Uterus transplantation: Toward clinical application in Japan

Reproductive futures within a context of uterus transplants in India

Reproduction is considered a core event in a cisgender heterosexual woman's life. Several hierarchies exist within the field of reproduction, with reproduction being privileged among people from dominant races, classes, castes, ages, and abilities. In this paper, I explore uterine transplantion as an emerging mode of reproduction, which privileges the experience of pregnancy in addition to genetic relatedness, specifically within the Indian context. The focus is on the socio-cultural and economic discourses surrounding the marketisation of reproductive technologies and how these recalibrate social and familial dynamics concerning reproduction. I argue that the mobilisation of the language of reproduction as a right could potentially transform into reproduction as a duty. Reproductive biopolitics is used as a lens to think through the value of wombs in relation to the bodies they inhabit, and the pressures the marketisation of wombs puts on both recipients and donors.

Uterine transplant: an ethical framework analysis from a Middle Eastern perspective

BACKGROUND

Significant advances in infertility treatment have been achieved over the past several decades, but women with uterine dysfunction, anomaly, or agenesis still need support to carry a pregnancy to term. Recently, advancements in surgical, anesthetic and immunosuppressive therapy have brought the idea of successful uterine transplant closer to reality, but many challenges must be overcome before uterine transplant can become more common, including ethical challenges related to the study and the conduct of this procedure.

METHODS

This was an updated ethical analysis of uterine transplant from a Middle Eastern perspective, using an established ethical framework that has been adapted for the analysis of research in non-Western cultures and developing countries.

RESULTS

Using the ethical framework, this analysis explored research developments in uterine transplant to date, using the following categories: collaborative partnership, social value, scientific validity, a fair selection of study population, favorable risk-benefit ratio, independent review, informed consent, and respect for recruited participants. The analysis revealed a significant need for region- and religion-specific ethical guidelines for uterine transplant procedures.

CONCLUSIONS

The horizons of research need to expand by addressing and researching the ethical issues related to uterine transplant trials and clinical procedures.

LIMITATIONS

Limitations included the challenges related to applying ethical analyses to work in developing countries, and the fact that this analysis was based on the views and interpretations of a single researcher.

Ischemia and reperfusion injury in uterus transplantation: A comprehensive review

Uterus transplantation (UTx) is the only available treatment for human beings who cannot carry children out to term. However, despite several clinical studies with a very limited number of UTx many issues have to be addressed. Up to date, there is a limited number of successful UTx with livebirth and the majority was achieved with live donors. Wide clinical application is inherently limited by the lack of organs, ischemia/reperfusion injury (IRI) as well as immunosuppression after UTx. The objective of this comprehensive literature review is to discuss these arising limitations of UTx with main focus on strategies to reduce IRI. This review showed, that usage of immunosuppressants, opioids or supplements, like amino acids, protects uterus from IRI, improving rising level of antioxidants and decreasing level of oxidative stress markers. The available data of experimental and clinical studies was compiled and will be discussed.

Uterus Transplantation as a Therapy Method in Mayer-Rokitansky-Küster-Hauser Syndrome

The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is the most common cause of uterine aplasia (underdevelopment or absence) at a frequency estimated to be worldwide of 1/4500 births of new-born female infants.

This is a literature review aiming to determine the sufficiency of the uterine transplantation (UTx) method as a therapeutic protocol for the MRKH syndrome.

Online searches were carried out in PubMed, Embase, CINAHL and Google scholar databases, during January and February 2019. The search included a combination of the various terms (see key words) as well as a combination of these terms in Greek and English so as to identify and display articles that would be as close as possible to the subject of research.

The online search yielded 95 articles. Eighty-five of these were considered as eligible and possible sources from the title and abstract presented but later were excluded, whereas 10 of them were selected to be included in the literature review. The literature review results showed that two therapeutic methods that are now successfully applied are the Vecchietti method and the Davydov method, which is the latest and less invasive technique but with equally if not improved immediate results. However, this treatment is not adequate to satisfy or provide a solution for the reproduction requirements of this patient group. The UTx proved sufficient.

Although uterus transplant could be considered the ideal solution for the management of infertility and the satisfaction of the reproductive and sexual needs of women with MRKH syndrome, since the first successful pregnancy after uterine transplantation is a reality in the recent years, it is early days to be considered as a safe mode of management.

Current Progress in Uterus Transplantation Research in Asia

Uterus transplantation (UTx) is now a possible approach for women with absolute uterine factor infertility to deliver a child, following the first successful delivery by Brännström et al. in Sweden in September 2014. This remarkable achievement attracted major attention worldwide and caused many countries to prepare for UTx, including countries in Asia. To date, three groups have performed UTx in humans in Asia, and many others are aiming for the clinical application of UTx with accumulation of basic experimental data. Therefore, it is likely that UTx will expand rapidly in Asia in the near future, although this will depend on ethical, social and religious views in each country. With this background, herein we summarize the current progress of UTx in East, Southeast and South Asia, with the purpose of increasing understanding of the current status of basic and clinical UTx research in each country and sharing progress and knowledge to ensure future development of UTx research in Asia.

Current status of uterine regenerative medicine for absolute uterine factor infertility

Though assisted reproduction technology has been developed, a treatment for absolute uterine factor infertility (AUFI), such as defects in the uterus, has not yet been established. Regenerative medicine has been developed and applied clinically over recent years; however, whole solid organs still cannot be produced. Though uterine regeneration has the potential to be a treatment for AUFI, there have been only a few studies on uterine regeneration involving the myometrium in vivo. In the present report, those relevant articles are reviewed. A literature search was conducted in PubMed with a combination of key words, and 10 articles were found, including nine in rat models and one in a mouse model. Of these studies, eight used scaffolds and two were performed without scaffolds. In four of these studies, scaffolds were re-cellularized with various cells. In the remaining four studies, scaffolds were transplanted alone, or other structures were used. Though the methods differed, the injured uterus recovered well, morphologically and functionally, in every study. Only 10 articles were relevant to our investigation, but the results were favorable, if limited to partial regeneration. Recently, uterus transplantation (UTx) has been investigated as a treatment for AUFI. However, UTx has many problems in the medical, ethical and social fields. Though the artificial uterus was also researched and some improvements in this technology were reported, it will take long time for this to reach a clinically applicable stage. Though the results of uterine regeneration studies were promising, these studies were conducted using animal models, so further human studies and trials are needed.

Uterus transplantation: Toward clinical application in Japan

Background

In recent years, uterus transplantation (UTx) has been applied as the treatment for patients with uterine factor infertility worldwide. Thus, the clinical application of UTx in Japan should be considered through both the history of UTx technology development in the world and future prospects.

Methods

Recent information on UTx was collected via a literature survey and the Internet.

Results

Basic research using various animals has been done mainly since 2000. In 2014, the world's first UTx baby was born in Sweden. In total, 24 UTx procedures have been performed at 10 institutes in nine countries and five births were obtained (as of May, 2017). In Japan, the "Project Team for Uterus Transplantation" initiated UTx experiments in 2008 and the "Japan Society for Uterus Transplantation" was organized in March, 2014. In the rest of the world, the "International Society for Uterus Transplantation" was established in January, 2016.

Conclusion

Uterus transplantation is still under development as a reproductive medicine tool and organ transplant procedure. A collaborative system that is not limited by facilities and specialties should strive to build an "all-Japan" team.