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Järvholm S, Kättström A, Kvarnström N, Dahm-Kähler P, Brännström M. Long-term health-related quality-of-life and psychosocial outcomes after uterus transplantation: a 5-year follow-up of donors and recipients. Hum Reprod 2024; 39:374-381. [PMID: 37995381 PMCID: PMC10833084 DOI: 10.1093/humrep/dead245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/29/2023] [Indexed: 11/25/2023] Open
Abstract
STUDY QUESTION What are the outcomes regarding health-related quality-of-life, mood, and marital relationship of recipients and donors 5 years after uterus transplantation (UTx) and uterus donation? SUMMARY ANSWER Both recipients and donors generally demonstrated long-term stability regarding psychosocial outcomes but with negative deviations associated with unsuccessful outcomes. WHAT IS KNOWN ALREADY UTx is the first infertility treatment for women with absolute uterine factor infertility. The procedure can be performed with either a uterus donation from a live donor (LD), typically a close relative, or from a deceased, multi-organ donor. There are many potential stressful events over several years after UTx both for recipients and for LDs and these events may have impacts on quality-of-life and mental well-being. STUDY DESIGN, SIZE, DURATION This, prospective observational cohort study includes the nine recipients and LDs of the first human UTx trial. They were assessed in 2017-2018 by questionnaires 5 years after UTx. PARTICIPANTS/MATERIALS, SETTING, METHODS The nine recipients (ages 32-43 years) and their respective LDs (ages 44-67 years) were either related (n = 8) or friends (n = 1). Eight recipients had congenital uterine absence and one was hysterectomized due to cervical cancer. For two recipients, UTx resulted in early graft failures, while six of the other seven recipients gave birth to a total of eight babies over the following 5 years. Physical and mental component summaries of health-related quality-of-life were measured with the SF-36 questionnaire. Mood was assessed by the Hospital Anxiety and Depression Scale. Relationship with partner was measured with the Dyadic Adjustment Scale. Comparisons were made between the values after 5 years and the values before uterus donation/transplantation. MAIN RESULTS AND THE ROLE OF CHANCE Five years after primary UTx, the majority of recipients scored above the predicted value of the general population on quality-of-life, except for two women, one of whom had a viable graft but no live birth and one recipient who was strained by quality-of-life changes, possibly related to parenthood transitions. Regarding mood, only one value (anxiety) was above the threshold for further clinical assessment. Recipients showed declining satisfaction with their marital relationships, but all reported scores above the 'at risk for divorce' threshold at the time of the final assessment in our study. The LDs were all found to be stable and above the predicted value of the general population regarding mental components of quality-of-life. Three LDs showed declined physical components, possibly related to older age. Only one LD reported a value in mood (anxiety) that would need further assessment. The marital satisfaction of LDs remained stable and unchanged compared to baseline values. Notably, the two recipients with early graft failures, and their related LDs, regained their mental well-being during the first years after graft failure and remained stable after 5 years. LIMITATIONS, REASONS FOR CAUTION The restricted sample size and the single-centre study-design are limitations of this study. Additionally the study was limited to LD UTx, as opposed to deceased donor UTx. WIDER IMPLICATIONS OF THE FINDINGS Our study shows that both LDs and recipients had acceptable or favourable quality-of-life outcomes, including mood assessment, at the 5-year follow-up mark, and that failure to achieve a live birth negatively affected these modalities both for LDs and recipients. Moreover, an important finding was that LDs and recipients are not reacting with depression after hysterectomy, which is common after hysterectomy in the general population. STUDY FUNDING/COMPETING INTEREST(S) Funding was provided by the Jane and Dan Olsson Foundation for Science, Knut and Alice Wallenberg Foundation, Handlanden Hjalmar Svensson Foundation, Swedish Governmental ALF Grant, and Swedish Research Council. There are no conflicts of interest to disclose. TRIAL REGISTRATION NUMBER NCT01844362.
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Affiliation(s)
- Stina Järvholm
- Department of Obstetrics & Gynecology, Institue of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Alva Kättström
- Department of Obstetrics & Gynecology, Institue of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Niclas Kvarnström
- Transplantation, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics & Gynecology, Institue of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Mats Brännström
- Department of Obstetrics & Gynecology, Institue of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Stockholm IVF-EUGIN, Stockholm, Sweden
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Deans R, Pittman J, Gerstl B, Haghighi K, Pleass H, KÄhler PD, Kvarnström N, Hseih W, Keung K, Luxton G, Yong K, Caldas R, Byun L, Loo C, Tippett J, Caponas G, Moses D, Wan KM, Arulpragasam K, Kiely N, Brännström M, Abbott J. The first Australian uterus transplantation procedure: A result of a long-term Australian-Swedish research collaboration. Aust N Z J Obstet Gynaecol 2023. [PMID: 37029932 DOI: 10.1111/ajo.13678] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/20/2023] [Indexed: 04/09/2023]
Abstract
AIMS The aim is to report the results of Australia's first uterus transplantation (UTx). METHODS Following long-standing collaboration between the Swedish and Australian teams, Human Research Ethics approval was obtained to perform six UTx procedures in a collaborative multi-site research study (Western Sydney Local District Health 2019/ETH13038), including Royal Hospital for Women, Prince of Wales Hospital, and Westmead Hospital in New Souh Wales. Surgeries were approved in both the live donor (LD) and deceased donor models in collaboration with the inaugural Swedish UTx team. RESULTS This is the first UTx procedure to occur in Australia, involving a mother donating her uterus to her daughter. The total operative time for the donor was 9 h 54 min. Concurrently, recipient surgery was synchronised to minimise graft ischaemic time, and the total operative time for the recipient was 6 h 12 min. Surgery was by laparotomy in the LD and recipient. The total warm ischaemic time of the graft was 1 h 53 min, and the cold ischaemic time was 2 h 17 min (total ischaemic time 4 h 10 min). The patient's first menstruation occurred 33 days after the UTx procedure. CONCLUSION Twenty-five years of Swedish and Australian collaboration has led to Australia's first successfully performed UTx surgery at The Royal Hospital for Women, Sydney, Australia.
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Affiliation(s)
- Rebecca Deans
- Department of Gynaecology, Royal Hospital for Women, New South Wales, Sydney, Australia
- Department of Gynaecology, University of New South Wales, New South Wales, Sydney, Australia
| | - Jana Pittman
- Department of Gynaecology, Royal Hospital for Women, New South Wales, Sydney, Australia
- Department of Gynaecology, University of New South Wales, New South Wales, Sydney, Australia
| | - Brigitte Gerstl
- Department of Gynaecology, University of New South Wales, New South Wales, Sydney, Australia
| | - Koroush Haghighi
- Department of Gynaecology, University of New South Wales, New South Wales, Sydney, Australia
- Department of Gynaecology, Prince of Wales Hospital, New South Wales, Sydney, Australia
| | - Henry Pleass
- Department of Gynaecology, Westmead Hospital, New South Wales, Sydney, Australia
- Department of Gynaecology, Sydney University, New South Wales, Sydney, Australia
| | - Pernilla Dahm KÄhler
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy, Gothenburg, Sweden
- The Faculty of Medicine, University of Gothenburg, Sweden, Gothenburg, Sweden
| | - Niclas Kvarnström
- The Faculty of Medicine, University of Gothenburg, Sweden, Gothenburg, Sweden
| | - Wayne Hseih
- Department of Gynaecology, Royal Hospital for Women, New South Wales, Sydney, Australia
- Department of Gynaecology, University of New South Wales, New South Wales, Sydney, Australia
| | - Karen Keung
- Department of Gynaecology, Prince of Wales Hospital, New South Wales, Sydney, Australia
| | - Grant Luxton
- Department of Gynaecology, Prince of Wales Hospital, New South Wales, Sydney, Australia
| | - Kenneth Yong
- Department of Gynaecology, Prince of Wales Hospital, New South Wales, Sydney, Australia
| | - Rita Caldas
- Department of Gynaecology, Royal Hospital for Women, New South Wales, Sydney, Australia
| | - Lily Byun
- Department of Gynaecology, Royal Hospital for Women, New South Wales, Sydney, Australia
| | - Christine Loo
- Department of Gynaecology, Prince of Wales Hospital, New South Wales, Sydney, Australia
- Department of Clinical Pathology, South-Eastern Area Laboratory Services, New South Wales, Sydney, Australia
| | - John Tippett
- Department of Gynaecology, Royal Hospital for Women, New South Wales, Sydney, Australia
| | - George Caponas
- Department of Gynaecology, Royal Hospital for Women, New South Wales, Sydney, Australia
| | - Daniel Moses
- Department of Gynaecology, University of New South Wales, New South Wales, Sydney, Australia
- Department of Gynaecology, Prince of Wales Hospital, New South Wales, Sydney, Australia
| | - King-Man Wan
- Department of Gynaecology, Royal Hospital for Women, New South Wales, Sydney, Australia
- Department of Gynaecology, University of New South Wales, New South Wales, Sydney, Australia
| | - Kaushalya Arulpragasam
- Department of Gynaecology, Royal Hospital for Women, New South Wales, Sydney, Australia
- Department of Gynaecology, University of New South Wales, New South Wales, Sydney, Australia
| | - Neill Kiely
- Department of Gynaecology, Royal Hospital for Women, New South Wales, Sydney, Australia
| | - Mats Brännström
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy, Gothenburg, Sweden
- The Faculty of Medicine, University of Gothenburg, Sweden, Gothenburg, Sweden
| | - Jason Abbott
- Department of Gynaecology, Royal Hospital for Women, New South Wales, Sydney, Australia
- Department of Gynaecology, University of New South Wales, New South Wales, Sydney, Australia
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Brännström M, Dahm-Kähler P, Kvarnström N, Enskog A, Olofsson JI, Olausson M, Mölne J, Akouri R, Järvholm S, Nilsson L, Stigson L, Hagberg H, Bokström H. Reproductive, obstetric, and long-term health outcome after uterus transplantation: results of the first clinical trial. Fertil Steril 2022; 118:576-585. [PMID: 35697530 DOI: 10.1016/j.fertnstert.2022.05.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 05/11/2022] [Accepted: 05/11/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate reproductive, obstetric, and long-term health of the first completed study of uterus transplantation (UTx). DESIGN Prospective. SETTING University hospital. PATIENT(S) Nine live donor UTx procedures were conducted and seven were successful. Donors, recipients, and children born were observed. INTERVENTION(S) In vitro fertilization was performed with embryo transfer (ET) of day 2 or day 5 embryos in natural cycles. Pregnancies and growth trajectory of the children born were observed. Health-related quality of life, psychosocial outcome, and medical health of donors and recipients were evaluated by questionnaires. MAIN OUTCOME MEASURE(S) The results of in vitro fertilization, pregnancies, growth of children, and long-term health of patients were reported. RESULT(S) Six women delivered nine infants, with three women giving birth twice (cumulative birth rates of 86% and 67% in surgically successful and performed transplants, respectively). The overall clinical pregnancy rate (CPR) and live birth rate (LBR) per ET were 32.6% and 19.6%, respectively. For day 2 embryos, the CPR and LBR per ET were 12.5% and 8.6%, respectively. For day 5 embryos, the CPR and LBR per ET were 81.8% and 45.4%, respectively. Fetal growth and blood flow were normal in all pregnancies. Time of delivery (median in full pregnancy weeks + days [ranges]) by cesarean section and weight deviations was 35 + 3 (31 + 6 to 38 + 0) and -1% (-13% to 23%), respectively. Three women developed preeclampsia and four neonates acquired respiratory distress syndrome. All children were healthy and followed a normal growth trajectory. Measures of long-term health in both donors and recipients were noted to be favorable. When UTx resulted in a birth, scores for anxiety, depression, and relationship satisfaction were reassuring for both the donors and recipients. CONCLUSION(S) The results of this first complete UTx trial show that this is an effective infertility treatment, resulting in births of healthy children and associated with only minor psychological and medical long-term effects for donors and recipients. CLINICAL TRIAL REGISTRATION NUMBER NCT02987023.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF-EUGIN, Stockholm, Sweden.
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Enskog
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan I Olofsson
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Michael Olausson
- Department of Transplantation, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Mölne
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Randa Akouri
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stina Järvholm
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Nilsson
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lennart Stigson
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Hagberg
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Bokström
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Ayoubi JM, Carbonnel M, Kvarnström N, Revaux A, Poulain M, Vanlieferinghen S, Coatantiec Y, Le Marchand M, Tourne M, Pirtea P, Snanoudj R, Le Guen M, Dahm-Kähler P, Racowsky C, Brännström M. Case Report: Post-Partum SARS-CoV-2 Infection After the First French Uterus Transplantation. Front Surg 2022; 9:854225. [PMID: 35836605 PMCID: PMC9273879 DOI: 10.3389/fsurg.2022.854225] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/11/2022] [Indexed: 12/15/2022] Open
Abstract
Absolute uterus factor infertility, whether congenital or acquired, renders the woman unable to carry a child. Although uterus transplantation (UTx) is being increasingly performed as a non-vital procedure to address this unfortunate condition, the immunosuppression required presents risks that are further compounded by pregnancy and during the puerperium period. These vulnerabilities require avoidance of SARS-CoV-2 infection in pregnant UTx recipients especially during the third trimester, as accumulating evidence reveals increased risks of morbidity and mortality. Here we describe a successful UTx case with delivery of a healthy child, but in which both mother and neonate developed asymptomatic SARS-CoV-2 infection seven days after RNA vaccination, on day 35 post-partum. Although the patient was successfully treated with a combination therapy comprised of two monoclonal antibodies, this case highlights the challenges associated with performing UTx in the era of Covid-19. More broadly, the risks of performing non-vital organ transplantation during a pandemic should be discussed among team members and prospective patients, weighing the risks against the benefits in improving the quality of life, which were considerable for our patient who achieved motherhood with the birth of a healthy child.
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Affiliation(s)
- Jean Marc Ayoubi
- Department of Obstetrics Gynecology and Reproductive Medicine, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Marie Carbonnel
- Department of Obstetrics Gynecology and Reproductive Medicine, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Aurelie Revaux
- Department of Obstetrics Gynecology and Reproductive Medicine, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Marine Poulain
- Department of Obstetrics Gynecology and Reproductive Medicine, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Sarah Vanlieferinghen
- Department of Obstetrics Gynecology and Reproductive Medicine, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | | | | | - Morgan Tourne
- Department of Pathology, Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Paul Pirtea
- Department of Obstetrics Gynecology and Reproductive Medicine, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Renaud Snanoudj
- Department of Nephrology and Transplantation, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Morgan Le Guen
- Department of Anesthesiology, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Catherine Racowsky
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA
| | - Mats Brännström
- Neonatal Care Unit, Foch Hospital, Suresnes, France.,Stockholm IVF-EUGIN, Stockholm, Sweden
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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] [What about the content of this article? (0)] [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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Karlsson CC, Dahm-Kähler P, Kvarnström N, Mölne J, Broecker V, Brännström M. Hysterectomy after uterus transplantation and detailed analyses of graft failures. Acta Obstet Gynecol Scand 2021; 101:355-363. [PMID: 34907538 DOI: 10.1111/aogs.14304] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/25/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The first live birth after uterus transplantation occurred in Sweden in 2014. Uterus transplantation has repeatedly, and at many centers worldwide, proven to be a feasible treatment for absolute uterine factor infertility. Hysterectomy in live donors and transplantation are well described in numerous reports. However, there are no reports of hysterectomy in the recipient after uterus transplantation, which will occur at either graft failure, after childbirth, or after numerous failed pregnancy attempts. We present the first report of hysterectomy in recipients after uterus transplantation with detailed analyses of findings in conjunction with graft failures. MATERIAL AND METHODS An analysis of recipient hysterectomies (n = 10), performed in 2012-2020, was conducted. Data from the international uterus transplantation registry (ISUTx registry) were extracted, and medical records were systematically reviewed, to collect and compile characteristics of recipients and donors, as well as pre-, per-, and postoperative data, including clinical course of graft failures. RESULTS Hysterectomy in recipients was performed in conjunction with cesarean section (n = 3), 3-6 months after cesarean section (n = 3), or after failed pregnancy attempts (n = 1) or graft failure (n = 3). The durations of anesthesia (2 h 36 min to 7 h 35 min) and hysterectomy surgery (1 h 42 min to 5 h 52 min) ranged widely, with long perioperative interruptions for insertion of ureteral catheters in two cases. Adhesions to the uterus were abundant, the majority being mild. Three uteri that subsequently showed graft failure (hysterectomy at 1, 3, and 8 months post transplantation) showed histological signs of ischemia in biopsies taken 1-week post-transplant and early signs of central hypoperfusion by Doppler ultrasound. In these graft failure explants, there were no epithelial linings in the uterine cavity or in the cervix. The inner uterine wall was severely ischemic and/or necrotic, whereas outer parts were partly viable. There were signs of moderate atherosclerosis of uterine arteries but no rejection. Mild postoperative complications were frequent (6/10), with one supravaginal hematoma requiring surgical drainage. CONCLUSIONS Hysterectomy after uterus transplantation is a complex and time-consuming procedure, and perioperative ureteral catheters may be helpful. Histopathology of early cervical biopsies showing ischemic signs may indicate subsequent irreversible damage, leading to graft failure.
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Affiliation(s)
- Camilla C Karlsson
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Mölne
- Department of Clinical Pathology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Verena Broecker
- Department of Clinical Pathology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Stockholm IVF-Eugin, Stockholm, Sweden
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Abstract
PURPOSE OF REVIEW Donor hysterectomy for live donor uterus transplantation was from the start performed by laparotomy, but minimal invasive surgery has entered the scene. In particular robotic-assisted laparoscopy is used since robotics is advantageous in the complex donor hysterectomy surgery in narrow space. This review covers the development and benefits of robotics and the published robotic donor hysterectomy experiences. RECENT FINDINGS Robotic donor hysterectomy publications are scarce with eight cases in Sweden, five in USA, and one each in China and Spain. Robotics have been performed for either the entire donor hysterectomy or with conversion to laparotomy for the last steps of the surgical procedure. The total operative times are in line with open surgery, although a decrease is expected in the future. The estimated blood loss and hospital stays are less than at open surgery. The complication panorama includes hydronephrosis, ureteric fistula and pressure alopecia. Live births with healthy babies have been reported. SUMMARY In uterus transplantation, robotic live donor hysterectomy has proven to be feasible, safe and associated with successful live births. The robotic donor hysterectomy is a low-volume procedure and an international registry to gather collective information is crucial for further evaluation and development.
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Affiliation(s)
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy at University of Gothenburg, Gothenburg
| | - Mats Brännström
- Department of Obstetrics and Gynecology
- Stockholm IVF-EUGIN, Stockholm, Sweden
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Leonhardt H, Thilander-Klang A, Båth J, Johannesson M, Kvarnström N, Dahm-Kähler P, Brännström M. Imaging evaluation of uterine arteries in potential living donors for uterus transplantation: a comparative study of MRA, CTA, and DSA. Eur Radiol 2021; 32:2360-2371. [PMID: 34767069 PMCID: PMC8921132 DOI: 10.1007/s00330-021-08350-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/08/2021] [Accepted: 09/20/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate uterine arteries (UA) of potential living donors for uterus transplantation (UTx) by comparison of CT angiography (CTA), digital subtraction angiography (DSA), and MR angiography (MRA) with care taken to minimize radiation doses. METHODS Prospective donors for a clinical UTx trial were included. CTA, DSA, and MRA measurements in three predefined segments of the UAs were evaluated. Radiation doses were estimated and 1-year graft survival was recorded. RESULTS Twelve potential donors (age 37-62 years) were investigated. There was no difference in visualized average UA lumen diameter when comparing CTA (mean 2.0 mm, SD 0.4), DSA (mean 2.1 mm, SD 0.6), and MRA (mean 2.0 mm, SD 0.3). MRA was not able to fully evaluate 10 (43%) out of 23 UA that proved to be patent on DSA. One UA was not identified by any of the modalities, and three MRA-absent UAs were identified by both CTA and DSA. The estimated mean effective dose was lower for DSA (5.1 mSv, SD 2.8) than CTA (7.1 mSv, SD 2.0), but not significantly (p value = 0.06). Three potential donors were excluded due to UA pathology and one due to adenomyosis. Eight donors underwent hysterectomy, with 1-year graft survival in six women. CONCLUSION MRI including MRA should be the initial modality to examine potential UTx donors to acquire valuable details of uterine anatomy, and if UAs are fully visualized, there is no need for further angiographic methods with radiation. If UAs are not visualized by MRA, CTA may be performed and in selective cases with addition of the invasive modality DSA. KEY POINTS • For uterine transplantation, pelvic MRI with MRA provides information of the uterine structure and of the diameters of uterine arteries in living donors. • Failure of MRA to demonstrate uterine arteries could be followed by CTA which will visualize the uterine arteries in a majority of cases. If MRA and additional CTA provide inconclusive results, the uterine arteries should be further evaluated by DSA. • Information of CTA can be used in the angio-system for DSA settings to minimize the radiation and contrast media doses.
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Affiliation(s)
- Henrik Leonhardt
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Sahlgrenska Academy at University of Gothenburg, Bruna stråket 11B, SE-413 45, Gothenburg, Sweden.
| | - Anne Thilander-Klang
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - John Båth
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Sahlgrenska Academy at University of Gothenburg, Bruna stråket 11B, SE-413 45, Gothenburg, Sweden
| | - Marit Johannesson
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Sahlgrenska Academy at University of Gothenburg, Bruna stråket 11B, SE-413 45, Gothenburg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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Dahm-Kähler P, Kvarnström N, Alfonzo Rodriguez E, Skogsberg Dahlgren U, Brännström M. Uterus transplantation for fertility preservation in patients with gynecologic cancer. Int J Gynecol Cancer 2021; 31:371-378. [PMID: 33649004 DOI: 10.1136/ijgc-2020-001804] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 11/04/2022] Open
Abstract
Cervical and endometrial cancer may impact women interested in future fertility in approximately 5-25% of cases. The recommended treatment for patients with early stage disease is hysterectomy and/or radiation leading to infertility. This is referred to as absolute uterine factor infertility. Such infertility was considered untreatable until 2014, when the first child was born after uterus transplantation. Thereafter, multiple births have been reported, mainly from women with Mayer-Rokitansky-Küster-Hauser syndrome, with congenital uterine absence, although also from a patient with iatrogenic uterine factor infertility caused by radical hysterectomy secondary to an early stage cervical cancer 7 years before uterus transplantation. A live birth after uterus transplantation may be considered promising for many who may not otherwise have this option.Uterus transplantation is a complex process including careful patient selection in both recipients and donors, in vitro fertilization, and complex surgery in the organ procurement procedure including harvesting the vessel pedicles with the thin-walled veins. Thereafter, the transplantation surgery with anastomosis to ensure optimal blood inflow and outflow of the transplanted organ. Knowledge regarding immunosuppression and pregnancy is essential. Lastly there is the hysterectomy component as the uterus must be removed. Multidisciplinary teams working closely are essential to achieve successful uterus transplantation and, ultimately, delivery of a healthy child. Both the living and deceased donor concept may be considered and we address both the advantages and disadvantages. This review summarizes the animal research thus far published on uterus transplantation, the suggested recipient selections including former gynecologic cancer patients, the living and deceased donor uterus transplantation concepts with reported results, and updated fertility outcomes.
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Affiliation(s)
- Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, Goteborg, Sweden
| | | | | | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, Gothenburg, Sweden
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10
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Pelanis E, Teatini A, Eigl B, Regensburger A, Alzaga A, Kumar RP, Rudolph T, Aghayan DL, Riediger C, Kvarnström N, Elle OJ, Edwin B. Evaluation of a novel navigation platform for laparoscopic liver surgery with organ deformation compensation using injected fiducials. Med Image Anal 2020; 69:101946. [PMID: 33454603 DOI: 10.1016/j.media.2020.101946] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 11/28/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022]
Abstract
In laparoscopic liver resection, surgeons conventionally rely on anatomical landmarks detected through a laparoscope, preoperative volumetric images and laparoscopic ultrasound to compensate for the challenges of minimally invasive access. Image guidance using optical tracking and registration procedures is a promising tool, although often undermined by its inaccuracy. This study evaluates a novel surgical navigation solution that can compensate for liver deformations using an accurate and effective registration method. The proposed solution relies on a robotic C-arm to perform registration to preoperative CT/MRI image data and allows for intraoperative updates during resection using fluoroscopic images. Navigation is offered both as a 3D liver model with real-time instrument visualization, as well as an augmented reality overlay on the laparoscope camera view. Testing was conducted through a pre-clinical trial which included four porcine models. Accuracy of the navigation system was measured through two evaluation methods: liver surface fiducials reprojection and a comparison between planned and navigated resection margins. Target Registration Error with the fiducials evaluation shows that the accuracy in the vicinity of the lesion was 3.78±1.89 mm. Resection margin evaluations resulted in an overall median accuracy of 4.44 mm with a maximum error of 9.75 mm over the four subjects. The presented solution is accurate enough to be potentially clinically beneficial for surgical guidance in laparoscopic liver surgery.
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Affiliation(s)
- Egidijus Pelanis
- The Intervention Centre, Oslo University Hospital Rikshospitalet 0424, Oslo, Norway; Institute of Clinical Medicine, University of Oslo 1072, Oslo, Norway.
| | - Andrea Teatini
- The Intervention Centre, Oslo University Hospital Rikshospitalet 0424, Oslo, Norway; Department of Informatics, University of Oslo 1072, Oslo, Norway
| | | | | | | | - Rahul Prasanna Kumar
- The Intervention Centre, Oslo University Hospital Rikshospitalet 0424, Oslo, Norway
| | | | - Davit L Aghayan
- The Intervention Centre, Oslo University Hospital Rikshospitalet 0424, Oslo, Norway; Institute of Clinical Medicine, University of Oslo 1072, Oslo, Norway; Department of Surgery N1, Yerevan State Medical University, 0025 Yerevan, Armenia
| | - Carina Riediger
- University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | | | - Ole Jakob Elle
- The Intervention Centre, Oslo University Hospital Rikshospitalet 0424, Oslo, Norway; Department of Informatics, University of Oslo 1072, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital Rikshospitalet 0424, Oslo, Norway; Institute of Clinical Medicine, University of Oslo 1072, Oslo, Norway; Department of Hepato-Pancreatic-Biliary surgery 0424, Oslo University Hospital, Oslo, Norway
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11
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Menjivar A, Torres X, Manyalich M, Fehrman-Ekholm I, Papachristou C, de Sousa-Amorim E, Paredes D, Hiesse C, Yucetin L, Oppenheimer F, Kondi E, Peri JM, Kvarnström N, Ballesté C, Dias L, Frade IC, Lopes A, Diekmann F, Revuelta I. Psychosocial risk factors for impaired health-related quality of life in living kidney donors: results from the ELIPSY prospective study. Sci Rep 2020; 10:21343. [PMID: 33288792 PMCID: PMC7721886 DOI: 10.1038/s41598-020-78032-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 11/06/2020] [Indexed: 01/10/2023] Open
Abstract
Living kidney donors' follow-up is usually focused on the assessment of the surgical and medical outcomes. Whilst the psychosocial follow-up is advocated in literature. It is still not entirely clear which exact psychosocial factors are related to a poor psychosocial outcome of donors. The aim of our study is to prospectively assess the donors' psychosocial risks factors to impaired health-related quality of life at 1-year post-donation and link their psychosocial profile before donation with their respective outcomes. The influence of the recipient's medical outcomes on their donor's psychosocial outcome was also examined. Sixty donors completed a battery of standardized psychometric instruments (quality of life, mental health, coping strategies, personality, socio-economic status), and ad hoc items regarding the donation process (e.g., motivations for donation, decision-making, risk assessment, and donor-recipient relationship). Donors' 1-year psychosocial follow-up was favorable and comparable with the general population. So far, cluster-analysis identified a subgroup of donors (28%) with a post-donation reduction of their health-related quality of life. This subgroup expressed comparatively to the rest, the need for more pre-donation information regarding surgery risks, and elevated fear of losing the recipient and commitment to stop their suffering.
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Affiliation(s)
- Ana Menjivar
- Medical School, University of Barcelona, Barcelona, Spain.,Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Xavier Torres
- Psychiatry and Clinical Psychology Service, Institut Clinic de Neurociencies, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Marti Manyalich
- Medical School, University of Barcelona, Barcelona, Spain.,Transplant Assessorial Unit, Medical Direction, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Ingela Fehrman-Ekholm
- Karolinska Institutet, Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Christina Papachristou
- Department for Internal Medicine and Psychosomatics, Charité, University Medicine, Berlin, Germany.,School of Psychology, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Erika de Sousa-Amorim
- Department of Nephrology and Renal Transplant, Hospital Clinic of Barcelona, Barcelona, Spain
| | - David Paredes
- Medical School, University of Barcelona, Barcelona, Spain.,Donation and Transplant Coordination Section, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Christian Hiesse
- Service de Néphrologie et de Transplantation Rénale, Hôpital Foch, Suresnes Cedex, France
| | - Levent Yucetin
- Organ Transplant Coordination, Antalya Medical Park Hospital, Antalya, Turkey
| | - Federico Oppenheimer
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Nephrology and Renal Transplant, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Entela Kondi
- Medical School, University of Barcelona, Barcelona, Spain.,Transplant Assessorial Unit, Medical Direction, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Josep Maria Peri
- Psychiatry and Clinical Psychology Service, Institut Clinic de Neurociencies, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Chloë Ballesté
- Medical School, University of Barcelona, Barcelona, Spain
| | - Leonidio Dias
- Nephrology and Transplant Departments, Hospital Geral de Santo António, Porto, Portugal
| | - Inês C Frade
- Liaison-Psychiatry and Health Psychology Unit, Hospital Geral de Santo António, Porto, Portugal
| | - Alice Lopes
- Liaison-Psychiatry and Health Psychology Unit, Hospital Geral de Santo António, Porto, Portugal
| | - Fritz Diekmann
- Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Nephrology and Renal Transplant, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Ignacio Revuelta
- Medical School, University of Barcelona, Barcelona, Spain. .,Laboratori Experimental de Nefrologia I Trasplantament (LENIT), Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain. .,Department of Nephrology and Renal Transplant, Hospital Clinic of Barcelona, Barcelona, Spain.
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12
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Brännström M, Kvarnström N, Groth K, Akouri R, Wiman L, Enskog A, Dahm-Kähler P. Evolution of surgical steps in robotics-assisted donor surgery for uterus transplantation: results of the eight cases in the Swedish trial. Fertil Steril 2020; 114:1097-1107. [DOI: 10.1016/j.fertnstert.2020.05.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/30/2022]
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13
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Akouri R, Maalouf G, Abboud J, Nakad T, Bedran F, Hajj P, Beaini C, Cricu LM, Aftimos G, El Hajj C, Eid G, Waked A, Hallit R, Gerges C, Rached EA, Matta M, El Khoury M, Barakat A, Kvarnström N, Dahm-Kähler P, Brännström M. First live birth after uterus transplantation in the Middle East. Middle East Fertil Soc J 2020. [DOI: 10.1186/s43043-020-00041-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Abstract
Background
The first live birth after uterus transplantation took place in Sweden in 2014. It was the first ever cure for absolute uterine factor infertility. We report the surgery, assisted reproduction, and pregnancy behind the first live birth after uterus transplantation in the Middle East, North Africa, and Turkey (MENAT) region.
A 24-year old woman with congenital absence of the uterus underwent transplantation of the uterus donated by her 50-year-old multiparous mother. In vitro fertilization was performed to cryopreserve embryos. Both graft retrieval and transplantation were performed by laparotomy. Donor surgery included isolation of the uterus, together with major uterine arteries and veins on segments of the internal iliac vessels bilaterally, the round ligaments, and the sacrouterine ligaments, as well as with bladder peritoneum. Recipient surgery included preparation of the vaginal vault, end-to-side anastomosis to the external iliac arteries and veins on each side, and then fixation of the uterus.
Results
One in vitro fertilization cycle prior to transplantation resulted in 11 cryopreserved embryos. Surgical time of the donor was 608 min, and blood loss was 900 mL. Cold ischemia time was 85 min. Recipient surgical time was 363 min, and blood loss was 700 mL. Anastomosis time was 105 min. Hospital stay was 7 days for both patients. Ten months after the transplantation, one previously cryopreserved blastocyst was transferred which resulted in viable pregnancy, which proceeded normally (except for one episode of minor vaginal bleeding in the 1st trimester) until cesarean section at 35 + 1 weeks due to premature contractions and shortened cervix. A healthy girl (Apgar 9-10-10) weighing 2620 g was born in January 2020, and her development has been normal during the first 6 months.
Conclusions
This is the first report of a healthy live birth after uterus transplantation in the MENAT region. We hope that this will motivate further progress and additional clinical trials in this area in the Middle East Region, where the first uterus transplantation attempt ever, however unsuccessful, was performed already three decades ago.
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Järvholm S, Dahm-Kähler P, Kvarnström N, Brännström M. Psychosocial outcomes of uterine transplant recipients and partners up to 3 years after transplantation: results from the Swedish trial. Fertil Steril 2020; 114:407-415. [PMID: 32709381 DOI: 10.1016/j.fertnstert.2020.03.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/16/2020] [Accepted: 03/30/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess the psychosocial outcomes of recipients and their partners 2 and 3 years after entering this first clinical uterus transplantation study. DESIGN Prospective observational study. SETTING University hospital. PATIENT(S) Nine women with absolute uterine factor infertility and their male partners participated. INTERVENTION(S) Psychosocial evaluations using questionnaires focusing on health-related quality-of-life, mood, relationship, and fertility-related quality-of-life were conducted at 2- and 3-year follow-up after transplantation. MAIN OUTCOME MEASURE(S) Scores were obtained on the validated questionnaires 36-Item Short Form Survey (SF-36), Hospital Anxiety and Depression Scale, Dyadic Adjustment Scale, and Fertility Quality of life measuring health-related quality-of-life, mood, relationship, and infertility-associated life quality, respectively. RESULT(S) There was a reversible decrease (at year 2) in the physical component of SF-36 concerning recipients, but not in partners. Negative deviations in the mental component of SF-36 were seen in four recipients, and in two of their partners at year 3, possibly related to the fact that live birth had not been achieved yet among three of these women. Childlessness also seemed to be related to reporting elevated anxiety scores. Most recipients and partners stated high satisfaction with marital relationship both at inclusion and at follow-up. CONCLUSION(S) The results of the present study show that even if the baseline psychosocial characteristics of the women to undergo transplantation and their partners were stable and equal or better compared with norm populations, graft failure and failure to achieve parenthood will pose psychological strains on couples in the period up to 3 years after transplantation. Psychological counseling should be offered past 3 years for recipients and their partners. CLINICAL TRIAL REGISTRATION NUMBER NCT01844362.
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Affiliation(s)
- Stina Järvholm
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at the University of Gothenburg, Göteborg, Sweden.
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at the University of Gothenburg, Göteborg, Sweden
| | - Niclas Kvarnström
- Department Transplantation, Sahlgrenska Academy at the University of Gothenburg, Göteborg, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at the University of Gothenburg, Göteborg, Sweden; Stockholm IVF-EUGIN, Stockholm, Sweden
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15
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Järvholm S, Kvarnström N, Dahm-Kähler P, Brännström M. Donors' health-related quality-of-life and psychosocial outcomes 3 years after uterus donation for transplantation. Hum Reprod 2020; 34:1270-1277. [PMID: 31241745 DOI: 10.1093/humrep/dez087] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/24/2019] [Indexed: 01/04/2023] Open
Abstract
STUDY QUESTION What are the effects on donors' health-related quality-of-life, mood and marital relationship 2 and 3 years after uterus donation for transplantation? SUMMARY ANSWER Overall, uterus donors were relatively stable regarding health-related quality-of-life, mood and marital relationship after donation, although slight negative deviations existed in a few participants, presumably associated with older age or with continued non-pregnancy outcomes from the donation. WHAT IS KNOWN ALREADY Uterus transplantation has recently proved to be a successful treatment for absolute uterine factor infertility. However, there is no previous research on health-related quality-of-life and long-term psychosocial outcomes of donors. The present cohort of nine donors represents the cases of the first clinical uterus transplantation study, which took place in Sweden. Long-term follow-up studies of health-related quality-of-life in other living donors, such as of kidneys and livers, suggest that donors have above average quality-of-life prior to donation and that this typically continues during the years after donation. In our previous 1-year report on psychosocial and quality-of-life outcomes, we found that two out of nine donors showed decreased health-related quality-of-life at 6 and 12 months post donation. STUDY DESIGN, SIZE, DURATION This complete, prospective cohort study included the nine donors of the first uterus transplantation trial, which took place in Sweden in 2013. Donors were assessed by questionnaires 2 and 3 years after surgery for uterus donation. PARTICIPANTS/MATERIALS, SETTING, METHODS The nine donors (aged 39 to 62 years) were all a close relative or friend of their recipient. Physical and mental component summaries of health-related quality-of-life were measured with the SF-36 questionnaire. Mood was assessed by the Hospital Anxiety Depression Scale. Relationship with partner was measured with the Dyadic Adjustment Scale. MAIN RESULTS AND THE ROLE OF CHANCE The physical and mental components of the SF-36 were generally above the mean scores for a normative population. At Year 3, the two oldest donors (above 60 years of age at surgery) showed clear negative deviations in the physical component. The mental component summary of SF-36 was essentially unaltered overall at Year 2, but slight negative deviations were seen in three donors at Year 3. These three donors were among the four with unsuccessful pregnancy outcomes for the recipients following donation. Scores of anxiety and depression (mood) were within normative values for all donors at Year 2, but one donor presented with increased (worse) values for both variables at Year 3. Two donors showed signs of relationship distress during the follow-up period and another had divorced during this period. LIMITATIONS, REASONS FOR CAUTION The small sample size is a limitation. WIDER IMPLICATIONS OF THE FINDINGS The present study suggests that live uterus donation does not in general negatively influence health-related quality-of-life, mood and relationship in a 2 to 3-year perspective follow-up. Longer follow-up studies, including larger number of donors and in different cultural settings, are needed. STUDY FUNDING/COMPETING INTEREST(S) The Jane and Dan Olsson Foundation for Science; the Wallenberg Foundation; an ALF grant from the Swedish state under an agreement between the government and the county councils; the Swedish Research Council; a Ferring Pharmaceuticals scholarship in memory of Robert Edwards; and the Iris Jonzén-Sandbloms and Greta Jonzéns Foundation. The authors have no competing interests. TRIAL REGISTRATION NUMBER NCT01844362.
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Affiliation(s)
- Stina Järvholm
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Stockholm IVF, EUGIN, Stockholm, Sweden
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Brännström M, Dahm-Kähler P, Kvarnström N, Akouri R, Rova K, Olausson M, Groth K, Ekberg J, Enskog A, Sheikhi M, Mölne J, Bokström H. Live birth after robotic-assisted live donor uterus transplantation. Acta Obstet Gynecol Scand 2020; 99:1222-1229. [PMID: 32196630 DOI: 10.1111/aogs.13853] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/09/2020] [Accepted: 03/18/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The proof-of-concept of uterus transplantation, as a treatment for absolute uterine factor infertility, came with the first live birth after uterus transplantation, which took place in Sweden in 2014. This was after a live donor procedure, with laparotomy in both donor and recipient. In our second, ongoing trial we introduced a robotic-assisted laparoscopic surgery of the donor to develop minimal invasive surgery for this procedure. Here, we report the surgery and pregnancy behind the first live birth from that trial. MATERIAL AND METHODS In the present study, within a prospective observational study, a 62-year-old mother was the uterus donor and her 33-year-old daughter with uterine absence as part of the Mayer-Rokitansky-Küster-Hauser syndrome, was the recipient. Donor surgery was mainly done by robotic-assisted laparoscopy, involving dissections of the utero-vaginal fossa, arteries and ureters. The last part of surgery was by laparotomy. Recipient laparotomy included vascular anastomoses to the external iliac vessels. Data relating to in vitro fertilization, surgery, follow up, obstetrics and postnatal growth are presented. RESULTS Three in vitro fertilization cycles prior to transplantation gave 12 cryopreserved embryos. The surgical time of the donor in the robot was 360 minutes, according to protocol. The durations for robotic surgery for dissections of the utero-vaginal fossa, arteries and ureters were 30, 160 and 84 minutes, respectively. The remainder of donor surgery was by laparotomy. Recipient surgery included preparations of the vaginal vault, three end-to-side anastomoses (one arterial, two venous) on each side to the external iliacs and fixation of the uterus. Ten months after transplantation, one blastocyst was transferred and resulted in pregnancy, which proceeded uneventfully until elective cesarean section in week 36+1 . A healthy boy (Apgar 9-10-10) was delivered. Follow up of child has been uneventful for 12 months. CONCLUSIONS This is the first report of a live birth after use of robotic-assisted laparoscopy in uterus transplantation and is thereby a proof-of-concept of use of minimal invasive surgery in this new type of transplantation.
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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
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Randa Akouri
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Michael Olausson
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Klaus Groth
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jana Ekberg
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Enskog
- Department of Anesthesiology and Intensive Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Johan Mölne
- Department of Clinical Pathology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Bokström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Brännström M, Enskog A, Kvarnström N, Ayoubi JM, Dahm-Kähler P. Global results of human uterus transplantation and strategies for pre-transplantation screening of donors. Fertil Steril 2019; 112:3-10. [PMID: 31277765 DOI: 10.1016/j.fertnstert.2019.05.030] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 01/06/2023]
Abstract
Absolute uterine factor infertility, due to absence or non-function of the uterus, is one of the few major subgroups of infertility that has remained without any treatment. Uterus transplantation has now been proposed as treatment for this type of infertility. The first attempt of human uterus transplantation was in 2000. This was a live donor case, but due to suboptimal surgical solutions it resulted in a necrotic uterus being removed after 99 days. This first human case, although a failure, inspired several research groups around the globe to initiate animal-based studies to investigate uterus transplantation in relation to surgery, immunosuppression, rejection and pregnancy outcome. The research was carried out in several animal species and advanced the field substantially. In 2011, the second uterus transplantation attempt was performed, and this involved a deceased donor procedure. Although the case was surgically successful, with resumed menstruations, clinical pregnancy with live birth could not be achieved. The first clinical trial of uterus transplantation was initiated in Sweden in 2013 and involved nine live donor procedures. The world's first live birth was reported from that trial in September 2014 and this was followed by two more births within that trial in November 2014. Births after uterus transplantation has since been reported from Sweden and other centers in Europe, North America, Latin America, and Asia. Thirty human uterus transplantation procedures have been reported in the scientific literature so far but by our personal knowledge the double number of procedures have been performed. The published cases will be reviewed in detail, and we will also describe the pregnancies of the live births that have been published. A small number of graft failures have occurred. These may in part be linked to suboptimal selection of donors, specifically concerning the quality of the uterine arteries. Consequently, we will also address the issue of strategies for pre-surgical screening of donors.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, University of Gothenburg, Göteborg, Sweden; Stockholm IVF-EUGIN, Stockholm, Sweden.
| | - Anders Enskog
- Department of Anesthesiology & Intensive Care, University of Gothenburg, Göteborg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, University of Gothenburg, Göteborg, Sweden
| | - Jean Marc Ayoubi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hopital Foch - Faculté de Medicine Paris Ouest (UVSQ), Suresnes, France
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, University of Gothenburg, Göteborg, Sweden
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18
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Kvarnström N, Enskog A, Dahm-Kähler P, Brännström M. Live versus deceased donor in uterus transplantation. Fertil Steril 2019; 112:24-27. [PMID: 31277763 DOI: 10.1016/j.fertnstert.2019.05.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 01/31/2023]
Abstract
Uterus transplantation to treat absolute uterine factor infertility is a rapidly evolving field still at its early clinical experimental stage. Most human uterus transplantation attempts and live births have been after transplantation with uteri from live donors, who, in most cases, are closely related to the recipient. However, successful transplant with live births after uterus transplantation from deceased donors has also been reported. This article discusses the pros and cons in relation to live and deceased donors for uterus transplantation.
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Affiliation(s)
| | - Anders Enskog
- Department of Anesthesiology & Intensive Care, Göteborg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, University of Gothenburg, Göteborg, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynecology, University of Gothenburg, Göteborg, Sweden; Stockholm IVF-EUGIN, Stockholm, Sweden
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Ayoubi JM, Carbonnel M, Pirtea P, Kvarnström N, Brännström M, Dahm-Kähler P. Laparotomy or minimal invasive surgery in uterus transplantation: a comparison. Fertil Steril 2019; 112:11-18. [PMID: 31277761 DOI: 10.1016/j.fertnstert.2019.05.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/23/2019] [Indexed: 12/28/2022]
Abstract
Uterus transplantation (UTx) is the first available treatment for absolute uterine factor infertility, a condition due to absence of the uterus or presence of a non-functional uterus. The proof-of-concept of UTx as an infertility treatment for this group of patients occurred in 2014 in Sweden by the first birth after human UTx. That and subsequent cases of the Swedish trial were live-donor UTx procedures with laparotomy of both donor and recipient. Although results of the initial Swedish clinical UTx trial were very favorable in terms of take-home-baby rate, the drawback was the long duration (>10 h) of donor surgeries and associated long recovery periods. There exist three later publications, with uterus procurements from live donors by laparotomy with a range of surgical durations of 5.3 hours to 13 hours. Our collaborative Swedish-French team has initiated efforts to introduce minimal invasive surgery in one trial in Sweden and one in France. The principle of these UTx trials is to use modern concepts of robotic-assisted laparoscopy primarily in the live donor. There also exists a small number of published UTx procedures with donor surgery by partial conventional laparoscopy and one published case with total robotic-assisted laparoscopy procedure. This review discusses open versus minimal invasive surgery in relation to the accumulated knowledge in the field. Moreover, we propose some future directions for the development of this surgery in UTx.
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Affiliation(s)
- Jean Marc Ayoubi
- Department of Obstetrics Gynecology and Reproductive Medicine, Hopital Foch-Faculté de Medicine Paris Ouest (UVSQ), Suresnes, France
| | - Marie Carbonnel
- Department of Obstetrics Gynecology and Reproductive Medicine, Hopital Foch-Faculté de Medicine Paris Ouest (UVSQ), Suresnes, France
| | - Paul Pirtea
- Department of Obstetrics Gynecology and Reproductive Medicine, Hopital Foch-Faculté de Medicine Paris Ouest (UVSQ), Suresnes, France
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF-EUGIN, Stockholm, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Brucker SY, Taran FA, Rall K, Schöller D, Dahm-Kâhler P, Kvarnström N, Järvholm S, Nadalin S, Königsrainer A, Wallwiener D, Brännström M. Experiences of a multistep process with medical and psychological interventions for patients with congenital uterine aplasia to achieve motherhood: the Gothenburg-Tübingen collaboration. Facts Views Vis Obgyn 2019; 11:121-126. [PMID: 31824633 PMCID: PMC6897517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Congenital uterine aplasia, also known as Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) is a condition associated to a non-functional uterus in the presence of functional ovaries. In a setting where surrogacy is illegal (or not accepted) and adoption is the only alternative, neovaginoplasty and subsequent uterus transplantation (UTx) can provide a route to motherhood for women with MRKHS. This review article describes a multistep process by which patients with MRKHS can achieve motherhood with their own biological child. This process involving a careful clinical diagnosis, psychological counselling, assessment of eligibility for neovagina creation and UTx, the surgical treatment, fertility treatment, and long-term follow-up was developed at the Tübingen University Hospital and in close collaboration with Sahlgrenska Academy, University of Gothenburg, Sweden, where the basic experimental and clinical groundwork for UTx was laid and the first-ever UTx procedure was performed.
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Affiliation(s)
- SY Brucker
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - F-A Taran
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - K Rall
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - D Schöller
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - P Dahm-Kâhler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - N Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - S Järvholm
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - S Nadalin
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Tübingen, Germany
| | - A Königsrainer
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Tübingen, Germany
| | - D Wallwiener
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - M Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden,Stockholm IVF, Stockholm, Sweden
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Järvholm S, Warren AM, Jalmbrant M, Kvarnström N, Testa G, Johannesson L. Preoperative psychological evaluation of uterus transplant recipients, partners, and living donors: Suggested framework. Am J Transplant 2018; 18:2641-2646. [PMID: 30058104 DOI: 10.1111/ajt.15039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/18/2018] [Accepted: 07/22/2018] [Indexed: 01/25/2023]
Abstract
Uterus transplant has become a real option for women with uterine-factor infertility to become pregnant and give birth. The screening before uterus transplant consists of a multidisciplinary evaluation and includes the potential recipient, living donor, and, to some extent, the recipient's partner and future co-parent. The psychological evaluation has evolved from broad-based screening in the first uterus transplant trial, where the aim was to find suitable candidates for a novel experimental procedure with an unknown outcome, to a more directed screening with specific psychological domains for a complex infertility treatment with promising results. This report outlines a consensus by investigators with pioneering experience in the field of the key factors and suggests a framework for psychological evaluation of recipients and their partners as well as for live uterus donors before uterus transplant. We identify the main areas of particular value to the recipient screening (general psychological health, factors associated with infertility, and medication adherence), the partner (general psychological health and factors associated with infertility), and the living donor (psychological health and motivation to donate, especially in the case of the nondirected donor).
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Affiliation(s)
- Stina Järvholm
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Sahlgrenska Academy, Institute of Clinical Sciences, Gothenburg, Sweden
| | - Ann Marie Warren
- Division of Trauma, Acute Care, and Critical Care Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Maria Jalmbrant
- Imperial College Healthcare NHS Trust, London, UK.,Middlesex University, London, UK
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Liza Johannesson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Sahlgrenska Academy, Institute of Clinical Sciences, Gothenburg, Sweden.,Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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Abstract
Tissue engineering of the whole pancreas can improve current treatments for diabetes mellitus. The ultimate goal is to tissue engineer pancreas from an allogeneic or xenogeneic source with human cells. A demonstration of methods for the efficient dissection, decellularization, and recellularization of porcine pancreas might benefit the field. Akin to human pancreases, porcine pancreases have a special anatomical arrangement with three lobes (splenic, duodenal, and connection) rounded by the duodenum and small intestine. The duodenal lobe of the pancreas connects to the duodenum by several small blood vessels. Tissue engineering of the pancreas is complicated because of its exocrine and endocrine nature. In this paper, we show a detailed protocol to dissect the whole porcine pancreas and decellularize it with detergents while saving its structure and some extracellular matrix components. To achieve complete perfusion, the aorta is chosen as inlet and the portal vein as outlet. The other blood vessels (hepatic artery, splenic vein, splenic artery, mesenteric artery and vein tree) and bile duct are ligated. To prevent the formation of thrombus, the pig is heparinized and, immediately after dissection, the organ is flushed with cold heparin. To inhibit the action of exocrine enzymes, the pancreas decellularization is set at 4 °C. The decellularization is performed by perfusion of Triton X-100, sodium deoxycholate, and deoxyribonuclease, with an intermittent and final extensive washing. With a successful decellularization, the pancreas appears white, and a histological evaluation with hematoxylin and eosin shows an absence of nuclei with a preserved extracellular matrix structure. Thus, the proposed method can be used to successfully dissect and decellularize whole porcine pancreas.
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Affiliation(s)
- Vijay Kumar Kuna
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg
| | | | - Erik Elebring
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg
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Brännström M, Dahm-Kähler P, Kvarnström N. Robotic-assisted surgery in live-donor uterus transplantation. Fertil Steril 2018; 109:256-257. [PMID: 29395094 DOI: 10.1016/j.fertnstert.2017.12.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 12/06/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF, Stockholm, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Elebring E, Kuna VK, Kvarnström N, Sumitran-Holgersson S. Cold-perfusion decellularization of whole-organ porcine pancreas supports human fetal pancreatic cell attachment and expression of endocrine and exocrine markers. J Tissue Eng 2017; 8:2041731417738145. [PMID: 29118967 PMCID: PMC5669317 DOI: 10.1177/2041731417738145] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 09/29/2017] [Indexed: 12/23/2022] Open
Abstract
Despite progress in the field of decellularization and recellularization, the outcome for pancreas has not been adequate. This might be due to the challenging dual nature of pancreas with both endocrine and exocrine tissues. We aimed to develop a novel and efficient cold-perfusion method for decellularization of porcine pancreas and recellularize acellular scaffolds with human fetal pancreatic stem cells. Decellularization of whole porcine pancreas at 4°C with sodium deoxycholate, Triton X-100 and DNase efficiently removed cellular material, while preserving the extracellular matrix structure. Furthermore, recellularization of acellular pieces with human fetal pancreatic stem cells for 14 days showed attached and proliferating cells. Both endocrine (C-peptide and PDX1) and exocrine (glucagon and α-amylase) markers were expressed in recellularized tissues. Thus, cold-perfusion can successfully decellularize porcine pancreas, which when recellularized with human fetal pancreatic stem cells shows relevant endocrine and exocrine phenotypes. Decellularized pancreas is a promising biomaterial and might translate to clinical relevance for treatment of diabetes.
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Affiliation(s)
- Erik Elebring
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Vijay K Kuna
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Niclas Kvarnström
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Suchitra Sumitran-Holgersson
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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26
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Castellón LAR, Amador MIG, González RED, Eduardo MSJ, Díaz-García C, Kvarnström N, Bränström M. The history behind successful uterine transplantation in humans. JBRA Assist Reprod 2017; 21:126-134. [PMID: 28609280 PMCID: PMC5473706 DOI: 10.5935/1518-0557.20170028] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
This paper aimed to describe the basic aspects of uterine transplant (UTx)
research in humans, including preliminary experiences in rodents and domestic
species. Studies in rats, domestic species, and non-human primates validated and
optimized the UTx procedure in terms of its surgical aspects, immunosuppression,
rejection diagnosis, peculiarities of pregnancy in immunosuppressed patients,
and patients with special uterine conditions. In animal species, the first live
birth from UTx was achieved in a syngeneic mouse model in 2003. Twenty-five UTx
procedures have been performed in humans. The first two cases were unsuccessful,
but established the need for rigorous research to improve success rates. As a
result of a controlled clinical study under a strictly designed research
protocol, nine subsequent UTx procedures have resulted in six healthy live
births, the first of them in 2014. Further failed UTx procedures have been
performed in China, Czech Republic, Brazil, Germany, and the United States, most
of which using living donors. Albeit still an experimental procedure in, UTx is
the first potential alternative for the treatment of absolute uterine factor
infertility (AUFI).
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Affiliation(s)
| | | | | | | | - César Díaz-García
- Department of Gynecology and Obstetrics, La Fe University Hospital, University of Valencia, Valencia, Spain
| | - Niclas Kvarnström
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Stockholm IVF, Stockholm, Sweden
| | - Mats Bränström
- Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Stockholm IVF, Stockholm, Sweden
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Brännström M, Johannesson L, Bokström H, Kvarnström N, Mölne J, Dahm-Kähler P, Enskog A, Milenkovic M, Ekberg J, Diaz-Garcia C, Gäbel M, Hanafy A, Hagberg H, Olausson M, Nilsson L. Livebirth after uterus transplantation. Lancet 2015; 385:607-616. [PMID: 25301505 DOI: 10.1016/s0140-6736(14)61728-1] [Citation(s) in RCA: 443] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Uterus transplantation is the first available treatment for absolute uterine infertility, which is caused by absence of the uterus or the presence of a non-functional uterus. Eleven human uterus transplantation attempts have been done worldwide but no livebirth has yet been reported. METHODS In 2013, a 35-year-old woman with congenital absence of the uterus (Rokitansky syndrome) underwent transplantation of the uterus in Sahlgrenska University Hospital, Gothenburg, Sweden. The uterus was donated from a living, 61-year-old, two-parous woman. In-vitro fertilisation treatment of the recipient and her partner had been done before transplantation, from which 11 embryos were cryopreserved. FINDINGS The recipient and the donor had essentially uneventful postoperative recoveries. The recipient's first menstruation occurred 43 days after transplantation and she continued to menstruate at regular intervals of between 26 and 36 days (median 32 days). 1 year after transplantation, the recipient underwent her first single embryo transfer, which resulted in pregnancy. She was then given triple immunosuppression (tacrolimus, azathioprine, and corticosteroids), which was continued throughout pregnancy. She had three episodes of mild rejection, one of which occurred during pregnancy. These episodes were all reversed by corticosteroid treatment. Fetal growth parameters and blood flows of the uterine arteries and umbilical cord were normal throughout pregnancy. The patient was admitted with pre-eclampsia at 31 full weeks and 5 days, and 16 h later a caesarean section was done because of abnormal cardiotocography. A male baby with a normal birthweight for gestational age (1775 g) and with APGAR scores 9, 9, 10 was born. INTERPRETATION We describe the first livebirth after uterus transplantation. This report is a proof-of-concept for uterus transplantation as a treatment for uterine factor infertility. Furthermore, the results show the feasibility of live uterus donation, even from a postmenopausal donor. FUNDING Jane and Dan Olsson Foundation for Science.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF, Stockholm, Sweden.
| | - Liza Johannesson
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF, Stockholm, Sweden
| | - Hans Bokström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Mölne
- Department of Clinical Pathology and Genetics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF, Stockholm, Sweden
| | - Anders Enskog
- Department of Anesthesiology and Intensive Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Milan Milenkovic
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF, Stockholm, Sweden
| | - Jana Ekberg
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Cesar Diaz-Garcia
- Department of Obstetrics and Gynecology, La Fe University Hospital, University of Valencia, Valencia, Spain
| | - Markus Gäbel
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ash Hanafy
- Department of Obstetrics and Gynecology, Griffith University, Gold Coast, QLD, Australia
| | - Henrik Hagberg
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK; King's Health Partners, St Thomas' Hospital, London, UK
| | - Michael Olausson
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Nilsson
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF, Stockholm, Sweden
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Johannesson L, Kvarnström N, Mölne J, Dahm-Kähler P, Enskog A, Diaz-Garcia C, Olausson M, Brännström M. Uterus transplantation trial: 1-year outcome. Fertil Steril 2014; 103:199-204. [PMID: 25439846 DOI: 10.1016/j.fertnstert.2014.09.024] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 08/20/2014] [Accepted: 09/16/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To report the 12-month outcome of seven patients with viable uteri after uterus transplantation (UTx). DESIGN Prospective observational study. SETTING University hospital. PATIENT(S) Seven patients with absolute uterine infertility and viable uteri for 12 months after live-donor UTx. INTERVENTION(S) Predetermined immunosuppression was with tacrolimus and mychophenolate mofetil (MMF) during 6 months, whereupon MMF should be withdrawn. Frequent ultrasound examinations were performed to assess uterine appearance and uterine artery blood flow. Cervical biopsies (for histological detection of rejection) were obtained at preset time points, with temporary adjustments of immunosuppression if there were signs of rejection. Menstruations were systematically recorded. MAIN OUTCOME MEASURE(S) Menstruation, uterine artery blood flow, histology of cervical biopsies, and blood levels of tacrolimus. RESULT(S) All patients showed regular menses after 1-2 months. Uterine artery blood flow was unchanged, with a median pulsatility index of 1.9 (range, 0.5-5.4). Blood levels of tacrolimus were approximately 10, 9, and 8 (μg/L) during months 2, 9, and 12, respectively. Four recipients showed mild inflammation in biopsies after MMF withdrawal and were treated with corticosteroids and azathioprine during the remainder of the 12 months. Subclinical rejection episodes were detected on ectocervical biopsies in five recipients. Histology showed apoptotic bodies and occasional spongiosis in the squamous epithelium. Moderate infiltration of lymphocytes and neutrophils was seen in the epithelial/stromal interface. All rejection episodes were successfully treated for 2 weeks with corticosteroids or dose increments of tacrolimus. CONCLUSION(S) We demonstrate long-term uterine viability after UTx, with continued menstruation and unaltered uterine artery blood flow. Subclinical rejection episodes were effectively reversed by temporary increase of immunosuppression. CLINICAL TRIAL REGISTRATION NUMBER NCT01844362.
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Affiliation(s)
- Liza Johannesson
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Johan Mölne
- Department of Clinical Pathology and Genetics, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Anders Enskog
- Department of Anesthesiology and Intensive Care, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Cesar Diaz-Garcia
- Department of Gynecology and Obstetrics, La Fe University Hospital, University of Valencia, Valencia, Spain
| | - Michael Olausson
- Department of Transplantation, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden; Stockholm IVF, Stockholm, Sweden.
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Manyalich M, Menjívar A, Yucetin L, Peri J, Torres X, Dias L, Hiesse C, Papachristou C, Fehrman-Ekholm I, Kvarnström N, Ballesté C, Paredes D, Revuelta I, Diekmann F, Rimola A, Fondevila C, Martínez M, Legendre C, Pereira R, Carvalho I, Lopes A. Living Donor Psychosocial Assesment/Follow-up Practices in the Partners' Countries of the ELIPSY Project. Transplant Proc 2012; 44:2246-9. [DOI: 10.1016/j.transproceed.2012.07.106] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Fehrman-Ekholm I, Lennerling A, Kvarnström N, Rizell M, Olausson M. [Living donor kidney transplantation--a successful story. Very cost-effective--and the donors live long with good health]. Lakartidningen 2011; 108:2492-2495. [PMID: 22462270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Fehrman-Ekholm I, Kvarnström N, Söfteland JM, Lennerling A, Rizell M, Odén A, Simonsson T. Post-nephrectomy development of renal function in living kidney donors: a cross-sectional retrospective study. Nephrol Dial Transplant 2011; 26:2377-81. [PMID: 21459783 DOI: 10.1093/ndt/gfr161] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Increasing numbers of living donor kidney transplantations calls for better knowledge about long-term donor outcomes and risks. METHODS To explore long-term kidney donor outcomes and risks, we conducted a cross sectional retrospective study. To this end, we analysed renal function using measured glomerular filtration rate (mGFR) and estimated glomerular filtration rate (eGFR) as well as microalbuminuria, blood pressure (BP), body mass index, haemoglobin, albumin and parathyroid hormone in kidney donors nephrectomized between 1965 and 2005. RESULTS A total number of 573 kidney donors agreed to undergo medical follow-up examinations. The mean age (standard deviation) at donation was 47 (11) years and the mean time since donation was 14 (9) years. Both mean mGFR [68 (15) mL/min/1.73 m(2) body surface; P = 0.028] and mean eGFR [71 (16) mL/min/1.73 m(2) body surface; P < 0.001], based on modified diet renal dysfunction and iohexol or Cr-EDTA clearance, respectively, were found to decrease with age and to increase with time since donation. Special multivariable regression analyses reveal that for 30-year old donors, the median eGFR typically increases during the first 17 years, then remains constant for ~8 years and slowly declines thereafter. For 50-year-old donors, the median eGFR is expected to increase during the first 15 years or so and then to enter a phase of slight progressive decline. In total, 23% (126/546) of the donors were on antihypertensive medication. An additional 22% (117/543) of the donors were found to suffer from hitherto undiagnosed hypertension (BP >140/90 mm Hg). CONCLUSION Renal function of the remaining kidney in living donors is expected to improve for many years but will show signs of slight deterioration in the longer run.
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Affiliation(s)
- Ingela Fehrman-Ekholm
- The Transplant Institute, Transplantation Centre, Sahlgrenska University Hospital, Gothenburg, Sweden.
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32
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Friman S, Nordén G, Lennerling A, Fehrman-Ekholm I, Felldin M, Hansson S, Rydberg L, Holgersson J, Rizell M, Kvarnström N, Gustafsson B, Gäbel M, Olausson M, Mjörnstedt L. Kidney transplantation--a 46-year experience from the Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden. Clin Transpl 2011:119-125. [PMID: 22755408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The limiting factor in organ transplantation is the availability of organs. Ongoing work to improve donation rates both at the public and the organizational level in donating hospitals is essential. We also think that encouragement of live donation is important, and the possibility of ABO incompatible transplantation has increased the number of LD transplantations. The one-year graft survival rate is excellent and focus has shifted towards achieving long-term results to reduce the attrition rate. There is also an increasing interest in studying and working to reduce comorbidities on a long-term basis and thus, improve survival rates and recipient quality of life.
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Affiliation(s)
- S Friman
- Sahlgrenska University Hospital, Gothenburg, Sweden.
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Fehrman-Ekholm I, Möller S, Steinwall J, Nordén G, Lennerling A, Holmdahl J, Kvarnström N, Olausson M. Single or Double Arteries in the Remnant Kidney After Donation: Influence on the Long-Term Outcome of the Donor. Transplant Proc 2009; 41:764-5. [DOI: 10.1016/j.transproceed.2009.01.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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