Preconception SCD treatment decision tree for clinicians and patients highlights complex considerations and the need for transparent, shared decision-making. These choices are not equally available to all people: for people without expert SCD care and/or where resources are limited, access to blood transfusions may be sorely limited. In cases of severe SCD and in settings where red cell transfusion is unavailable or impossible, hydroxyurea during pregnancy might need to be considered even without strong evidence to address safety.