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Veroux M, Scollo P, Giambra MM, Roscitano G, Giaquinta A, Setacci F, Veroux P. Living-Donor Uterus Transplantation: A Clinical Review. J Clin Med 2024; 13:775. [PMID: 38337468 PMCID: PMC10856556 DOI: 10.3390/jcm13030775] [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: 01/03/2024] [Revised: 01/22/2024] [Accepted: 01/27/2024] [Indexed: 02/12/2024] Open
Abstract
Uterus transplantation (UTx) is currently the only available treatment for absolute uterine factor infertility. More than 90 uterus transplantations have been performed worldwide, mostly from living donors. Living-donor (LD) UTx is a challenging surgical procedure since it poses ethical issues, and it is a high-risk and invasive surgery with higher hysterectomy-related risks compared to conventional hysterectomy. A total of 59 living-donor hysterectomies have been reported in the literature, including 35 performed with a laparotomic approach, 20 with a robotic approach and 4 with a laparoscopic approach. The mean donor age was 45.6 ± 9.1 years, and 22 were unrelated with the recipients, 34 were emotionally related (27 mothers, 5 sisters, 2 mother's sisters). The mean recipient age was 28.8 ± 4.5 years. Mayer-Rokitansky-Küster-Hauser syndrome was the most common indication for uterus transplant. Robotic living-donor hysterectomy had the longest operative time but resulted in a lower blood loss and postoperative stay compared to laparotomic and laparoscopic approaches. Twenty-nine births from LD-UTx have been reported, four after robotic living-donor hysterectomy and twenty-five after a laparotomic procedure. UTx is now an effective treatment for women with UFI. While living-donor UTx in some cases may be considered an experimental procedure, it offers the extraordinary possibility to give women the opportunity to have a pregnancy. Many efforts should be made to reduce the potential risks for donors, including the use of mini-invasive techniques, and the efficacy of UTx in the recipients, giving the potential harm of immunosuppression in a recipient of a non-life-saving organ.
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Affiliation(s)
- Massimiliano Veroux
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Paolo Scollo
- Maternal and Child Department, Obstetrics and Gynecology, Cannizzaro Hospital, 95123 Catania, Italy;
| | - Martina Maria Giambra
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Giuseppe Roscitano
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Alessia Giaquinta
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Francesco Setacci
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Pierfrancesco Veroux
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
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Jones BP, Vali S, Kasaven LS, Mantrali I, Saso S, Bracewell-Milnes T, Nicopoullos J, Thum MY, Diaz-Garcia C, Quiroga I, Yazbek J, Smith JR. INvestigational Study Into Transplantation of the Uterus (INSITU): a cross-sectional survey among women with uterine factor infertility in the UK assessing background, motivations and suitability. BMJ Open 2023; 13:e073517. [PMID: 38070921 PMCID: PMC10728960 DOI: 10.1136/bmjopen-2023-073517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
IMPORTANCE The study summarises the selection prescreen criteria currently used in the UK for a uterus transplant and highlights the number of women who are suitable to proceed. OBJECTIVES To assess the demographics, motivations, reasons and suitability among women with absolute uterine factor infertility (AUFI) to undergo uterine transplantation (UTx). DESIGN A cross-sectional survey. SETTING An electronic questionnaire was sent via email to women with AUFI who had previously been referred to the UTx research team or approached the Womb Transplant UK Charity. The questions assessed suitability to undergo UTx based on demographic information, perceptions to adoption and surrogacy and reasons why UTx was preferable. Responses were assessed against the study selection criteria. PARTICIPANTS Women with AUFI. RESULTS 210 women completed the questionnaire. The most common aetiology of AUFI in our cohort was Mayer-Rokitansky-Küster-Hauser (68%; n=143) whereas 29% (n=62) had previously undergone hysterectomy. 63% (n=132) of the cohort had previously considered adoption, 5% (n=11) had attempted it and 2 (1%) had successfully adopted. The most common reason cited to undergo UTx over adoption was to experience gestation (n=63; 53%), while 37% (n=44) wanted a biologically related child. 76% (n=160) of participants had previously considered surrogacy, 22 (10%) had attempted it and 2 (1%) had successfully become mothers using a surrogate. The most common reason to undergo UTx over surrogacy was to experience gestation (n=77; 54%). 15% (n=21) were concerned about the legal implications, 14% (n=20) identified the financial cost as a barrier and 8% (n=12) could not consider it due to religious reasons. On adhering to the selection criteria, 65 (31%) women were suitable to proceed with the trial. CONCLUSION The study demonstrates that implementing commonly used selection criteria for a UTx led to an attrition rate of more than two-thirds of women who requested to initially undergo the process. As more studies present outcomes following UTx, critical assessment of the selection criteria currently used is warranted to ensure potential recipients are not being unnecessarily excluded. TRIAL REGISTRATION NUMBER NCT02388802.
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Affiliation(s)
- Benjamin P Jones
- Lister Fertility Clinic, The Lister Hospital, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Saaliha Vali
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Lorraine S Kasaven
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Ifigenia Mantrali
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Srdjan Saso
- Imperial College Healthcare NHS Trust, London, UK
| | - Timothy Bracewell-Milnes
- Lister Fertility Clinic, The Lister Hospital, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - James Nicopoullos
- Lister Fertility Clinic, The Lister Hospital, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Meen-Yau Thum
- Lister Fertility Clinic, The Lister Hospital, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | | | | | - Joseph Yazbek
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - James Richard Smith
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
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Dewani D, Karwade P, Mahajan KS. Uterine Transplantation and Fertility Preservation: A Hopeful Horizon for Cancer Survivors. Cureus 2023; 15:e50178. [PMID: 38192936 PMCID: PMC10771962 DOI: 10.7759/cureus.50178] [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: 11/25/2023] [Accepted: 12/08/2023] [Indexed: 01/10/2024] Open
Abstract
Uterine transplantation, a groundbreaking medical intervention, stands as a beacon of hope for cancer survivors grappling with the dual challenges of a cancer diagnosis and potential fertility loss due to aggressive treatments. This review provides a comprehensive exploration of uterine transplantation as an innovative solution for fertility preservation in the context of cancer survivorship. The multifaceted discussion encompasses the impact of cancer on fertility, the imperative of fertility preservation, and the evolution of uterine transplantation as a transformative procedure. The post-transplantation care section delves into the intricacies of recovery, the delicate balance of immunosuppressive therapy, and the ongoing support required for recipients to embrace the full spectrum of reproductive possibilities and overall well-being. Ethical considerations surrounding uterine transplantation, including donor selection, risk assessment, and societal perspectives, are critically examined to navigate the ethical landscape of this evolving field. In conclusion, uterine transplantation is presented as a medical breakthrough and a symbol of interdisciplinary collaboration, resilience, and unwavering hope. The review underscores the role of collaborative efforts among medical professionals, researchers, ethicists, and psychologists in advancing this transformative field. Looking to the future, uterine transplantation signifies a paradigm shift in fertility preservation, offering a tangible path toward parenthood for cancer survivors. The procedure, grounded in science, ethics, and compassion, illuminates the way forward, inspiring a future where fertility preservation becomes an attainable reality for those whose reproductive dreams were once compromised by cancer treatments.
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Affiliation(s)
- Deepika Dewani
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pravin Karwade
- Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Kalyani S Mahajan
- Obstetrics and Gynecology, Symbiosis Medical College for Women, Symbiosis International University, Pune, IND
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Hunter SA, Feldman MK. Imaging of Uterine Transplantation. Radiol Clin North Am 2023; 61:889-899. [PMID: 37495295 DOI: 10.1016/j.rcl.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Uterus transplantation (UTx) is a novel procedure being studied as a treatment of absolute uterine factor infertility. Imaging plays an important role throughout the life cycle of a uterus transplant. In this review, we will first describe the surgical technique of UTx. The article will then focus on the importance of imaging in the evaluation of potential recipients and donors and during the immediate post-surgical time course as graft viability is established. Imaging as part of including in vitro fertilization, pregnancy, and complications will also be discussed.
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Affiliation(s)
- Sara A Hunter
- Section of Abdominal Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, L-10, Cleveland, OH 44195, USA
| | - Myra K Feldman
- Section of Abdominal Imaging, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, A-21, Cleveland, OH 44195, USA.
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Johannesson L, Testa G, Beshara MM, da Graca B, Walter JR, Quintini C, Latif N, Hashimoto K, Richards EG, O’Neill K. Awareness and Interest in Uterus Transplantation over Time: Analysis of Those Seeking Surgical Correction for Uterine-Factor Infertility in the US. J Clin Med 2023; 12:4201. [PMID: 37445236 PMCID: PMC10342774 DOI: 10.3390/jcm12134201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/07/2023] [Accepted: 06/15/2023] [Indexed: 07/15/2023] Open
Abstract
This study describes the characteristics of women who contacted an active program performing uterus transplantation (UTx) in the US, expressing interest in becoming a uterus transplant recipient or a living donor. Basic demographic and self-reported clinical information was collected from women who contacted any of the three US UTx programs from 2015 to July 2022. The three centers received 5194 inquiries about becoming a UTx recipient during the study timeframe. Among those reporting a cause of infertility, almost all of the reports (4066/4331, 94%) were absence of a uterus, either congenitally (794/4066, 20%) or secondary to hysterectomy (3272/4066, 80%). The mean age was 34 years, and 49% (2545/5194) had at least one child at the time of application. The two centers using living donors received 2217 inquiries about becoming living donors. The mean age was 34 years, and 60% (1330/2217) had given birth to ≥1 child. While most of the UTx clinical trial evidence has focused on young women with congenital absence of the uterus, these results show interest from a much broader patient population in terms of age, cause of infertility, and parity. These results raise questions about whether and to what extent the indications and eligibility criteria for UTx should be expanded as the procedure transitions from the experimental phase to being offered as a clinical treatment.
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Affiliation(s)
- Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75246, USA
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Menas M. Beshara
- TX A&M College of Medicine, Texas A&M University, Dallas, TX 75231, USA
| | - Briget da Graca
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Jessica R. Walter
- Department of Obstetrics & Gynecology, Northwestern University, Chicago, IL 60611, USA
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Nawar Latif
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19107, USA
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH 44103, USA
| | - Elliott G. Richards
- Obstetrics and Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, OH 44103, USA
| | - Kathleen O’Neill
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19107, USA
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da Graca B, Johannesson L, Testa G, Wall AE. The Ethical Evolution of Uterus Transplantation From Concept to Clinical Procedure. Clin Obstet Gynecol 2022; 65:24-36. [PMID: 35045022 DOI: 10.1097/grf.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Uterus transplantation (UTx) offers women with absolute uterine factor infertility a path to motherhood that enables them to carry their own pregnancy. Debates about the ethics of UTx have evolved in tandem with its clinical evolution: clinical trials have provided evidence regarding risks and benefits to donors and recipients that were initially uncertain; technical advances have altered the balance between risks and benefits; and the experiences of donors and recipients has revealed questions that were not anticipated. As UTx transitions to a clinical procedure, questions remain about long-term risks and benefits, applications beyond carrying a pregnancy, and cost and access.
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Affiliation(s)
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
| | - Anji E Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
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8
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Gullo G, Etrusco A, Fabio M, Cucinella G, Rossi C, Billone V. The reproductive potential of uterus transplantation: future prospects. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022138. [PMID: 35546000 PMCID: PMC9171877 DOI: 10.23750/abm.v93i2.12868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 02/09/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND AIM Absolute uterine factor infertility (AUFI) is a form of infertility whereby conception and/or maintenance of pregnancy is impossible as a result of uterine absence or its completed dysfunction. It affects 1/500 women of reproductive age while the incidence is about 8% of infertile couples. Uterus transplantation (UTx) has been gaining ground as a viable option to enable women with AUFI to have biological children and as an alternative to surrogacy, a highly controversial practice still banned in many countries. METHODS The authors have set out to strike a reasonable balance between UTx benefits and the still numerous risks, whether clinical or ethical, associated with such an innovative form of transplant, which is not life-saving, requires immunosuppression throughout pregnancy and the organ to be removed right after childbirth. RESULTS While still far from achieving mainstream status, considerable strides have been made in UTx outcomes, with many live births already recorded. Procedures from living donor are reportedly more effective in terms of success rates. Organ tissue engineering has been explored and developed with promising results. CONCLUSIONS UTx entails various risks and ethical quandaries which have to do with reproductive autonomy and rights. New human attempts and clinical trials of UTx should be performed to further optimize the procedure in relation to safety and effectiveness. Techniques such as tissue engineering could lead in the medium-long term to a wholly bioengineered uterus to be used for transplantation, relying on scaffolds from decellularized organs or tissues that can be recellularized by several types of autologous somatic/stem cells. Such advances hold promise in terms of solving UTx-related complications and organ supply difficulties.
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Affiliation(s)
- Giuseppe Gullo
- a:1:{s:5:"en_US";s:115:"Department of Obstetrics and Gynecology, Villa Sofia Cervello Hospital, University of Palermo, 90146 Palermo, Italy";}.
| | - Andrea Etrusco
- Department of Obstetrics and Gynecology, Villa Sofia Cervello Hospital, University of Palermo, 90146 Palermo, Italy.
| | - Manuela Fabio
- Department of Obstetrics and Gynecology, Villa Sofia Cervello Hospital, University of Palermo, 90146 Palermo, Italy.
| | - Gaspare Cucinella
- Department of Obstetrics and Gynecology, Villa Sofia Cervello Hospital, University of Palermo, 90146 Palermo, Italy.
| | - Claudio Rossi
- Department of Obstetrics and Gynecology, Villa Sofia Cervello Hospital, University of Palermo, 90146 Palermo, Italy.
| | - Valentina Billone
- Department of Obstetrics and Gynecology, Villa Sofia Cervello Hospital, University of Palermo, 90146 Palermo, Italy.
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da Graca B, Johannesson L, Testa G, Wall A. Uterus transplantation: ethical considerations. Curr Opin Organ Transplant 2021; 26:664-668. [PMID: 34636768 DOI: 10.1097/mot.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Uterus transplantation (Utx) offers women with absolute uterine factor infertility the opportunity to carry their own pregnancies. As Utx transitions from an experimental to standard clinical procedure, we review the status of the ethical issues applicable to the stakeholders involved. RECENT FINDINGS With more than 65 Utx procedures reported to date, evidence is accruing that enables the chance of success - a live birth - for the recipient to be weighed against the risks the recipient incurs through the Utx process, as well as risks to living donors undergoing surgery, to children exposed in utero to immunosuppressants and the uterine graft environment, and to third parties related to uterus procurement from multiorgan deceased donors. Experience has also informed aspects of recipient and donor autonomy that must be safeguarded. SUMMARY Clinical trial results provides a basis for weighing the interests of the stakeholders implicated in Utx, and so can inform transplant centers' and regulatory bodies' development of policies and protocols that will determine access to Utx and allocation of organs, together with other considerations of justice. Additional evidence, particularly on long-term outcomes, is needed, and new questions can be expected to arise as access to and indications for Utx broaden.
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Affiliation(s)
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute
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Guntram L. May I have your uterus? The contribution of considering complexities preceding live uterus transplantation. MEDICAL HUMANITIES 2021; 47:425-437. [PMID: 33627444 PMCID: PMC8639951 DOI: 10.1136/medhum-2020-011864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/31/2020] [Indexed: 06/12/2023]
Abstract
Uterus transplantation combined with in vitro fertilisation (IVF) (henceforth called UTx-IVF) as a treatment for infertility caused by an absence or malfunction of the uterus is advancing. About 50 transplantations have been conducted worldwide and at least 14 children have been born-9 of them by women taking part in a Swedish research project on UTx-IVF. The Swedish research protocol initially stated that the potential recipient must 'have her own donor' who is preferably related to the recipient. But what does it mean to ask someone for a uterus? What challenges does this question instigate? And what norms may it enact? In this article, I explore how 10 women-who have considered, and sometimes pursued, UTx-IVF-describe their experiences of searching for a donor. I aim to show how an analysis of such accounts can help us unpack some of the specific relational and gendered dimensions of UTx-IVF and by doing so enrich discussions of risks, benefits, care and support in UTx-IVF. Drawing on research in social sciences and medical humanities that has demonstrated how assisted reproductive technologies and organ donation can provoke social and familial conundrums, with respect to such topics as embodiment and identity, I present three patterns that describe different dimensions of the interviewees' quest for a uterus donor. I discuss the negotiations that took place, how expectations unfolded and how entanglements were managed as the interviewees considered asking someone for a donation. Such an examination, I suggest, contributes to make care and support more attuned to the experiences and entanglements that UTx-IVF entails for those pursuing it. This will become increasingly important if (or when) UTx-IVF becomes part of general healthcare. To conclude, I problematise responsibilities and relational challenges in medical innovation, and in this way provide insights into how the ethical debate over UTx-IVF can broaden its scope.
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Affiliation(s)
- Lisa Guntram
- TEMA-Department of Thematic Studies, Linkopings universitet Institutionen for Tema, Linkoping, Sweden
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11
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Hamidian Jahromi A, Horen SR, Wall A, Johannesson L. Proposing a Novel Organ Allocating System for Uterus Transplantation: Implications and Issues. EXP CLIN TRANSPLANT 2021; 19:1241-1243. [PMID: 34546159 DOI: 10.6002/ect.2021.0260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Alireza Hamidian Jahromi
- From the Plastic and Reconstructive Surgery Department, Rush University Medical Center, Chicago, Illinois, USA
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12
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Vali S, Jones BP, Saso S, Fertleman M, Testa G, Johanesson L, Alghrani A, Smith JR. Uterine transplantation: legal and regulatory implications in England. BJOG 2021; 129:590-596. [PMID: 34532958 DOI: 10.1111/1471-0528.16927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 12/01/2022]
Abstract
Uterus transplantation (UTx) is fast evolving from an experimental to a clinical procedure, combining solid organ transplantation with assisted reproductive technology. The commencement of the first human uterus transplant trial in the United Kingdom leads us to examine and reflect upon the legal and regulatory aspects closely intertwined with UTx from the process of donation to potential implications for fertility treatment and the birth of the resultant child. As the world's first ephemeral transplant, the possibility of organ restitution requires consideration and is discussed herein. TWEETABLE ABSTRACT: Uterine transplantation warrants a closer look at the legal frameworks on fertility treatment and transplantation in England.
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Affiliation(s)
- S Vali
- Department of Surgery and Cancer, Hammersmith Hospital, Imperial College London, London, UK.,Cutrale Perioperative and Ageing Research Group, Imperial College London, London, UK
| | - B P Jones
- Department of Surgery and Cancer, Hammersmith Hospital, Imperial College London, London, UK.,West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - S Saso
- Department of Surgery and Cancer, Hammersmith Hospital, Imperial College London, London, UK.,West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - M Fertleman
- Cutrale Perioperative and Ageing Research Group, Imperial College London, London, UK
| | - G Testa
- Baylor University Medical Centre, Dallas, TX, USA
| | - L Johanesson
- Baylor University Medical Centre, Dallas, TX, USA
| | - A Alghrani
- School of Law and Social Justice, University of Liverpool, Liverpool, UK
| | - J R Smith
- Department of Surgery and Cancer, Hammersmith Hospital, Imperial College London, London, UK.,West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
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Richards EG, Farrell RM, Ricci S, Perni U, Quintini C, Tzakis A, Falcone T. Uterus transplantation: state of the art in 2021. J Assist Reprod Genet 2021; 38:2251-2259. [PMID: 34057644 PMCID: PMC8490545 DOI: 10.1007/s10815-021-02245-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To provide a comprehensive review of uterus transplantation in 2021, including a discussion of pregnancy outcomes of all reported births to date, the donor and recipient selection process, the organ procurement and transplant surgeries, reported complications, postoperative monitoring, preimplantation preparation, and ethical considerations. METHODS Literature review and expert commentary. RESULTS Reports of thirty-one live births following uterus transplantation have been published from both living and deceased donors. The proper selection of donors and recipients is a labor-intensive process that requires advanced planning. A multidisciplinary team is critical. Reported complications in the recipient include thrombosis, infection, vaginal stricture, antenatal complications, and graft failure. Graft rejection is a common occurrence but rarely leads to graft removal. While most embryo transfers are successful, recurrent implantation failures in uterus transplant patients have been reported. Rates of preterm delivery are high but appear to be declining; more data, including long-term outcome data, is needed. CONCLUSIONS Uterus transplantation is an emerging therapy for absolute uterine factor infertility, a condition previously without direct treatment options. It is paramount that reproductive health care providers are familiar with the uterus transplantation process as more patients seek and receive this treatment.
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Affiliation(s)
- Elliott G Richards
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ruth M Farrell
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stephanie Ricci
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Uma Perni
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Cristiano Quintini
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andreas Tzakis
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tommaso Falcone
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Abstract
Uterine transplantation (UTx) is a fertility restoring treatment for women with absolute uterine factor infertility. At a time when there is no question of the procedure's feasibility, and as the number of livebirths begins to increase exponentially, various important reproductive, fetal, and maternal medicine implications have emerged. Detailed outcomes from 17 livebirths following UTx are now available, which are reviewed herein, along with contextualized extrapolation from pregnancy outcomes in other solid organ transplants. Differences in recipient demographics and reproductive aspirations between UTx and other transplant recipients make extrapolating management strategies and outcomes in other solid organ transplants inappropriate. Whereas preterm delivery remains prominent, small for gestational age or hypertensive disorders do not appear to be as prevalent following UTx when compared to other solid organ transplants. Given the primary objective of undertaking UTx is to achieve a livebirth, publication of reproductive outcomes is essential at this early stage, to reflect on and optimize the management of future cases.
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15
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Aljerian K. Uterine transplant: an ethical framework analysis from a Middle Eastern perspective. Curr Med Res Opin 2021; 37:1049-1060. [PMID: 33705236 DOI: 10.1080/03007995.2021.1902296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Significant advances in infertility treatment have been achieved over the past several decades, but women with uterine dysfunction, anomaly, or agenesis still need support to carry a pregnancy to term. Recently, advancements in surgical, anesthetic and immunosuppressive therapy have brought the idea of successful uterine transplant closer to reality, but many challenges must be overcome before uterine transplant can become more common, including ethical challenges related to the study and the conduct of this procedure. METHODS This was an updated ethical analysis of uterine transplant from a Middle Eastern perspective, using an established ethical framework that has been adapted for the analysis of research in non-Western cultures and developing countries. RESULTS Using the ethical framework, this analysis explored research developments in uterine transplant to date, using the following categories: collaborative partnership, social value, scientific validity, a fair selection of study population, favorable risk-benefit ratio, independent review, informed consent, and respect for recruited participants. The analysis revealed a significant need for region- and religion-specific ethical guidelines for uterine transplant procedures. CONCLUSIONS The horizons of research need to expand by addressing and researching the ethical issues related to uterine transplant trials and clinical procedures. LIMITATIONS Limitations included the challenges related to applying ethical analyses to work in developing countries, and the fact that this analysis was based on the views and interpretations of a single researcher.
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Affiliation(s)
- Khaldoon Aljerian
- Forensic and Legal Medicine Unit, Department of Pathology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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16
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Abstract
PURPOSE To provide a comprehensive review of uterus transplantation in 2021, including a discussion of pregnancy outcomes of all reported births to date, the donor and recipient selection process, the organ procurement and transplant surgeries, reported complications, postoperative monitoring, preimplantation preparation, and ethical considerations. METHODS Literature review and expert commentary. RESULTS Reports of thirty-one live births following uterus transplantation have been published from both living and deceased donors. The proper selection of donors and recipients is a labor-intensive process that requires advanced planning. A multidisciplinary team is critical. Reported complications in the recipient include thrombosis, infection, vaginal stricture, antenatal complications, and graft failure. Graft rejection is a common occurrence but rarely leads to graft removal. While most embryo transfers are successful, recurrent implantation failures in uterus transplant patients have been reported. Rates of preterm delivery are high but appear to be declining; more data, including long-term outcome data, is needed. CONCLUSIONS Uterus transplantation is an emerging therapy for absolute uterine factor infertility, a condition previously without direct treatment options. It is paramount that reproductive health care providers are familiar with the uterus transplantation process as more patients seek and receive this treatment.
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17
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Jones BP, Saso S, Yazbek J, Thum MY, Quiroga I, Ghaem-Maghami S, Smith JR. Uterine Transplantation: Scientific Impact Paper No. 65 April 2021. BJOG 2021; 128:e51-e66. [PMID: 33913235 DOI: 10.1111/1471-0528.16697] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
A uterine transplant, or womb transplant, provides a potential treatment for women who cannot become pregnant or carry a pregnancy because they do not have a womb, or have a womb that is unable to maintain a pregnancy. This is estimated to affect one in 500 women. Options for those who wish to start a family include adoption and surrogacy, but these are associated with legal, cultural, ethical and religious implications that may not be appropriate for some women and their families. A womb transplant is undertaken when the woman is ready to start a family, and is removed following the completion of their family. Womb transplants have been performed all over the world, with more than 70 procedures carried out so far. At least 23 babies have been born as a result, demonstrating that womb transplants can work. While the procedure offers a different option to adoption and surrogacy, it is associated with significant risks, including multiple major surgeries and the need to take medications that help to dampen the immune system to prevent rejection of the womb. To date there has been a 30% risk of a transplant being unsuccessful. Although the number of transplants to date is still relatively small, the number being performed globally is growing, providing an opportunity to learn from the experience gained so far. This paper looks at the issues that have been encountered, which may arise at each step of the process, and proposes a framework for the future. However, long term follow-up of cases will be essential to draw reliable conclusions about any overall benefits of this procedure.
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Affiliation(s)
- B P Jones
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - S Saso
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - J Yazbek
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - M-Y Thum
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - I Quiroga
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - S Ghaem-Maghami
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - J R Smith
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
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18
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Abstract
Uterus transplantation (UTx) offers women with absolute uterine factor infertility the option to gestate and birth their own biologically related child. The first birth following living donation UTx happened in 2014. The first birth following deceased donation happened in December 2017, with further successes since. Interest in deceased donation UTx is increasing. The authors established a database to track UTx clinical trials and outcomes. Utilising this database and existing literature, this article reviews the first reported cases of deceased donation UTx and outcomes, and drawing upon comparisons with living donor UTx, comments upon the future for this area of reproductive transplantation research. This is the first article to bring together the literature on deceased donation UTx procedures and outcomes.
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Jones BP, Ranaei-Zamani N, Vali S, Williams N, Saso S, Thum MY, Al-Memar M, Dixon N, Rose G, Testa G, Johannesson L, Yazbek J, Wilkinson S, Richard Smith J. Options for acquiring motherhood in absolute uterine factor infertility; adoption, surrogacy and uterine transplantation. THE OBSTETRICIAN & GYNAECOLOGIST : THE JOURNAL FOR CONTINUING PROFESSIONAL DEVELOPMENT FROM THE ROYAL COLLEGE OF OBSTETRICIANS & GYNAECOLOGISTS 2021; 23:138-147. [PMID: 34248417 PMCID: PMC8252631 DOI: 10.1111/tog.12729] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 11/29/2022]
Abstract
KEY CONTENT Following the diagnosis of absolute uterine factor infertility (AUFI), women may experience considerable psychological harm as a result of a loss of reproductive function and the realisation of permanent and irreversible infertility.Adoption enables women with AUFI, and their partners, to experience social and legal parenthood, also often providing benefits for the adopted child.Surrogacy offers the opportunity to have genetically related offspring. Outcomes are generally positive in both surrogates and the children born as a result.Uterine transplantation is the only option to restore reproductive anatomy and functionality. While associated with considerable risk, it allows the experience of gestation and the achievement of biological, social and legal parenthood. LEARNING OBJECTIVES To gain an understanding of the routes to parenthood available for women with AUFI experiencing involuntary childlessness, such as adoption, surrogacy and, most recently, uterine transplantationTo consider a suggested management plan to facilitate counselling in women with AUFI who experience involuntary childlessness. ETHICAL ISSUES In the UK, while the number of children requiring adoption continues to increase, the number being adopted from care is decreasing.Some cultures may hold ethical or religious beliefs that surrogacy is unacceptable, and its legal position in many jurisdictions is problematic.Restrictive selection criteria and high costs may limit future availability of uterine transplantation.
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Affiliation(s)
- Benjamin P Jones
- Clinical Research Fellow Department of Surgery and Cancer Imperial College London Du Cane Road London W12 0NN UK
| | - Niccole Ranaei-Zamani
- Clinical Research Fellow Department of Surgery and Cancer Imperial College London Du Cane Road London W12 0NN UK
| | - Saaliha Vali
- Specialty Trainee in Obstetrics and Gynaecology Queen Charlotte's & Chelsea Hospital Imperial College NHS Trust London W12 OHS UK
| | - Nicola Williams
- Research Associate in Ethics Department of Politics, Philosophy and Religion Lancaster University Lancaster LA14YQ UK
| | - Srdjan Saso
- Gynaecology Oncolology Subspecialty Trainee Hammersmith Hospital Imperial College NHS Trust London W12 OHS UK
| | - Meen-Yau Thum
- Fertility Specialist The Lister Fertility Clinic London SW1W 8RH UK
| | - Maya Al-Memar
- Specialty Trainee in Obstetrics and Gynaecology Queen Charlotte's & Chelsea Hospital Imperial College NHS Trust London W12 OHS UK
| | - Nuala Dixon
- Clinical Nurse Specialist Queen Charlotte's & Chelsea Hospital Imperial College NHS Trust London W12 OHS UK
| | - Gillian Rose
- Consultant Gynaecologist Queen Charlotte's & Chelsea Hospital Imperial College NHS Trust London W12 OHS UK
| | - Giuliano Testa
- Transplant Surgeon Baylor University Medical Center Dallas Texas 75246-2088 USA
| | - Liza Johannesson
- Gynaecology Oncology Surgeon and Medical Director of Uterus Transplant Baylor University Medical Center Dallas Texas 75246-2088 USA
| | - Joseph Yazbek
- Consultant Gynaecologist Hammersmith Hospital Imperial College NHS Trust London W12 OHS UK
| | - Stephen Wilkinson
- Professor of Bioethics Department of Politics, Philosophy and Religion Lancaster University Lancaster LA14YQ UK
| | - J Richard Smith
- Consultant Gynaecologist Hammersmith Hospital Imperial College NHS Trust London W12 OHS UK
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20
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Uterine Transplantation Using Living Donation: A Cross-sectional Study Assessing Perceptions, Acceptability, and Suitability. Transplant Direct 2021; 7:e673. [PMID: 34104711 PMCID: PMC8183710 DOI: 10.1097/txd.0000000000001124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. A uterine transplantation is a nonvital, quality-of-life–enhancing solid organ transplant. Given improvements in donor risk profile and the anticipated shortage of suitable deceased donors, nondirected donation could facilitate sustainability as uterine transplantation moves from research into the clinical realm. The aim of this article is to determine perceptions and identify motivations of potential nondirected living uterus donors and assess acceptability and suitability.
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21
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The Evolution of Transplantation From Saving Lives to Fertility Treatment: DUETS (Dallas UtErus Transplant Study). Ann Surg 2021; 272:411-417. [PMID: 32657928 DOI: 10.1097/sla.0000000000004199] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE We report the results of the first 20 uterus transplants performed in our institution. SUMMARY BACKGROUND DATA Uterus transplantation (UTx) aims at giving women affected by absolute uterine-factor infertility the possibility of carrying their own pregnancy. UTx has evolved from experimental to an established surgical procedure. METHODS The Dallas Uterus Transplant Study (DUETS) program started in 2016. The uterus was transplanted in orthotopic position with vascular anastomoses to the external iliac vessels and removed when 1 or 2 live births were achieved. Immunosuppression lasted only for the duration of the uterus graft. RESULTS Twenty women, median age 29.7 years, enrolled in the study, with 10 in phase 1 and 10 in phase 2. All but 2 recipients had a congenital absence of the uterus. Eighteen recipients received uteri from living donors and 2 from deceased donors. In phase 1, 50% of recipients had a technically successful uterus transplant, compared to 90% in phase 2. Four recipients with a technical success in phase 1 have delivered 1 or 2 babies, and the fifth recipient with a technical success is >30 weeks pregnant. In phase 2, 2 recipients have delivered healthy babies and 5 are pregnant. CONCLUSIONS UTx is a unique type of transplant; whose only true success is a healthy child birth. Based on results presented here, involving refinement of the surgical technique and donor selection process, UTx is now an established solution for absolute uterine-factor infertility.
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22
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Human Uterus Transplantation from Living and Deceased Donors: The Interim Results of the First 10 Cases of the Czech Trial. J Clin Med 2021; 10:jcm10040586. [PMID: 33557282 PMCID: PMC7916074 DOI: 10.3390/jcm10040586] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 01/16/2023] Open
Abstract
Introduction: Uterus transplantation (UTx) is a rapidly evolving treatment of uterine-factor infertility. We report the results of the first 10 UTx procedures performed at our institution. Methods: The program started in April 2016 as a two-arm study comparing the efficacy of UTx from live donors (LD) and deceased donors (DD). Results: Between April 2016 and April 2018, we performed five DD UTx and five LD UTx. Two grafts had to be removed early due to thrombosis. One graft was removed due to chronic rejection and previous herpes simplex infection at month 7. Graft survival is 70% at one year. Recipient survival is 100% at two years. Live donor survival is 100% at three years. Three live-births have been achieved, two from a LD and one from a graft from a nulliparous DD. Vaginal anastomotic stenosis occurred in 63% (5/8) of grafts. Self-expanding stents have shown preliminary suitability for the treatment of vaginal stenosis. Three recipients developed severe acute rejection. Conclusion: The interim results of our study demonstrate mid-term viability in 70% of grafts. The LD UTx produced two live births and the DD UTx produced one live birth. Nulliparous donors should be considered for donation.
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23
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Bruno B, Arora KS. Ethical Implications of Donor Type for Uterus Transplantation: Why We Should Remain Wary of Using Living Donors. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2020; 93:587-592. [PMID: 33005123 PMCID: PMC7513439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the last few years, research teams have made significant advancements in treating absolute uterine factor infertility through uterus transplantation, culminating in the birth of the first US baby born from a uterus transplant in November 2017. However, studies have differed on the choice of either deceased or living donors, with some centers even exploring both methods. As researchers continue to investigate the medical feasibility of these approaches, it is also important for the medical community to consider how deceased and living uterus donation differ ethically. We argue that if living and deceased donation demonstrate equivalent clinical efficacy and the deceased donor pool is sufficient, living uterus donation should be reevaluated and may no longer be ethically justifiable.
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Affiliation(s)
- Bethany Bruno
- Cleveland Clinic Lerner College of Medicine, Cleveland,
OH,To whom all correspondence should be addressed:
Bethany Bruno, MA, 9500 Euclid Ave, P4-104, Cleveland OH 44195; Tel:
216-636-5599; Fax: 216-445-6960; ; ORCID iD:
https://orcid.org/0000-0003-0445-6876
| | - Kavita Shah Arora
- Department of Obstetrics and Gynecology, MetroHealth
Medical Center, Cleveland, OH,Department of Bioethics, Case Western Reserve
University, Cleveland, OH
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24
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The landscape of vascularized composite allograft donation in the United States. Curr Opin Organ Transplant 2020; 24:699-704. [PMID: 31577595 DOI: 10.1097/mot.0000000000000703] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Vascularized composite allograft (VCA) donation and transplantation has now demonstrated feasibility and impact to the lives of patients suffering from devastating and traumatic injury. This review summarizes the current landscape of VCA donation in the United States. RECENT FINDINGS VCA donations are nonlife-saving allografts, for nonlife-saving transplants - and therefore, conservative donor selection focused on the optimization of donors for the lowest risk to transplant recipients is paramount. VCA donors in the United States are a demographically and clinically diverse group that largely reflects the characteristics of the VCA candidates waiting for transplants. Public opinion about VCA donation is generally supportive, but has lower support for VCA transplants than for solid organ transplants. SUMMARY As an emerging area of transplantation, VCA donation is evolving in the United States with growing interest by the public, and those suffering from catastrophic injury for which reconstructive transplantation may offer excellent outcomes and a high quality of life.
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25
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Chmel R, Pastor Z, Matecha J, Janousek L, Novackova M, Fronek J. Uterine transplantation in an era of successful childbirths from living and deceased donor uteri: Current challenges. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 164:115-120. [DOI: 10.5507/bp.2019.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 04/25/2019] [Indexed: 01/18/2023] Open
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Peters HE, Juffermans LJM, Lambalk CB, Dekker JJML, Fernhout T, Groenman FA, de Groot CJM, Hoksbergen AWJ, Huirne JAF, de Leeuw RA, van Mello NM, Nederhoed JH, Schats R, Verhoeven MO, Hehenkamp WJK. Feasibility study for performing uterus transplantation in the Netherlands. Hum Reprod Open 2020; 2020:hoz032. [PMID: 32128452 PMCID: PMC7048682 DOI: 10.1093/hropen/hoz032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/10/2019] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION Is it feasible to perform uterus transplantations (UTx) in a tertiary centre in the Netherlands? SUMMARY ANSWER Considering all ethical principles, surgical risks and financial aspects, we have concluded that at this time, it is not feasible to establish the UTx procedure at our hospital. WHAT IS KNOWN ALREADY UTx is a promising treatment for absolute uterine factor infertility. It is currently being investigated within several clinical trials worldwide and has resulted in the live birth of 19 children so far. Most UTx procedures are performed in women with the Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, a congenital disorder characterized by absence of the uterus. In the Netherlands, the only possible option for these women for having children is adoption or surrogacy. STUDY DESIGN SIZE DURATION We performed a feasibility study to search for ethical, medical and financial support for performing UTx at the Amsterdam UMC, location VUmc. PARTICIPANTS/MATERIALS SETTING METHODS For this feasibility study, we created a special interest group, including gynaecologists, transplant surgeons, researchers and a financial advisor. Also, in collaboration with the patients' association for women with MRKH, a questionnaire study was performed to research the decision-making in possible recipients. In this paper, we present an overview of current practices and literature on UTx and discuss the results of our feasibility study. MAIN RESULTS AND THE ROLE OF CHANCE A high level of interest from the possible recipients became apparent from our questionnaire amongst women with MRKH. The majority (64.8%) positively considered UTx with a live donor, with 69.6% having a potential donor available. However, this 'non-life-saving transplantation' requires careful balancing of risks and benefits. The UTx procedure includes two complex surgeries and unknown consequences for the unborn child. The costs for one UTx are calculated to be around €100 000 and will not be compensated by medical insurance. The Clinical Ethics Committee places great emphasis on the principle of non-maleficence and the 'fair distribution of health services'. LIMITATIONS REASONS FOR CAUTION In the Netherlands, alternatives for having children are available and future collaboration with experienced foreign clinics that offer the procedure is a possibility not yet investigated. WIDER IMPLICATIONS OF THE FINDINGS The final assessment of this feasibility study is that that there are not enough grounds to support this procedure at our hospital at this point in time. We will closely follow the developments and will re-evaluate the feasibility in the future. STUDY FUNDING/COMPETING INTERESTS This feasibility study was funded by the VU Medical Center (Innovation grant 2017). No conflicts of interest have been reported relevant to the subject of all authors. TRIAL REGISTRATION NUMBER n.a.
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Affiliation(s)
- H E Peters
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - L J M Juffermans
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - C B Lambalk
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J J M L Dekker
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - T Fernhout
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - F A Groenman
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - C J M de Groot
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - A W J Hoksbergen
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J A F Huirne
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - R A de Leeuw
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - N M van Mello
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J H Nederhoed
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - R Schats
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - M O Verhoeven
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - W J K Hehenkamp
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
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Shcherbyna VY. BIOETHICS AND TECHNOLOGIES OF REPRODUCTIVE MEDICINE. BIOTECHNOLOGIA ACTA 2020. [DOI: 10.15407/biotech13.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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28
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Ramani A, Testa G, Ghouri Y, Koon EC, Di Salvo M, McKenna GJ, Bayer J, Marie Warren A, Wall A, Johannesson L. DUETS (Dallas UtErus Transplant Study): Complete report of 6-month and initial 2-year outcomes following open donor hysterectomy. Clin Transplant 2019; 34:e13757. [PMID: 31758566 DOI: 10.1111/ctr.13757] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/12/2019] [Accepted: 11/17/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Uterus transplantation has shown success in treating women with uterine factor infertility who want to carry their own pregnancy. METHODS We report the medical, sexual, and psychological outcomes of our first cohort of 13 living donor hysterectomies. As we have transitioned from open to robotically assisted hysterectomy, this report represents the complete series of open donor hysterectomies at our center, all with ≥6-month postoperative outcomes. RESULTS The open donor hysterectomy had a median of a 6.5-hour surgical time, 0.8 L estimated blood loss, 6-day hospital stay, and 28-day sick leave. Three donors had a grade III or IV complications, one reported new-onset psychological symptoms, and 9 experienced transient sexual discomfort. All complications were addressed and resolved, and all donors returned to their presurgical social and physical activities. CONCLUSION Since uterus transplantation is not life-saving or life-extending, the risks in living uterus donation must be weighed against the benefit of giving another woman the opportunity to give birth to her own child. This report provides data to support more detailed informed consent regarding the medical, psychological, and sexual complications of open living donor hysterectomy and allows for further evaluation of the ethical acceptability of this procedure.
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Affiliation(s)
- Azaan Ramani
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Yumna Ghouri
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Eric C Koon
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA
| | - Marco Di Salvo
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Greg J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Johanna Bayer
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Ann Marie Warren
- Division of Trauma, Acute Care, and Critical Care Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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Guntram L, Zeiler K. The Ethics of the Societal Entrenchment-approach and the case of live uterus transplantation-IVF. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2019; 22:557-571. [PMID: 31102175 PMCID: PMC6842335 DOI: 10.1007/s11019-019-09891-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
In 2014, the first child in the world was born after live uterus transplantation and IVF (UTx-IVF). Before and after this event, ethical aspects of UTx-IVF have been discussed in the medical and bioethical debate as well as, with varying intensity, in Swedish media and political fora. This article examines what comes to be identified as important ethical problems and solutions in the media debate of UTx-IVF in Sweden, showing specifically how problems, target groups, goals, benefits, risks and stakes are delineated and positioned. It also demonstrates how specific assumptions, norms and values are expressed and used to underpin specific positions within this debate, and how certain subjects, desires and risks become shrouded or simply omitted from it. This approach-which we label the Ethics of the Societal Entrenchment-approach, inspired by Koch and Stemerding (1994)-allows us to discuss how the identification of something as the problem helps to shape what gets to be described as a solution, and how specific solutions provide frameworks within which problems can be stated and emphasised. We also offer a critical discussion of whether some of these articulations and formations should be seen as ethically troubling, and if so, why.
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Affiliation(s)
- Lisa Guntram
- Department of Thematic Studies – Technology and Social Change, Linköping University, 581 83 Linköping, Sweden
| | - Kristin Zeiler
- Department of Thematic Studies – Technology and Social Change, Linköping University, 581 83 Linköping, Sweden
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30
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Ngaage LM, Ike S, Elegbede A, Vercler CJ, Gebran S, Liang F, Rada EM, Cooney C, Brandacher G, Redett RJ, Johannesson L, Rasko YM. The changing paradigm of ethics in uterus transplantation: a systematic review. Transpl Int 2019; 33:260-269. [PMID: 31674693 DOI: 10.1111/tri.13548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/03/2019] [Accepted: 10/28/2019] [Indexed: 11/27/2022]
Abstract
The first uterus transplantation was performed in 2000. As key milestones are reached (long-lasting graft survival in 2011, and first birth from a transplanted womb in 2014), the ethical debate around uterus transplant evolves. We performed a systematic review of articles on uterus transplantation. Ethical themes were extracted and categorized according to four bioethical principles. Papers were divided into time periods separated by key events in uterus transplant history: Phase I (first technical achievement, 2002-2011), Phase II (clinical achievement, 2012-2014), and Phase III (after the first childbirth, 2015-2018). Eighty-one articles were included. The majority of ethics papers were published in Phase III (65%, P < 0.0001), that is after the first birth. Eighty percent of papers discussed nonmaleficence making it the most discussed principle. The first birth acted as a pivotal point: nonmaleficence was discussed by a lower proportion of articles (P = 0.0073), as was beneficence (P = 0.0309). However, discussion of justice increased to become the most discussed principle of the time period (P = 0.0085). The ethical debate surrounding uterus transplantation has evolved around landmark events that signify scientific progress. As safety and efficacy become evident, the focus of ethical debate shifts from clinical equipoise to socioeconomic challenges and equitable access to uterus transplantation.
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Affiliation(s)
- Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Samantha Ike
- London North West University Healthcare Trust, London, UK
| | - Adekunle Elegbede
- Department of Plastic & Reconstructive Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian J Vercler
- Plastic Surgery Section, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Selim Gebran
- Division of Plastic & Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Fan Liang
- Division of Plastic & Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Erin M Rada
- Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Carisa Cooney
- Department of Plastic & Reconstructive Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gerald Brandacher
- Department of Plastic & Reconstructive Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic & Reconstructive Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
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O’Donovan L, Williams NJ, Wilkinson S. Ethical and policy issues raised by uterus transplants. Br Med Bull 2019; 131:19-28. [PMID: 31504233 PMCID: PMC6821981 DOI: 10.1093/bmb/ldz022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/09/2019] [Accepted: 06/20/2019] [Indexed: 12/15/2022]
Abstract
INTRODUCTION In 2014, Brännström and colleagues reported the first human live birth following uterine transplantation (UTx). Research into this treatment for absolute uterine factor infertility has since grown with clinical trials currently taking place across centers in at least thirteen countries worldwide. SOURCES OF DATA This review summarizes and critiques the academic literature on ethical and policy issues raised by UTx. AREAS OF AGREEMENT There is general agreement on the importance of risk reduction and, in principle, to the sharing and maintenance of patient data on an international registry. AREAS OF CONTROVERSY There are numerous areas of controversy ranging from whether it is ethically justified to carry out uterus transplants at all (considering the associated health risks) to how deceased donor organs for transplant should be allocated. This review focuses on three key issues: the choice between deceased and living donors, ensuring valid consent to the procedure and access to treatment. GROWING POINTS UTx is presently a novel and rare procedure but is likely to become more commonplace in the foreseeable future, given the large number of surgical teams working on it worldwide. AREAS TIMELY FOR DEVELOPING RESEARCH Uterus transplantation requires us to re-examine fundamental questions about the ethical and social value of gestation. If eventually extended to transgender women or even to men, it may also require us to reconceptualize what it is to be a 'father' or to be a 'mother', and the definition of these terms in law.
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Affiliation(s)
- Laura O’Donovan
- Department of Politics, Philosophy, & Religion, County South, Lancaster University, Lancaster, LA1 4YQ, United Kingdom
| | - Nicola Jane Williams
- Department of Politics, Philosophy, & Religion, County South, Lancaster University, Lancaster, LA1 4YQ, United Kingdom
| | - Stephen Wilkinson
- Department of Politics, Philosophy, & Religion, County South, Lancaster University, Lancaster, LA1 4YQ, United Kingdom
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Chmel R, Pastor Z, Novackova M, Matecha J, Cekal M, Fronek J. Clinical pregnancy after deceased donor uterus transplantation: Lessons learned and future perspectives. J Obstet Gynaecol Res 2019; 45:1458-1465. [DOI: 10.1111/jog.13992] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/14/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Roman Chmel
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
- Transplantation Surgery DepartmentInstitute of Clinical and Experimental Medicine Prague Czech Republic
| | - Zlatko Pastor
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
| | - Marta Novackova
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
| | - Jan Matecha
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
- Faculty of Medicine in PlzeňCharles University Czech Republic
| | - Milos Cekal
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
| | - Jiri Fronek
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
- Transplantation Surgery DepartmentInstitute of Clinical and Experimental Medicine Prague Czech Republic
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First Healthy Baby After Deceased Donor Uterus Transplantation: Birth to a New Era? Transplantation 2019; 103:652-653. [PMID: 30907853 DOI: 10.1097/tp.0000000000002627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Successful human uterine transplantation followed by subsequent pregnancy and live birth in a woman for whom this would otherwise have been impossible is a laudable goal. Research programs have been developed in several countries aimed at achieving this goal. The pioneering Swedish program has reported live births in six women, two of whom had a second pregnancy and birth. Five other live births have been reported from other countries. Most transplants were from a live donor, although recently a live birth has been reported following transplant from a deceased donor. The surgical procedure on a live donor is highly invasive, complex, hazardous, and long and may decrease her quality of life. The use of a deceased donor would partly simplify this issue and is being explored in several centers. Also explored are technical modifications to simplify the procedure and shorten the operating times. The American Society for Reproductive Medicine (ASRM) reminds us of the full array of options available to patients: 'including gestational carriers (surrogacy), adoption and child-free living'. The ASRM also recommends 55 years as the upper age limit for transfer of donor oocytes and embryos in healthy women. Would it not be more practical and less onerous for the prospective live donor to carry the pregnancy instead? Uterine transplantation remains an experimental procedure that requires the study and resolution of ethical, technical, financial, and social issues, all very important.
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Affiliation(s)
- V Gomel
- a Department of Obstetrics & Gynecology , University of British Columbia , Vancouver , BC , Canada
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Shapiro ME, Ward FR. Uterus Transplantation: A Step Too Far. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:36-37. [PMID: 30040573 DOI: 10.1080/15265161.2018.1478027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Corin Z, Furman R, Lifshitz S, Samuelov O, Greenbaum D. How Do You Donate Life When People Are Not Dying: Transplants in the Age of Autonomous Vehicles. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:27-29. [PMID: 30040577 DOI: 10.1080/15265161.2018.1478024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Rogers A. Allocating Uterus Transplants-Who Gets to Be a Gestational Mother? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:38-39. [PMID: 30040575 DOI: 10.1080/15265161.2018.1478025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Bartlett VL, Bliton MJ, Finder SG. Experience and Ethics at the "Cutting Edge": Lessons From Maternal-Fetal Surgery for Uterine Transplantation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:29-31. [PMID: 30040570 DOI: 10.1080/15265161.2018.1478041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Williams NJ. Deceased Donation in Uterus Transplantation Trials: Novelty, Consent, and Surrogate Decision Making. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:18-20. [PMID: 30040583 DOI: 10.1080/15265161.2018.1478043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Mabel H, Farrell RM, Tzakis AG. On Gender and Reproductive Decision-Making in Uterine Transplantation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:3-5. [PMID: 30040551 DOI: 10.1080/15265161.2018.1489655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
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Wall A, Testa G. Living Donation, Listing, and Prioritization in Uterus Transplantation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:20-22. [PMID: 30040574 DOI: 10.1080/15265161.2018.1478026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Allyse M. "Whole Again": Why Are Penile Transplants Less Controversial Than Uterine? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:34-35. [PMID: 30040581 DOI: 10.1080/15265161.2018.1478044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
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Vong G. The Purported Procurement Priority of Lifesaving Organs Over Non-Lifesaving Organs: Uterus Transplants and the Ethical Importance of Potential Lives. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:25-26. [PMID: 30040563 DOI: 10.1080/15265161.2018.1478032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Bayefsky MJ, Berkman BE. Toward the Ethical Allocation of Uterine Transplants. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:16-17. [PMID: 30040555 DOI: 10.1080/15265161.2018.1478039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Mertes H, Van Assche K. UTx With Deceased Donors Also Places Risks and Burdens on Third Parties. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:22-24. [PMID: 30040566 DOI: 10.1080/15265161.2018.1478029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
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