Contraception After Transplant

Fertility often returns within months of a successful transplant, and pregnancy in the first year carries risks of graft loss, rejection and infection. Immunosuppressants such as mycophenolate and cyclophosphamide are teratogenic, so highly effective contraception is needed throughout treatment and pregnancy is planned only when graft function is stable.

Assessment. Organ, time since transplant, graft function, rejection history, immunosuppressants, hypertension, diabetes, lipids, infection history, thrombosis risk and pregnancy intention.

Uncomplicated transplant. Stable graft with no rejection, hypertension or vascular disease.

Complicated transplant. Graft failure, acute or chronic rejection, cardiac allograft vasculopathy, hypertension or other vascular disease.

Effectiveness. First-year pregnancies per 100 women with typical use: implants 0.05, intrauterine devices 0.2 to 0.8, injectables 3, combined pills 8.

Eligibility.

Method comparison. Intrauterine devices and implants are preferred because they avoid interactions and have the lowest failure. Combined methods are used only in stable, uncomplicated, normotensive patients. The long-standing concern that intrauterine devices fail or cause infection under immunosuppression is not supported by current evidence.

Medicine interactions. Ciclosporin and tacrolimus levels can rise with oestrogen and fall with enzyme inducers. Mycophenolate may lower hormone levels and is highly teratogenic. Azathioprine and corticosteroids do not interact meaningfully.

Special groups. Patients with diabetes or hypertension after transplant follow the restrictive categories. Adolescent transplant recipients need contraception counselling early.

Regimen lines.

• Levonorgestrel 52 mg device: 5 years; copper T 380A: up to 12 years; insertion within 12 days of the start of bleeding or at any time if reasonably not pregnant; no backup.

• Etonogestrel 68 mg rod: 3 years; levonorgestrel two 75 mg rods: 5 years or 3 years by system; backup 7 days if inserted after day 7 of bleeding.

• DMPA 150 mg intramuscularly every 13 weeks, up to 4 weeks late, or 104 mg subcutaneously every 13 weeks, up to 4 weeks late; bone health reviewed in long-term steroid users.

• Progestin-only pill: one tablet daily without a break; late window 3 hours for the traditional pill, 12 hours for desogestrel and 24 hours for drospirenone; backup 2 days after a late or missed pill.

• Combined methods: not used in complicated transplant.

• When mycophenolate is used, a long-acting method or two methods together are advised.

Timing of pregnancy. Delay conception for at least 1 year after transplant with stable graft function, no recent rejection and teratogenic medicines replaced.

Follow up. Review at transplant clinic visits, including blood pressure, graft function, interactions and pregnancy intention.

Contraceptive failure. Pregnancy on mycophenolate needs urgent specialist review to change therapy and counsel on the foetal risk.

Infection. Pelvic infection with a device in an immunosuppressed patient needs prompt treatment and early review; remove the device if there is no improvement.

Rejection or graft dysfunction. Reassess the method; stop oestrogen-containing methods.

Bleeding. Treat bothersome bleeding with ibuprofen only if kidney function is normal and not on calcineurin inhibitors, otherwise discuss alternatives with the transplant team.

Red flags. Fever, graft pain, rising creatinine, severe hypertension, leg swelling.

Referral and escalation. Refer rejection, infection, pregnancy and uncertain interactions to the transplant team.