Current approaches in managing pregnancy in kidney transplant recipients

End-stage renal disease impacts fertility, causing functional menopause in female patients. Within 3 months of successful renal transplant, menstrual function normalizes, ovulation recommences due to improved hypothalamic–pituitary–ovarian axis function, and, thereby, fertility is restored in 80–90% of women in the childbearing age group. In such circumstances, any unplanned pregnancy poses a significant risk to the mother and the child, and the allograft. Pregnancy, in general, does not negatively impact long-term allograft function or survival if the baseline function of the allograft is excellent. Risk predictors of clinical adverse outcomes and graft loss during pregnancy include short transplant–pregnancy interval, preconception graft function, hypertension, preconception proteinuria, and preeclampsia. The recommended and safer maintenance immunosuppressive regimen during pregnancy is calcineurin inhibitors (CNI) (tacrolimus/cyclosporine), azathioprine, and steroids. Sirolimus/everolimus and mycophenolate mofetil should be withdrawn 6 weeks before planned conception. To avoid acute rejections, drug levels should be monitored closely, and the dosage should be modified to reach the recommended target level. Addressing contraception must be a crucial component of the pretransplant counseling process to prevent premature unplanned pregnancies. Mechanical contraceptives are safe for transplant recipients, convenient, and easy to use, with no concerns regarding interaction with immune suppressants; nevertheless, their efficacy depends on user compliance which is difficult to achieve in most cases. However, combined oral contraceptives and progestin-only contraceptives have an inhibitory effect on P 450 3A4, thus increasing the concentration of CNIs particularly cyclosporine. Furthermore, CNIs, in particular, tacrolimus, have an inductive effect on P 450 3A4, potentially reducing the contraceptive efficacy. Therefore, successful pregnancy depends on thorough prepregnancy counseling, careful family planning, and multidisciplinary teamwork. Breastfeeding is not contraindicated and should not be discouraged.