Family planning and kidney disease: Fertility and sexual health

Being diagnosed with kidney disease will undoubtedly change parts of your life. This can include lifestyle changes, such as following a kidney-friendly food and fluid plan or exercising more regularly. Or it may require more radical changes like undergoing regular dialysis treatments or a kidney transplant if your kidney disease has progressed to kidney failure. 

But you may have questions about how kidney disease will impact your family planning. Can you still have a healthy sex life? Will it affect your birth control options? Will having kidney disease affect your ability to have a healthy baby?

With help from nephrologist (and one of our former Clinical Scientist in Nephrology fellows), Dr. Jessica Tangren, AKF explores all of these questions and more in a three-part series on family planning and kidney disease. Part one focuses on fertility and sexual health, part two on pregnancy and part three on labor and delivery and postpartum. This is part one: fertility and sexual health.

In general, how does kidney disease impact sexual health for men and women?

Unfortunately, 70% of men and 84% of women with kidney disease report issues of sexual dysfunction. 

This is because the kidneys play an important role in the cardiovascular system (your heart and blood vessels), filtering the blood of waste and toxins, and regulating the body's electrolytes and hormones.  Changes in your circulation and high blood pressure can cause problems with sexual arousal. Abnormal blood electrolyte or hormone levels can lead to low libido (sexual drive/desire) or sexual arousal challenges. 

For men, kidney disease and its related conditions (like diabetes or heart disease) or treatments (like dialysis or medicines) can cause erectile dysfunction — meaning they have difficulty getting or maintaining an erection. 

In addition to low libido or sexual arousal challenges, kidney disease can impact a woman's menstrual cycle (her period) and cause fertility issues. 

"As your kidney disease progresses, the clearance of many hormones that regulate your menstrual cycle is impacted," explained Dr. Tangren. The hormone prolactin, which stimulates the production of breastmilk, can rise in concentration as kidney disease disrupts the production of the inhibitor hormone that stops prolactin production. Ultimately, this can prevent ovulation (meaning an egg is not released by the ovaries).

How does kidney disease impact fertility?

For both men and women, kidney disease can lead to fertility issues (issues relating to becoming pregnant). 

For men, in addition to leading to erectile dysfunction, kidney disease can also lead to a decrease in sperm count and can impair sperm motility. Both issues can make it harder to successfully conceive.

For women, the disruption of normal hormonal levels can disrupt ovulation cycles. 

"Women with advanced stage kidney disease and women on dialysis have low fertility or sub-fertility because they do not have normal menstrual cycles," said Dr. Tangren. "We see that many patients who are on dialysis actually don't have regular periods. Many women stop having periods altogether. But even women on dialysis who are having periods, many times they're having 'anovulatory' cycles, which means they are not releasing an egg for fertilization." 

Does this mean people with kidney disease cannot have children?

No. This is not necessarily the case. However, it is important to know how it may make the process more challenging.

Dr. Tangren explained that there are methods to increase fertility for women with kidney disease. "There's a few scenarios where we do see that fertility can be restored, and one is after a transplant," she said. "Within six weeks, your menstrual cycles can come back and you're basically fertile very quickly after transplant.

"We also see this in women on dialysis who go on a more intensified dialysis regimen. So, more clearance [of the buildup of waste and toxins from the failed kidneys] than the typical three times a week, four hours of dialysis. Women who switched to nocturnal hemodialysis or go on home hemodialysis where, all of a sudden, their clearance is ramped up, can actually start to have normal menstrual cycles again." 

She added that when women make those treatment changes "it's really important to talk about contraception if you don't want to have a pregnancy because you can actually start to have normal periods again."

Does having kidney disease impact birth control options for women?

"You can and definitely should be on some form of birth control, even if you have kidney disease," according to Dr. Tangren. "In my opinion, by far the safest and most effective forms of birth control for women with kidney disease are what we call LARC's — or long-acting reversible contraception — and those would be forms of contraception like an IUD [intrauterine device]…There's also an option for a small implant in the arm that can be removed if a woman no longer wants contraception." 

The "classic" combined oral contraceptive (the pill) is also an option. However, Dr. Tangren cautions that these all have estrogen in them, which can be a problem for women with certain kinds of kidney disease. "Estrogen can raise your blood pressure," explained Dr. Tangren, "and in women who have proteinuric kidney disease for any reason (like lupus) — so they're spilling protein in their urine related to their kidney disease — we try to avoid estrogen because it can increase proteinuria and increase blood pressure. There is also an increased risk for blood clots with combined oral contraceptive pills." 

However, if you are interested in birth control options, you should talk to your doctor about what the best options are for you and your kidney disease.

If you have kidney disease and want to start a family, what should you know before you get started?

If you have kidney disease and would like to get pregnant, planning ahead is key. You should also know that it may be more challenging for you to get pregnant, and pregnancy may be a more physically demanding process for you than for someone without kidney disease.

"My number one piece of advice is that having a pregnancy with kidney disease is definitely a marathon, it's not a sprint," said Dr. Tangren. She advised, "Talk to your doctor early about your plans for parenthood and your hopes for parenthood, [so] they can talk with you about the safest time to consider pregnancy within your own kidney disease trajectory. Everybody's kidney disease is different and… so I do have patients who I have advised to wait until we get [their] kidney disease under better control before thinking about starting a family."

Dr. Tangren also notes that you may need to be the one to bring up the idea with your nephrologist. "Nephrologists are really bad about asking about family planning," she noted. But she also said that "your nephrologist should be allying with you about how to make pregnancy safest for you." 

"My other important piece of advice is if a nephrologist ever tells you that you cannot have children because of your kidney disease, please find a different nephrologist," said Dr. Tangren. "That is outdated advice that no person should be getting from their physician. There are so many good nephrologists out there who will be able to help you through this. If your nephrologist isn't comfortable, have them help you find someone who is comfortable, because the answer should never be 'never' about having kids."

To find out more about kidney disease and pregnancy, check out part two in this family planning and kidney disease series. 

To find out more about kidney disease and labor and delivery and postpartum, check out part three in this family planning and kidney disease series. 

Disclaimer:The information provided here is not intended to replace professional medical advice, diagnosis or treatment. Please consult your obstetrician (OBGYN), primary care doctor and/or nephrologist about your specific family planning needs and goals.