Читать книгу Assisted Reproduction Techniques - Группа авторов - Страница 154

Women with chronic kidney disease have disrupted hypothalamus‐pituitary‐ovarian axis function leading to deranged menstrual cycles, anovulation and therefore reduced fertility [1]. When chronic kidney disease reaches end‐stage, prolactin is raised (due to reduced renal clearance) and there are often low LH and FSH levels due to lack of pulsatile gonadotropin releasing hormone release [2]. Estradiol and progesterone levels are characteristically low, and women tend to reach menopause 4.5 years earlier compared with women in general population [3]. Therefore, pregnancy is rare in women on hemodialysis with an incidence of conception as low as 0.3% [4]. With the development of more intense hemodialysis regimes, the live birth rates seen in women on dialysis are improving [5]. In women who have undergone peritoneal dialysis, there is an increased incidence of tubal infertility due to the risk of generalized peritonitis [6].

The incidence of renal transplantation is increasing. After successful renal transplantation, the hypogonadotropic hypogonadism seen in women with end‐stage renal disease can normalize within six months [7]. Normal ovulatory cycles can be restored with regular menstrual cycles [8,9].

There is still much debate surrounding the optimal time women should be advised to wait to conceive after renal transplant. However, both the American Society of Transplantation and European Transplantation Society suggest that the optimal time is after one year post transplantation [1].

If conception is achieved, the allografted kidney is able to adapt to the physiological changes of pregnancy and the elevated glomerular filtration rates. It is able to cope with the intrarenal vasodilatation allowing for greater creatinine clearance required for pregnancy [10]. Recent data demonstrated a live birth rate of around 75% in women who conceived a pregnancy after renal transplantation [6,11]. Reassuringly, the miscarriage and ectopic pregnancy rates do not differ from that of the general population [12].

Encouragingly, recent data have also shown that live birth in renal transplant recipients does not adversely affect the functioning of the graft and the long‐term survival of the woman [11]. The same study reported survival rates after a live birth in women with a renal graft as 92% at 10 years and 75% at 20 years [11].

When considering IVF treatment in renal transplant recipients, there are specific risks that clinicians should be aware of and patients should be well counseled before embarking on fertility treatment. It is important to consider that both renal transplantation and IVF are independently associated with greater risks of preterm birth, small for gestational age and perinatal mortality [13]. There are only a few case reports and series published on live births following IVF treatment in women who have been renal transplant recipients [13,14,15].