Successful singleton pregnancy outcome resulting from in vitro fertilization after renal transplantation.

Abstract

Numerous reports in the literature of successful pregnancy after transplant encourage female recipients to consider conception (1). However, there remain some dilemmas on using assisted reproductive techniques (ARTs), including in vitro fertilization (IVF) and embryo transfer, in women with a functioning graft because ovulation induction may cause high-order multiple pregnancy and ovarian hyperstimulation syndrome (OHSS), both of which raise the risk for mother and fetus. To our knowledge, there have been four reports of successful pregnancy and delivery using ARTs after transplants: three renal transplants (2–4) and one liver transplant (5). All of the pregnancies were multiple gestations, and one patient experienced a complication of OHSS (3) as the result of ovulation induction after renal transplant. This is the first reported successful singleton pregnancy without OHSS in a transplant patient undergoing ART. A 32-year-old woman, who had undergone renal transplantation for immunoglobulin-A nephropathy at age 31 years, was referred to our urology department for a consultation on achieving pregnancy with IVF treatment. Immunosuppressants consisted of cyclosporine (2.5 mg/kg/day with trough concentration of 73.8 ng/mL), mycophenolate mofetil (2,000 mg/day), and methylprednisolone (4 mg/day). Sixteen months after transplantation, she failed to conceive three times by artificial insemination. She and her husband were eager for IVF treatment even after we fully explained the potential risk associated with pregnancy and the use of IVF in renal allograft recipients, and written informed consent was obtained from them. At this point, the renal function remained stable with serum urea and creatinine concentration of 10.8 mg/dL and 1.10 mg/dL, respectively. Proteinuria was not noted and blood pressure was well controlled by losartan potassium (12.5 mg/day). Mycophenolate was changed to azathioprine (25 mg/day) 2 months before starting standard IVF. A total of 13 oocytes were obtained, of which seven fertilized normally. Embryo transfer of three good quality embryos was undertaken. An intrauterine single pregnancy was confirmed 3 weeks posttransfer. A girl weighing 2,058 g with good APGAR scores was delivered by cesarean section at 35 weeks gestation. The postoperative course was uneventful for the mother and neonate. The incidence of multiple gestation, and the overall pregnancy rate, depends on the number of embryos transferred in IVF and embryo transfer. Our team decided to transfer the limited number of embryos to avoid high-order multiple pregnancy. OHSS is the serious iatrogenic complication of ovulation induction. Severe OHSS can be a devastating disorder, with ovarian enlargement, ascites and pleural effusions, hemoconcentration and hypercoagulability, ovarian torsion or rupture, severe electrolyte disturbance, seizures, respiratory compromise, and even death. In the first report of OHSS in a renal transplant patient undergoing ovulation induction for IVF treatment, the enlarged ovaries caused impairment of renal function after urinary tract obstruction, although no other systemic manifestations of OHSS were evident (3). Therefore, even the risk of such mild hyperstimulation, characterized by ovarian enlargement and minimal symptoms, should be well regulated, especially for renal transplant patients inducing ovulation for ART. In summary, female renal transplant recipients may be candidates for IVF treatment when efforts are made to eliminate the risk for multiple gestation and OHSS. Makoto Tamaki Masafumi Ami Naoki Kimata Takaaki Tsutsui Yoshihiko Watanabe Tsukuru Saito Junko Muto Naoki Kumagai Atsushi Shimizu Kazuhide Saito Kota Takahashi