DISCUSSING FERTILITY OUTCOME, SEXUALITY, CONTRACEPTION, GRAFT SITUATION, PREGNANCY TIMING, FETAL WELLBEING AND OUTCOME IN DONORS AND RECIPIENTS

1. Reproductive Outcome In OrganReproductive Outcome In Organ
Transplanted Female PatientsTransplanted Female Patients
Almataria Teaching Hospital, Nasser InstituteAlmataria Teaching Hospital, Nasser Institute
Cairo, EgyptCairo, Egypt
Dr. Mamdouh SabryDr. Mamdouh Sabry
MD. Ain Shams, PhD. FranceMD. Ain Shams, PhD. France
Consultant Ob. & Gyn.Consultant Ob. & Gyn.

2.  The progress in surgical techniques, biotechnologyThe progress in surgical techniques, biotechnology
and immunosuppressive drugs increased numbers ofand immunosuppressive drugs increased numbers of
age reproductive women undergoing allogeneic organage reproductive women undergoing allogeneic organ
transplant year by year.transplant year by year.
 Fertility and sexuality is restored in short time in menFertility and sexuality is restored in short time in men
and women, contraception is mandatory and fertility isand women, contraception is mandatory and fertility is
a demand.a demand.
 First reported pregnancy in renal transplanted case,First reported pregnancy in renal transplanted case,
year 1958 from identical twin. 1978 first successfulyear 1958 from identical twin. 1978 first successful
pregnancy in liver transplant recipient.pregnancy in liver transplant recipient.
 The contraception, graft situation, pregnancy timingThe contraception, graft situation, pregnancy timing
and outcome in donors and recipients, lactation andand outcome in donors and recipients, lactation and
fetal wellbeing and outcome are evaluated.fetal wellbeing and outcome are evaluated.

3. Data Collection
 Data from most groups and societies of organ
transplantation.
 Up to date.com.
 Evaluation of 23 publications, obser., case rep. and few
follow up studies.
 Medline & Medscape.
 Our experience in N. In. , Hema. On. Gp., Ped. On. Gp.,
and organ transplant group.

4. Organ transplantation
-Transplantation order:
Kidney
Liver
Heart
Lung
Kidney/Pancreas
Pancreas
Intestine
Heart/Lung
Liver/Kidney
-Pregnancy order:
Kidney
Liver
Kidney/Pancreas
Heart
Lung
Liver/Kidney
Heart/Lung
Pancreas
Intestine

5. Before Pregnancy
-Vaccination against HBV, Strept pn., tetanus and
influenza. Rubella given before.
-Team work approach including high- risk obstet.,
transplant physician and perinatologists.
-Anesthetic agents for general or regional
anesthesia are not contraindicated.
-IUD or Merina or subdermal implants are
preferable for contraception ( Cat, B, WHO )

6. When To Be Pregnant
• Confirm the following;
-Good general condition 1-2 years after transpl. .
-No rejection last year.
-Adequate and stable graft function last year ( in
renal t., creatinine < 1.5, no or minimal
proteinuria)
-No acute infections ( CMV, HBV, HCV )
-Immunosuppressive (IS) stable doses.
-Normal bl. pressure or one medication controlled.
-Normal allograft imaging findings.
-Pt. compliance with ttt and follow up.
-Data confirmed by all societies and centers.

7. Obstetric Management
-70% successful pregnancy rate in transplant
recipients, with favorable outcome for mother, child
and graft. Donors have increased risk of PE, PTL.
-Preeclampsia, hypertension, fetal growth restriction
and PTL are the commonest adverse pregnancy
outcomes, many complications are organ specific.
-Vaginal delivery is preferable at labor onset, unless
maternal or fetal indications for induction exists,
Cesarean section is indicated for obstetric reason,
avoiding graft injury.
-Antibiotic prophylaxis, >> steroid dose at delivery.
-Steroids are preferred in acute rejection.

8. -Vaccination against HBV, Strept pn., tetanus and
influenza. Rubella given before.
-Team work approach including high- risk obstet.,
transplant physician and perinatologists.
-Anesthetic agents for general or regional
anesthesia are not contraindicated.
-IUD or Merina or subdermal implants are
preferable for contraception ( Cat, B, WHO )
-Lactation remains a controversial issue needing
more investigations, some with, some against.
Check infant's serum level of medication.

9. I-suppressive Agents During Pregnancy
- Most drugs are considered relatively safe during
pregnancy, value overshadows risk.
- Corticosteroids for induction, acute rejection and
immunosuppression (IS) maintenance.
- Cyclosporine to prolong survival of liver (TP).
- Azathioprine mainly to maintain (IS).
- Mycophenolate mofetil to maintain (IS) and ttt of
chronic rejection.
- Tacrolimus / Sirolimus for (IS)
- Anti-CD3 (OKT3), rare , to treat rejection during
pregnancy.

10. Infants Risk
-Prematurity in 50% of cases with its risk.
-IUGR in up to 20% of cases or low birth weight.
-Immune suppression with low immunoglobulin
level and lymphocytic counts that returns to normal
in 6 months.
-The rate of congenital fetal malformation is similar
to general population, but still pregnancies number
in such cases is small, further follow up is needed.
-Increase risk of congenital infections (CMV, HCV)
-Increase risk of autoimmune disease???

11. To Conclude
-Is pregnancy possible after organ (TP) ?
-Pregnancy is avoided for how long ?
-(IS) drugs may be used during pregnancy ?
-In utero exposure to (IS) drugs causes
future immune insufficiency or neurologic
deficits ?
-Is breast feeding possible with (IS) drugs ?
-What is the best method of contraception ?
-Is the graft function affected later on ?

12. Thank You
Best Wishes