Table 2 Management of patients prior to starting or already taking immunosuppressive drugs

A: Management prior to starting immunosuppressive treatment

1. Patient information to clarify the consequences of the planned treatment on future fertility and the couple desire for subsequent fertility (”Bioethics Law of 2004 and 2011 France (Art. L. 2141-)11)

2. Verify the absence of pregnancy.

3. Send to a fertility preservation centre, particularly if cyclophosphamide (see Table 3).

4. Effective contraception until desire for pregnancy, even in case of supposedly already altered ovarian reserve if the treatment is teratogenic and/or pregnancy would be at risk due to the underlying disorder. The metabolic effects of calcineurins and mTOR inhibitors as well as glucocorticoids will require the prescription of a progestin-only rather than a combined oestrogen-progestin contraceptive.

5. Screening for potential gynaecological neoplasias (cervical-vaginal smear, mammography) that could be worsened by immunosuppressive treatment

B Pre-conception management of a parent treated with immunosuppressive agent

1. Pre-conception consultation to discuss stopping/changing immunosuppressive drug with referring team.

2. Preconception consultation with the couple: an explanation will be offered concerning the possible strategies and obligations in order to minimise the maternal-foetal risks if pregnancy is possible; these include the need for a stable disease, multidisciplinary management, a possible period of weaning from the treatment or immuno-suppression switch, the risk of organ rejection and/ or reactivation of an underlying disease, the risk of transmitting a genetic disorder causing organ failure (Wilson’s disease, polycystic kidney disease, etc.).

3. The pregnancy will need to be planned, and the treatment will need to be modified if necessary in a pre-conception time period adapted to its half-life (See Table 1, last column).

4. If pregnancy inadvertently occurs while taking immunosuppressive treatment, reassure the patient, test for known complications (ultrasound fetal examination) and consider stopping or replacing the treatment according to the context.

5. During a planned pregnancy while on authorised treatment, the dosages of immunosuppressive agents should be closely monitored in order to avoid overdose situations that are shared with the foetus, but also to avoid underdosing, which would compromise the control of the disease or the function of the graft. During pregnancy there are variations in absorption and metabolism of the drugs.