Contraception in End-Stage Renal Disease

Recommended Contraceptive Methods

The American College of Cardiology recommends levonorgestrel-releasing intrauterine devices (IUDs) as the preferred hormonal contraceptive for ESRD patients, providing highly effective contraception with minimal systemic hormone exposure 1, 2
Copper (non-hormonal) IUDs are equally safe and highly effective, making them an excellent alternative for patients who prefer to avoid hormones entirely, with minimal systemic effects 1
Subdermal progestin implants (like etonogestrel) are highly effective with failure rates <1% per year and are appropriate for ESRD patients, according to the Journal of Arthritis care & research 3
Barrier methods (condoms, diaphragms) carry no medical risks and provide protection against sexually transmitted infections, though they have higher failure rates (18-28% per year with typical use), as reported by the Journal of Arthritis care & research 3

The European Society of Cardiology warns that monthly injectable forms of medroxyprogesterone are inappropriate for patients with fluid overload concerns, and should be used cautiously or avoided in ESRD patients due to significant fluid retention risks 2, 4
If DMPA is used, patients require close monitoring for weight gain, edema, and signs of volume overload, as recommended by the Journal of the American College of Cardiology 2, 4

The American College of Cardiology states that estrogen-containing contraceptives (combined oral contraceptives, patches, vaginal rings) are contraindicated in ESRD due to substantially increased thromboembolism risk in this population 4, 5
The transdermal estrogen patch results in even greater estrogen exposure than oral formulations and should be specifically avoided in ESRD patients, according to the Journal of Arthritis care & research 3

The American College of Cardiology suggests that tubal ligation or hysteroscopic sterilization (Essure) may be considered for ESRD patients desiring permanent contraception, though surgical risks must be carefully weighed 2, 4
Hysteroscopic sterilization may be preferable to laparoscopic tubal ligation because it avoids general anesthesia and abdominal insufflation, as reported by the Journal of the American College of Cardiology 2, 4
Vasectomy of a male partner is often the safest permanent option when the female partner has ESRD, though this requires frank discussion about the woman's prognosis, according to the Journal of the American College of Cardiology 4

The American College of Cardiology states that levonorgestrel emergency contraception ("morning-after pill") is not contraindicated in ESRD, though acute fluid retention is a potential risk that should be discussed 3, 4
The benefits of preventing unplanned pregnancy generally outweigh the temporary risk of fluid retention in ESRD patients, as reported by the Journal of Arthritis care & research 3

The American Journal of Kidney Diseases reports that pregnancy in women on conventional hemodialysis (15-24 hours/week) has live birth rates of only 50-87%, with high rates of prematurity, low birth weight, and maternal complications 6
Unplanned pregnancy in ESRD patients taking teratogenic medications (such as renin-angiotensin system inhibitors or immunosuppressants in transplant recipients) poses additional serious risks, according to Kidney International 1
Contraceptive counseling should occur early and be revisited regularly, including discussion of failure rates, the specific risks of pregnancy in ESRD, and the patient's values and preferences, as recommended by the Journal of the American College of Cardiology 4, 5