Journal of Nephrology

, Volume 32, Issue 1, pp 39–50 | Cite as

Fertility and reproductive care in chronic kidney disease

  • Sandra Marie DumanskiEmail author
  • Sofia Bano Ahmed


In both women and men, chronic kidney disease (CKD) is associated with decreased fertility. Though a multitude of factors contribute to the reduction in fertility in this population, progressively impaired function of the hypothalamic–pituitary–gonadal axis appears to play a key role in the pathophysiology. There is limited research on strategies to manage infertility in the CKD population, but intensive hemodialysis, kidney transplantation, medication management and assisted reproductive technologies (ART) have all been proposed. Though fertility and reproductive care are reported as important elements of care by CKD patients themselves, few nephrology clinicians routinely address fertility and reproductive care in clinical interactions. Globally, the average age of parenthood is increasing, with concurrent growth and expansion in the use of ART. Coupled with an increasing prevalence of CKD in women and men of reproductive age, the importance of understanding fertility and reproductive technologies in this population is highlighted. This review endeavors to explore the female and male factors that affect fertility in the CKD population, as well as the evidence supporting strategies for reproductive care.


Fertility Kidney Hormone Dialysis Transplant Novel reproductive technologies 



We thank Ms. Hayley Duff for graphic design.


Not applicable.

Compliance with ethical standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Research involving human participants and/or animals

 This article does not contain any studies with human participants performed by any of the authors.

Informed consent

Not applicable.


  1. 1.
    Wiles KS, Nelson-Piercy C, Bramham K (2018) Reproductive health and pregnancy in women with chronic kidney disease. Nat Rev Nephrol 14:165–184Google Scholar
  2. 2.
    Levidiotis V, Chang S, McDonald S (2009) Pregnancy and maternal outcomes among kidney transplant recipients. J Am Soc Nephrol 20:2433–2440Google Scholar
  3. 3.
    Piccoli GB, Conijn A, Consiglio V, Vasario E, Attini R, Deagostini MC et al (2010) Pregnancy in dialysis patients: is the evidence strong enough to lead us to change our counselling policy? Clin J Am Soc Nephrol 5:62–71Google Scholar
  4. 4.
    Lehtihet M, Hylander B (2015) Semen quality in men with chronic kidney disease and its correlation with chronic kidney disease stages. Andrologia 47:1103–1108Google Scholar
  5. 5.
    Holley JL, Schmidt RJ (2013) Changes in fertility and hormone replacement therapy in kidney disease. Adv Chronic Kidney Dis 20(3):240–245Google Scholar
  6. 6.
    Van Ek GF, Krouwel EM, Nicolai MPJ, Den Oudsten BL, Den Ouden MEM, Dieben SWM et al (2017) What is the role of nephrologists and nurses of the dialysis department in providing fertility care to CKD patients? A questionnaire study among care providers. Int Urol Nephrol 49:1273–1285Google Scholar
  7. 7.
    Ramesh S, James MT, Holroyd-Leduc JM, Wilton SB, Seely EW, Wheeler DC, Ahmed SB (2017) Sex hormone status in women with chronic kidney disease: survey of nephrologists’ and renal allied health care providers’ perceptions. Can J Kidney Health Dis 4:1–13Google Scholar
  8. 8.
    Tong A, Jesudason S, Craig JC, Winkelmayer WC (2015) Perspectives on pregnancy in women with chronic kidney disease: systematic review of qualitative studies. Nephrol Dial Transplant 30:652–661Google Scholar
  9. 9.
    Hill NR, Fatoba ST, Oke JL, Hirst JA, O’Callaghan CA, Lasserson DS, Hobbs FDR (2016) Global prevalence of chronic kidney disease—a systematic review and meta-analysis. PLoS One 11(7):e0158765Google Scholar
  10. 10.
    Vinhas J, Gardete-Correia L, Boavida JM, Raposo JF, Mesquita A, Fona MC et al (2011) Prevalence of chronic kidney disease and associated risk factors, and risk of end-stage renal disease: data from the PREVADIAB study. Nephron Clin Pract 119:c35–40Google Scholar
  11. 11.
    Jiang L, Liang Y, Qiu B, Wang F, Duan X, Yang X et al (2010) Prevalence of chronic kidney disease in a rural Chinese adult population: the Handan Eye Study. Nephron 114(4):C295–C302Google Scholar
  12. 12.
    Kramer H, Palmas W, Kestenbaum B, Cushman M, Allison M, Astor B et al (2008) Chronic kidney disease prevalence estimates among racial/ethnic groups: the multi-ethnic study of atherosclerosis. Clin J Am Soc Nephrol 3(5):1391–1397Google Scholar
  13. 13.
    White SL, Polkinghorne KR, Atkins RC, Chadban SJ (2010) Comparison of the prevalence and mortality risk of CKD in Australia using the CKD epidemiology collaboration (CKD-EPI) and modification of diet in renal disease (MDRD) study GFR estimating equations: the AusDiab (Australian Diabetes, Obesity and Lifestyle) Study. Am J Kidney Dis 55(4):660–670Google Scholar
  14. 14.
    Juutilainen A, Kastarinen H, Antikainen R, Peltonen M, Salomaa V, Tuomilehto J et al (2012) Trends in estimated kidney function: the FINRISK surveys. Eur J Epidemiol 27(4):305–313Google Scholar
  15. 15.
    Zhang Q, Rothenbacher D (2008) Prevalence of chronic kidney disease in population-based studies: systematic review. BMC Public Health 8:117Google Scholar
  16. 16.
    Barclay K, Myrskyla M (2016) Advanced maternal age and offspring outcomes: reproductive aging and counterbalancing period trends. Popul Dev Rev 42(1):61–94Google Scholar
  17. 17.
    Piccoli GB, Minelli F, Versino E, Cabiddu G, Attini R, Vigotti FN et al (2016) Pregnancy in dialysis patients in the new millennium: a systematic review and meta-regression analysis correlating dialysis schedules and pregnancy outcomes. Nephrol Dial Transplant 31(11):1915–1934Google Scholar
  18. 18.
    Nazario RDCP, Turato ER (2007) Fantasies about pregnancy and motherhood reported by fertile adult women under hemodialysis in the Brazilian Southeast: a clinical-qualitative study. Rev Lat Am Enferm 15:55–61Google Scholar
  19. 19.
    Eckardt K, Coresh J, Devuyst O, Johnson RJ, Kottgen A, Levey AS et al (2013) Evolving importance of kidney disease: From subspecialty to global health burden. Lancet 382(9887):158–69Google Scholar
  20. 20.
    Vander Borght M, Wyns C (2018) Fertility and infertility: definition and epidemiology. Clin Biochem. Google Scholar
  21. 21.
    WHO Scientific Group on Recent Advances in Medically Assisted Conception (1992) Recent advances in medically assisted conception. WHO Technical Report Series. Accessed 22 Jun 2018
  22. 22.
    Cochrane R, Regan L (1997) Undetected gynaecological disorders in women with renal disease. Hum Reprod 12(4):667–670Google Scholar
  23. 23.
    Ahmed SB, Ramesh S (2016) Sex hormones in women with kidney disease. Nephrol Dial Transplant 31(11):1787–1795Google Scholar
  24. 24.
    Piccoli GB, Cabiddu G, Attini R, Vigotti F, Fassio F, Rolfo A et al (2015) Pregnancy in chronic kidney disease: questions and answers in a changing panorama. Best Pract Res Clin Obstet Gynaecol 29:625–642Google Scholar
  25. 25.
    Piccoli GB, Cabiddu G, Daidone G, Guzzo G, Maxia S, Ciniglio I et al (2014) The children of dialysis: Live-born babies from on-dialysis mothers in Italy—an epideminological perspective comparing dialysis, kidney transplantation and the overall population. Nephrol Dial Transplant 29(8):1578–1586Google Scholar
  26. 26.
    Knight M, Kurinczuk JJ, Tuffnell D, Brocklehurst P (2005) The UK obstetric surveillance system for rare disorders of pregnancy. BJOG 112:263–265Google Scholar
  27. 27.
    Statistical bulletin: Conceptions in England and Wales 2015 (2017) Office for national statistics. Accessed 20 Aug 2018
  28. 28.
    Bramham K, Nelson-Piercy C, Gao H, Pierce M, Bush N, Spark P et al (2013) Pregnancy in renal transplant recipients: a UK national cohort study. Clin J Am Soc Nephrol 8:290–298Google Scholar
  29. 29.
    Holley JL, Schmidt RJ, Bender FH (1997) Gynecologic and reproductive issues in women on dialysis. Am J Kidney Dis 29(5):685–690Google Scholar
  30. 30.
    Lim VS, Henriquez C, Sievertsen G, Frohman LA (1980) Ovarian function in chronic renal failure: evidence suggesting hypothalamic anovulation. Ann Int Med 93(1):21–27Google Scholar
  31. 31.
  32. 32.
    Ahmed SB, Vitek WS, Holley JL (2017) Fertility, contraception, and novel reproductive technologies in chronic kidney disease. Semin Nephrol 37(4):327–336Google Scholar
  33. 33.
    Sievertsen GD, Lim VS, Nakawatase C, Frohman LA (1980) Metabolic clearance and secretion rates of human prolactin in normal subjects and in patients with chronic renal failure. J Clin Endocrinol Metab 5(1):846–852Google Scholar
  34. 34.
    Matuszkiewicz-Rowinska J, Skorzewska K, Radowicki S, Niemczyk S, Sokalski A, Przedlacki J et al (2004) Endometrial morphology and pituitary–gonadal axis dysfunction in women of reproductive age undergoing chronic haemodialysis—a multicenter study. Nephrol Dial Transplant 19:2074–2077Google Scholar
  35. 35.
    Chakhtoura Z, Meunier M, Caby J, Mercadal L, Arzouk N, Barrou B, Touraine P (2015) Gynecologic followup of 129 women on dialysis and after kidney transplantation: a retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 187:1–5Google Scholar
  36. 36.
    Harlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW et al (2012) Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause 19(4):387–395Google Scholar
  37. 37.
    Rose C, Gill J, Zalunardo N, Johnston O, Mehrotra A, Gill JS (2016) Timing of pregnancy after kidney transplantation and risk of allograft failure. Am J Transplant 16:2360–2367Google Scholar
  38. 38.
    Filocamo JT, Zanazzi M, Marzi VL, Lombardi G, Popolo GD, Mancini G et al (2009) Sexual dysfunction in women during dialysis and after renal transplantation. J Sex Med 6:3125–3131Google Scholar
  39. 39.
    Tauchmanova L, Carraro R, Sabbatini M, De Rosa M, Orio F, Palomba S et al (2004) Hypothalamic–pituitary–gonadal axis function after successful kidney transplantation in men and women. Hum Reprod 19:867–873Google Scholar
  40. 40.
    Pietrzak B, Wielgos M, Kaminski P, Jabiry-Zieniewicz Z, Bobrowska K (2006) Menstrual cycle and sex hormone profile in kidney-transplanted women. Neuro Endocrinol Lett 27:198–202Google Scholar
  41. 41.
    Barua M, Hladunewich M, Keunen J, Pierratos A, McFarlane P, Sood M, Chan CT (2008) Successful pregnancies on nocturnal home hemodialysis. Clin J Am Soc Nephrol 3:392–396Google Scholar
  42. 42.
    Van Eps C, Hawley C, Jeffries J, Johnson DW, Campbell S, Isbel N et al (2012) Changes in serum prolactin, sex hormones and thyroid function with alternate nightly nocturnal home haemodialysis. Nephrology 17:42–47Google Scholar
  43. 43.
    Wilkosz P, Greggains GD, Tanbo TG, Fedorcsak P (2014) Female reproductive decline is determined by remaining ovarian reserve and age. PLoS One 9(10):e108343Google Scholar
  44. 44.
    Iwase A, Nakamura T, Osuka S, Takikawa S, Goto M, Kikkawa F (2015) Anti-Mullerian hormone as a marker of ovarian reserve: what we have learned and what should we know? Reprod Med Biol 15(3):127–136Google Scholar
  45. 45.
    Stoumpos S, Lees J, Welsh P, Hund M, Geddes CC, Nelson SM, Mark PB (2018) The utility of anti-Mullerian hormone in women with chronic kidney disease, on haemodialysis and after kidney transplantation. Reprod Biomed Online 36:219–226Google Scholar
  46. 46.
    Sikora-Grabka E, Adamczak M, Kuczera P, Szotowska M, Madej P, Wiecek A (2016) Serum anti-Mullerian hormone concentration in young women with chronic kidney disease on hemodialysis, and after successful kidney transplantation. Kidney Blood Press Res 41:552–560Google Scholar
  47. 47.
    Cui L, Sheng Y, Sun M, Hu J, Qin Y, Chen Z (2016) Chronic pelvic inflammation diminished ovarian reserve as indicated by serum anti-Mullerian hormone. PLoS One 11(6):e0156130Google Scholar
  48. 48.
    Senates E, Colak Y, Erdem ED, Yesil A, Coskunpinar E, Sahin O et al (2013) Serum anti-Mullerian hormone levels are lower in reproductive age women with Crohn’s disease compared to healthy control women. Crohn’s Colitis 7:e29–e34Google Scholar
  49. 49.
    Chen L, Yang T, Lu D, Feng Y, Chen H, Chen D et al (2018) Central role of dysregulation of TGF-B/Smad in CKD progression and potential targets of its treatment. Biomed Pharmacother 101:670–681Google Scholar
  50. 50.
    Dumont A, Robin G, Catteau-Jonard S, Dewailly D (2015) Role of anti-Mullerian hormone in pathophysiology, diagnosis and treatment of polycystic ovary syndrome: a review. Reprod Biol Endocrinol 13:137Google Scholar
  51. 51.
    Garg D, Tal R (2016) The role of AMH in the pathophysiology of polycystic ovarian syndrome. Reprod Biomed Online 33:15–28Google Scholar
  52. 52.
    Basok EK, Atsu N, Rifaioglu MM, Kantarci G, Yildirim A, Tokuc R (2009) Assessment of female sexual function and quality of life in predialysis, peritoneal dialysis, hemodialysis, and renal transplant patients. Int Urol Nephrol 41:473–481Google Scholar
  53. 53.
    Holley J, Schmidt R (2010) Sexual dysfunction in CKD. Am J Kidney Dis 56(4):612Google Scholar
  54. 54.
    Navaneethan SD, Vecchio M, Johnson DW, Saglimbene V, Graziano G, Pellegrini F et al (2010) Prevalence and correlates of self-reported sexual dysfunction in CKD: a meta-analysis of observational studies. Am J Kidney Dis 56(4):670–685Google Scholar
  55. 55.
    Okundaye I, Abrinko P, Hou S (1998) Registry of pregnancy in dialysis patients. Am J Kidney Dis 31(5):766–773Google Scholar
  56. 56.
    Shahir AK, Briggs N, Katsoulis J, Levidiotis V (2013) An observational outcomes study from 1966 to 2008, examining pregnancy and neonatal outcomes from dialysed women using data from the ANZDATA registry. Nephrology 18:276–284Google Scholar
  57. 57.
    Hladunewich M, Schatell D (2016) Intensive dialysis and pregnancy. Hemodial Int 20:339–348Google Scholar
  58. 58.
    Leroy C, Rigot J, Leroy M, Decanter C, Le Mapihan K, Parent A et al (2015) Immunosuppressive drugs and fertility. Orphanet J Rare Dis 10:136Google Scholar
  59. 59.
    Houssiau F, Vasconcelos C, D’Cruz D, Sebastiani G, Garrido E, Danieli M et al (2002) Immunosuppressive therapy in lupus nephritis: the Euro-Lupus Nephritis Trial, a randomized trial of low-dose versus high-dose intravenous cyclophosphamide. Arthritis Rheum 46:2121–2131Google Scholar
  60. 60.
    Zhang X, Li C, Ma X, Zhao J, An Y, Liu S et al (2014) Short-interval lower-dose intravenous cyclophosphamide as induction and maintenance therapy for lupus nephritis: a prospective observational study. Clin Rheumatol 33:939–945Google Scholar
  61. 61.
    Wiles K, Lightstone L (2018) Glomerular disease in women. Kidney Int Rep 3:258–270Google Scholar
  62. 62.
    De Vos M, Smitz J, Woodruff T (2014) Fertility preservation 2: fertility preservation in women with cancer. Lancet 384(9950):1302–1310Google Scholar
  63. 63.
    Elizur S, Chian R, Pineau C, Son W, Holzer H, Huang J et al (2008) Fertility preservation treatment for young women with autoimmune diseases facing treatment with gonadotoxic agents. Rheumatology 47(10):1506–1509Google Scholar
  64. 64.
    Rodriguez-Wallberg KA, Oktay K (2012) Recent advances in oocyte and ovarian tissue cryopreservation and transplantation. Best Pract Res Clin Obstet Gynaecol 26(3):391–405Google Scholar
  65. 65.
    Lambertini M, Boni L, Michelotti A, Gamucci T, Scotto T, Gori S et al (2015) Ovarian suppression with triptorelin during adjuvant breast cancer chemotherapy and long-term ovarian function, pregnancies, and disease-free survival. JAMA 314(24):2632–2640Google Scholar
  66. 66.
    Somers EC, Marder W, Christman GM, Ognenovski V, McCune WJ (2005) Use of a gonadotropin-releaseing hormone analog for protection against premature ovarian failure during cyclophosphamide therapy in women with severe lupus. Arthritis Rheum 52:2761–2767Google Scholar
  67. 67.
    Marder W, McCune WJ, Wang L, Wing JJ, Fisseha S, McConnell DS et al (2012) Adjunctive GnRH-a treatment attenuates depletion of ovarian reserve associated with cyclophosphamide therapy in premenopausal SLE patients. Gynecol Endocrinol 28:624–627Google Scholar
  68. 68.
    Sullivan-Pyke CS, Senapati S, Mainigi MA, Barnhart KT (2017) In vitro fertilization and adverse obstetric and perinatal outcomes. Semin Perinatol 41(6):345–353Google Scholar
  69. 69.
    Orquevaux P, Masseau A, Le Guern V, Gayet V, Vauthier D, Guettrot-Imbert G et al (2017) In vitro fertilization in 37 women with systemic lupus erythematosus or antiphospholipid syndrome: a series of 97 procedures. J Rheumatol 44:613–618Google Scholar
  70. 70.
    Pietrzak B, Mazanowska N, Kocixzewska-Najman B, Szymusik I, Grzechocinska B, Pazik J et al (2015) Successful pregnancy outcome after in vitro fertilization in a kidney graft recipient: a case report and literature review. Ann Transplant 20:338–341Google Scholar
  71. 71.
    Nouri K, Bader Y, Helmy S, Ott J, Jirecek S, Tempfer CB (2011) Live birth after in vitro fertilization and single embryo transfer in a kidney transplant patient: a case report and review of the literature. J Assist Reprod Genet 28(4):351–353Google Scholar
  72. 72.
    Norrman E, Bergh C, Wennerholm U (2015) Pregnancy outcome and long-term follow-up after in vitro fertilization in women with renal transplantation. Human Reprod 30(1):205–213Google Scholar
  73. 73.
    Marak CP, Chopra A, Alappan N, Ponea AM, Guddati AK (2013) Ovarian hyperstimulation syndrome as an etiology of obstructive uropathy. Case Rep Obstet Gynecol 2013:653704Google Scholar
  74. 74.
    Thoreau A, Tran PL, Gabriele M, Marie HFS, Boukerrou M (2018) Ureteral obstruction and ruptured kidney following ovarian hyperstimulation syndrome. J Gynecol Obstet Hum Reprod 47(4):167–169Google Scholar
  75. 75.
    Al-Inany HG, Youssef MA, Ayeleke RO, Brown J, Lam WS, Broekmans FJ (2016) Gonadotropin-releasing hormone antagonists for assisted reproductive technology. Cochrane Database Syst Rev 4:CD001750Google Scholar
  76. 76.
    Piccoli B, Arduino S, Attini R, Parisi S, Fassio F, Biolcati M et al (2013) Multiple pregnancies in CKD patients: an explosive mix. Clin J Am Soc Nephrol 8(1):41–50Google Scholar
  77. 77.
    Iglesias P, Carrero JJ, Diez JJ (2012) Gonadal dysfunction in men with chronic kidney disease: clinical features, prognostic implications and therapeutic options. J Nephrol 25(1):31–42Google Scholar
  78. 78.
    Zachoval R, Jarabak J, Slatinska J, Burgelova M, Sobotka V, Vranova J, Krhut J (2013) Dynamics of fertility in patients on waiting list for kidney transplantation. Bratisl Lek Listy 114(12):711–715Google Scholar
  79. 79.
    Eckersten D, Giwercman A, Pihlsgard M, Bruun L, Christensson A (2018) Impact of kidney transplantation on reproductive hormone levels in males: a longitudinal study. Nephron 138:192–201Google Scholar
  80. 80.
    Eckersten D, Giwercman A, Bruun L, Cristensson A (2015) Anti-Mullerian hormone, a Sertoli cell-derived marker, is decreased in plasma of male patients in all stages of chronic kidney disease. Andrology 3:1160–1164Google Scholar
  81. 81.
    Eckersten D, Giwercman A, Christensson A (2015) Male patients with terminal renal failure exhibit low serum levels of antimullerian hormone. Asian J Androl 17:149–153Google Scholar
  82. 82.
    Kaprara A, Huhtaniemi IT (2017) The hypothalamus–pituitary–gonad axis: tales of mice and men. Metabolism. Google Scholar
  83. 83.
    Gill-Sharma MK (2009) Prolactin and male fertility: the long and short feedback regulation. Int J Endocrinol. Google Scholar
  84. 84.
    Hotaling JM, Patel Z (2014) Male endocrine dysfunction. Urol Clin N Am 41(1):39Google Scholar
  85. 85.
    Eckersten D, Tsatsanis C, Giwercman A, Bruun L, Pihlsgard M, Christensson A (2017) MicroRNA-155 and anti-Mullerian hormone: new potential markers of subfertility in men with chronic kidney disease. Nephron Extra 7:33–41Google Scholar
  86. 86.
    Fryckstedt J, Hylander B (2008) Sexual function in patients with end-stage renal disease. Scand J Urol Nephrol 42:466–471Google Scholar
  87. 87.
    Tanio J, Jahnukainen K, Nurmio M, Pakarinen M, Jalanko H, Jahnukainen T (2014) Testicular function, semen quality, and fertility in young men after renal transplantation during childhood or adolescence. Transplantation 98(9):987–993Google Scholar
  88. 88.
    Akbari F, Alavi M, Esteghamati A, Mehrsai A, Djaladat H, Zohrevand R et al (2003) Effect of renal transplantation on sperm quality and sex hormone levels. BJU Int 92(3):281–283Google Scholar

Copyright information

© Italian Society of Nephrology 2019

Authors and Affiliations

  1. 1.Cumming School of MedicineUniversity of CalgaryCalgaryCanada
  2. 2.Department of MedicineUniversity of CalgaryCalgaryCanada
  3. 3.Libin Cardiovascular Institute of AlbertaCalgaryCanada
  4. 4.Alberta Kidney Disease NetworkCalgaryCanada

Personalised recommendations