Fertility is one of the potential benefits for women undergoing kidney transplantation; however, population-based information about the likelihood of pregnancy and successful fetal outcome is not available. In this observational study of 16 195 female kidney transplant recipients aged 15–45 years in the United States between 1990 and 2003, we determined the pregnancy rate and live birth rate using Medicare claims data from the first three posttransplant years. The pregnancy rate was 33 per thousand female transplant recipients between 1990 and 2003 and progressively declined from 59 in 1990 to 20 in 2000. The live birth rate between 1990 and 2003 was 19 per thousand female transplant recipients and declined in parallel with the pregnancy rate. Despite a decrease in therapeutic abortions over time, the proportion of pregnancies resulting in fetal loss (45.6%) remained constant during the study due to an increase in spontaneous abortions and other causes of fetal loss. The pregnancy rate in kidney transplant recipients was markedly lower and declined more rapidly than reported in the general American population during the same period. The live birth rate was substantially lower than reported in voluntary registries of transplant recipients, and the proportion of pregnancies resulting in unexpected fetal loss increased over time.