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Brännström M, Racowsky C, Carbonnel M, Wu J, Gargiulo A, Adashi EY, Ayoubi JM. Uterus transplantation: from research, through human trials and into the future. Hum Reprod Update 2023; 29:521-544. [PMID: 37328434 PMCID: PMC10477946 DOI: 10.1093/humupd/dmad012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/29/2023] [Indexed: 06/18/2023] Open
Abstract
Women suffering from absolute uterine factor infertility (AUFI) had no hope of childbearing until clinical feasibility of uterus transplantation (UTx) was documented in 2014 with the birth of a healthy baby. This landmark accomplishment followed extensive foundational work with a wide range of animal species including higher primates. In the present review, we provide a summary of the animal research and describe the results of cases and clinical trials on UTx. Surgical advances for graft removal from live donors and transplantation to recipients are improving, with a recent trend away from laparotomy to robotic approaches, although challenges persist regarding optimum immunosuppressive therapies and tests for graft rejection. Because UTx does not involve transplantation of the Fallopian tubes, IVF is required as part of the UTx process. We provide a unique focus on the intersection between these two processes, with consideration of when oocyte retrieval should be performed, whether, and for whom, preimplantation genetic testing for aneuploidy should be used, whether oocytes or embryos should be frozen and when the first embryo transfer should be performed post-UTx. We also address the utility of an international society UTx (ISUTx) registry for assessing overall UTx success rates, complications, and live births. The long-term health outcomes of all parties involved-the uterus donor (if live donor), the recipient, her partner and any children born from the transplanted graft-are also reviewed. Unlike traditional solid organ transplantation procedures, UTx is not lifesaving, but is life-giving, although as with traditional types of transplantation, costs, and ethical considerations are inevitable. We discuss the likelihood that costs will decrease as efficiency and efficacy improve, and that ethical complexities for and against acceptability of the procedure sharpen the distinctions between genetic, gestational, and social parenthood. As more programs wish to offer the procedure, we suggest a scheme for setting up a UTx program as well as future directions of this rapidly evolving field. In our 2010 review, we described the future of clinical UTx based on development of the procedure in animal models. This Grand Theme Review offers a closing loop to this previous review of more than a decade ago. The clinical feasibility of UTx has now been proved. Advancements include widening the criteria for acceptance of donors and recipients, improving surgery, shortening time to pregnancy, and improving post-UTx management. Together, these improvements catalyze the transition of UTx from experimental into mainstream clinical practice. The procedure will then represent a realistic and accessible alternative to gestational surrogacy for the treatment of AUFI and should become part of the armamentarium of reproductive specialists worldwide.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Stockholm IVF-EUGIN, Stockholm, Sweden
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
| | - Catherine Racowsky
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Marie Carbonnel
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- University Versailles, Saint-Quentin en Yvelines, France
| | - Joseph Wu
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Antonio Gargiulo
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Eli Y Adashi
- Department of Medical Science, Brown University, Providence, RI, USA
| | - Jean Marc Ayoubi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- University Versailles, Saint-Quentin en Yvelines, France
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2
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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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3
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Wilson NK, Schulz P, Wall A, Parrott M, Testa G, Johannesson L, Sam T. Immunosuppression in Uterus Transplantation: Experience From the Dallas Uterus Transplant Study. Transplantation 2023; 107:729-736. [PMID: 36445981 DOI: 10.1097/tp.0000000000004437] [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: 12/02/2022]
Abstract
BACKGROUND Uterus transplantation is a temporary transplant allowing women with absolute uterine factor infertility to experience pregnancy and childbirth. The degree of immunosuppression (IS) required to prevent rejection while minimizing toxicity to the recipient and fetus remains an area of investigation. METHODS In this article, we describe immunosuppressive therapy, rejection episodes, infections, and adverse events in 14 uterus transplant recipients. Induction consisted of antithymocyte globulin and methylprednisolone. Ten recipients (71%) received no steroids postoperatively, and 4 (29%) had steroids tapered off at 42 d. All received oral tacrolimus, either immediate release (n = 2, 14%) or extended release (n = 12, 86%). Mycophenolate was used in 4 cases (29%), de novo azathioprine in 9 (64%), and de novo everolimus in 1 (7%). RESULTS Sixteen clinically silent, treatment-responsive rejection episodes occurred in 10 recipients. Five recipients (36%) experienced acute kidney injury. In 3 recipients, IS was discontinued due to renal dysfunction. Eleven infection episodes were noted in 7 recipients. No babies had congenital abnormalities. CONCLUSIONS Our experience demonstrates that safe IS regimens can be used for uterus transplant recipients before and during pregnancy.
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Affiliation(s)
- Nicole K Wilson
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX
| | - Philipp Schulz
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Anji Wall
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Megan Parrott
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giuliano Testa
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Liza Johannesson
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX
| | - Teena Sam
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX
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4
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Ayoubi JM, Carbonnel M, Racowsky C, de Ziegler D, Gargiulo A, Kvarnström N, Dahm-Kähler P, Brännström M. Evolving clinical challenges in uterus transplantation. Reprod Biomed Online 2022; 45:947-960. [DOI: 10.1016/j.rbmo.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
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5
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Polk H, Johannesson L, Testa G, Wall AE. The Future of Uterus Transplantation: Cost, Regulations, and Outcomes. Clin Obstet Gynecol 2022; 65:101-107. [PMID: 35045031 DOI: 10.1097/grf.0000000000000685] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Uterus transplantation (UTx) has evolved rapidly since technical success was first demonstrated, and is now practiced worldwide, using both living and deceased donors. As UTx transitions from an experimental to widely available standard clinical procedure, new challenges and questions are becoming more urgent. These include issues of cost and coverage, the establishment of guidelines and registries to ensure quality of care and monitor outcomes, regulatory oversight (including for the allocation organs from deceased donors), and the extent to which indications for UTx should be expanded.
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Affiliation(s)
| | - Liza Johannesson
- Obstetrics and Gynecology
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Anji E Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
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6
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Warren AM, McMinn K, Testa G, Wall AE, Saracino G, Waddimba AC, Johannesson L. Psychological Characteristics of Recipients Pretransplantation in the Dallas UtErus Transplant Study (DUETS). Prog Transplant 2021; 31:330-336. [PMID: 34704857 DOI: 10.1177/15269248211046002] [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: 11/17/2022]
Abstract
INTRODUCTION Uterus transplantation is now a viable option for fertility treatment for women with absolute uterine factor infertility. Psychological assessment is recommended as a part of the perioperative evaluation process. RESEARCH OBJECTIVE The purpose of this study was to examine the psychological characteristics and mental health history of the 20 women who participated in the Dallas UtErus Transplant Study (DUETS) trial. DESIGN This retrospective observational descriptive study was part of a prospective clinical trial. Prior to transplant, 20 women completed a clinical psychological interview, 19 of whom also completed psychological assessment measures including the Hospital Anxiety and Depression Scale, Patient Health Questionnaire 9 item, Generalized Anxiety Disorder 7 item, PTSD Checklist for DSM-5, 36-Item Short Form, Connor-Davidson Resilience Scale 10 item, and Dyadic Adjustment Scale. RESULTS Women who participated in the trial had high health-related quality of life and minimal psychological history, with most reporting psychological distress associated with their initial infertility diagnosis (N = 13). None of the participants endorsed psychological distress to meet clinical concerns on the psychological measures used. Satisfaction with relationship adjustment with their partners was also high. CONCLUSIONS Women with absolute uterine factor infertility who underwent uterus transplant demonstrated low psychological distress on assessment measures, were resilient, had high health related quality of life, and strong satisfaction with the quality of relationships with their partners. Although some women reported either current or past psychological diagnosis, most reported psychological distress that occurred at the time of the infertility diagnosis and appeared to resolve over time.
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Affiliation(s)
- Ann Marie Warren
- 466551Baylor Scott & White Research Institute, Dallas, TX, USA.,Division of Trauma, Acute Care, and Critical Care Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Kenleigh McMinn
- Division of Trauma, Acute Care, and Critical Care Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Giuliano Testa
- Annette C. and Harold Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Anji E Wall
- Annette C. and Harold Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Giovanna Saracino
- Annette C. and Harold Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Anthony C Waddimba
- 466551Baylor Scott & White Research Institute, Dallas, TX, USA.,Health Systems Science, Department of Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Liza Johannesson
- Annette C. and Harold Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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7
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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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8
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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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9
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Putman JM, Zhang L, Gregg AR, Testa G, Johannesson L. Clinical pregnancy rates and experience with in vitro fertilization after uterus transplantation: Dallas Uterus Transplant Study. Am J Obstet Gynecol 2021; 225:155.e1-155.e11. [PMID: 33716072 DOI: 10.1016/j.ajog.2021.02.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/25/2021] [Accepted: 02/27/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND The clinical pregnancy rates among patients with uterus transplantation have been reported by only a limited number of centers, and those centers have not used preimplantation genetic testing for aneuploidy in their protocol. OBJECTIVE This study examined clinical pregnancy rates among women with absolute uterine-factor infertility undergoing in vitro fertilization using good-quality, expanded-blastocyst-stage, euploid embryos after uterus transplantation. STUDY DESIGN This cohort observational study involved 20 women who underwent uterus transplantation over 3 years. Notably, 14 of these patients had successful transplants and were followed prospectively for a median of 14.1 months (range, 11-34.8 months). In vitro fertilization was performed before subjects underwent uterus transplantation, and good-quality expanded-blastocyst-stage euploid embryos were obtained and frozen for future embryo transfer. Interventions consisted of in vitro fertilization, preimplantation genetic testing for aneuploidy, uterus transplantation, and frozen embryo transfer. RESULTS All 14 subjects with successful transplants underwent single embryo transfer of a warmed, good-quality, euploid, expanded blastocyst and had at least 1 documented clinical pregnancy within the uterus. In 71.4%, the first embryo transfer resulted in clinical pregnancy. The median time from successful uterus transplantation to first embryo transfer was 4.5 months; from successful uterus transplantation to first clinical pregnancy, 7.3 months; and from successful uterus transplantation to first live birth, 14.1 months. A total of 13 live births have occurred in 12 subjects. CONCLUSION Women with absolute uterine-factor infertility who have surgically successful uterus transplantation and in vitro fertilization using preimplantation genetic testing for aneuploidy can achieve high clinical pregnancy rates. We have reduced the time interval from uterus transplantation to embryo transfer by at least 50% and the interval from uterus transplantation to clinical pregnancy by >6 months compared with previous studies. We believe our approach may shorten the time from transplant to clinical pregnancy and therefore decrease patient exposure to immunosuppressant therapies.
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10
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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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11
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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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12
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Rosenzweig M, Wall A, Spak CW, Testa G, Johannesson L. Pregnancy after CMV infection following uterus transplantation: A case report from the Dallas Uterus Transplant Study. Transpl Infect Dis 2021; 23:e13653. [PMID: 34038016 DOI: 10.1111/tid.13653] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 11/30/2022]
Abstract
Uterus transplantation is a repeatedly proven treatment for women with absolute uterine-factor infertility, which is the congenital or acquired absence of the uterus, who desire to carry, and ultimately deliver, a child. No stranger to the field of transplant or obstetrics is cytomegalovirus. Cytomegalovirus is both a frequent complication after transplant, presenting as an opportunistic infection, and a common congenital disease in the newborn child from pregnancy. To date, there have been no reported cases of pregnancy following uterus transplantation from cytomegalovirus-positive donors into cytomegalovirus-negative recipients. We present a case report describing our experience of a cytomegalovirus-negative recipient, transplanted with a uterus from a cytomegalovirus-positive living donor, and subsequently diagnosed with active cytomegalovirus infection despite prophylactic treatment. She was treated for infection prior to embryo transfer and carried a healthy child to term. This case suggests transplanting a cytomegalovirus-positive uterus into a negative donor is possible to do safely.
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Affiliation(s)
- Matthew Rosenzweig
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Cedric W Spak
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.,Division of Transplant Infectious Diseases, Baylor University Medical Center, Dallas, TX, USA
| | - Giuliano Testa
- 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.,Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA
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13
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Davidson T, Ekberg J, Sandman L, Brännström M. The costs of human uterus transplantation: a study based on the nine cases of the initial Swedish live donor trial. Hum Reprod 2021; 36:358-366. [PMID: 33247912 DOI: 10.1093/humrep/deaa301] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/08/2020] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Thomas Davidson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jana Ekberg
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Lars Sandman
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.,Stockholm IVF-EUGIN, Stockholm, Sweden
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14
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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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15
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Chattopadhyay R, Richards E, Libby V, Flyckt R. Preimplantation genetic testing for aneuploidy in uterus transplant patients. Ther Adv Reprod Health 2021; 15:26334941211009848. [PMID: 33959719 PMCID: PMC8064656 DOI: 10.1177/26334941211009848] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 03/11/2021] [Indexed: 11/17/2022] Open
Abstract
Uterus transplantation is an emerging treatment for uterine factor infertility. In vitro fertilization with cryopreservation of embryos prior is required before a patient can be listed for transplant. Whether or not to perform universal preimplantation genetic testing for aneuploidy should be addressed by centers considering a uterus transplant program. The advantages and disadvantages of preimplantation genetic testing for aneuploidy in this unique population are presented. The available literature is reviewed to determine the utility of preimplantation genetic testing for aneuploidy in uterus transplantation protocols. Theoretical benefits of preimplantation genetic testing for aneuploidy include decreased time to pregnancy in a population that benefits from minimization of exposure to immunosuppressive agents and decreased chance of spontaneous abortion requiring a dilation and curettage. Drawbacks include increased cost per in vitro fertilization cycle, increased number of required in vitro fertilization cycles to achieve a suitable number of embryos prior to listing for transplant, and a questionable benefit to live birth rate in younger patients. Thoughtful consideration of whether or not to use preimplantation genetic testing for aneuploidy is necessary in uterus transplant trials. Age is likely a primary factor that can be useful in determining which uterus transplant recipients benefit from preimplantation genetic testing for aneuploidy.
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Affiliation(s)
- Rhea Chattopadhyay
- Department of Obstetrics and Gynecology, Case Western Reserve University School of Medicine, University Hospitals MacDonald Women's Hospital, Cleveland, OH, USA
| | - Elliott Richards
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
| | - Valerie Libby
- Department of Obstetrics and Gynecology, Case Western Reserve University School of Medicine, University Hospitals MacDonald Women's Hospital, Cleveland, OH, USA
| | - Rebecca Flyckt
- Department of Obstetrics and Gynecology, Case Western Reserve University School of Medicine, University Hospitals MacDonald Women's Hospital, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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16
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Twelve Live Births After Uterus Transplantation in the Dallas UtErus Transplant Study. Obstet Gynecol 2021; 137:241-249. [PMID: 33416285 DOI: 10.1097/aog.0000000000004244] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/05/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To describe aggregated pregnancy outcomes after uterus transplantation from a single, experienced center. METHODS This prospective study reports on live births among 20 women who received a uterus transplant from 2016 to 2019 at Baylor University Medical Center at Dallas. These live births occurred between November 2017 and September 2020. The main measures were live birth, maternal complications, and fetal and newborn outcomes. RESULTS There were six graft failures (four surgical complications and two with poor perfusion postoperatively). Of the 14 technically successful transplants, at least one live birth occurred in 11 patients. Thus far, the live birth rate per attempted transplant is 55%, and the live-birth rate per technically successful transplant is 79%. Ten uteri were from nondirected living donors and one uterus was from a deceased donor. In vitro fertilization was performed to achieve pregnancy. Ten recipients delivered one neonate, and one recipient delivered two neonates. One organ rejection episode was detected during pregnancy and was resolved with steroids. The median birth weight was 2,890 g (range 1,770-3,140 g [median 68th percentile]). Maternal weight gain was higher than Institute of Medicine recommendations. Maternal medical complications were observed in five recipients (elevated creatinine level, gestational diabetes, gestational hypertension [n=2], and preeclampsia). In five recipients, maternal medical or obstetric complications led to an unplanned preterm delivery (elevated creatinine level, preeclampsia; preterm labor [n=3]). The median gestational age at delivery was 36 6/7 weeks (range 30 6/7-38 weeks). All neonates were liveborn, with Apgar scores of 8 or higher at 5 minutes. CONCLUSION Over the first 3 years, our program experienced a live-birth rate per attempted transplant of 55% and a live-birth rate per technically successful transplant of 79%. In our experience, uterus transplantation resulted in a third-trimester live birth in all cases in which pregnancies reached 20 weeks of gestation. Maternal medical and obstetric complications can occur; however, these were manageable by applying principles of generally accepted obstetric practice. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02656550.
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17
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Johannesson L, Wall A, Warren AM, Gregg AR, Testa G. Decisions on second pregnancy after uterus transplantation and timing for removal of the uterus-DUETS (Dallas UtErus Transplant Study). BJOG 2021; 128:1610-1614. [PMID: 33660932 DOI: 10.1111/1471-0528.16685] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/30/2022]
Affiliation(s)
- L Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA.,Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA
| | - A Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - A M Warren
- Division of Trauma, Acute Care, and Critical Care Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - A R Gregg
- Department of Obstetrics and Gynecology, PRISMA Health - University of South Carolina School of Medicine, Columbia, SC, USA
| | - G Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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18
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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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19
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Iske J, Elkhal A, Tullius SG. The Fetal-Maternal Immune Interface in Uterus Transplantation. Trends Immunol 2021; 41:213-224. [PMID: 32109373 DOI: 10.1016/j.it.2020.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 01/10/2020] [Accepted: 01/11/2020] [Indexed: 12/16/2022]
Abstract
Uterus transplants (UTxs) have been performed worldwide. Overall frequencies have been low, but globally initiated UTx programs are expected to increase clinical implementation. The uterus constitutes a unique immunological environment with specific features of tissue renewal and a receptive endometrium. Decidual immune cells facilitate embryo implantation and placenta development. Although UTx adds to the complexity of immunity during pregnancy and transplantation, the procedure provides a unique clinical and experimental model. We posit that understanding the distinct immunological properties at the interface of the transplanted uterus, the fetus and maternal circulation might provide valuable novel insights while improving outcomes for UTx. Here, we discuss immunological challenges and opportunities of UTx affecting mother, pregnancy and healthy livebirths.
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Affiliation(s)
- Jasper Iske
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Institute of Transplant Immunology, Integrated Research and Treatment Center Transplantation, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Abdallah Elkhal
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefan G Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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20
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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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21
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Carmona F, Rius M, Díaz-Feijoo B, Musquera M, Tort J, Alcaraz A. Uterine transplantation. First viable case in Southern Europe. Med Clin (Barc) 2020; 156:297-300. [PMID: 33380366 DOI: 10.1016/j.medcli.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/10/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION AND OBJECTIVES To describe the development and characteristics living donor uterine transplantation program of the Hospital Clínic (Barcelona, Spain) and to report the first successful procedure in Southern Europe. PATIENTS AND METHODS A 31-year-old female suffering of Rokitansky Syndrome underwent uterus transplant from her living sister, as a part of our research protocol. Before the transplant, the patient underwent an in vitro fertilization procedure and twelve embryos were obtained and cryopreserved. The uterus obtention procedure was performed entirely by robotic surgery and lasted 10h, being the main objective to obtain arterial and venous pedicles of good quality in order to ensure the vitality of the graft. The surgical procedure in the recipient was performed by laparotomy and the vascular anastomoses were performed in a terminolateral fashion, with polypropylene 8-0, the vaginal cuff of the graft was sutured to the recipient vaginal vault and the round and utero-sacral ligaments were fixed to the remaining recipient ligaments. Immunosuppressive treatment was prescribed following the protocols from other groups modified according to the solid organ transplantation protocols from our center. RESULTS The donor and recipient were discharged without any major complications. The recipient ultrasound scan showed a normal flow in both uterine arteries and veins. A grade II rejection was treated with high dose corticoids with subsequent normal biopsies and a vaginal stricture was treated with the placement of an esophageal stent for 4 weeks. The patient had her first menstrual period 47 days after the surgery. CONCLUSIONS The case reported here open new options in Spain for a wide group of patients that had no medical solution for a disease that deeply impairs their quality of life.
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Affiliation(s)
- Francisco Carmona
- Service of Gynecology, Institut Clínic de Ginecologia, Obstetrícia, i Neonatologia, Hospital Clinic of Barcelona, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; Institut d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Villarroel 170, 08036 Barcelona, Spain.
| | - Mariona Rius
- Service of Gynecology, Institut Clínic de Ginecologia, Obstetrícia, i Neonatologia, Hospital Clinic of Barcelona, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Berta Díaz-Feijoo
- Service of Gynecology, Institut Clínic de Ginecologia, Obstetrícia, i Neonatologia, Hospital Clinic of Barcelona, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain; Institut d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Villarroel 170, 08036 Barcelona, Spain
| | - Mireia Musquera
- Service of Urology, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
| | - Jaume Tort
- Organització Catalana de Trasplantaments (OCATT), Passeig del Taulat, 106-116, 08005 Barcelona, Spain
| | - Antonio Alcaraz
- Service of Urology, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain
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22
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Chmel R, Cekal M, Pastor Z, Chmel R, Paulasova P, Havlovicova M, Macek M, Novackova M. Assisted Reproductive Techniques and Pregnancy Results in Women with Mayer-Rokitansky-Küster-Hauser Syndrome Undergoing Uterus Transplantation: the Czech Experience. J Pediatr Adolesc Gynecol 2020; 33:410-414. [PMID: 32224249 DOI: 10.1016/j.jpag.2020.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 03/16/2020] [Accepted: 03/19/2020] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVE This study aimed to evaluate the reproductive potential of patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) who were candidates for uterus transplantation (UTx) before inclusion in the experimental trial, and to summarize the existing experience with posttransplantation embryo transfers in functionally successful cases. DESIGN AND SETTING A prospective study at a tertiary medical center. PARTICIPANTS Ten pre-UTx women with MRKHS and 7 successful UTx cases. INTERVENTIONS AND MAIN OUTCOME MEASURES Ovarian stimulations, frozen embryo collection, embryo transfers, and incidence of pregnancy in MRKHS women in the pre- and posttransplantation periods. RESULTS The average number of ovarian stimulations to collect the required frozen embryos was 1.9 (1-3). On average, the number of aspirated oocytes was 16.4 (7-38), 12.6 (5-26) oocytes were fertilized, and 7.0 (1-18) embryos were cryopreserved per cycle. To date, the average number of embryo transfers per recipient was 4.9 (3-8), and the embryo transfer/pregnancy rate was 8.8% (3 of 34). Three pregnancies have been achieved to date, including a missed abortion in the 8th week, a birth in the 35th week, and an ongoing pregnancy in the 30th week. CONCLUSIONS Despite the small number of UTx cases, our data indicated that women with MRKHS showed a good response to ovarian stimulation and blastocyst formation. Although the procedures for fertilization, cryopreservation, and transfer of the embryos were standardized, the success rate per embryo transfer achieved in the study group has been low to date.
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Affiliation(s)
- Roman Chmel
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic.
| | - Milos Cekal
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Zlatko Pastor
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Roman Chmel
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Petra Paulasova
- Department of Biology and Medical Genetics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Marketa Havlovicova
- Department of Biology and Medical Genetics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Milan Macek
- Department of Biology and Medical Genetics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Marta Novackova
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
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Chmel R, Novackova M, Pastor Z. Lessons learned from the Czech uterus transplant trial related to surgical technique that may affect reproductive success. Aust N Z J Obstet Gynaecol 2020; 60:625-627. [PMID: 32573763 DOI: 10.1111/ajo.13184] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 05/07/2020] [Indexed: 12/19/2022]
Abstract
Uterus transplantation is an experimental method in the treatment of infertility in women with congenital or acquired absence of uterus. The majority of uterus transplants worldwide have been performed in women with Mayer-Rokitansky-Küster-Hauser syndrome, with neovagina and absent uterus. We report two aspects affecting reproductive success related to the surgical technique of transplantation. The first is the stenosis of vaginal-neovaginal anastomosis between the graft's vaginal rim and the recipient's neovagina. The second is a firm fixation of the uterus close to the pubic symphysis. Both these aspects contribute to the technical difficulty of embryo transfer to the transplanted uterus.
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Affiliation(s)
- Roman Chmel
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Marta Novackova
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Zlatko Pastor
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
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24
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Kisu I, Banno K, Aoki D. Re: Rethinking the time interval to embryo transfer after uterus transplantation –
DUETS
(Dallas UtErus Transplant Study). BJOG 2019; 126:1508-1509. [DOI: 10.1111/1471-0528.15921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Iori Kisu
- Department of Obstetrics and Gynaecology Keio University School of Medicine Tokyo Japan
| | - Kouji Banno
- Department of Obstetrics and Gynaecology Keio University School of Medicine Tokyo Japan
| | - Daisuke Aoki
- Department of Obstetrics and Gynaecology Keio University School of Medicine Tokyo Japan
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