cytochrome p4503A2 bearing the potential interaction with CNi, necessitating close observation of CNi blood level. Similarly its use is not advocated in patients with chronic liver disease.
Depo Medroxyprogesteron:
is injection every 3 months highly effective with main advantage of no drug-drug interaction with immunosuppressants. Main shortcomings are osteoporosis and the increased risk of thromboembolism. Its metabolized in liver , therefore its not used in patients with liver disease.
Etonogestrel implant:
Its effective sub cutaneous contraceptive implant, that last effectively for 3 years, It has similar profile to depo medroxyprogesteron but lesser effect on bone density which is usually impacted secondary to the use of cortisone .
Transdermal patch:
It delivers estrogen and progestron through the skin. Some studies reported higher Thromboembolic risks than combined contraceptive pills.
Progestin only pills:
Main advantage is the avoidance of estrogen, the drawbacks are amenorrhea and failure rate of 5% which can drop to 0.5% if used correctly.Its metabolized in the liver with interaction with CNi. Its quite helpful in patients with hypertension and hypertension and cardiac disease.Silmilarly , its causing hyperlipidemia
IUD:
Either copper or levonorgestrel based, advantages, are no increase in thromboembolism, no drug-drug interaction and no bone effect. Side effect reported by some studies is increased local infection
Types and effectiveness of various types of contraception
Counseling of transplant recipients regarding pregnancy and contraception after successful kidney transplantation is essential. Females can regain their ovulatory cycles and fertility as soon as one-month post-transplant, so effective contraceptive method is essential to guard against unplanned pregnancy which can eventually lead to various maternal and fetal complications.
It is proven from available evidence that delay in conception for at least one-year post-transplantation and ensuring adequate graft function, GFR > 60 ml/min/1.73 m2, proteinuria less than 0.5 gm/day and well controlled blood pressure are associated with good pregnancy and graft outcomes. So effective contraception till that target is crucial.
Contraceptive methods are mainly 2 groups, permanent and temporary as shown in table 1 and 2 respectively.
table 1, 2 of contraceptive methods, advantages and adverse effects of each
Pregnancy after kidney transplantation is possible as most causes of infertility caused by renal failure are corrected. But pregnancy must be planned well as it’s still considered high risk pregnancy as associated with adverse events on mother, fetus and graft. Thus pregnancy should be postponed till the graft is stable to avoid harmful interaction between pregnancy and the graft.
Almost all contraceptive methods can be used post transplantation with variable failure rates and interaction with IS drugs.
Contraceptive methods are classified into
1- perminant as tuballigation in females and vasectomy in males
Very effective method but irreversible.
2- Temporary methods including
a- Barrier methods (safe but high failure rates) :
– male and female condums.
– Diaphragm or cervical cap with spermicides.
– Contraceptive spongs.
b- Hormonal methods : low failure rate but may interfere with IS e.g.
– Compined contraceptive pills
– Progesterone dermal patches
The safest and best methods for kidney recipients is IUD and transdermal progesterone as they have low failure rates, cheap and no interaction with IS
while other hormonal methods are effective but can interfere with IS as they are metabolized by CYP 450 A30 , also they may increase thrombotic tendency so better to be avoided in patients with previous VTE , stroke and antiphospholipid Antibodies syndrome.
the education of patients and their partners about the risks of unplanned pregnancy is avital point , as both of them are involved in choosing the method of contraception and the timing of pregnancy.
to avoid premature , unplanned pregnancy the methods of contraception should be educated before kidney transplantation .
Other important point include choosing of safe immunosuppressive medication and safe antihypertensive drugs .
Temporary Permanent
Copper and progestin intrauterine devices – Female tubal ligation
– Male vasectomy
Hormone methods
Estrogen and progesterone
Oral contraceptive pill
Transdermal patch
Vaginal ring
Progesterone only
Implant
Barrier methods
Diaphragm with spermicide
Cervical cap with spermicide
Contraceptive sponge
Male condom
Female condom
Regarding the effectiveness of various types of contraceptive methods
devices
Failure Rates of Different Contraceptive Methods (Pearl Index)
Type of Contraception Failure Rate (Pearl Index)
Lactation for 12 mo 25
Coitus interruptus 9
Symptothermal method 1.5–11
Spermicidal foam 3
Diaphragm 2
Intrauterine device 1-3
Progesterone-only pill 1-2
Condom 0.4-1.6
Combined pill 0.1
Vasectomy 0.1
Tubal ligation 0.04
1- Combined hormonal contraceptives ( COCP )
COCP are considered ascategory 4.
Usually they are very effective with low failure rate , therefore they are in common use .
The most common side effect of this drug are due to the presence of estrogen, which include
· Worsening of migraine headaches,
· thromboembolism, and
· exacerbation of hypertension control.
COCP are metabolized by the cytochrome P4503A4 enzyme ; therefore drug drug interaction with CNI could be a problem .
Failure rate : 0.1 (Pearl Index)
It is contra indicated in
· a history of MI ,
· CVA
· DVT
· Migraine
· Poorly controlled hypertension
· active liver disease or liver adenoma .
2- Depot medroxyprogesterone acetate
Depot medroxyprogesterone acetate (Depo- Provera) is slow released (3month) a synthetic
Progestin it is very effective and safe method . failure rate = 2% because of poor drug adherence (delaying of injection ) .
Side effects : reversible osteoporosis , thromboembolisim .
Precaution in liver disease .
Advantage : no drug-drug interactions with immune suppressive drug .
It is a good choice .
3- Etonogestrel implant (E I )
E I T IS implanted subcutaneously in the upper arm.
Very effective ( 99% ) , duration of effect is 41 The effectiveness is > 99%, and the protection is 3 years.
It has temporary effect , the normal cycle restart ( within 3 weeks ) once it is stoped .
Side effect : bleeding irregularity .
The risk-benefit characteristic is like that of depo- provera.
it is safely advised, very effective and reversible effect.
4 – Transdermal contraceptive patch .
It is a cutaneous patch that release estrogen and progesterone. The blood level of these hormones are higher than that of COCP .
The risk of thromboembolism is similar to ( in one study it is twice higher than) COCP .
5-Progestin-only pills.
It contains only progestin (no estrogen ) therefore there is no estrogen related side effect .
Side effects : risk of amenorrhea with 5% failure rate, high first-pass liver , there is drug -drug interaction, weight gain, dyslipidemia .
Contraindicated in liver disease.
Failure Rate (Pearl Index) is 1-2 .
6-Intrauterine devices.
Intrauterine devices (IUDs) are category 2 .this method carry no additional risk of pelvic infection .
Advantages : easy insertion, long lasting, low failure rate (Pearl index, 1-3), no drug – drug interaction, No thromboembolism , ] cost-effective , long-lasting methods .
Contraindications : history of ectopic pregnancy and pelvic inflammatory condition.
Copper IUD and the levonorgestrel-releasing IUD has both effectivity and safety.
Although there is no good evidence , the immunosuppressive medication may decrease the efficacy of IUD .
7-The vaginal ring
The vaginal ring is a silastic ring that is impregnated with etonogestrel and ethinyl estradiol. It is effective (Pearl index, 1-3), controls the menstruation , has a lower blood level ( lower exposure )of ethinyl estradiol in comparison with COCP.
8-Barrier methods of contraception
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective with high failure rate (Pearl index, 0.4-1.6) and usually with poor compliance.
Success rate can reach 97% if used correctly and consistently.
Advantage : convenient and easy to use, no drug drug interaction.
Can be used in kidney transplant recipient , but is better when it is combined with other methods.
Education regarding this method enhance \ awareness and compliance and reduce the failure rate .
-The risk of rejection with invention of modern immunosuppressive on is reduced resulting in increasing number of women with reproductive age with good graft functions.
-Ovulation may start as soon as 1 month after transplant thereafter it is crucial to plan for a timely safe conception and effective maternity care .
the period of 1 year after transplant appears to be sufficient to minimise the risk of adverse events of pregnancy.
-Adequate graft function before conception ( no proteinuria and well controlled blood pressure) is key factor for safe pregnancy as both conditions associated with poor outcomes to foetus and pregnant mother after kidney transplant.
Methods of contraception must discussed before and soon after transplant surgery as fertility reversed 1-6 months after transplant.
Methods of contraceptions after kidney transplant:
either permenant or temporary
Permanent methods
female tubal ligation or male vasectomy but vasectomy associated with decreased risk of ectopic pregnancy but it is irreversible and invasive procedure.
Temporary methods…
* combined hormonal contraceptions:
– classified as category 4 in complicated transplant.
– contraceptive containing estrogen and progestin are commenly used in daily practice due to their effectiveness and minimal failure rates.
– studies showed low dose of oral contraceptives there were no pregnancy for at least 18 months.
– combined contraception is the main contraceptive methods in 58%.of women in study population.
– 42% of women used combined contraceptives for reducing menonhagia and reducing development of ovarian cysts.
– combined oral contraception metabolized by cytochrome p 450 , these drugs interact with calcineurin inhibitors in female kidney transplant.
– combined oral contraceptives are contraindicated :
1-history of myocardial infarction.
2- stroke or deep vein thrombosis.
3- migraine or uncontrolled hypertension.
4- active liver diseases or hepatic adenoma.
*Depot medroxyprogesterone acetate :
– synthetic progestin with slow release over three months.
– high effective and safe I failure rate 2%..
– reversible decrease in bone density due to normalize of DMPA acetate.
– risk of thrombo-embolism.
– No interaction with immune-suppression.
-good choice as motivated as patients adhere to injections sequdule.
– metabolise through liver so contra-indicated with active liver diseases.
ETONOGESTREL IMPLANT :
–single silastic rod implanted subcutaneously in the upper arm.
-effectiveness is 97% and the protection lasts for 3 years .
-on removal, the etonogestrol drops rapidly and most patient ovulate after 3 weeks .
-adverse effects bleeding irregularities in minority of patients.
-affect bone density especially with using of steroids after transplan.
– safely advice, highly effective and reversible.
transdermal contraceptives pathches:
_ patch was placed transdermal through abdomen which delivers estrogen and progesterone, but level of ear roger higher than combined contraceptives.
– carry risk of thrombo-embolism like contraceptive methods by about 2 folds more.
progestin only pills:
– benefits of avoidance of estrogen related risks.
Intrauterine devices :
-classified as category 2.
– studies showed that immune-compromised women at great risk of developing pelvic infections.
-but risk of infection significant increase after IUD insertion s but no benefit to use prophylactic antibiotics after IUD insertion.
-advantages:.
*effect reversible after removal.
* long lasting, low failure rate and easy insertions.
* not interact with immenosuppression.
* no risk of thrombo-embolism.
– contraindicated:-
* pelvic ectopic pregnancy.
* history of pelvic inflammation.
-copper IUD effective and safe for 10 years, while levonorgestrel-releasing intrauterine device lasts for 5 years.
-post-transplant immenosuppession decrease efficacy of IUD because modify lencoeyte response.
The vaginal ring :
silastic ring impregnated with etonogestrel and ethinyl estradiol
-effective and control of menstrual cycle .
-low side effects as compared to combined contraceptive due to low concentration of of ethinyl estradiol .
-serum ethinyl estradiol is lower compared to patch or combined contraceptive.
BARRIER METHODS OF CONTRACEPTION
Less effective due to high failure rate and non-compliance.
if used correctly can be successful up to 97%.
*advantages :
easy method
convient
not interact with immunosuppressive
better with use with another methods of birth control
Contraception after kidney transplantation
Temporary method
Type
1) IUCD
PRO
CONS
2) Combined hormonal contraceptives
PRO
CONS
3) Depot medroxyprogesterone acetate
PRO
CONS
4) Etonogestrel implant
PRO
CONS
5) Transdermal contraceptive patch
PRO
CONS
6) Progestin-only pills
PRO
CONS
7) The vaginal ring.
PRO
CONS
8) Barrier methods of contraception.
PRO
CONS
Permanent method
Type
PRO
CONS
2.Male vasectomy
PRO
CONS
In conclusion pregnancy following renal transplant has higher risk as compare to general population. However, pregnancy generally permitted after 2 years of renal transplant in uncomplicated condition. Proper counseling regarding risks and benefits of each contraception method is essential before renal transplant.
Methods of contraception should be taken in consideration for kidney recipient women due to maternal and fetal complications that occur in higher rate than in general population.
Each one of these methods has it’s risk, side effects and effectiveness all should be discussed with the family to prevent unplanned pregnancy.
There are 2 main methods of contraception Permanent and temporary.
Permenant method consists of 2 main types female tubal ligation and male vasectomy,tubal ligation carries risk of ectopic pregnancy while vasectomy has no this risk and it’s non reversible.
Temporary method subdivided into different methods like:
Combined hormonal contraceptives
Depot medroxyprogestrone acetate
Etonogestrel implant
Transdermal patch
Progestin only pills
Intrauterine devices
Vaginal ring
Barrier methods of contraception
Combined hormonal contraceptives are widely used ,highly effective with minimum failure rate also used to regulate menstrual bleeding and protect from ovarian cysts.
Depot medroxyprogesteone acetate is synthetic progestin slow release over 3 months it’s highly effective and safe with no drug interactions with IS medications.
Etonogestrel implant is implanted subcutaneous in the upper arm effective and last for 3 years and if removed ovulation can occur after 3 wks so it’s rapidly reversible.
Transdermal contraceptives patch by using patch placed on the abdomen .
Progestin only pills are used to avoid estrogen related risks .
Intrauterine devices have low failure rate ,easily inserted , can be used for long duration,reversible, no IS drug interactions and no risk of thromboembolism.
The vaginal ring has advantage of low concentration of ethinyl estradiol.
Barrier methods like condoms,spermicides,,diaphragm,cervical cap and spongs all are less affective than other methods but they are easy to use and have no drug interactions.
THESE METHODS ARE CLASSIFICADES IN:
A – PERMANENTS :
-Female tubal ligation: reversible surgical method, but there is a risk of tubal pregnancy.
– Male vasectomy: less risk of ectopic pregnancy, but is a invasive and irreversible procedure.
B – TEMPORARY:
– COMBINED HORMONAL ORAL CONTRACEPTIVES:
Contraceptives containing estrogen and progestin – in a study of 26 women who used combined low-dose oral contraceptives after renal transplant for at least 18 months, no pregnancy was reported.
Depot medroxyprogesterone acetate (DMPA) is a synthetic progestin with slow release over 3 months. It is a highly effective and safe contraceptive method. The failure rate is only 2% due to delay in repeat injections.
– INTRAUTERINE DEVICES :
Currently available data suggest that immunocompromised women are not at greater risk of developing pelvic infections and no differences in infectious morbidity. However, many studies indicated that the risk of infection is significantly increased immediately after IUD insertion in immunocompromised patients. The advantages of the IUD include easy insertion, long lasting, and low failure rate. Previous ectopic pregnancy and history of pelvic inflammation are contraindications to the use of IUDs.
Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years, are both effective and safe to use after kidney transplant
– VAGINAL RINGS:
It is effective controls the menstrual cycles and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
– SUBCUTANEOUS IMPLANTS : the effectiveness is > 99%, and the protection lasts for 3 years.
– BARRIERS METHODS
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate and the difficulty in achieving compliance. But, barrier success rate can reach 97% if used correctly and consistently. 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.
A] Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation
Contraception is important after transplantation, as pregnancy post- trabsplant has to be planned and timed. Fertility returns within months following a renal transplant, and so pregnancy can occur., However pregnancy in one who has had a renal transplant is asscociated with some increased risks, and the immunosuppresants are mostly teratogenic.
There are two main methods of contraception: permamnent and temporary. The permanent methods include tubal ligation and vasectomy. Vasectomy is preferred as its less likely to increase the risk of ectopic pregnancies [in the female] assocuated with tubal ligation.
The temporary forms of contraception include
In summary, pregnancy must be planned post transplant: so contraception must be discussed before the transplant is doneand also post transplant. The available types opf contraceptives have been discussed above. The permanent form of contraception is safe, so is the IUD and the combined hormone contraceptives. The patient must be wholly infomed about the risks associated with pregnancy, the different types of copntraception and their associated risks, and will use this knowledge to make an informed decision about the type of contraceptive she will use.
I) permanent methods
A) tubal ligation
B) male vasectomy
Permanent methods the most effective
Male vasectomy has advantage over tubal ligation in avoidance of ectopic pregnancy but it is invasive and irreversible
II) temporary methods
A) Combined hormonal contraceptives
they are highly effective and with minimal failure rate
The risks with combined hormonal contraceptives are attributed to the estrogen component of these formulations, including exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control. Therefore; Patients who have a history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have active liver disease or hepatic adenoma are advised not to use combined hormonal contraceptives, as they may aggravate these conditions
Note: COCs are metabolized by cytochrome P450 so may have interaction with some Is medications like CNIs
B) Depot medroxyprogesterone acetate (synthetic progestin with slow release over 3 months) DMPA
It is a highly effective and safe contraceptive method. The failure rate is only 2% due to delay in repeat injections.
SE: – decrease bone density but it is reversible once it is stopped
– Thromboembolic complications and this is the main risk factor
– Not used for patients with liver affection as it is metabolized in liver
Adv.: + no drug interaction
+ more compliance as only one injection every 3 months but needs adherence to the time of injection
C) Etonogestrel implant
The etonogestrel implant is a single silastic rod implanted subcutaneously in the upper
arm.41 The effectiveness is > 99%, and the protection lasts for 3 years. On removal, the etonogestrel drops rapidly, with most patients ovulating after 3 weeks.
So it can be safely advised to kidney transplant female recipient , because it is highly
effective, and is rapidly reversible
Etonogestrel implant has risk-benefit features similar to DMPA but has been shown to cause fewer decreases in bone mineral density
D) Transdermal contraceptive patch
Same mechanism, efficacy and side effects of COCs but it deliver estrogen and progesterone from a patch inserted subcutaneously; mainly in the abdomen with higher level of estrogen which may contribute to higher risks than COCs
E) Progestin-only pills
5% failure rate during the first year are the major concerns; this rate drops to < 0.5% if used correctly and constantly.
Progestin-only pills require ensured compliance to reduce failure rates
It spares the risks of estrogen containing methods
Interactions with medications that are metabolized by the liver can occur especially with CNI medications whiche requires careful monitoring of CNI levels
progestin-only pills should be avoided in patients with liver disease.
Progestin-only pills increase the risk of weight gain.
F) Intrauterine devices
Copper IUD and the levonorgestrel-releasing intrauterine system are both effective and safe to use after kidney transplant. Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years
Adv.: + easy insertion,
+ long lasting, and
+ low failure rate
+ reversible after IUD removal
+ no drug interaction
+ no risk of thromboembolism
Disdv.: the risk of pelvic infection
G) The vaginal ring
impregnated with etonogestrel and ethinyl estradiol. It is effective and works by controlling the menstrual cycles and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol
H) Barrier methods of contraception
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate.
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
the pregnancy-associated risks described and the fact that fertility can be efficiently reverted within
1 to 6 months after a 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.
These measures would reduce the possible complications and adverse events that might occur during
pregnancy after a kidney transplant. Other concerns include the optimization of immunosuppressive agents
and antihypertensive medications.
There are 2 principal methods of permanent contraception and several temporary methods.
1. Permanent methods include
· female tubal ligation
· male vasectomy.
Vasectomy has the advantage of having fewer associated risks of ectopic pregnancy than tubal ligation, but it is a nonreversible and invasive procedure.
2. Temporary methods involve the use of
· combined hormonal oral contraception,
· intrauterine devices
· vaginal rings
· subcutaneous implants
· barriers, and natural methods like coitus interruptus.
Combined hormonal contraceptives are commonly used in daily practice as they are highly effective and
with a minimal failure rate. The risks with combined hormonal contraceptives are attributed to the estrogen component of these formulations, including
· exacerbation of migraine
· headaches, the risk of thromboembolism, and
· worsening hypertension control
· Combined hormonal contraceptives are primarily metabolized by the cytochromeP4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients.
Depot medroxyprogesterone acetate is a synthetic progestin with a slow-release over 3 months. It is a
highly effective and safe contraceptive method. The failure rate is only 2% due to delays in repeat
injections. The reversible decrease in bone density and concern about thromboembolic are the main causes of DMPA cessation.
Etonogestrel implant is a single silastic rod implanted subcutaneously in the upper arm. The effectiveness is > 99%, and the protection lasts for 3 years. On removal, the etonogestrel drops rapidly, with most patients ovulating after 3 weeks.
The adverse effect of this method is the bleeding irregularity and decreases in bone mineral density encountered in a minority of patients.
A transdermal contraceptive patch that delivers estrogen and progesterone through the transcutaneous on the abdomen but unfortunately the circulating levels of estrogen are substantially higher than with combined hormonal contraceptives which explains why Some studies have shown more than a 2-fold increase in the risk of venous thromboembolism associated with this method.
Progestin-only pills: The advantage of progestin-only pills is the avoidance of estrogen-related but with an increase in the incidence of amenorrhea, the risk of weight gain, and a 5% failure rate during the first year. Progestin-only pills require ensured compliance to reduce failure rates Interactions with medications that are metabolized by the liver can occur with progestin-only pills, and they should be avoided in patients with liver disease.
Intrauterine devices are classified as a category
2 compared with combined pills, which are classified as category 4 in complicated transplants. we have always been concerned regarding the development of pelvic infections but currently available data suggest that immunocompromised women are not at greater risk of developing pelvic infections.
Also, the risk of Previous ectopic pregnancy and a history of pelvic inflammation is considered contraindications to the use of IUDs.
Copper IUD and the levonorgestrel-releasing intrauterine system are both effective and safe to use after kidney transplants. Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years.
Theoretically, posttransplant immunosuppressive medications may decrease the efficacy of IUDs, possibly because they modify the leucocyte response. However, there is no solid evidence suggesting that the safety and effectiveness of the IUD would be compromised in the transplant patient.
The vaginal ring is a silastic ring that is impregnated with etonogestrel and Ethinylestradiol. It is effective controls the menstrual cycles, and has the advantage of a lower concentration of Ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to Ethinyl estradiol
Barrier methods of contraception Like condoms, spermicides, diaphragm, cervical
cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the
relatively high failure rate and difficulty in achieving compliance. The 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.
Education of couples regarding this method of contraception encourages awareness and compliance
and may reduce the failure rate of this method.
In conclusion
Early counseling, ideally before transplant, to discuss the methods of contraception and to allow women to make an informed choice regarding contraception and subsequent pregnancy is of paramount importance.
It sounds logical that patients must be made aware of the benefits and risks of each method used after transplant through proper education. Effective and suitable contraception is important to reduce the risk of unplanned pregnancy A multidisciplinary team approach involving obstetricians and nephrologists should be adopted to decide the appropriate timing for conception, ascertain appropriate follow-up, and advise on methods of contraception that suit the patient.
There is no ideal contraceptive method; the best is to individualize the method of contraception according to a patient’s individual risk.
Restoration of fertility post-transplant can be seen in 1 to 6mnth of transplant and post-transplant counselling regarding various methods of contraception is very important.
Various method of contraception-
I) Permanent methods: These can be utilized in patients not willing for further child-bearing.
1) Female tubal ligation: Associated with risk of ectopic pregnancy and has failure rates of 0.5%.
2) Male vasectomy: Invasive and non-reversible.
II) Temporary methods:
1)Combined hormonal contraceptives: These include contraceptives containing estrogen and progestin. The failure rate associated with their use is 0.3%. But the estrogen component can cause migraine headache exacerbation, increased blood pressures and thromboembolic events, hence are contraindicated in patients with history of stroke, myocardial infarction, deep vein thrombosis, migraine and uncontrolled hypertension as well as active liver disease and hepatic adenoma.
2) Depot Medroxy Progesterone Acetate (DMPA): It is long acting (3 months) with failure rate of 6% (due to delayed repeat injection). Its use has been associated with decreased bone mineral density.
3) Etonorgesterol implant: It is a very long-acting form of contraception with protection for 3 years, implanted in the upper arm subcutaneously and fertility reversal is achieved in 3 weeks post-removal with a failure rate of less than 1%.
4) Transdermal contraceptive patch: It delivers estrogen and progesterone, has 2 times increased risk of venous thromboembolism and has low failure rates (0.3%).
5) Progestin only pills: These avoid risks associated with estrogen but have failure rate of 5% initially which decreases to less than 0.5% later. They are useful in patients with high blood pressures but should be avoided in active liver disease and close monitoring of calcineurin inhibitor drug levels is required. They are associated with weight gain and altered lipid profile.
6) Intrauterine devices (IUD): They are long acting, cost-effective, easily inserted and have low failure rates (0.6-0.8%) with absence of increased risk of thromboembolism, immunosuppression drug interaction or associated increased pelvic infection rates. They should not be used in patients with history of pid.
i.Copper IUD:
ii. Levonorgesterol releasing IUD:
7) The vaginal ring: It is impregnated with etonorgesterol and ethinyl estradiol in lower concentration with low failure rates (1-3%)
8) Barrier methods of contraception: These include condoms, spermicides, diaphragm, cervical cap and sponges. They are easy to use, have no drug interactions but have relative high failure rates (12-23%) and associated with compliance issues. They are useful as an adjunct to other forms of contraception
Improvement of fertility post-transplant can be seen in 1-6 months. Therefore, the role of pre-transplant and post-transplant counselling regarding methods of contraception is essential.
Several methods of contraception available post-transplantation:
I) Permanent methods: Patients not willing for further childbearing.
· Female tubal ligation: Associated with risk of ectopic pregnancy and failure rates of 0.5%.
· Male vasectomy: Invasive and non-reversible, but decreases the risk of ectopic pregnancy and has failure rate of 0.5%
II) Temporary methods:
1) Combined hormonal contraceptives: include contraceptives containing oestrogen and progestin
a. failure rate is 0.3%.
b. oestrogen component can cause migraine headache exacerbation, increased blood pressures and thromboembolic events, so contraindicated in patients with history of stroke, myocardial infarction, deep vein thrombosis, migraine, and uncontrolled hypertension as well as active liver disease and hepatic adenoma. Drug interactions with calcineurin inhibitors needs to be considered.
2) Depot Medroxy Progesterone Acetate (DMPA):
a. long acting (3 months) with failure rate of 6% (due to delayed repeat injection).
b. has no drug interactions but should not be used in patients with active liver disease and risks of thromboembolic events.
c. associated with decreased bone mineral density.
3) Etonorgesterol implant:
a. long-acting form (for 3 years)
b. implanted in the upper arm subcutaneously and fertility reversal is achieved in 3 weeks post-removal
c. failure rate of less than 1%.
4) Transdermal contraceptive patch:
a. delivers oestrogen and progesterone
b. 2 times increased risk of venous thromboembolism
c. has low failure rates (0.3%).
5) Progestin only pills:
a. These avoid risks associated with oestrogen
b. failure rate of 5% initially which decreases to less than 0.5% later
c. useful in patients with high blood pressures
d. should be avoided in active liver disease
e. close monitoring of calcineurin inhibitor drug levels is required.
f. associated with weight gain and altered lipid profile.
6) Intrauterine devices (IUD):
a. long acting, cost-effective, easily inserted
b. low failure rates (0.6-0.8%)
c. absence of increased risk of thromboembolism, immunosuppression drug interaction or associated increased pelvic infection rates.
d. should not be used in patients with history of previous ectopic pregnancy or pelvic inflammation.
e. Copper IUD: have long life of 10 years
f. Levonorgesterol releasing IUD:
7) The vaginal ring
a. impregnated with etonorgesterol and ethinyl oestradiol in lower concentration
b. low failure rates (1-3%)
8) Barrier methods of contraception:
a. such as condoms, spermicides, diaphragm, cervical cap and sponges.
b. easy to use
c. have no drug interactions
d. relative high failure rates (12-23%)
e. associated with compliance issues.
f. useful as an adjunct to other forms of contraception
9) Other methods: These are very unreliable
a) Lactation amenorrhea:
b) Coitus interruptus: 20% failure rate
c) Symptothermal methods: 15-24% failure rate.
Various method of contraception-
I) Permanent methods:
*Female tubal ligation: Associated with risk of ectopic pregnancy and has failure rates of 0.5%.
*Male vasectomy: Invasive and non-reversible.
II) Temporary methods:
1-Combined hormonal contraceptives:
Are containing estrogen and progestin.
The failure rate is 0.3%.
Side effects:
migraine headache exacerbation
increased blood pressures
thromboembolic events,
contraindications:
in patients with history of stroke, myocardial infarction, deep vein thrombosis, migraine and uncontrolled hypertension as well as active liver disease and hepatic adenoma.
2-Depot Medroxy Progesterone Acetate (DMPA):
It is long acting (3 months) with failure rate of 6%
Side effect:
decrease bone mineral density.
3- Etonorgesterol implant:
It is a very long-acting form of contraception with protection for 3 years, implanted in the upper arm subcutaneously and fertility reversal is achieved in 3 weeks post-removal with a failure rate of less than 1%.
4-Transdermal contraceptive patch:
It delivers estrogen and progesterone,has low failure rates (0.3%)
Side effects :
has 2 times increased risk of venous thromboembolism.
5- Progestin only pills:
These avoid risks associated with estrogen but have failure rate of 5% initially which decreases to less than 0.5% later.
Side effects:
weight gain
altered lipid profile.
6 -Intrauterine devices (IUD):
Advantages
They are long acting ,easily inserted, and have low failure rates (0.6-0.8%) with absence of increased risk of thromboembolism, immunosuppression drug interaction.
i.Copper IUD:
ii. Levonorgesterol releasing IUD:
7- The vaginal ring: It is impregnated with etonorgesterol and ethinyl estradiol in lower concentration with low failure rates (1-3%)
8- Barrier methods of contraception:
These include condoms, spermicides, diaphragm, cervical cap and sponges.
They are easy to use, have no drug interactions but have relative high failure rates (12-23%) .
They are useful as an adjunct to other forms of contraception
Evidence suggests that a period of 1 year after transplant appears to be sufficient to minimize the risk of adverse events due to pregnancy, as possible risks of acute rejection and graft loss and prematurity will be less after this time.Adequate graft function before conception (no proteinuria and well- controlled blood pressure) is the key factor toward a safe pregnancy because these 2 conditions are associated with poor outcomes to fetus and pregnant mothers after kidney transplant. Major complications to the fetus in pregnant transplant recipients include prematurity, intrauterine growth retardation, and low birth weight.The preterm delivery rate is 40% to 60% (whereas it is 5%-15% in the general population)
Complications and Pregnancy Outcomes in Female Patients After Kidney Transplantation:
Hypertension
Preeclampsia
Type 2 diabetes mellitus
Rejection
Graft loss within 2 y
Pregnancy Outcomes
Spontaneous abortion
Live birth
Prematurity ( 99%, and the protection lasts for 3 years.
On removal, the etonogestrel drops rapidly, with most patients ovulating after 3 weeks.
The adverse effect of this method is the bleeding irregularity encountered in a minority of patients.Etonogestrel implant has risk-benefit features similar to DMPA but has been shown to cause fewer decreases in bone mineral density.
It is safely advised, is highly effective, and is rapidly reversible.
Transdermal contraceptive patch
This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen.
The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives. events of nonfatal venous thromboembolism for the contraceptive patch, have a similar risk to combined hormonal contraceptives.
Combined hormonal contraceptives:
Combined hormonal contraceptives are classified as category 4 in complicated transplant.Contraceptives containing estrogen and progestin are commonly used in daily practice as they are highly effective and with minimal failure rate.
The risks with combined hormonal contraceptives are attributed to the estrogen component of these formulations, including exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control.
combined hormonal contraceptives were additionally used for reducing the development of ovarian cysts and menorrhagia. These drugs were found to regulate menstrual bleeding patterns and may protect from ovarian cysts.
Combined hormonal contraceptives are primarily metabolized by the cytochrome P4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients. Patients who have a history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have active liver disease or hepatic adenoma are advised not to use combined hormonal contraceptives, as they may aggravate these conditions.
Progestin-only pills
The advantage of progestin-only pills is the avoidance of estrogen-related risks.
The significant incidence of amenorrhea and the 5% failure rate during the first year are the major concerns.
Progestin-only pills require ensured compliance to reduce failure rates.
Progestin-only pills are orally administered, and, unlike DMPA and etonogestrel implant, they undergo the first-pass metabolism through the liver.
Interactions with medications that are metabolized by the liver can occur with progestin-only pills, and they should be avoided in patients with liver disease.
Their interaction with calcineurin inhibitors requires proper calcineurin inhibitor monitoring posttransplant.
Progestin-only pills increase the risk of weight gain, and both progestin-only pills and calcineurin inhibitors alter the metabolism of lipids in female kidney recipients.
Female kidney recipients who smoke or are at risk for cardiovascular problems such as high blood pressure may be able to use progestin-only pills since combined hormonal contraceptives are usually contraindicated for them.
Intrauterine devices
are classified as category 2
The advantages of the IUD include easy insertion, long lasting, and low failure rate.
The major advantage of using IUDs is that the effect is reversible after IUD removal, and immunosuppression drug interaction is not a concern in women with kidney transplants. In addition, it is not associated with increased risk of thromboembolism.
Previous ectopic pregnancy and history of pelvic inflammation are contraindications to the use of IUD.
Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years
Vaginal ring
impregnated with etonogestrel and ethinyl estradiol.It is effective ,controls the menstrual cycles, and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
Progesterone only Implant
Barrier methods
Diaphragm with spermicide
Cervical cap with spermicide
Contraceptive sponge
Male condom
Female condom
are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate and the difficulty in achieving compliance.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.
Permanent
Female tubal ligation
Male vasectomy
Vasectomy has the advantages of having less associated risks of ectopic pregnancy than tubal ligation, but it is a nonreversible and invasive procedure.
Kidney transplant recipients are advised to delay pregnancy for a minimum of 1 year after transplant to reduce potential neonatal and maternal complications. An effective and suitable contraception is important to reduce the risk of unplanned pregnancy.
Temporary contraception methods involve the use of combined hormonal oral contraception, intrauterine devices, vaginal rings, subcutaneous implants, barriers, and natural methods like coitus interruptus.
· Combined hormonal contraceptives: Contraceptives containing estrogen and progestin are commonly used in daily practice as they are highly effective and with minimal failure rate. Risks includes: exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control. Combined hormonal contraceptives are primarily metabolized by the cytochrome P4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients.
· Depot medroxyprogesterone acetate is a synthetic progestin with slow release over 3 months. It is a highly effective and safe contraceptive method. The major concern of DMPA is the thromboembolic risk. Depot medroxyprogesterone acetate has the advantage of no drug interactions with immuno – suppressive medications of transplant patients and is a good choice as long as patients are motivated to adhere to the injection schedule.
· Etonogestrel implant: The effectiveness is > 99%, and the protection lasts for 3 years. The adverse effect of this method is the bleeding irregularity encountered in a minority of patients. This implant, a new method of contraception for female kidney recipients, can be safely advised, is highly effective, and is rapidly reversible.
· Transdermal contraceptive patch: This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen. The risk with this method is similar to that shown with combined hormonal contraceptives.
· Progestin-only pills: The advantage of progestin-only pills is the avoidance of estrogen-related risks. Progestin-only pills are orally administered, and, unlike DMPA and etonogestrel implant, they undergo the first-pass metabolism through the liver. Interactions with medications that are metabolized by the liver can occur with progestin-only pills, and they should be avoided in patients with liver disease. Their interaction with calcineurin inhibitors requires proper calcineurin inhibitor monitoring posttransplant. Progestin-only pills increase the risk of weight gain, and both progestin-only pills and calcineurin inhibitors alter the metabolism of lipids in female kidney recipients.
· Intrauterine devices Intrauterine devices (IUDs): Currently available data suggest that immunocompromised women are not at greater risk of developing pelvic infections. The major advantage of using IUDs is that the effect is reversible after IUD removal, and immunosuppression drug interaction is not a concern in women with kidney transplants. Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years, rendering these cost-effective and long-lasting methods of contraception for women with kidney transplants.
· The vaginal ring: It is effective, controls the menstrual cycles, and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
· Barrier methods of contraception Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate and the difficulty in achieving compliance. 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.
· Permanent methods include female tubal ligation and male vasectomy.
Methods of contraception after kidney transplantation:
There are 2 principal methods of permanent contraception and several temporary methods . Permanent methods include female tubal ligation and male vasectomy.
Temporary methods involve the use of combined hormonal oral contraception, intrauterine devices, vaginal rings, subcutaneous implants, barriers, and natural methods like coitus interruptus
Combined hormonal contraceptives
The risks with combined hormonal contraceptives are attributed to the estrogen component of these formulations, including exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control.
In a study of 26 women who used combined low-dose oral contraceptives after renal transplant for at least 18 months, no pregnancy was reported.
These drugs were found to regulate menstrual bleeding patterns and may protect from ovarian cysts.
Combined hormonal contraceptives are primarily metabolized by the cytochrome P4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients.
Patients who have a history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have active liver disease or hepatic adenoma are advised not to use combined hormonal contraceptives
Depot medroxyprogesterone acetate
Depot medroxyprogesterone acetate (DMPA; DepoProvera, Pfizer, New York, NY, USA)
Acts slowly , failure rate about 2% , The reversible decrease in bone density is a concern that normalizes on DMPA cessation
medroxyprogesterone acetate has the advantage of no drug interactions with immuno – suppressive medications of transplant patients and is a good choice as long as patients are motivated to adhere to the injection schedule. The metabolism of DMPA is through the liver; therefore, it is not recommended for those with active liver diseas
Etonogestrel implant
The etonogestrel implant is a single silastic rod implanted subcutaneously in the upper arm. The effectiveness is > 99%, and the protection lasts for 3 years. The adverse effect of this method is the bleeding irregularity encountered in a minority of patients.41 Etonogestrel implant has risk-benefit features similar to DMPA but has been shown to cause fewer decreases in bone mineral density, a concern that is also commonly encountered after transplant due to the effect of steroids on can be safely advised .
It is highly effective, and is rapidly reversible can be safely advised for transplanted females .
Transdermal contraceptive patch
This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen , its effectiveness and adverse effects profile is as for combined hormonal contraceptive pills .
Progestin-only pills
The advantage of progestin-only pills is the avoidance of estrogen-related risks.48 The significant incidence of amenorrhea and the 5% failure rate during the first year are the major concerns; this rate drops to < 0.5% if used correctly and constantly
they undergo the first-pass metabolism through the liver. Interactions with medications that are metabolized by the liver can occur with progestin-only pills, and they should be avoided in patients with liver disease. Their interaction with calcineurin inhibitors requires proper calcineurin inhibitor monitoring posttransplant. Progestin-only pills increase the risk of weight gain, and both progestin-only pills and calcineurin inhibitors alter the metabolism of lipids in female kidney recipients.
Intrauterine Devices
Currently available data suggest that immunocompromised women are not at greater risk of developing pelvic infections
The advantages of the IUD include:
1- easy insertion, long lasting , cost effective and low failure rate
2-the effect is reversible after IUD removal
3- immunosuppression drug interaction is not a concern in women with kidney transplants.
4-It is not associated with increased risk of thromboembolism
The vaginal ring
The vaginal ring (NuvaRing is a silastic ring that is impregnated with etonogestrel and ethinyl estradiol. controls the menstrual cycles, and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
Barrier methods of contraception
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate and the difficulty in achieving compliance. Barrier success rate can reach 97% if used correctly and consistently.
They have the advantage of being a 1)convenient and easy to use method of contraception while also 2) 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.
Fertility is shortly regained (1-6 months after transplantation)
Unplanned pregnancy must be avoided in transplant recipients to avoid pregnancy-associated risks and to optimize immunosuppression and antihypertensive agents
Methods of contraception should be discussed before transplantation
There are different methods of contraception and their efficacy critically evaluated after kidney transplant and they are successful with acceptable risk.
individualizing the method of contraception according to a patient’s individual risks and expectations is essential.
There are 2 principal methods
A. permanent contraception such as female tubal ligation and male vasectomy.
B. several temporary methods such as
1. intrauterine devices (Copper and progestin)
2. Hormone methods Estrogen and progesterone e.g.: Oral contraceptive pill, Transdermal patch Vaginal Ring Progesterone Only Implant
3. Barrier methods Diaphragm with spermicide, Cervical cap with spermicide Contraceptive sponge, Male condom, Female condom
— Combined hormonal contraceptives
Are highly effective and with minimal failure rate. The risks are attributed to the estrogen component, including exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control.
As they metabolized by the cytochrome P4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors.
It’s not advice for women who have a history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and active liver disease or hepatic adenoma, as they may aggravate these conditions.
— Depot medroxyprogesterone acetate
Is a synthetic progestin with slow release over 3 months, highly effective and safe, failure rate is only 2% due to delay in repeat injections, the reversible decrease in bone density has the thromboembolic risk. no drug interactions (IS). The metabolism of DMPA is through the live therefore, it is not recommended for those with active liver disease
–Etonogestrel implant
Effectiveness is > 99%, and the protection lasts for 3 years is a single silastic rod implanted subcutaneously in the upper arm. side effect is the bleeding irregularity. fewer decreases in bone mineral density, transplant due to the effect of steroids on bones.
–Transdermal contraceptive patch
This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen. ▪︎The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives
—Progestin-only pills
The advantage of progestin-only pills is the avoidance of estrogen-related risks. the major concerns are amenorrhea and the 5% failure rate during the first year this rate drops to < 0.5% if used correctly and constantly▪︎
Interactions with medications that are metabolized by the liver can occur, and they should be avoided in patients with liver disease. Their interaction with calcineurin inhibitors requires proper calcineurin inhibitor monitoring post-transplant. Female kidney recipients who smoke or are at risk for cardiovascular problems such as high blood pressure may be able to use progestin-only pills.
–-IUCD
The major advantage of IUDs is that the effect is reversible after removal, . Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years and has no drug interaction with (IS)., it is not associated with increased risk of thromboembolism. Copper IUD and the levonorgestrel-releasing intrauterine system are both effective and safe to use after kidney transplant.
–The vaginal ring
Has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol
▪︎Serum ethinyl estradiol levels of patients showed much lower variations with the vaginal ring than with the patch or combined hormonal contraceptives.
—Barrier methods of contraception:
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the
relatively high failure rate and difficulty in achieving compliance.
– 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 post-transplant but are best when combined with another method of birth control to reduce their potential failure rate.
.
Contraception After Kidney Transplantation, From Myth to Reality:
A Comprehensive Review of the Current Evidence.
contraception after kidney transplantation.
Ovulation may start as soon as 1 month after transplant; therefore, it is crucial to plan for
a timely, safe conception and effective maternity care.
Education of patients and counseling with her partner during workup for kidney
transplant, decision of choosing the method of contraception that is appropriate for
them and the timing of pregnancy.
A multidisciplinary team approach involving obstetricians and transplant clinicians to
decide the appropriate timing for conception is recommended.
Methods of contraception after kidney transplantation:
(1) Permanent :
Female tubal ligation devices Male vasectomy.
May be used if couple complete their families or if they do not want children.
Advantage:
Less risk of ectopic pregnancy, low failure rate.
Disadvantage:
Nonreversible and invasive procedure.
(2)Temporary:
Combined hormonal contraceptives:
Estrogen and progesterone Oral contraceptive pill.
Transdermal patch.
The risk with this method is similar to that shown with combined hormonal
contraceptives.
Vaginal ring:
Impregnated with etonogestrel and ethinyl estradiol.
Controls the menstrual cycles.
Advantage of a lower concentration of ethinyl estradiol compared with combined
hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
Advantage:
Highly effective and with minimal failure rate 0.1%.
Disadvantage:
Exacerbation of migraine headaches, the risk of thromboembolism, and worsening
hypertension control. Venous thrombosis.
Drugs’ interactions with CNI.
Contraindication:
Myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled
hypertension and p active liver disease or hepatic adenoma.
Progesterone only Implant:
Depot medroxyprogesterone acetate:
Progestin with slow release over 3 months.
Advantage:
Effective a good choice and safe method.
No drug interactions with immunosuppressive medications.
Disadvantage:
The failure rate is 2%.
Thromboembolic risk.
Decrease in bone density.
Contraindication:
Active liver disease.
Etonogestrel implant:
The effectiveness is > 99%, and the protection lasts for 3 years.
Rapidly reversible.
Less bone effect on bone density.
Disadvantage:
Bleeding irregularity.
Progestin-only pills:
Advantage of progestin-only pills is the avoidance of estrogen-related risks.
Disadvantage:
Amenorrhea and the 5% failure.
Interactions with medications that are metabolized by the liver.
Interaction with CNI requires proper monitoring.
Weight gain.
Contraindication:
Active liver disease.
Intrauterine devices:
Copper and progestin intrauterine device both effective in posttransplant.
Classified as category 2.
Advantage:
Easy insertion, long lasting, and low failure rate 1-3.
Copper IUD has an effective duration of 10 years, and the Levonorgestrel-releasing
intrauterine system lasts for 5 years.
Contraindications:
Previous ectopic pregnancy and history of pelvic inflammation.
Barrier methods of contraception:
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective
contraceptive methods for organ transplant recipients due to the relatively high failure
rate 0.4-1.6.
Advantage of being a convenient and easy to use method of contraception while also
avoiding potential drug interact.
Barrier methods can be used posttransplant but are best when combined with another
method of birth control to reduce their potential failure rate.
Though OCP most commonly used in posttransplant patient, long-acting reversible
contraception is an ideal method of contraception for women with transplants because
they are highly effective, require a single office visit for initiation, and do not require daily
adherence.
As the findings of the Contraceptive CHOICE project recently established that long-
acting reversible contraception, including intrauterine devices and contraceptive
implants, provides the most effective contraception and decreases the rate of unplanned
pregnancies in general.(1)
The benefits generally outweigh the risks for most contraceptive methods (including
intrauterine devices) in an uncomplicated solid organ transplantation patient (2).
References:
1-Winner B, Peipert JF, Zhao Q, Buckel C, Madden T, Allsworth JE, et al. Effectiveness
Of long-acting reversible contraception. N Engl J Med. 2012; 366:1998–2007.
2-Centers for Disease Control and Prevention (CDC) U S. medical eligibility criteria
For contraceptive use, 2010. MMWR Recomm Rep. 2010; 59(RR-4):1–86.
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 and it should be individualized. This review has addressed this issue which sometimes is ignored by transplant teams.
Considering pregnancy-associated risks 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.
Methods of contraception after kidney trans- plantation
There are 2 principal methods of permanent contraception and several temporary methods. Permanent methods include female tubal ligation and male vasectomy.
Vasectomy has the advantage of having less associated risks of ectopic pregnancy than tubal ligation, but it is a nonreversible and invasive procedure.
Combined hormonal contraceptives
Contraceptives containing estrogen and progestin are commonly used in daily practice as they are highly effective and with minimal failure rate .
The risks with combined hormonal contraceptives are attributed to the estrogen component of these formulations, including exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control.
Depot medroxyprogesterone acetate
It is a highly effective and safe contraceptive method. The failure rate is only 2% due to delay in repeat injections.
The major concern of DMPA is the thromboembolic risk and reversible decrease in bone density.
It has advantage of no drug interaction with immunosupressives commonly used in kidney transplant patients.
Etonogestrel implant
The etonogestrel implant is a single silastic rod implanted subcutaneously in the upper arm. The effectiveness is > 99%, and the protection lasts for 3 years.
The adverse effect of this method is the bleeding irregularity encountered in a minority of patients
Transdermal contraceptive patch
Some studies have shown more than 2-fold increase in the risk of venous thromboembolism associated with this method.
Progestin-only pills
The advantage of progestin-only pills is the avoidance of estrogen-related risks.
The significant incidence of amenorrhea and the 5% failure rate during the first year are the major concerns; this rate drops to < 0.5% if used correctly and constantly.
Should be avoided in patients of liver disease
Intrauterine devices
Currently available data suggest that immunocompromised
women are not at greater risk of developing pelvic infections.
The advantages of the IUD include easy insertion, long lasting, and low failure rate and the fact that the effect is reversible after IUD removal, and immunosuppression drug interaction is not a concern in women with kidney transplants.
The vaginal ring
The vaginal ring is impregnated with etonogestrel and ethinyl estradiol.
The advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives is lower risk of complications related to ethinyl estradiol
Barrier methods of contraception
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate
They have the advantage of being a convenient and easy to use method of contraception while also avoiding potential drug interactions.
Permanent:
Female Tubal ligation (risk of ectopic pregnancy) and male vasectomy. nonreversible and invasive procedure.
Temporary:
Combined hormonal contraceptives and Transdermal contraceptive patch:
They are highly effective and with minimal failure rate.
Side effects: exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control.
N.B. Combined hormonal contraceptives are primarily metabolized by the cytochromeP4503A4, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important.
Contraindicated in: history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have active liver disease or hepatic adenoma.
Depot medroxyprogesterone acetate:
Highly effective and safe contraceptive method.
Side effect: Thromboembolic risk, alteration in bone density.
Advantages: no drug interactions with immuno -suppressive medications of transplant patients and is a good choice as long as patients are motivated to adhere to the injection schedule.
Contraindicated in: active liver disease.
Etonogestrel implant:
The effectiveness is > 99%, and the protection lasts for 3 years.
Adverse effect: may be associated with bleeding irregularity.
Progestin-only pills:
5% failure rate during the first year.
Side effect: Amenorrhea, weight gain.
Disadvantages:
Require ensured compliance, orally administered (undergo the first-pass metabolism),drug interactions.
Contraindicated in liver diseases.
Intrauterine devices:
Highly effective (category 2)
Advantages:
Easy insertion, long lasting, and low failure rate, the effect is reversible after IUD removal, no drug interactions, no risk of thromboembolism. Cost-effective and long-lasting.
Contraindications:
Previous ectopic pregnancy and history of pelvic inflammation.
The vaginal ring:
Effective
Barrier methods of contraception:
Less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate, and the difficulty in achieving compliance.
Advantages: convenient and easy to use method of contraception, no potential drug interactions.
Menstrual functions and fertility improve shortly after successful kidney transplantation. Ovulation may improve as early as 1-month post-transplantation. An unplanned pregnancy can cause severe problems for the mother and fetus. For that, couples should e educated regarding protection, especially at least for the first year. Close monitoring is also essential for optimal pregnancy outcomes with optimized renal function, controlled blood pressure, and proteinuria.
Contraception methods differ in terms of effectiveness and reversibility. Male vasectomy and tubal ligation are permanent with lowest failure rates 0.1 and 0.04, respectively. Other reversible methods vary in efficacy and duration. Natural methods include timing and lactation with failure rate of 25 compared to 9 for coitus interrupts. A summary is provided in the table below:
(please see attached photo ; as table could not be pasted)
Role of pre-transplant and post-transplant counselling regarding various methods of contraception is highly important.as restoration of fertility can be seen in 1-6 months following Tr
Different methods of contraception include:
Permanent methods; indicated when not willing for further child-bearing including tubal ligation: with risk of ectopic pregnancy and failure rates of 0.5% and including male vasectomy It is Invasive and irreversible, but decreases risk of ectopic pregnancy ;its failure rate 0.5%
Temporary methods include :
* Combined hormonal contraceptive: containing estrogen and progestin. Failure rate is 0.3%. Estrogen component can cause migraine exacerbation, increased blood pressures and thromboembolic events; contraindicated in patients with history of stroke, myocardial infarction, DVT, migraine and uncontrolled hypertension & active liver disease and hepatic adenoma. Drug interactions with calcineurin inhibitors is to be considered.
* DEPO MEDROXY PROGESTERONE ACETATE (DMPA): long acting (3 months) with failure rate of 6% (related delayed repeat injection). No drug interactions but contraindicated in patients with active liver disease and those risks of thromboembolic events. It has side effects decreased bone mineral density.
* Etonoregesterol : an implant with very long-acting form of contraception for 3 years, implanted in the upper arm subcutaneously and fertility reversal is achieved in 3 weeks post-removal ;its failure rate of less than 1%.
*Transdermal contraceptive patch: ( estrogen and progesterone), has 2 fold increased risk of venous thromboembolism and low failure rates (0.3%).
* Progestin pills: avoiding risks associated with estrogen but with failure rate of 5% initially which decreases to less than 0.5% later. It has advantage in patients with high blood pressures ;to be avoided in active liver disease with close monitoring of calcineurin inhibitor. They are associated with weight gain and dyslipidemia.
*Intrauterine device; long acting ,easily inserted cost-effective, and have low failure rates (0.6-0.8%) without increased risk of thromboembolism, immunosuppression drug interaction or increased pelvic infection rates. They are contraindicated in patients with history of previous ectopic pregnancy or pelvic inflammation.
*Vaginal ring; impregnated with etonorgesterol and ethinyl estradiol with lower concentration ; low failure rates (1-3%)
* Others : These are very unreliable including lactation amenorrhea, coitus interruptus: 20% ;failure rate & Sympto thermal methods;15-24% failure rate; all considered unreliable.
There are 2 principal methods of permanent contraception and several temporary methods. It is better to use combined methods and provide education to enhance compliance.
Permanent methods include female tubal ligation and male vasectomy. Vasectomy has the advantage of having less associated risks of ectopic pregnancy than tubal ligation, but it is a nonreversible and invasive procedure. Temporary methods involve the use of the following:
Combined hormonal contraceptives:
Combined hormonal contraceptives are classified as category 4 in complicated transplant. Contraceptives containing estrogen and progestin are commonly used in daily practice as they are highly effective and have minimal failure rate
Disadvantages:
Ø exacerbation of migraine headaches
Ø the risk of thromboembolism
Ø worsening hypertension control
Ø drug interaction with CNI
Advantages:
Ø effective in preventing pregnancy by 100%
Ø reducing the development of ovarian cysts and menorrhagia.
Contraindications
Ø History of myocardial infarction, stroke, deep venous thrombosis, migraine and uncontrolled hypertension.
Ø Patients who have active liver disease or hepatic adenoma.
Depot medroxyprogesterone acetate:
This is a synthetic progestin with slow release over 3 months. It is a highly effective and safe contraceptive method. The failure rate is only 2% due to delay in repeat injections.
Disadvantages:
Reversible decrease in bone density
thromboembolic risk
Advantage:
No drug interactions with immuno – suppressive medications
Contraindications:
Active liver disease
Etonogestrel implant
This is a single silastic rod implanted subcutaneously in the upper arm. The effectiveness is > 99%, and the protection lasts for 3 years. On removal, the etonogestrel drops rapidly, with most patients ovulating after 3 weeks.
Disadvantages:
Ø Bleeding irregularity in a minority of patients.
Ø Fewer decreases in bone mineral density than the previous method
Transdermal contraceptive patch
Trans-dermal patch is placed on the abdomen. The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives.
Disadvantages:
Nonfatal venous thromboembolism events
Progestin-only pills
Advantage:
Ø Avoidance of estrogen-related risks.
Ø Can be used in those who smoke or are at risk for cardiovascular problems such as high blood pressure.
Disadvantages:
Ø amenorrhea
Ø 5% failure rate during the first year which drops to < 0.5% if used correctly and constantly require ensured compliance to reduce failure rates.
Ø interaction with calcineurin inhibitors
Ø Interactions with medications that are metabolized by the liver
Contraindications:
Ø Liver disease.
Ø weight gain
Ø alter the metabolism of lipids
Intrauterine devices
Those are classified as category 2 in complicated transplants. Copper IUD and the levonorgestrel-releasing intrauterine system are both effective and safe to use after kidney transplant. Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years. Currently available data suggest that immunocompromised women are not at greater risk of developing pelvic infections as shown in a study in 649 women with human immunodeficiency virus infection. Other studies indicated that the risk of infection is significantly increased immediately after IUD insertion in immunocompromised patients. Grimes and associates studied the use of antibiotic prophylaxis for IUD insertion but found this conferred little benefit.
Advantages:
Ø easy insertion
Ø long lasting
Ø low failure rate
Ø reversible effect after IUD removal
Ø no immunosuppression drug interaction
Ø Not associated with increased risk of thromboembolism.
Ø Levonorgestrel-releasing intrauterine system was shown to reduce menstrual blood loss.
A study in 649 patients showed no increase in overall complications in women regardless of immune status. Another study in 599 participants showed no differences in infectious morbidity.
Contraindications:
Previous ectopic pregnancy and history of pelvic inflammation
Theoretically, posttransplant immunosuppressive medications may decrease the efficacy of IUDs, possibly because they modify the leucocyte response but there is no solid evidence .
The vaginal ring
The vaginal ring is a silastic ring that is impregnated with etonogestrel and ethinyl estradiol.
Advantage:
Ø controls the menstrual cycles
Ø lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
Ø In a trial, the vaginal ring group showed that exposure to ethinyl estradiol was significantly 3.4 times lower than in the patch group and 2.1 times lower than in the combined hormonal contraception group. Serum ethinyl estradiol levels of patients showed much lower variations with the vaginal ring than with the patch or combined hormonal contraceptives.
Barrier methods of contraception
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate and the difficulty in achieving compliance. Barrier success rate can reach 97% if used correctly and consistently.
Advantages:
Ø Convenient and easy to use method of contraception
Ø Avoiding potential drug interactions.
▪︎Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation.
Transplantation Improves fertility in women ,
Ovulation may starts about 1 month after transplant; therefore, it is crucial to plan for a timely, safe conception and effective maternity.
Evidence suggests that a period of 1 year after transplant appears to be sufficient to minimize the risk of adverse events due to pregnancy.
risks includes
acute rejection and graft loss.
prematurity will be less after 1 year .
Hypertension and DM.
Adequate graft function before conception (no proteinuria and well-controlled blood pressure) is the key factor toward a safe pregnancy .
▪︎Methods of contraception after kidney transplantation
There are 2 principal methods of permanent contraception and several temporary methods
*Permanent methods
Permanent methods include female tubal ligation ,high risk of ectopic pregnancies.
and male vasectomy which is invasive and permanent.
*Temporary methods:
*Hormone methods
Using Hormonal estrogen or progesteron alone or combined .
It is provided in different forms ( pills ,patches,implants ,injection)
Main side effects are related to estrogen, including exacerbation of migraines, the risk of thromboembolism, and worsening hypertension control.
it is also metabolised by the cytochrome P450 with possibility of interaction with CNI.
Progesterone only methods avoids the side effects of estrogen but still can cause thromboembolism.
* intrauterine devices is long acting, cost-effective, low failure rates ,with no risk of thromboembolism,no effect on CNI metabolism.
* Barrier methods( male or female condoms ,vaginal ring )
These are safe regarding drug interactions but high failure rates .
Ovulation may start as soon as 1 month after transplant; therefore, it is crucial to plan for a timely, safe conception and effective maternity care.
period of 1 year after transplant appears to be sufficient to minimize the risk of adverse events due to pregnancy
Adequate graft function before conception (no proteinuria and wellcontrolled blood pressure)
methods of contraception are discussed before and initiated soon after transplant surgery to prevent premature, unplanned, and unadvised pregnancies.
Contraception methods :
Permanent methods include female tubal ligation and male vasectomy
Temporary methods :
OCPs: side effects increase migrane , thrombosis and HTN
careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients.
DMPA : The major concern of DMPA is the thromboembolic risk. But benefit from no drug interaction with immunosuppressive drugs . Not used in hepatic patients.
Etonogestrel implant has risk-benefit features similar to DMPA but has been shown to cause fewer decreases in bone mineral density but 99 % success percent.
advantage of progestin-only pills is the avoidance of estrogen-related risks
IUD : category 2 while OCP category 4
The advantages of the IUD include easy insertion, long lasting, and low failure rate and reversible with immunosuppression drug interaction .
Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years,
Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate
minimum of 1 year after transplant to reduce potential neonatal and maternal complications.
Thank You, this is much better Ahmed
There are two principal methods of permanent contraception and several temporary methods.
Permanent methods:
Temporary methods:
Hormone methods:
Combined hormonal contraceptives:
They are highly effective with a minimal failure rate.
The risks are attributed to the estrogen component of these formulations, including exacerbation of migraine headaches, the risk of thromboembolism, and worsening hypertension control.
They are primarily metabolised by the cytochrome P450 and hence the possibility of interaction with CNI.
Depot medroxyprogesterone acetate:
Is synthetic progesterone with a slow release over 3 months.
It is highly effective, and safe, with a low failure rate.
The major concern about it is the risk of thromboembolism.
There is no interaction with IS medication.
Metabolised in the liver, so it is not recommended in cases of liver disease.
Etonogestrel implant:
A single silastic rod is implanted subcutaneously in the upper arm.
It is more than 99% effective and the protection lasts for 3 years with a fewer decrease in BMD.
The adverse effect is irregular bleeding.
In general, it is safe, highly effective, and rapidly reversible.
Transdermal contraceptive patch:
This method delivers estrogen and progesterone through a transdermal patch placed on the abdomen. The risk is similar to that of combined oral contraceptive pills.
Progestin-only pills:
The advantage of this method is the avoidance of estrogen and its problems.
Amenorrhea and 5% failure rate in the first year are the major concerns.
Requires compliance.
Metabolised in the liver and has an interaction with CNI.
Increases the risk of weight gain through altering lipid metabolism.
May be useful in females with high cardiovascular risk.
Intrauterine devices:
Classified as category 2.
There is a controversy about the risk of PID in immunocompromised woman.
Some suggested the use of prophylactic AB but then it was found to be of little benefit.
The major advantage is that the effect is reversible.
other advantages:
The vaginal ring:
has an advantage of lower concentration of ethinyl estradiol compared to combined oral contraceptive pills and is effective.
Barrier methods of contraception:
Less effective due to the relatively high failure rate and the difficulty in achieving compliance.
The advantage of them is being a convenient and easy to use and the avoidance of drug interaction.
They should be combined with other method to reduce their potential failure rate.
Fertility rate improved after kidney transplant within months and there’s high risk effects of pregnancy on graft and may lead to graft loss due to increase incidence of uncontrolled hypertension and develops of preeclampsia; also evidence of teratogenic effects of immunosuppressive drug on foetus with high risk of prematurity.
So ladies with kidney transplant should counselling regarding conception from one to two years after transplant to avoid unplanned pregnancy and should monitoring her blood pressure and her medication 3 months before pregnancy to avoid teratogenic effects of immunosuppressive agents.
Methods of contraception:
Permanent by tubal ligation but still history of ectopic pregnancy.
Another permanent option is male vasectomy
Temporary method is combined oral hormonal therapy (oestrogen & progesterone ); but there is risk of hypertension and arterial and venous thrombosis and exacerbation of migraines.
Progesterone only pills but still risk of thrombosis
vaginal ring
intrauterine contraception device (IUCD) safe and effective method but there’s risk of infection and bleeding.
Male and female condoms but high risk of failure rate
it’s not safe and not effective.
Lactation:
All immunosuppressive agents excreted in breast milk in small level and not side effects on babies.
But cellcept should shift to azathioprine during pregnancy and lactation because it’s effects on foetus
Sirolimus contraindicated in pregnancy and lactation.
Rituximab should be avoiding in pregnancy and lactation.
References:
Mina Al-Badri, MBCHB, Juliana M. Kling, MD, MPH and Suneela Vegunta, MD; Reproductiveplanning for women after solid-organ transplant:Cleveland Clinic Journal of Medicine September 2017, 84 (9) 719-728; DOI: https://doi.org/10.3949/ccjm.84a.16116
Thank You, Sahar
Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation :
1- pregnancy after renal transplantation is normal and encountered. however, both maternal and fetal complications rates are higher if compared with non-transplant patients.
2- pregnancy affects graft functions. therefore, it is advised to delay pregnancy to be at least 1 year post-transplantation to ensure stable and satisfactory graft functions.
3-effective and suitable contraception is important as it decreases the risks of unplanned pregnancy with its complications.
4- different methods can be used for contraception. each method has its own benefits and risks. also, no ideal method is the best. the decision should be individualized.
5- early counseling by a multidisciplinary team is important. this team will negotiate with the patient the best timing of pregnancy and the suitable method of contraception.
6- combined oral contraceptive pills can be used safely in stable graft function.
7- IUD is safe and effective with no evidence of increased infection.
8- permanent methods are valid options in some selected patients.
Thank You
Counselling the female recipient pre& post-transplant about the contraception is very important , for safe pregnancy for the mother & the fetus.
Various methods of contraception available post-transplantation include:
· Permanent methods: mostly surgical method,
1-Female tubal ligation: (risk of ectopic pregnancy, failure rates of 0.5%).
2- Male vasectomy: (decreases the risk of ectopic pregnancy, failure rate of 0.5%)
· Temporary methods:
These include:
1. intrauterine devices (Copper & progestin IUD), it is long acting, cost-effective, easily inserted and have low failure rates (0.6-0.8%) with no risk of DVT , nor drug interaction
2. Hormone methods
Hormonal contraceptives are either estrogen or progesterone based or combined. They are commonly used , highly effective with minimal failure rate. It`s side effects incude exacerbation of migraines, the risk of VTE, and worsening hypertension control.
– Estrogen and progesterone
– Oral contraceptive pill
– Transdermal patch
– Vaginal ring
– Progesterone only
Implant
3. Barrier methods(they haven’t drug interactions but have relative high failure rates (12-23%) and associated with compliance issues. They are useful as an adjunct to other forms of contraception.
– Diaphragm with spermicide
– Cervical cap with spermicide
– Contraceptive sponge
– Male condom
– Female condom
Thank You
Contraception After Kidney Transplantation, From Myth to Reality: A Comprehensive Review of the Current Evidence
A multidisciplinary team approach involving obstetricians and transplant clinicians is needed to decide the appropriate timing for conception is recommended as its mainly individualizing.
Methods of contraception after kidney trans – plantation:
1-Permenant.
Female tubal ligation 0.04 (Pearl Index).
Male vasectomy with failure rate 0.1 (Pearl Index).
2-Temporary.
a-Combined hormonal contraceptives.
Highly effective and with minimal failure rate(0.1 according to (Pearl Index).
b-Depot medroxyprogesterone acetate.
It is a highly effective and safe contraceptive method. The failure rate is only 2% due to delay in repeat injections.
c-Etonogestrel implant.
The effectiveness is > 99%, and the protection lasts for 3 years.
d-Transdermal contraceptive patch.
minimal failure rate(0.1 according to (Pearl Index) like COC.
e- Progestin-only pills.
The 5% failure rate during the first year are the major concerns; this rate drops to < 0.5% if used correctly and constantly.
f- Intrauterine devices.
Failure Rate (Pearl Index) 1-3.
g- The vaginal ring.
It is effective (Pearl index, 1-3).
h- Barrier methods of contraception.
Barrier success rate can reach 97% if used correctly and consistently with high failure rate e (Pearl index, 0.4-1.6).
Thank You
Contraception After Kidney Transplantation
Fertility in patients with end stage renal disease can be efficiently reverted within 1 to 6 months after kidney transplant; that’s why methods of contraception should be discussed before and initiated soon after transplant surgery to prevent premature, unplanned, and unadvised pregnancies.
There are 2 main methods of contraception:
Contraception is classified into temporary/reversible and permanent/irreversible.
Irreversible contraception is usually achieved by surgical procedures like vasectomy or tubal ligation and others.
Reversible contraception is achieved using intrauterine devices or drug eluting implants, or hormonal contraceptive pills/injections or patches and also male/female condoms and others.
There is no study evaluated the efficacy of different types of contraception in transplanted females, however results are extrapolated from non-transplant population.
Hormonal contraceptives
Hormonal contraceptives are either estrogen or progesterone based or combined. Hormonal contraceptives are commonly used (58% in one study). They are highly effective with minimal failure rate. Estrogen based contraceptives is associated with exacerbation of migraines, the risk of VTE, and worsening hypertension control. Hormonal contraceptives have protective effects in menstrual bleeding patterns and may protect from ovarian cysts.
Another option of hormonal therapy also include etonogestrel implant which is a single silastic rod implanted SC in the upper arm. It is highly effective and protective for 3 years. Etonogestrel risk-benefit features similar to DMPA but causes fewer decreases in BMD. On removal, the etonogestrel drops rapidly, with most patients ovulating after 3 weeks.
Transdermal contraceptive patch is also part of hormonal therapy which is a patch placed on the abdomen to deliver estrogen and progesterone.
Intrauterine devices
IUDs are easy to insert, long lasting, and has low failure rate. The effect is reversible after IUD removal. No concern of interaction with IS drugs. No increased risk of VTE. No increase in overall complications in women regardless of immune status. No differences in infectious morbidity.
The vaginal ring
It is an effective method of contraception. Vaginal ring is a silastic ring impregnated with etonogestrel and ethinyl estradiol. It is associated with lower incidence of adverse events. A lower concentration of ethinyl estradiol compared with patch or combined hormonal contraceptives.
Barrier methods include condoms, spermicides, diaphragm, cervical cap and sponges are commonly used but associated with failure rates due to compliance issues. Education of couples on its use increases the awareness, compliance and may reduce the failure rate.
Thank You
methods of contraception after kidney transplantion
1.permnanat mtthods,like
2.irrevisble methods , which can be comibened together like,
Thank You
Contraception After Kidney Transplantation, From Myth to Reality: A Comprehensive Review of the Current Evidence
¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤¤
☆Introduction:
▪︎It is crucial to plan for a timely, safe conception and effective maternity care because ovulation may start as soon as 1 month after transplant.
▪︎Evidence suggests that a period of 1 year after transplant appears to be sufficient to minimize the risk of adverse events due to pregnancy.
☆Methods of contraception after kidney transplantation:
_________________
A) Permanent Methods: These include:
1.Female tubal ligation
2. Male vasectomy: Has the advantage of having less associated risks of ectopic pregnancies than tubal ligation,
B) Temporary methods: These include:
1. Copper & progestin intrauterine devices
2. Hormone methods
– Estrogen and progesterone
– Oral contraceptive pill
– Transdermal patch
– Vaginal ring
– Progesterone only
Implant
3. Barrier methods
– Diaphragm with spermicide
– Cervical cap with spermicide
– Contraceptive sponge
– Male condom
– Female condom
◇Combined hormonal contraceptives:
_______________________________________
▪︎Are commonly used in daily practice as they are highly effective and with minimal failure rate.
▪︎Careful attention regarding the drugs’ interactions with calcineurin inhibitors .
◇Depot medroxyprogesterone acetate:
_______________________________________
Is a highly effective and safe contraceptive method.
▪︎The failure rate is only 2% due to delay in repeat
injection.
▪︎ It has the advantage of no drug interactions with immunosuppressive medications and is a good choice as long as patients are motivated to adhere to the injection schedule.
◇Etonogestrel implant:
_________________________
▪︎The effectiveness is > 99%, and the protection lasts for 3 years.
▪︎It is a new method of contraception for female kidney recipients, can be safely advised, is highly effective, and is rapidly reversible.
◇Transdermal contraceptive patch:
______________________________________
▪︎This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen. ▪︎The circulating levels of estrogen
are substantially higher than with combined
hormonal contraceptives.
◇Progestin-only pills:
_________________________
▪︎The significant incidence of amenorrhea and the 5% failure rate during the first year are the major concerns.
▪︎Interactions with medications that
are metabolized by the liver can occur with
progestin-only pills, and they should be avoided in patients with liver disease.
▪︎Their interaction with calcineurin inhibitors requires proper calcineurin
inhibitor monitoring posttransplant.
▪︎Alter the metabolism of lipids in female kidney recipients.
◇Intrauterine devices:
________________________
▪︎Intrauterine devices (IUDs) are classified as category 2 compared with combined pills, which are classified as category 4 in complicated transplants.
▪︎ The advantages of the IUD include easy insertion, long lasting, low failure rate, the effect is reversible after removal, and immunosuppression drug interaction
is not a concern in women with kidney transplants.
▪︎It is not associated with increased risk of
thromboembolism.
▪︎Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing
intrauterine system lasts for 5 years, rendering these cost-effective and long-lasting methods ofcontraception for women with kidney transplants.
▪︎Theoretically, posttransplant immunosuppressive medications may decrease the efficacy of IUDs, possibly because they modify the leucocyte response.
▪︎There is no solid evidence suggesting that
the safety and effectiveness of the IUD would be compromised in the transplant patient.
◇The vaginal ring:
___________________
▪︎Has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events
related to ethinyl estradiol
▪︎Serum ethinyl estradiol levels of patients showed much lower variations with the vaginal ring than with the patch or combined hormonal contraceptives.
◇Barrier methods of contraception:
______________________________________
▪︎Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the
relatively high failure rate and
the difficulty in achieving compliance.
▪︎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.
▪︎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.
▪︎Education of couples regarding this method of contraception reduce it’s failure rate.
Thank You
. –One- year after transplant is sufficient to minimize the risk of adverse events due to pregnancy, as possible risks of acute rejection and graft loss, and prematurity
will be less after this time.
– Adequate graft function before conception (no proteinuria and well-controlled blood pressure) is the key factor toward a safe pregnancy because these 2 conditions are associated with poor outcomes for the fetus and pregnant mothers after kidney transplant.
-Female fertility can be efficiently reverted within 1 to 6 months after a kidney transplant; methods of contraception must be discussed before and initiated soon after transplant surgery to prevent premature, unplanned, and unadvised pregnancies.
Methods of contraception after kidney transplantation:
There are 2 principal methods of permanent contraception and several temporary methods.
Temporary methods:
Combined hormonal contraceptives
-Combined hormonal contraceptives are classified as category 4 in complicated transplants.
-The risks with combined hormonal contraceptives are attributed to the estrogen component of these formulations, including exacerbation of migraine
headaches, the risk of thromboembolism, and worsening hypertension control.
-Combined hormonal contraceptives are primarily metabolized by the cytochrome P4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients.
-Patients who have a history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have
active liver disease or hepatic adenoma are advised not to use combined hormonal contraceptives, as they may aggravate these conditions.
Depot medroxyprogesterone acetate (DMPA):
-It is a synthetic progestin with a slow-release over 3 months. It is a highly effective and safe contraceptive method. The failure rate is only 2% due to delays in repeat injections.
-The major concern of DMPA is the thromboembolic risk.
-It has the advantage of no drug interactions with immunosuppressive medications for transplant patients and is a good choice as long as patients are motivated to adhere to the injection schedule.
-The metabolism of DMPA is through the liver; therefore, it is not recommended for those with active liver disease.
Etonogestrel implant:
-The etonogestrel implant is a single silastic rod implanted subcutaneously in the upper arm.
-The effectiveness is > 99%, and the protection lasts for 3 years.
-The adverse effect of this method is the bleeding irregularity encountered in a minority of patients.
-It causes fewer decreases in bone mineral density, a concern that is also commonly encountered after transplant due to the effect of steroids on bones.
Transdermal contraceptive patch
-It delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen.
– The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives.
-Some studies have shown more than a 2-fold increase in the risk of venous thromboembolism associated with this method.
Progestin-only pills
-The advantage of progestin-only pills is the avoidance of estrogen-related risks.
-The significant incidence of amenorrhea and the 5% failure rate during the first year are the major concerns; this rate drops to < 0.5% if used correctly and constantly.
-It undergoes the first-pass metabolism through the liver. Interactions with medications that are metabolized by the liver can occur with progestin-only pills, and they should be avoided in patients with liver disease.
-Their interaction with calcineurin inhibitors requires proper calcineurin inhibitor monitoring post-transplant.
-It increases the risk of weight gain, and both progestin-only pills and calcineurin inhibitors alter the metabolism of lipids in female kidney recipients.
Intrauterine devices
-Intrauterine devices (IUDs) are classified as category 2 compared with combined pills, which are classified as category 4 in complicated transplants.
– They are not at greater risk of developing pelvic infections.
-The advantages of the IUD include easy insertion, long-lasting, low
failure rate, the effect is reversible after IUD removal, an immunosuppression drug interaction is not a concern in women with kidney transplants,and is not associated with increased risk of thromboembolism.
-The levonorgestrel-releasing intrauterine system was shown to reduce menstrual blood loss.
-Previous ectopic pregnancy and history of pelvic inflammation are contraindications to the use of IUDs.
-Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years.
The vaginal ring
-The vaginal ring is impregnated with etonogestrel and ethinyl estradiol.
– It is effective, controls the menstrual cycles, and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal
contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
Barrier methods of contraception
-Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the
relatively high failure rate and difficulty in achieving compliance.
– 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.
Permanent methods include:
-Female tubal ligation
– Male vasectomy.
–There is no ideal contraceptive method; the best is to individualize the method of contraception according to a patient’s risk
Thank You
Restoration of fertility post-transplant can be seen in 1-6 months. Hence the role of pre-transplant and post-transplant counselling regarding various methods of contraception is very important.
Various methods of contraception available post-transplantation include:
I) Permanent methods: These can be utilized in patients not willing for further child-bearing.
1) Female tubal ligation: Associated with risk of ectopic pregnancy and has failure rates of 0.5%.
2) Male vasectomy: Invasive and non-reversible, but decreases the risk of ectopic pregnancy and has failure rate of 0.5%
II) Temporary methods:
1) Combined hormonal contraceptives: These include contraceptives containing estrogen and progestin. The failure rate associated with their use is 0.3%. But the estrogen component can cause migraine headache exacerbation, increased blood pressures and thromboembolic events, hence are contraindicated in patients with history of stroke, myocardial infarction, deep vein thrombosis, migraine and uncontrolled hypertension as well as active liver disease and hepatic adenoma. Drug interactions with calcineurin inhibitors needs to be assessed.
2) Depot Medroxy Progesterone Acetate (DMPA): It is long acting (3 months) with failure rate of 6% (due to delayed repeat injection). It has no drug interactions but should not be used in patients with active liver disease and risks of thromboembolic events. Its use has been associated with decreased bone mineral density.
3) Etonorgesterol implant: It is a very long-acting form of contraception with protection for 3 years, implanted in the upper arm subcutaneously and fertility reversal is achieved in 3 weeks post-removal with a failure rate of less than 1%.
4) Transdermal contraceptive patch: It delivers estrogen and progesterone, has 2 times increased risk of venous thromboembolism and has low failure rates (0.3%).
5) Progestin only pills: These avoid risks associated with estrogen but have failure rate of 5% initially which decreases to less than 0.5% later. They are useful in patients with high blood pressures but should be avoided in active liver disease and close monitoring of calcineurin inhibitor drug levels is required. They are associated with weight gain and altered lipid profile.
6) Intrauterine devices (IUD): They are long acting, cost-effective, easily inserted and have low failure rates (0.6-0.8%) with absence of increased risk of thromboembolism, immunosuppression drug interaction or associated increased pelvic infection rates. They should not be used in patients with history of previous ectopic pregnancy or pelvic inflammation.
i. Copper IUD: They have long life of 10 years
ii. Levonorgesterol releasing IUD: They have life of 5 years and are associated with less menstrual blood loss with very low failure rates (0.2%)
7) The vaginal ring: It is impregnated with etonorgesterol and ethinyl estradiol in lower concentration with low failure rates (1-3%)
8) Barrier methods of contraception: These include condoms, spermicides, diaphragm, cervical cap and sponges. They are easy to use, have no drug interactions but have relative high failure rates (12-23%) and associated with compliance issues. They are useful as an adjunct to other forms of contraception
9) Other methods: These are very unreliable
i. Lactation amenorrhea:
ii. Coitus interruptus: 20% failure rate
iii. Symptothermal methods: 15-24% failure rate.
Thank You
Fertility after kidney transplant returns to normal with in one month and pregnancy happens within few months post transplant.
It’s should be counseling conception at least one year post transplant to avoid unplanned pregnancy and reduce risk of maternal and fetal complications and reduce risk of hypertension and preeclampsia and risk of graft loss; Also avoid teratogenic effects of immunosuppressive drug.
Method of contraception after transplant:
2 permanent contraception
– [ ] Female tubal ligation
– [ ] Male vasectomy
male vasectomy is non reversible and invasive procedure
Female tubal ligation has risk of ectopic pregnancy.
Combined hormonal contraception and effective and low failure rate and less risk of menorrhagia
It’s has risk of thromboembolic and migraines and hypertension.
It’s contraindicated in the active liver disease and MI , stroke .
Depot medroxy progesterone acetate :
It’s synthetic progestin with slow release over 3 months
It’s effective and safe and no drug interaction with immunosuppressive agents
It’s has risk of thrombosis and not give in patients with liver disease.
Etonogestrel implants:
It’s single silastic rod implanted subcutaneous in upper arm and fertility returns after 3 weeks.
Transdermal contraception patches
Progestin only pills:
It’s progestin pills
It’s has interaction with calcinurine inhibitors and drug level needs monitoring
It’s associated with weight gain and high blood pressure
It’s contraindicated in liver disease
Vaginal rings
It’s ethinyl estradiol
IUCD
It’s safe and effective and low failure rate
No evidence of thrombosis or drug interaction
No risk of infection and fertility reversible after removal of IUCD
Barrier method of contraception like male and female condoms and spermicide are less effective and it’s have higher rate of failure
Summary
Even though the risk of maternal and fetal problems following kidney transplantation is greater than in the general population. pregnancy after kidney transplant is normal and regularly observed.
Preventive counselling should begin as soon as possible after the transplant, preferably before the procedure, to explain contraceptive techniques and enable women to make an educated decision about contraception and eventual pregnancy.
It is natural that patients should be made aware of the advantages and hazards associated with each procedure employed following transplantation via appropriate education. It is important to use an effective and appropriate method of contraception in order to limit the chance of unexpected pregnancy. Women should be informed of the impact of pregnancy on graft function, fetal well-being, and the risk of developing maternal problems during and after the procedure. If you do not want children, you may want to consider using a permanent form of contraception following a kidney transplant because of the dangers connected with pregnancy after a kidney transplant.
It is recommended that kidney transplant patients avoid becoming pregnant for at least one year after their transplant in order to lessen the risk of newborn and maternal problems.
– Following a kidney transplant, a variety of contraceptive techniques may be used. A prominent reason for the widespread use of combined hormonal contraceptives is their efficacy. The advantages of estrogen-based contraceptives in an uncomplicated stable transplant patient who does not have a contraindication to using combination hormonal contraceptives exceed the risks of using them, according to the evidence. Intrauterine devices are an effective means of contraception and should be regarded as a safe and effective approach following transplantation since there is no data to indicate that kidney transplant patients have a higher infection risk than the general population. 75
Permanent methods of contraception are valid\soptions for couples who decide not to have children.
In order to determine the most ideal time for conception, determine the most appropriate follow-up, and provide advice, a multidisciplinary team approach comprising obstetricians and nephrologists should be used.
-Hormonal contraceptives that work in conjunction:
Depot medroxyprogesterone acetate is a very effective and safe approach that releases medroxyprogesterone acetate gradually over a three-month period. There have been no reported drug-drug interactions with immunosuppressive drugs. It should not be used in patients with active liver disease or a history of thromboembolic events since it is reversible and has a failure rate of 2 per cent owing to the delay in repeat injection.
-Only progestin tablets have a 5 per cent failure rate, which may be reduced to 0.5 per cent when taken appropriately and continuously. Drug interaction with CNI results in weight gain, and lipid metabolism problems, and should be avoided in patients with liver disease.
-Intrauterine devices are rated as category 2 by the Centers for Disease Control and Prevention (CDC). They are an effective, reversible, and safe method of contraception that has a low failure rate, no drug-drug interaction, and is not related to an increased risk of thrombophilia.
-Transdermal contraceptive patch: The transdermal contraceptive patch is applied to the abdomen and delivers both estrogens and progesterone. The effectiveness and negative effects of combination contraception are comparable.
-Etonogestrel implant: a very successful approach with the efficacy of >99 per cent that is both safe and reversible in a short period of time. It consists of a single silastic rod implanted subcutaneously in the upper arm that has a duration of action of three years. Although it has a lower risk of osteoporosis, it is connected with bleeding and irregular menses.
There are 2 principal methods of permanent contraception and several temporary methods .
Permanent methods ;
Include female tubal ligation and male vasectomy. Vasectomy has the advantage of having less associated risks of ectopic pregnancy than tubal ligation, but it is a nonreversible and invasive procedure.
Temporary methods;
involve the use of combined hormonal oral contraception, intrauterine devices, vaginal rings, subcutaneous implants, barriers, and natural methods like coitus interruptus.
Combined hormonal contraceptives;
Contraceptives containing estrogen and progestin are ;
1- Highly effective and with minimal failure rate .
2- Metabolized by the cytochromeP4503A4 system; hence, careful attention regarding the drugs’ interactions with calcineurin inhibitors is important in female kidney transplant recipients.
3-Contraindicated in patients who have a history of myocardial infarction, stroke, deep venous thrombosis, migraine, and uncontrolled hypertension and patients who have active liver disease or hepatic adenoma .
Depot medroxyprogestrone acetate.
1-It is a synthetic progestin with slow release over 3 months.
2- The metabolism of DMPA is through the liver; therefore, it is not recommended for those with active liver disease.
3-It is a highly effective and safe contraceptive method and the failure rate is only 2% due to delay in repeat injections.
4- It has the advantage of no drug interactions with immunosuppressive medications of transplant patients and is a good choice as long as patients are motivated to adhere to the injection schedule.
5- It’s side effects include ;
a-Reversible decrease in bone density,which normalizes on DMPA cessation.
b- The thromboembolic risk.
Etonogestrel implant;
1-A new method of contraception for female kidney recipients, can be safely advised, is highly effective, and is rapidly reversible.
2-It is implanted subcutaneously in the upper arm.
3-The effectiveness is > 99%, and the protection lasts for 3 years.
4- The adverse effect of this method is;
a- The bleeding irregularity encountered in a minority of patients.
b- Etonogestrel implant has risk-benefit features similar to DMPA but has been shown to cause fewer decreases in bone mineral density, a concern that is also commonly encountered after transplant due to the effect of steroids on bones.
Transdermal contraceptive patch ;
1-This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen.
2-The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives.
3- Some studies have shown more than 2-fold increase in the risk of venous thromboembolism associated with this method.
Progestin-only pills;
1-The advantage of progestin-only pills is the avoidance of estrogen-related risks.
2-They are significantly effective with 5% failure rate . This rate drops to < 0.5% if used correctly and constantly.
3- Progestin-only pills require ensured compliance to reduce failure rates.
4- They undergo the first-pass metabolism through the liver.
5- Interactions with medications that are metabolized by the liver can occur with progestin-only pills, and they should be avoided in patients with liver disease. Their interaction with calcineurin inhibitors requires proper calcineurin inhibitor monitoring post transplant.
6- Progestin-only pills increase the risk of weight gain.
8-Female kidney recipients who smoke or are at risk for cardiovascular problems such as high blood pressure may be able to use progestin-only pills since combined hormonal contraceptives are usually contraindicated for them.
Intrauterine devices;
1-Intrauterine devices (IUDs) are classified as category 2 compared with combined pills, which are classified as category 4 in complicated transplants.
2-Currently available data suggest that immunocompromised women are not at greater risk of developing pelvic infections.
3-The advantages of the IUD include easy insertion, long lasting, and low failure rate .
4-The major advantage of using IUDs is that the effect is reversible after IUD removal, and immunosuppression drug interaction is not a concern in women with kidney transplants. In addition, it is not associated with increased risk of thromboembolism.
The vaginal ring;
1- It is effective controls the menstrual cycles, and has the advantage of a lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, thus minimizing the adverse events related to ethinyl estradiol.
Barrier methods of contraception;
1-Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods for organ transplant recipients due to the relatively high failure rate and the difficulty in achieving compliance.
2- Barrier success rate can reach 97% if used correctly and consistently.
3-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.
4- All of these barrier methods can be used post transplant but are best when combined with another method of birth control to reduce their potential failure rate.
Conclusion;
Combined hormonal contraceptives are commonly used for their effectiveness.
The benefits of estrogen-based contraceptives in an uncomplicated stable transplant recipient who have no contraindication to use combined hormonal contraceptives likely outweigh the potential for harm.
Intrauterine devices are an effective method of contraception and should be considered as a safe and an effective method after transplant with no evidence to suggest increased infection rate in kidney transplant recipients.
Permanent methods of contraception are valid options for couples who decide not to have children.
A multidisciplinary team approach involving obstetricians and nephrologists should be adopted to decide the appropriate timing for conception, ascertain appropriate follow-up, and advise on methods of contraception that suit the patient.
There is no ideal contraceptive method; the best is to individualize the method of contraception according to a patient’s individual risk.
Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation
Introduction
Contraception in post-kidney transplant women is successful with acceptable risk.
It needs a multidisciplinary approach that involves obstetricians & transplant physicians to:
– reduce the risk of unplanned pregnancies.
– improve pregnancy outcomes
– reduce maternal complications
– advice on the appropriate method of contraception on individual basis.
– prevent interactions with the IS & antihypertensive medications
Methods of contraception post-plantation:
A. Permanent methods:
– Female tubal ligation
– Male vasectomy; is irreversible but effective & prevents risks of ectopic
pregnancy associated with tubal ligation.
A. Temporary methods:
– Combined hormonal oral contraception
– Intrauterine devices
– Vaginal rings
– Subcutaneous implants
– Barriers
– Coitus interruptus.
Combined hormonal contraceptives:
– Are category 4 in complicated transplant according to the US CDC.
– Are commonly used(58% in one study)
– Estrogen & progestin pills are highly effective with minimal failure rate
– The risks with combined hormonal contraceptives are due to the estrogen
component & include exacerbation of migraines, the risk of VTE, &
worsening hypertension control.
– They may regulate menstrual bleeding patterns & may protect from ovarian
cysts.
– Interaction with CNIs medications(metabolism by cytochromeP4503A4
system)
– Not to be used if there is H/O of MI, stroke, DVT, migraine, & uncontrolled
hypertension.
– Depot medroxyprogesterone acetate (DMPA, a synthetic progestin with slow
release over 3 months).
Is highly effective & safe.
Failure rate is only 2% due to delay in repeat injections.
The major concern is the VTE.
No interactions with IS medications.
Not recommended if there is active liver disease.
The etonogestrel implant:
– Is a single silastic rod implanted SC in the upper arm.
– Effectiveness is > 99%, & protection lasts for 3 years.
– On removal, the etonogestrel drops rapidly, with most patients ovulating
after 3 weeks.
– Menestrual irregularity occurs in a minority.
– Risk-benefit features similar to DMPA but causes fewer decreases in BMD.
Transdermal contraceptive patch:
– A patch placed on the abdomen delivers estrogen & progesterone.
– The circulating levels of estrogen are substantially higher than with
combined hormonal contraceptives
– Some studies shown >2-fold increase in the risk of VTE.
Progestin-only pills:
– Advantage of avoidance of estrogen-related risks.
– Significant incidence of amenorrhea.
– 5% failure rate during the 1st year; this rate drops to < 0.5% if used correctly
& constantly.
– Requires good adherence to reduce failure rates.
– Orally taken, &, unlike DMPA & etonogestrel implant, they undergo the 1st–
pass metabolism in the liver.
Their interaction with CNIs requires proper CNI trough monitoring post-
transplant; both of them cause dyslipidemia.
– Progestin-only pills increase the risk of weight gain.
– Female kidney recipients who smoke or are at risk for CV problems such as
high BP may be able to use progestin-only pills since combined hormonal
contraceptives are usually contraindicated for them.
Intrauterine devices (IUDs)
– Are category 2 in complicated transplants.
– No greater risk of developing pelvic infections, even in women with HIV
infection.
However, many studies indicated that the risk of infection is significantly
increased immediately after IUD insertion in immunocompromised patients.
Antibiotics prophylaxis is not useful for IUD insertion.
– IUD is easy to insert, long lasting, & has low failure rate.
– The effect is reversible after IUD removal
– No concern of interaction with IS drugs.
– No increased risk of VTE.
– No increase in overall complications in women regardless of immune status.
– No differences in infectious morbidity.
– The levonorgestrel-releasing IUD reduces menstrual blood loss.
– IUD use is contraindicated if there is previous H/O ectopic pregnancy or
pelvic inflammation.
– Copper IUD & the levonorgestrel-releasing IUD are both effective & safe to
use after kidney transplant.
– Copper IUD has an effective duration of 10 years.
– Levonorgestrel-releasing intrauterine system lasts for 5 years.
The vaginal ring
combined hormonal contraceptives, thus less adverse events related
to ethinyl estradiol.
Barrier methods (condoms, spermicides, diaphragm, cervical cap, sponges)
difficulty in achieving compliance.
reduce their potential failure rate.
compliance & may reduce the failure rate.
Pregnancy after transplantation was considered a challenging entity due to complex nature of patients , immunosuppression and fear of graft dysfunction. In this review authors evaluated different methods of contraception and their efficacy. A MDT approach to decide about appropriate timing of conception is recommended. early counselling and individualization according to patient risks is recommended.
Contraception Methods.
1-Permanent
Female- Tubal ligation
Males-Vasectomy
2-Temporary
a- Combined Hormonal contraception
It has low failure rates but can interact with CNI due t cytochrome P450. It can cause hyercoagupathy with risk of DVT , stroke and MI. It can effect liver functions and can cause hepatic adenoma
b-Depot Medroxyprogesterone acetate
It is synthetic progesterone and is safe and effective . It cannot be used in liver disease and side effects are reversible.
c-Etonogestril implant
Single subcutaneous implant in upper arm. efficacy around 99%
d-Transdermal contraceptive patches
Efficacy similar to the combined contraceptives and deliver both estrogens and progesterone.
e-Progesterone only pills
These are safe in patients with cardiovascular issues and have failure rates around 5%
f-IUD
It is effective with no side effects. No interaction with immunosuppressive drugs
g-Vaginal Ring
This ring is impregnated with etonogestril and Estradiol. It is effective with less side effects due to low serum levels
f- Barrier Methods
These have high failure rates and include condoms, cervical cap , diaphragm, spermicides and sponges. These can be combined with other modalities.
Fertility is regained effectively within 1-6 months post transplant, contraceptive methods are essential to avoid unplanned pregnancy with its associated complications and to use safe immunosuppressive agents.
Permanent methods:
Female tubal ligation, associated with risk of ectopic pregnancy.
Male vasectomy.
Non reversible and invasive procedures
Temporary methods:
Combined hormonal contraceptives:
Contain estrogen and progesterone.
Effective with low failure rate, decrease menorrhagia and development of ovarian cysts.
Side effects: thromboembolic events, exacerbation of migraine and poor control of HTN.
metabolized by cytochrome P450 with many drug interactions
Requires close monitoring of CNI levels.
Depot medroxyprogesterone acetate (DMPA):
Sustained release synthetic progestin
Highly effective and safe with no drug interaction with immunosuppressive agents
Side effects: reversible decrease in bone density, thromboembolic risk, need compliance to injection schedule.
Etonogestrel implant:
Single silastic rod implanted subcutaneously
Safe, highly effective, lasts for 3 years and rapidly reversible.
Side effects: bleeding irregularity, decrease in bone density.
Transdermal contraceptive patch:
Estrogen and progesterone through transdermal route.
Side effects: same as combined hormonal with 2-fold increase in risk of venous thromboembolism.
Progestin only pills:
No estrogen related complications
Side effects: 5% failure rate (can be improved with compliance), significant incidence of amenorrhea, increase risk of weight gain and alter metabolism of lipids.
First pass metabolism through liver leading to potential drug interaction
Needs close monitoring of CNI.
Intrauterine devices:
Easy insertion, cost-effective, long lasting, low failure rates, safe with reversible effects and no drug interactions.
Some studies showed significant increase in risk of infection after IUD insertion in immunocompromised patients while other randomized study showed no difference in infectious morbidity.
can’t be used in patients with history of ectopic pregnancy or pelvic inflammation.
The vaginal ring:
Silastic ring impregnated with etonogestrel and ethinyl estradiol.
Effective, control menstrual cycles with significant lower exposure to ethinyl estradiol and lower variation in serum level.
Barrier methods of contraception:
Easy to use with no potential drug interactions
Less effective with higher failure rate and difficult to achieve compliance
Better to be used with another method to decrease failure rate
*** Summarise the types and the effectiveness of the various methods of contraception after kidney transplantation
# This study evaluated the efficacy of the different options for contraception and it is success after kidney transplant.
# The fertility can be efficiently reverted within 1 to 6 months after KT, so early counseling for using contraception reduce the risk of unplanned pregnancies, maternal complications and improve the outcomes after KT.
# A period of 1 year after KT is sufficient to minimize the risk of :
1* Adverse events of pregnancy (prematurity, intrauterine growth
retardation, low birth weight and preeclampsia.)
2* cute rejection and graft loss
# Adequate graft function before pregnancy (no proteinuria, controlled blood pressure) is important to prevent such complications.
# # Methods of contraception after kidney trans plantation
We have two types of contraception:
A) Permanent contraception include:
1* Female tubal ligation
2* Male vasectomy ( less associated risks of ectopic pregnancy than tubal ligation, non reversible and invasive procedure.)
B) Temporary methods include:
1# Combined hormonal contraceptives
* Are classified as category 4 in complicated transplant.
*Contraceptives containing estrogen and progestin are highly effective and with minimal failure rate.
*Study reported that, use of combined low dose oral contraceptives after RT for at least 18 months, sufficient to prevent pregnancy.
*It reducing the development of ovarian cysts and menorrhagia
*The primarily metabolism of this hormones in the cytochrome P4503A4 system, so it has drug interactions with calcineurin inhibitors
*The risks with combined hormonal contraceptives are due to estrogen component, so patients with history of myocardial infarction,stroke, deep venous thrombosis, migraine, uncontrolled hypertension,active liver disease and hepatic adenoma are advised not to use combined hormonal contraceptives, because it may aggravate these conditions.
2# Depot medroxyprogesterone acetate
*Is a synthetic progestin with slow release over 3 months.
* It is a highly effective and safe contraceptive method with failure rate 2% due to delay in repeat injections.
* DMPA has advantage of no drug interactions with immuno suppressive medications and is a good choice as long as patients are motivated to adhere to the injection schedule.
*The metabolism through the liver, so not recommended in active liver disease also there is risk of reversible decrease in bone density and thromboembolic effect.
3# Etonogestrel implant
*It is a single silastic rod implanted subcutaneously in the upper arm.
*The effectiveness is > 99%, and the protection lasts for 3 years.
*After removal the etonogestrel drops rapidly and ovulation occur after 3 weeks.
*The adverse effect is the irregular bleeding in few patients
*IT has risk benefit features like DMPA, but cause fewer decreases in bone mineral density, so commonly encountered after transplant due to the effect of steroids on bones
4# Transdermal contraceptive patch
*This system delivers estrogen and progesterone through the transdermal route using a patch placed on the abdomen.
* The circulating levels of estrogen are substantially higher than with combined hormonal contraceptives.
*The risk with this method is similar to combined hormonal contraceptives.
*Some studies showed the risk of venous thromboembolism more than 2-fold
associated with this method.
5# Progestin-only pills
*The advantage of progestin only pills is the avoidance of estrogen related risks.
*The adverse effect is amenorrhea and there is 5% failure rate during the first year this, but it can drops to < 0.5% if used correctly and constantly so it need good compliance
* Interactions with medications that are metabolized by the liver can occur, they should be avoided in liver disease, and due to interaction with calcineurin inhibitors the later requires proper monitoring posttransplant.
*The main S/E is weight gain, and both Progestin only pills and calcineurin inhibitors alter the metabolism of lipids in female kidney recipients.
*Female kidney recipients who smoke, cardiovascular disease and hypertension can use progestin only pills since combined hormonal contraceptives are contraindicated
6# Intrauterine devices
* (IUDs) are classified as category 2
*Immunocompromised women are not at greater risk of developing pelvic infections.
* However, many studies indicated that the risk of infection is significantly increased immediately after IUD insertion in immunocompromised patients.
*The use of antibiotic prophylaxis for IUD insertion with little benefit.
* The advantages:
Easy insertion, long lasting, low failure rate, the effect is reversible after removal, no immunosuppression drug interaction and not associated with increased risk of thromboembolism.
* A prospective study showed no increase in overall complications in women regardless of immune status.
*levonorgestrel releasing intrauterine system reduce menstrual blood loss.
* Previous ectopic pregnancy and history of pelvic inflammation are contraindications to the use of IUDs.
* Copper IUD has an effective duration of 10 years, and the levonorgestrel-releasing intrauterine system lasts for 5 years rendering.
.
7# The vaginal ring
*The vaginal ring is a silastic ring that is impregnated with etonogestrel and
ethinyl estradiol.
* It is effective in controls the menstrual cycles and lower concentration of ethinyl estradiol compared with combined hormonal contraceptives, so can reduce the adverse events.
8# Barrier methods of contraception
*Barriers (condoms, spermicides, diaphragm, cervical cap, sponges) are less effective contraceptive methods due to the high failure rate.
*The advantage: easy to use, no drug interactions with immunosuppressive medications.
*All of these barrier methods can be used posttransplant ,and to reduce the failure rate better to combined with another method of Contraception and education the couples for good compliance.
.
Pregnancy after a kidney transplant is normal and common. As fertility is expected to return efficiently within 1 to 6 months. The risk of maternal and fetal complications is higher than in the general population. therefore; it is important to discuss with the patient the method of contraception before transplantation to avoid unplanned pregnancy and give the proper education that helps her to make an informed choice.
Women with kidney transplants should be advised to delay pregnancy for 1 year after transplant, in order to minimize the risk of pregnancy adverse events. Good graft function before conception with no proteinuria and well-controlled blood pressure is the most determined point for pregnancy outcome. There is no ideal method, and the best is to individualize the method according to the patient’s risk.
Methods of contraception after kidney transplantation:
1- Combined hormonal contraceptives:
It is considered category 4 in complicated transplants. Combined pills containing estrogen and progestin are commonly used on a daily base. It is highly effective with a minimal failure rate. It can exacerbate migraine and hypertension and can cause venous thrombosis and deterioration of liver function. It is metabolized by the cytochrome P4503A4 system so; it has interaction with calcineurin inhibitors. Nevertheless; the benefit of them outweigh the harm and their use should be advised.
a- Depot medroxyprogesterone acetate:
It’s a slowly released, injectable form, with a low failure rate. It has no drug interactions, its adverse effects include a decrease in bone density and thromboembolic risk. It is not recommended for liver disease.
b- Etonogestrel implant:
It is implanted subcutaneously in the upper arm. Highly effective with protection lasts for 3 years and is rapidly reversible. Its adverse effect includes bleeding irregularity and decreases bone density.
c- Transdermal contraceptive patch:
Transdermal patch placed on the abdomen. The main side effect is the thromboembolic event.
2- Progestin-only pills
It has a higher failure rate than the combined hormonal contraceptive, and to increase its effectiveness compliance with the pills is required. It has first-pass metabolism in the liver, so it interacts with calcineurin inhibitors. It can cause weight gain, and alter lipid metabolism.
3- Vaginal ring:
It is a silastic ring contains etonogestrel and ethinyl estradiol. It is effective with fewer adverse effects if compared to combined hormonal contraceptives.
4- Intrauterine devices (IUDs)
IUDs are considered category 2. Data suggest that immunosuppressant women are not at increased risk of developing a pelvic infection. The advantages of the IUD include easy insertion, long-lasting, and low failure rate, as well, their effect is reversible after IUD removal and no drug interaction with the immunosuppressive medications. No thromboembolic event risk. Copper IUD and levonorgestrel-releasing IUD are both effective. IUDs are cost-effective and long-lasting methods for kidney transplants.
5- Barrier methods of contraception:
They are less effective methods as they have a high failure rate and difficulty in achieving compliance.
6- Permanent methods of contraceptive
a- female tubal ligation
b- male vasectomy.
They are a valid option for couples who decide not to have children.