This document discusses sexual and reproductive health issues after kidney transplantation. It notes that more than half of male patients with renal failure have biochemical hypogonadism, which is a risk factor for sexual dysfunction. Several medications commonly used after transplantation can negatively impact erectile function and fertility in men. Treatment with phosphodiesterase 5 inhibitors can help erectile dysfunction. Female patients may experience ovulatory and menstrual irregularities due to hypothalamic-pituitary changes from chronic kidney disease. Pregnancy is possible after transplantation if kidney function is good with no proteinuria or hypertension and at least one year post-transplant. Fertility preservation techniques before transplantation like ovum pickup and preservation are discussed.

1. Sexual and productive health
after kidney transplantation
By
Salwa Mahmoud Elwasif, MD
Fellow of Internal Medicine and Nephrology

2. • References:

3. • Professor Ahmed Hassan
• Duration of presentation : 18 min
• Number of slides: 43
• Basic knowledge

4. • Maslow Hierarchy of Needs ‫لإلحتياجات‬ ‫ماسلو‬ ‫هرم‬

5. Reproductive
health
Sexual
health
Better
quality
of life

7. Transl Androl Urol 2019;8(2):173181
Hormonal And Seminal Parameter Changes
With ESRD And Renal Transplantation.

8. more than half of male patients with renal failure have
biochemical hypogonadism, which is a potentially reversible
risk factor for sexual dysfunction and osteoporosis
(Albaaj et al, 2006)

9. Medication Effects On The Male
Reproductive System
RecommendationsEffects on male reproductive systemMedication
class
Medication
Can continue when trying
for pregnancy
1-Reduces sperm counts
2-Decreases fertility
Calcineurin
inhibitor
Tacrolimus
Can continue when trying
for pregnancy
1-Decreases sperm counts, testosterone
level, and fertility
2-Increasing LH and FSH in male rat s
Calcineurin
inhibitor
Cyclosporine
Discuss risks and benefits of
continuing vs stopping
medication prior to attempting
conception
1-Decreases testosterone, with resulting
increases in FSH and LH,
2-Decreases pregnancy rate
3-Sirolimus Hypothetical teratogenic effect
mTORinhibitor
Sirolimus
Discuss risks and benefits of
continuing vs stopping
medication prior to attempting
conception
1-? Direct sperm effects,
2-Hypothetical teratogenic effect from
paternal exposure
AntimetaboliteMycophenolate
FSH = follicle-stimulating hormone; LH = luteinizing hormone. Eur Urol Focus. 2018 April ; 4(3): 307–310.

10. Commonly Used Drugs Associated With
Erectile Dysfunction In Men With tx
Androgens, estrogens,
progesterone
Hormones
Atenolol, pindolol, propranololBeta blockers
HydralazineVasodilators
Thiazides, spironolactoneDiuretics
Clonidine, methyldopa, reserpineSympatholytics
BarbituratesSedatives
Tricyclic antidepressants, MAO inhibitorsPsychotropic drugs:
Digoxin, ranitidineOthers
Review Article Austin J Nephrol Hypertens. 2015;2(1): 1031

11. Treatment with phosphodiestrase 5 inhibitors
• Examples of PDEI:
– sildenafil
– tadalafil
– vardenafil
• Uses:
– Erectile dysfunction
– Pulmonary hypertension (FDA approval)
• Side effects:
– Hypotension
– sudden hearing loss
– anterior optic neuropathy

12. • Male gynecomastia
• Be aware of male cancer breast

13. Erythropoietin and sexual dysfunction
• Erythropoietin (rHuEpo) therapy has been shown to
improve sexual function in the male population, with
several studies suggesting a direct effect upon
endocrine function, as well as correction of anaemia..

14. Erythropoietin and sexual dysfunction
• Male dialysis patients complaining of sexual dysfunction
after correction of anaemia with rHuEpo are
characterized by higher levels of serum
testosterone and SHBG, but not suppression of
hyperprolactinaemia or hyperoestrogenism.
(Lawrence et al, 1997)

15. Female sexual dysfunction

17. • Ovulatory and menstrual irregularities observed in
the CKD are likely to be the consequence of
hypothalamic and pituitary, rather than ovarian.

18. • LH and FSH levels rise in response to the
administration of the antiestrogenic agent
(Clomiphene Citrate), suggests that the ovary
remains responsive to Gonadotropins.

19. • Upregulated production of Prolactin due to CKD-
mediated inhibition of dopaminergic activity Normal
cyclic GnRH secretion decreases, resulting in the loss
of pulsatile LH and FSH release.

20. Effects of Oral Contraceptive Use on the
Renal and Systemic Vascular Response
• Oral contraceptives (OC) exhibit increased plasma
levels of Angiotensin II with only modest
hemodynamic consequences, suggesting estrogen-
mediated Ang II type 1 (AT1) receptor down
regulation

21. Oral contraceptive pills
• Increases renal tubular responsiveness to changes in
sodium intake leading to -Increased GFR -Increase in
renal nitric oxide -Increase in renin–angiotensin
activity (RAS) linked to a greater risk of Diabetic
Nephropathy

22. Criteria to allow pregnancy
• Both nondiabetic and diabetic OC users have an
increased response to captopril compared with their
OC nonuser counterparts.
1) From the clinical point of view:
a) Normal or good kidney function (differently defined: usually as above 60 ml/min)
b) No proteinuria or scarce proteinuria (differently defined: usually as below 300–500 mg/day)
c) No hypertension or well-controlled hypertension (the latter usually defined as treated in
monotherapy and without organ damage)
d) Low-dose immunosuppression with “allowed” drugs
e) At least 2 years after KT (this interval has recently been reduced to 1 year after KT) (strong
suggestion, several sources of observational data).
2) Further clinical maternal elements include:
a) No recent rejection episode
b) No recurrent urinary tract infection
c) Discontinuation of potentially teratogen drugs for at least 6 weeks
3) low-risk mother is young (under 35), non-obese, non-diabetic, with
a spontaneous singleton pregnancy

23. Fetal complication
• IUGR
• IUFD
• Congenital anomalies

24. Maternal complications
• Premature labour
• Chorioaminitis
• PET
• HTN
• Proteinuria

25. Management of proteinuria in KT
pregnancy
• Low-dose acetyl salicylate is indicated in proteinuric
patients (as well as in patients with reduced kidney
function or hypertension) (strong recommendation, different
levels of evidence in various diseases)
• Two recent meta-analyses suggest that early ASA use
(start before 16 weeks) is associated with better
outcomes.
• To counterbalance hyperfiltration, albumin infusion
should be avoided, moderate protein restriction can be
attempted (medium recommendation, indirect evidence)
Journal of Nephrology (2018) 31:665–681

26. Fertility preservation
• Controlled Ovulation induction
• Ovum pickup and preservation
• Duration of preservation: 3:5 yr