Family Planning in Liver Transplant: Patient and Provider Knowledge and Practices

Abstract

Fertility is often impaired in adolescents and women with cirrhosis, but it is rapidly restored after liver transplantation (LT). Early and unplanned pregnancies confer increased risks to maternal, fetal, and graft health, underscoring the need for reproductive counseling. However, data on reproductive practices or counseling in the LT setting are limited. An anonymous online Qualtrics (Provo, UT) survey was sent to transplant patients and providers to gauge knowledge and practices surrounding contraception and pregnancy. Eligible participants included transplant patients aged 14‐45 years and their transplant providers. Patient response was 50.0% (74/148), 14 of whom were pre‐LT patients and 60 of whom were post‐LT patients. Counseling occurred in 37% of patients prior to transplant and 82% after transplant. Most patients (86%) considered family planning a high priority in their transplant care. Contraception‐ and pregnancy‐specific counseling was provided by LT providers in 60% and 44% of patients, respectively. The most desired mode of counseling by patients was in‐person discussion with an LT provider (89%). Despite most post‐LT patients receiving counseling, only 41% used contraception during the first year after LT, of whom 32% relied on high failure methods. Of the 31/43 (72.1%) provider responses, 96% voiced interest in additional reproductive education. Most providers (90%) correctly advised that patients delay pregnancy during the first year after LT, although misconceptions about safety of estrogen and intrauterine devices were selected by 53% and 42%, respectively. Some favored resources by providers were educational pamphlets in clinic (88%) and automated note templates to prompt family planning inquiry (72%). Transplant patients and providers have key deficiencies in their knowledge of contraception and corresponding practices. Most post‐LT patients receive counseling, yet contraception practices are inadequate for preventing unplanned pregnancy. Discussion with transplant providers was the most favored counseling modality by patients, underscoring our critical role in optimizing post‐LT reproductive care.

Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases

“…The number of pregnancies in LT recipients is rising, and reproductive health is a central issue among recipients of childbearing age. (407)(408)(409)(410) To best support reproductive intentions and help prevent unintentional pregnancies, transplant providers should discuss family planning with patients, ideally pre-LT and in the early postoperative period. Of the 543 pregnancies reported to the Transplant Pregnancy Registry International from November 1985 through May 2018, 40% were unplanned.…”

Promoting safe sexual practices and sexual health maintenance in pediatric and young adult solid organ transplant recipients

“…63% of this group requested more face‐to‐face guidance on the subject 2 . Similarly, adult kidney and liver transplant recipients also report high rates of sexual health concerns with ill‐preparation from their transplant providers 3‐8 …”

“…64% had previously conducted family planning counseling with their transplant patients. Knowledge gaps showed 52.6% believed all transplant recipients should avoid estrogen‐containing contraceptives, 36.8% favored use of barrier methods for transplant recipients, 26.3% felt IUDs were less effective in transplant recipients and 42.1% believed IUDs increased risk of PID 8 . Limited data suggest that adult transplant practitioners also feel unprepared to address their patients’ sexual health concerns 6,10 .…”

“…2 Similarly, adult kidney and liver transplant recipients also report high rates of sexual health concerns with ill-preparation from their transplant providers. [3][4][5][6][7][8] Transplant practitioners also report feeling underequipped to discuss aspects of sexual health reaching beyond teratogenicity of staple immunosuppressants. In a survey of 69 pediatric renal transplant nephrologists, Ashoor et al found that 67% felt comfortable counseling on safer sex, but less than half regularly discussed contraceptive options, unintended pregnancy, or provided specialist referrals for contraception.…”

“…Knowledge gaps showed 52.6% believed all transplant recipients should avoid estrogen-containing contraceptives, 36.8% favored use of barrier methods for transplant recipients, 26.3% felt IUDs were less effective in transplant recipients and 42.1% believed IUDs increased risk of pelvic inflammatory disease (PID). 8 Limited data suggest that adult transplant practitioners also feel unprepared to address their patients' sexual health concerns. 6,10 Proper sexual health care is vast, requires strong multidisciplinary care, pushes boundaries of social mores, and some guidance warrants exploration of local statutes to ensure compliance.…”