Feasibility study for performing uterus transplantation in the Netherlands

Vascularized Composite Allotransplantation of the Uterus: A Systematic Review of Eligibility Criteria

BACKGROUND

Uterus transplantation (UTx) is the sole clinical treatment for patients with a diagnosis of uterine infertility factor to experience gestation and delivery. Following UTx, candidates who have been largely healthy must agree to extensively interface with the healthcare system and practice strict adherence to an immunosuppressive regimen to protect the allograft until delivery of a live birth. Aside from the risks associated with immunosuppression, UTx recipients often face complicated pregnancies, with a possibility of pregnancy loss and allograft failure. Therefore, appropriate recipient eligibility criteria are central to transplantation success. The objective of this study is to investigate eligibility criteria reported by UTx programs globally.

METHODS

A systematic review of UTx literature was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines, using PubMed, Cochrane, Ovid/MEDLINE, and Scopus. ClinicalTrials.gov entries and program websites were queried for eligibility criteria as well.

RESULTS

Two hundred ninety-six studies were identified, 79 of which were included in the final review. Twenty-one clinical trials and 6 patient-facing websites were included. Most reported eligibility criteria included females of reproductive age, excellent in vitro fertilization candidacy, psychological stability, absence of systemic infection, and willingness to comply with all treatment protocols. The importance of factors such as social support and recipient relationship with their partner varied between centers.

CONCLUSION

Although consensus exists across certain eligibility criteria, the importance of other criteria presents greater ambiguity across centers. As UTx programs expand, and more patients gain access to the procedure, the evolution of eligibility criteria must be documented to optimize best practices across centers.

Psychological evaluation of candidates for the uterus transplantation French trial

INTRODUCTION

Since 2017, women with absolute uterine infertility due to Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome have been eligible to participate in a uterine transplantation clinical trial conducted by Foch Hospital in France. The aim of this study is to assess the psychological state of potential candidates, including recipients, their partners, and their living-related donors.

MATERIAL AND METHODS

Sixteen potential uterus transplant candidates, including recipients, partners, and living-related donors, participated in the study. The psychological evaluation of these candidates was conducted using three validated questionnaires: the Dyadic Adjustment Scale (DAS-16), the Hospital Anxiety and Depression Scale (HADS), and the Fertility Quality of Life (FertiQoL) questionnaire.

RESULTS

No depression symptoms were observed in any participant according to the HADS. Most recipients did not exhibit signs of anxiety; however, three partners and three donors reported moderate to high anxiety levels. A positive correlation was found between the recipient's psychological distress related to infertility (FertiQoL) and the anxiety scores of their donors. The emotional aspect of infertility was identified as the most distressing factor for the recipients.

CONCLUSIONS

While the overall psychological state of the participants was generally good, anxiety was notably present among donors and partners. Therefore, providing psychological support throughout the uterine transplantation process is essential for not only the recipients but also their partners and donors.

The costs per live birth after uterus transplantation: results of the Swedish live donor trial

STUDY QUESTION

What is the cost per live birth after live donor uterus transplantation in a Swedish clinical trial setting?

SUMMARY ANSWER

The total cost per child, from a health care perspective, was calculated to be €124 894 and if only surgically successful transplants are considered, the total cost per live birth was €107 120.

WHAT IS KNOWN ALREADY

Uterus transplantation has proved to be a feasible treatment for uterine factor infertility by accomplished live births, both after live donor and deceased donor transplantation procedures. Our previous study, the only existing cost analysis of uterus transplantation, found that the initial (up to 2 months after surgeries) societal costs of preoperative interventions, live donor uterus transplantation surgeries, and postoperative care were between €50 000 and €100 000 (mean €74 000) in Year 2020 values per uterus transplantation. That study also included costs of sick leave for both donors and recipients.

STUDY DESIGN, SIZE, DURATION

This real-data health economic cost study is based on a prospective cohort study, which included nine live donor uterus transplantation procedures. Study duration included the time from the first pre-transplantation investigation until postoperative controls after graft removal.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Recipients, live donors, and neonates of nine uterus transplantation procedures participated. The recipients and donors underwent pre-transplantation investigations with imaging, laboratory tests, and psychological/medical screening. In vitro fertilization with embryo cryopreservation was performed in advance of transplantation. Donor hysterectomy and transplantation were by laparotomy and the recipient received immunosuppression. Pregnancy attempts by ET started 1 year after transplantation and delivery was by caesarean section. Hysterectomy was performed either after birth of one or two children, after graft failure, or after multiple pregnancy failures. Nine transplantation procedures resulted in seven surgically successful (adequate blood flow and regular menstruations) grafts and six women delivered a total of nine children.

MAIN RESULTS AND THE ROLE OF CHANCE

The total cost of preoperative investigations, live donor uterus transplantation, postoperative care, immunosuppression, IVF, follow-up, pregnancy care, delivery, and graft removal after completed childbirth(s) or failure to achieve live birth was calculated, based on inclusion of cost for six women, giving birth to a total of nine children, and three women, with no childbirth. Cost for live donors was also included in the analysis. The total cost per child was calculated to be €124 894. However, if only surgical successful transplants (seven out of nine transplants) are considered, the cost per live birth was €107 120. The cost for preoperative preparations with IVF, surgeries, and postoperative follow-up during the initial 2 months was around 53% of total costs. Smaller sub-costs were those for monitoring, ETs with additional IVF (14%), immunosuppression and other drugs from Month 3 until hysterectomy (13%), and pregnancy care with delivery and neonatal care (13%).

LIMITATIONS, REASONS FOR CAUTION

Limitations are the restricted sample size, the experimental phase of the procedure and that the results only reflect the cost in one country (Sweden).

WIDER IMPLICATIONS OF THE FINDINGS

The results provide the first information concerning the cost per child of the uterus transplantation intervention. In the future, the cost per child will most likely decrease due to predicted increase in the rate of surgical success, decreased surgical durations, decreased graft duration to achieve live birth(s), and increased rate of transplantations giving not only one, but two or three singletons.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was received from the Jane and Dan Olsson Foundation for Science, the Knut and Alice Wallenberg Foundation, the Swedish Research Council, and an ALF grant from the Swedish state under an agreement between the government and the county councils. There are no conflicts of interest for any of the authors.

TRIAL REGISTRATION NUMBER

NCT01844362.

Cost-effectiveness analysis of uterus transplantation vs. gestational carrier for treatment of absolute uterine factor infertility in the United States

OBJECTIVE

To compare the cost-effectiveness of treatment for patients with absolute uterine factor infertility to achieve one or two singleton births by gestational carrier vs. uterus transplant.

DESIGN

Decision analysis from the US healthcare sector perspective, with time horizons to achieve one or two singleton births.

SUBJECTS

Patients with uterine factor infertility desiring family building.

EXPOSURE

Gestational carrier or uterus transplant.

MAIN OUTCOME MEASURES

Incremental cost-effectiveness ratios, comparing the costs (2020 US Dollars) and effectiveness (quality-adjusted life years [QALYs] and live births) to achieve one or two births by gestational carrier vs. uterus transplant.

RESULTS

In the base case of one singleton birth, the overall cost using a gestational carrier was $97,712.90 ($56,985.20-$153,084.20) compared with $116,137.20 ($67,142.88-$182,290.86) after uterus transplant. Quality-adjusted life years were higher in the gestational carrier arm (0.93) compared with the uterus transplant (0.90) and overall rates of live birth were also higher in the gestational carrier arm (94%) compared with the uterus transplant arm (77%). Costs of the gestational carrier and uterus transplant recipient were the most significant cost variables in the model. Monte Carlo simulation showed that uterus transplant had a 37% chance of being the cost-effective strategy for a single live birth at a willingness to pay of $150,000/QALY. In the case of two singleton births, the cost using a gestational carrier was $186,278.56 ($103,597.81-$296,010.27) compared with $164,276.84 ($111,961.91-$229,394.43) after uterus transplant. Quality-adjusted life years were again higher in the gestational carrier arm (0.93) than the uterus transplant (0.89). Overall rates of two live births were also higher in the gestational carrier arm (86%) compared with the uterus transplant arm (66%). Monte Carlo simulation showed that uterine transplant has a 62% chance of being the cost-effective strategy for two live births at a willingness to pay $150,000/QALY.

CONCLUSION

In the United States, treatment of uterine factor infertility with a gestational carrier is likely the most cost-effective approach for patients delivering a single child. However, the absolute costs associated with uterus transplants were 14% less than a gestational carrier for those having two live singleton births.

Permanently infertile couples and family building-a cross-sectional survey in Denmark

STUDY QUESTION

Which decision-making factors influence family building among permanently infertile couples?

SUMMARY ANSWER

Ethical, legal, and financial considerations outweigh genetic relatedness in decision-making, favouring domestic gestational surrogacy, if this were possible, over international options.

WHAT IS KNOWN ALREADY

Permanent infertility affects 4-5% of people in the fertile age. Their family-building options include adoption, surrogacy, uterus transplantation, foster care, and intentional multiple parenthood. However, in most countries, including Denmark, legal barriers constrain these methods due to surrogacy restrictions, suspended international adoptions, and the experimental status of uterus transplantation. Despite existing research on surrogacy, adoption, and specific causes of permanent infertility, a significant gap remains in our understanding of how couples with permanent infertility make family-building decisions within these limited frameworks.

STUDY DESIGN, SIZE, DURATION

This cross-sectional study with 150 permanently infertile Danish participants was conducted from June to November 2023 using an online questionnaire. Multiple strategies, such as online forums, fertility clinics, hospital departments, and snowballing, were used to recruit a diverse sample.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study included couples aged 26-50 years facing permanent infertility due to the following primary causes: women without a uterus (15%), women with a non-functional uterus (47%) or women for whom pregnancy would be life-threatening (9%), male couples (16%), transgender partner couples (2%), and other causes (11%). The survey collected data on demographics, reproductive history, family-building choices, and communication strategies. Closed questions were analysed using descriptive statistics.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 150 respondents, 41% had used transnational surrogacy, 27% adoption, 14% chose to remain childless, and 19% were undecided. Critical factors on family-building decisions were ethical, legal, and financial concerns which ranked higher than genetic relatedness. Despite the complexity of family building, most participants were open about their child's origin and received social support. If all family-building methods were legal and available in Denmark, domestic gestational surrogacy would be the preferred method, with uterus transplantation and remaining childless being least popular.

LIMITATIONS, REASONS FOR CAUTION

The sample size is relatively small, despite the use of a variety of recruitment strategies. Nevertheless, this has ensured a diverse cohort representing the different reasons for infertility and family-building choices. It is important to note that the strategies may have favoured individuals achieving parenthood.

WIDER IMPLICATIONS OF THE FINDINGS

The finding of our study reveals a notable gap between available family-building options in Denmark and the preferences of couples facing permanent infertility. These insights could be instrumental for organizations reviewing and developing family-building frameworks. Furthermore, for healthcare professionals guiding couples experiencing infertility issues in their attempts to build a family, an understanding of these preferences is essential to facilitate informed decisions about their future family plans.

STUDY FUNDING/COMPETING INTEREST(S)

The project was financed by the Independent Research Fund Denmark. The authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Perception of having children through surrogacy in individuals with MRKH in Vietnam: a qualitative study

Introduction

Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) is rare condition that has a negative impact on quality of life because affected women lack a uterus and vagina, and are therefore unable to engage in sexual intercourse and experience natural pregnancy. This study evaluated perceptions of surrogacy in Vietnamese women with MRKH who have started families.

Method

Women with MRKH who had undergone successful vaginal reconstruction, were married, and had started families participated in a semi-structured, in-depth, one-on-one online video interview with an experienced female psychologist. Open-ended questions were used to encourage participants to express their perceptions of surrogacy; prominent themes were discussed, compared, and combined.

Results

Twenty women (mean age 31 years) agreed to participate. Key themes identified from interviews were the importance of having genetic offspring, consideration of surrogacy as a preferred solution to infertility, the barriers to surrogacy in Vietnam, lack of reproductive information and counselling, individuals concealing their health condition, the impact of religion on the possibility of surrogacy, the economic cost of surrogacy, and the difficulty in finding a surrogate under the restrictions imposed by Vietnamese law.

Discussion

Based on the perceptions of women from MRKH from Vietnam, there is an opportunity to improve how infertility is managed in these people, including information about surrogacy. These data show that individuals with MRKH should be provided with information about the possibility of surrogacy, encouraged to be open and seek support, and be managed by a multidisciplinary team that includes psychological support; the provision of economic support for fertility treatments in women with MRKH should also be considered.

Living-Donor Uterus Transplantation: A Clinical Review

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.

Miracles of science: Birth after uterus transplantation

AIM

The concept of regaining childbearing ability via uterus transplantation (UTx) motivates many infertile women to pursue giving birth to their own children. This article provides insight into maternal and neonatal outcomes of the procedure globally and facilitates quality of care in related medical fields.

METHODS

The authors searched ISI Web of Science, MEDLINE, non-PubMed-indexed journals, and common search engines to identify peer-review publications and unpublished sources in scientific reference databases.

RESULTS

The feasibility of the procedure has been proven with 46 healthy children in 88 procedures so far. Success relies upon dedicated teamwork involving transplantation surgery, obstetrics and reproductive medicine, neonatology, pediatrics, psychology, and bioethics. However, challenges exist owing to donor, recipient, and fetus. Fetal growth in genetically foreign uterine allograft with altered feto-maternal interface and vascular anatomy, immunosuppressive exposure, lack of graft innervation leading to "unable-to-feel" uterine contractions and conception via assisted reproductive technology create notable risks during pregnancy. Significant portion of women are complicated by at least one or more obstetric problems. Preeclampsia, gestational hypertension and diabetes mellitus, elevated kidney indices, and preterm delivery are common complications.

CONCLUSIONS

UTx has short- and long-term satisfying outcome. Advancements in the post-transplant management would undoubtedly lead this experimental procedure into mainstream clinical practice in the near future. However, both women and children of UTx need special consideration due to prematurity-related neonatal problems and the long-term effects of transplant pregnancy. Notable health risks for the recipient and fetus should be discussed with potential candidates for UTx.

Uterus transplantation: from research, through human trials and into the future

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.

Uterus Transplantation as a Surgical Innovation

Uterus transplantation (UTx) research has been introduced in several countries, with trials in Sweden and the United States producing successful outcomes. The growing interest in developing UTx trials in other countries, such as Spain, the Netherlands, Japan, and Australia, raises important questions regarding the ethics of surgical innovation research in the field of UTx. This paper examines the current state of UTx in the context of the surgical innovation paradigm and IDEAL framework and discusses the ethical challenges faced by those considering the introduction of new trials. We argue that UTx remains an experimental procedure at a relatively early stage of the IDEAL framework, especially in the context of de novo trials, where protocols are likely to deviate from those used previously and where researchers are likely to have limited experience of UTx. We conclude that countries considering the introduction of UTx trials should build on the strengths of the reported outcomes to consolidate the evidence base and shed light on the uncertainties of the procedure. Authorities responsible for the ethical governance of UTx trials are advised to draw on the ethical framework used in the oversight of surgical innovation.

Differences between living and deceased donation in human uterus transplantation: A narrative review

The decision to use a living or deceased donor to perform uterus transplantation (UTx) is an evaluation of benefit and harm and is based on the medical team's choices. The current study determines the differences between living and deceased donation in human UTx according to determinant factors in choosing the donor type. For this review study, the PubMed database was searched without time, language, and location limitations up to May 2022. From 113 identified articles, 45 papers were included in the study for review. According to the results, in comparison to living donation, the biggest advantage of deceased donation is the lack of surgical and or psychological risks for the donor. In contrast, a comprehensive pre-transplantation medical assessment is less possible in deceased donation, and preplanned surgery cannot be realized. According to published peer-reviewed clinical trials on UTx, the graft failure rates in living and deceased donor UTx are 21% and 36%, respectively. Supposing all recipients who did not have graft failure underwent embryo transfer, live birth rates in living and deceased donor UTx procedures are almost 63% and 71%, respectively. Currently, considering the occurrence of live births from both donations, particularly from nulliparous deceased donor, increased demand for UTx in the near future, shortage of uterus grafts, and lack of sufficient data for a comprehensive comparison between the 2 types of donation, the use of both donations still seems necessary and rational.

Desire for children and fertility preservation in transgender and gender-diverse people: A systematic review

The decision to pursue one's desire for children is a basic human right. For transgender and gender-diverse (TGD) people, gender-affirming care may alter the possibilities to fulfill one's desire for children due to the impact of this treatment on their reproductive organs. We systematically included 76 studies of varying quality describing the desire for children and parenthood; fertility counseling and utilization; and fertility preservation options and outcomes in TGD people. The majority of TGD people expressed a desire for children. Fertility preservation utilization rates were low as there are many barriers to pursue fertility preservation. The most utilized fertility preservation strategies include oocyte vitrification and sperm banking through masturbation. Oocyte vitrification showed successful outcomes, even after testosterone cessation. Sperm analyses when banking sperm showed a lower quality compared to cis male samples even prior to gender-affirming hormone treatment and an uncertain recovery of spermatogenesis after discontinuing treatment.

The costs of human uterus transplantation: a study based on the nine cases of the initial Swedish live donor trial

STUDY QUESTION

What are the costs of live donor uterus transplantation in a European setting?

SUMMARY ANSWER

The total costs for preoperative investigations, including IVF, and live donor uterus transplantation including postoperative costs for 2 months, were calculated to be €74 564 (mean), with the costs of recipient being somewhat higher than for donor and the cost components of total costs distributed between sick leave (25.7%), postoperative hospitalization (17.8%), surgery (17.1%), preoperative investigations (15.7%), anaesthesia (9.7%), drugs (7.8%), tests after surgery (4.0%) and for re-hospitalization (2.2%).

WHAT IS KNOWN ALREADY

Uterus transplantation has proved to be successful by demonstrations of live births, both after live donor and deceased donor procedures. The transplantation is considered as a complex and expensive infertility treatment. There exist no analyses of costs involved in uterus transplantation.

STUDY DESIGN, SIZE, DURATION

This prospective cohort study included nine uterus transplantations procedures, performed in Sweden in 2013. Study duration of this health economic study included 6-12 months of pre-transplantation investigations and the time interval from transplantation to 2 months after.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Nine triads of uterus recipient, partner of recipient and uterus donor participated. All prospective recipients were in stable relationships and performed IVF with their partners before transplantation. The nine donors were relatives or family friends. The recipients and donors underwent pre-transplantation investigations with imaging, laboratory tests and psychological/medical screening prior to transplantation. Transplantation was by laparotomy in both donor and recipient. Standard immunosuppression and postoperative medication were used. After discharge from the hospital, the recipients were followed frequently with laboratory tests and examinations.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean costs for preoperative investigations, including IVF, and live donor uterus transplantation with postoperative costs for 2 months, were calculated to be €74 564 (range €50 960-€99 658), from a societal perspective. The four largest components were cost of sick leave (€19 164), cost of postoperative hospitalization (€13 246), surgery cost (€12 779) and costs for preoperative investigations, including IVF (€11 739). Smaller components were costs for anaesthesia (€7207), costs for drugs (€5821), costs for post-surgical tests (€2985) and costs for re-hospitalization (€1623). The costs of the recipient (€42 984) were somewhat higher than the costs of the donor (€31 580), but in terms of costs, they should be viewed as one entity. By using a health care perspective, excluding cost for productivity loss, the total costs would be reduced by 26%.

LIMITATIONS, REASONS FOR CAUTION

A limitation is the restricted sample size and that this is in the experimental, clinical stage of development.

WIDER IMPLICATIONS OF THE FINDINGS

The results provide the first information concerning the costs for pre-transplantation investigations and uterus transplantation procedures with postoperative follow-up. We consider the total estimate to be in the higher interval, because of the extensive research protocol. It is likely that the cost of live donor uterus transplantation will vary between countries and that the costs will be lower in a future clinical setting.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was received from the Jane and Dan Olsson Foundation for Science; the Knut and Alice Wallenberg Foundation; an ALF grant from the Swedish state under an agreement between the government and the county councils; and the Swedish Research Council. None of the authors have a conflict of interest with regard to the study.

TRIAL REGISTRATION NUMBER

NCT01844362.

Options for acquiring motherhood in absolute uterine factor infertility; adoption, surrogacy and uterine transplantation

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.