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Pittman J, Abbott J, Cavazzoni E, Pleass H, Brännstrom M, Rogers N, Deans R. Deceased donor availability for uterus transplantation in Australia. Aust N Z J Obstet Gynaecol 2023; 63:780-785. [PMID: 37395604 DOI: 10.1111/ajo.13722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Uterus transplantation is an emerging treatment option for uterine factor infertility. Most uterus transplantation research programs use living donors, although this comes with considerable surgical and psychological risks and not all women desiring uterus transplantation will have an available living donor. A deceased donor program eliminates donor risks; however, the availability of deceased uterus donors is currently unknown in Australia. AIMS To establish the feasibility of a deceased donor uterus transplantation program in Australia and consider expanded inclusion criteria for this model. MATERIALS AND METHODS A retrospective review of the New South Wales (NSW) Organ and Tissue Donation Service database was undertaken to identify potential deceased uterus donors, with comparison to the broad deceased donor inclusion criteria from three international uterus transplantation trials including female, brain-dead, multi-organ donation, no major abdominal surgery, and <60 years of age. RESULTS Between January 1, 2018, and December 31, 2022, 648 deceased donors were available in NSW. Of these, 43% (279/648) were female and 67% of the women (187/279) were also multi-organ donors. When the brain-dead donor-only and age criteria (<60 years) were applied, a total of 107 deceased donors met the available criteria for uterus transplantation, with an average of 21 deceased donors per year in NSW. CONCLUSIONS There appears to be adequate deceased donor organ availability to establish a deceased uterus transplantation program in NSW, Australia. Should interest in uterus transplantation increase, including criteria such as older and nulliparous donors could increase organ availability for a uterus transplantation program.
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Affiliation(s)
- Jana Pittman
- School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Jason Abbott
- School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Elena Cavazzoni
- The Children's Hospital Westmead, Sydney, New South Wales, Australia
| | - Henry Pleass
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Mats Brännstrom
- Departments of Obstetrics and Gynaecology, University of Gothenburg, Gothenburg, Sweden
| | | | - Rebecca Deans
- School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The Royal Hospital for Women, Sydney, New South Wales, Australia
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Brännström M, Racowsky C, Carbonnel M, Wu J, Gargiulo A, Adashi EY, Ayoubi JM. Uterus transplantation: from research, through human trials and into the future. Hum Reprod Update 2023; 29:521-544. [PMID: 37328434 PMCID: PMC10477946 DOI: 10.1093/humupd/dmad012] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/29/2023] [Indexed: 06/18/2023] Open
Abstract
Women suffering from absolute uterine factor infertility (AUFI) had no hope of childbearing until clinical feasibility of uterus transplantation (UTx) was documented in 2014 with the birth of a healthy baby. This landmark accomplishment followed extensive foundational work with a wide range of animal species including higher primates. In the present review, we provide a summary of the animal research and describe the results of cases and clinical trials on UTx. Surgical advances for graft removal from live donors and transplantation to recipients are improving, with a recent trend away from laparotomy to robotic approaches, although challenges persist regarding optimum immunosuppressive therapies and tests for graft rejection. Because UTx does not involve transplantation of the Fallopian tubes, IVF is required as part of the UTx process. We provide a unique focus on the intersection between these two processes, with consideration of when oocyte retrieval should be performed, whether, and for whom, preimplantation genetic testing for aneuploidy should be used, whether oocytes or embryos should be frozen and when the first embryo transfer should be performed post-UTx. We also address the utility of an international society UTx (ISUTx) registry for assessing overall UTx success rates, complications, and live births. The long-term health outcomes of all parties involved-the uterus donor (if live donor), the recipient, her partner and any children born from the transplanted graft-are also reviewed. Unlike traditional solid organ transplantation procedures, UTx is not lifesaving, but is life-giving, although as with traditional types of transplantation, costs, and ethical considerations are inevitable. We discuss the likelihood that costs will decrease as efficiency and efficacy improve, and that ethical complexities for and against acceptability of the procedure sharpen the distinctions between genetic, gestational, and social parenthood. As more programs wish to offer the procedure, we suggest a scheme for setting up a UTx program as well as future directions of this rapidly evolving field. In our 2010 review, we described the future of clinical UTx based on development of the procedure in animal models. This Grand Theme Review offers a closing loop to this previous review of more than a decade ago. The clinical feasibility of UTx has now been proved. Advancements include widening the criteria for acceptance of donors and recipients, improving surgery, shortening time to pregnancy, and improving post-UTx management. Together, these improvements catalyze the transition of UTx from experimental into mainstream clinical practice. The procedure will then represent a realistic and accessible alternative to gestational surrogacy for the treatment of AUFI and should become part of the armamentarium of reproductive specialists worldwide.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Stockholm IVF-EUGIN, Stockholm, Sweden
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
| | - Catherine Racowsky
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Marie Carbonnel
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- University Versailles, Saint-Quentin en Yvelines, France
| | - Joseph Wu
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Antonio Gargiulo
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Eli Y Adashi
- Department of Medical Science, Brown University, Providence, RI, USA
| | - Jean Marc Ayoubi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- University Versailles, Saint-Quentin en Yvelines, France
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D'Amico G, Del Prete L, Eghtesad B, Hashimoto K, Miller C, Tzakis A, Quintini C, Falcone T. Immunosuppression in uterus transplantation: from transplant to delivery. Expert Opin Pharmacother 2023; 24:29-35. [PMID: 35723045 DOI: 10.1080/14656566.2022.2090243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Uterus transplantation introduces unique challenges regarding immunosuppression, including the effects of immunosuppressive drugs on the fetus and graft rejection during pregnancy. Although immunosuppressive regimens are based on protocols used after solid organ transplantation, in recipients of uterus grafts, the physician must consider therapy modifications based on the phase of the transplant, from the intra-operative period through to delivery. AREAS COVERED This review discusses the current immunosuppressive rationale in uterus transplantation, focusing on the therapy in each phase of the transplant. The authors present an overview of the already approved immunosuppressive medications for solid organ transplantation, their application in uterus transplant prior to pregnancy, during pregnancy and as rejection treatment. EXPERT OPINION Most medications used for uterus transplant are adopted from solid organ transplantation experience, especially kidney transplantation, and rejection is treated in standard fashion. Research is needed to clarify the drugs' effects on fetal and neonatal well-being and to develop new medications to achieve better tolerance. Early markers of uterus graft rejection need to be identified, and prior rejection episodes should no longer be a cause to remove the graft during delivery in a recipient who wants a further pregnancy.
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Affiliation(s)
- Giuseppe D'Amico
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Luca Del Prete
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA.,General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Bijan Eghtesad
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Koji Hashimoto
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Charles Miller
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andreas Tzakis
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cristiano Quintini
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tommaso Falcone
- Cleveland Clinic, Obstetrics and Gynecology and Women's Health Institute, Cleveland, Ohio, USA
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Johannesson L, Richards E, Reddy V, Walter J, Olthoff K, Quintini C, Tzakis A, Latif N, Porrett P, O’Neill K, Testa G. The First 5 Years of Uterus Transplant in the US. JAMA Surg 2022; 157:790-797. [PMID: 35793102 PMCID: PMC9260640 DOI: 10.1001/jamasurg.2022.2612] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance Uterus transplant is a viable surgical treatment for women affected by absolute uterine-factor infertility, which affects 1 in 500 women. Objective To review transplant and birth outcomes of uterus transplant recipients in the US since the first case in 2016. Design, Setting, and Participants In this cohort study, 5 years of uterus transplant outcome data were collected from the 3 centers performing uterus transplants in the US: Baylor University Medical Center, Dallas, Texas; Cleveland Clinic, Cleveland, Ohio; and University of Pennsylvania, Philadelphia. A total of 33 women with absolute uterine-factor infertility who underwent uterus transplant between February 2016 and September 2021 were included. Main Outcomes and Measures Graft survival, live birth, and neonatal outcome. Results Of the 33 included uterus transplant recipients, 2 (6%) were Asian, 1 (3%) was Black, 1 (3%) was South Asian, and 29 (88%) were White; the mean (SD) age was 31 (4.7) years; and the mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 24 (3.6). Most uterus transplant recipients (31 of 33 [94%]) had a congenitally absent uterus (Mayer-Rokitansky-Küster-Hauser syndrome), and 21 of 33 (64%) received organs from living donors. Mean (range) follow-up was 36 (1-67) months. There was no donor or recipient mortality. One-year graft survival was 74% (23 of 31 recipients). Through October 2021, 19 of 33 recipients (58%) had delivered 21 live-born children. Among recipients with a viable graft at 1 year, the proportion with a live-born child was 83% (19 of 23). The median (range) gestational age at birth of neonates was 36 weeks 6 days (30 weeks, 1 day to 38 weeks), and the median (range) birth weight was 2860 (1310-3940) g (median [range], 58th [6th-98th] percentile). No congenital malformations were detected. Conclusions and Relevance Uterus transplant is a surgical therapy that enables women with uterine-factor infertility to successfully gestate and deliver children. Aggregate data from US centers demonstrate safety for the recipient, living donor, and child. These data may be used to counsel women with uterine-factor infertility on treatment options.
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Affiliation(s)
- Liza Johannesson
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas
| | - Elliott Richards
- Obstetrics and Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vikrant Reddy
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Jessica Walter
- Division of Reproductive Endocrinology and Infertility, Feinberg School of Medicine, Northwestern Medicine, Chicago, Illinois
| | - Kim Olthoff
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Cristiano Quintini
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andreas Tzakis
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nawar Latif
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia
| | - Paige Porrett
- Division of Transplantation, Department of Surgery, The University of Alabama at Birmingham
| | - Kathleen O’Neill
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia
| | - Giuliano Testa
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
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Castro F, Ejzenberg D, Pinheiro RS, Ducatti L, Arantes RM, Nacif L, Waisberg D, Martino RB, Santos VR, Soares JM, Baracat EC, D'Albuquerque LAC, Andraus W, Canaval H, Canaval G, Rico JM, Vanin A. Uterus procurement from deceased donor for transplantation. Transpl Int 2021; 34:2570-2577. [PMID: 34668605 DOI: 10.1111/tri.14143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 10/06/2021] [Accepted: 10/17/2021] [Indexed: 11/28/2022]
Abstract
Women with absolute uterine factor infertility cannot get pregnant. The current experience in uterine transplantation is limited and the use of a deceased donor uterus in this area is incipient after some initial unsuccessful attempts. The birth of healthy babies through this modality in four different centers has given a new impetus to the use of this transplantation technique. We aimed to develop a technique for uterus procurement and preparation for transplantation from a brain dead donor. Fifteen uteri were retrieved from multi-organ donor patients, 10 of these were used in bench surgeries with the proposed technique. All procedures were performed after obtaining family's consent. This study allowed the clinical use of two of the 15 organs that were procured for transplantation. One of these organs resulted in the first live birth worldwide using a uterus transplanted from a deceased donor, a landmark in reproductive medicine. Another outcome was the optimization of the surgical technique involving less manipulation of the uterine vascular pedicles. The success of this novel technique suggests that the proposed model can be replicated and optimized further to facilitate the transplantation of uterus from deceased donors.
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Affiliation(s)
- Felipe Castro
- Department of Liver and Digestive Tract Organ Transplantation, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.,Department of Gynecology and Obstetrics, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.,Department of Gynecology and Obstetrics, Clinica Imbanaco, Cali, Colombia.,Department of Liver Transplantation, Clinica Imbanaco, Cali, Colombia
| | - Dani Ejzenberg
- Department of Gynecology and Obstetrics, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Rafael S Pinheiro
- Department of Liver and Digestive Tract Organ Transplantation, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Liliana Ducatti
- Department of Liver and Digestive Tract Organ Transplantation, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Rubens M Arantes
- Department of Liver and Digestive Tract Organ Transplantation, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Lucas Nacif
- Department of Liver and Digestive Tract Organ Transplantation, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Daniel Waisberg
- Department of Liver and Digestive Tract Organ Transplantation, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Rodrigo B Martino
- Department of Liver and Digestive Tract Organ Transplantation, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Vinicius R Santos
- Department of Liver and Digestive Tract Organ Transplantation, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Jose Maria Soares
- Department of Gynecology and Obstetrics, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Edmund Chada Baracat
- Department of Gynecology and Obstetrics, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Department of Liver and Digestive Tract Organ Transplantation, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Wellington Andraus
- Department of Liver and Digestive Tract Organ Transplantation, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Hoover Canaval
- Department of Gynecology and Obstetrics, Clinica Imbanaco, Cali, Colombia
| | - Gustavo Canaval
- Department of Gynecology and Obstetrics, Clinica Imbanaco, Cali, Colombia
| | - Juan Manuel Rico
- Department of Liver Transplantation, Clinica Imbanaco, Cali, Colombia
| | - Anabel Vanin
- Department of Liver Transplantation, Clinica Imbanaco, Cali, Colombia
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