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Jones BP, Vali S, Kasaven LS, Mantrali I, Saso S, Bracewell-Milnes T, Nicopoullos J, Thum MY, Diaz-Garcia C, Quiroga I, Yazbek J, Smith JR. INvestigational Study Into Transplantation of the Uterus (INSITU): a cross-sectional survey among women with uterine factor infertility in the UK assessing background, motivations and suitability. BMJ Open 2023; 13:e073517. [PMID: 38070921 PMCID: PMC10728960 DOI: 10.1136/bmjopen-2023-073517] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
IMPORTANCE The study summarises the selection prescreen criteria currently used in the UK for a uterus transplant and highlights the number of women who are suitable to proceed. OBJECTIVES To assess the demographics, motivations, reasons and suitability among women with absolute uterine factor infertility (AUFI) to undergo uterine transplantation (UTx). DESIGN A cross-sectional survey. SETTING An electronic questionnaire was sent via email to women with AUFI who had previously been referred to the UTx research team or approached the Womb Transplant UK Charity. The questions assessed suitability to undergo UTx based on demographic information, perceptions to adoption and surrogacy and reasons why UTx was preferable. Responses were assessed against the study selection criteria. PARTICIPANTS Women with AUFI. RESULTS 210 women completed the questionnaire. The most common aetiology of AUFI in our cohort was Mayer-Rokitansky-Küster-Hauser (68%; n=143) whereas 29% (n=62) had previously undergone hysterectomy. 63% (n=132) of the cohort had previously considered adoption, 5% (n=11) had attempted it and 2 (1%) had successfully adopted. The most common reason cited to undergo UTx over adoption was to experience gestation (n=63; 53%), while 37% (n=44) wanted a biologically related child. 76% (n=160) of participants had previously considered surrogacy, 22 (10%) had attempted it and 2 (1%) had successfully become mothers using a surrogate. The most common reason to undergo UTx over surrogacy was to experience gestation (n=77; 54%). 15% (n=21) were concerned about the legal implications, 14% (n=20) identified the financial cost as a barrier and 8% (n=12) could not consider it due to religious reasons. On adhering to the selection criteria, 65 (31%) women were suitable to proceed with the trial. CONCLUSION The study demonstrates that implementing commonly used selection criteria for a UTx led to an attrition rate of more than two-thirds of women who requested to initially undergo the process. As more studies present outcomes following UTx, critical assessment of the selection criteria currently used is warranted to ensure potential recipients are not being unnecessarily excluded. TRIAL REGISTRATION NUMBER NCT02388802.
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Affiliation(s)
- Benjamin P Jones
- Lister Fertility Clinic, The Lister Hospital, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Saaliha Vali
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Lorraine S Kasaven
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Ifigenia Mantrali
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Srdjan Saso
- Imperial College Healthcare NHS Trust, London, UK
| | - Timothy Bracewell-Milnes
- Lister Fertility Clinic, The Lister Hospital, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - James Nicopoullos
- Lister Fertility Clinic, The Lister Hospital, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Meen-Yau Thum
- Lister Fertility Clinic, The Lister Hospital, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | | | | | - Joseph Yazbek
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - James Richard Smith
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
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Brännström M, Racowsky C, Carbonnel M, Wu J, Gargiulo A, Adashi EY, Ayoubi JM. Uterus transplantation: from research, through human trials and into the future. Hum Reprod Update 2023; 29:521-544. [PMID: 37328434 PMCID: PMC10477946 DOI: 10.1093/humupd/dmad012] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/29/2023] [Indexed: 06/18/2023] Open
Abstract
Women suffering from absolute uterine factor infertility (AUFI) had no hope of childbearing until clinical feasibility of uterus transplantation (UTx) was documented in 2014 with the birth of a healthy baby. This landmark accomplishment followed extensive foundational work with a wide range of animal species including higher primates. In the present review, we provide a summary of the animal research and describe the results of cases and clinical trials on UTx. Surgical advances for graft removal from live donors and transplantation to recipients are improving, with a recent trend away from laparotomy to robotic approaches, although challenges persist regarding optimum immunosuppressive therapies and tests for graft rejection. Because UTx does not involve transplantation of the Fallopian tubes, IVF is required as part of the UTx process. We provide a unique focus on the intersection between these two processes, with consideration of when oocyte retrieval should be performed, whether, and for whom, preimplantation genetic testing for aneuploidy should be used, whether oocytes or embryos should be frozen and when the first embryo transfer should be performed post-UTx. We also address the utility of an international society UTx (ISUTx) registry for assessing overall UTx success rates, complications, and live births. The long-term health outcomes of all parties involved-the uterus donor (if live donor), the recipient, her partner and any children born from the transplanted graft-are also reviewed. Unlike traditional solid organ transplantation procedures, UTx is not lifesaving, but is life-giving, although as with traditional types of transplantation, costs, and ethical considerations are inevitable. We discuss the likelihood that costs will decrease as efficiency and efficacy improve, and that ethical complexities for and against acceptability of the procedure sharpen the distinctions between genetic, gestational, and social parenthood. As more programs wish to offer the procedure, we suggest a scheme for setting up a UTx program as well as future directions of this rapidly evolving field. In our 2010 review, we described the future of clinical UTx based on development of the procedure in animal models. This Grand Theme Review offers a closing loop to this previous review of more than a decade ago. The clinical feasibility of UTx has now been proved. Advancements include widening the criteria for acceptance of donors and recipients, improving surgery, shortening time to pregnancy, and improving post-UTx management. Together, these improvements catalyze the transition of UTx from experimental into mainstream clinical practice. The procedure will then represent a realistic and accessible alternative to gestational surrogacy for the treatment of AUFI and should become part of the armamentarium of reproductive specialists worldwide.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Stockholm IVF-EUGIN, Stockholm, Sweden
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
| | - Catherine Racowsky
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Marie Carbonnel
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- University Versailles, Saint-Quentin en Yvelines, France
| | - Joseph Wu
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Antonio Gargiulo
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Eli Y Adashi
- Department of Medical Science, Brown University, Providence, RI, USA
| | - Jean Marc Ayoubi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- University Versailles, Saint-Quentin en Yvelines, France
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3
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Lee JY. Who should provide the uterus? The ethics of live donor recruitment for uterus transplantation. JOURNAL OF MEDICAL ETHICS 2023:jme-2023-109227. [PMID: 37640534 DOI: 10.1136/jme-2023-109227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
Uterus transplantation (UTx) is an experimental surgery likely to face the issue of organ shortage. In my article, I explore how this issue might be addressed by changing the prevailing practices around live uterus donor recruitment. Currently, women with children - often the mothers of recipients - tend to be overrepresented as donors. Yet, other potentially eligible groups who may have an interest in providing their uterus - such as transgender men, or cisgender women who do not wish to gestate or to have children - tend to be excluded as potential donors. Moving forward, I recommend that donor inclusion criteria for UTx be broadened to be more inclusive of these latter groups.
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Affiliation(s)
- J Y Lee
- Department of Public Health, University of Copenhagen, Kobenhavn 1172, Denmark
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4
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Bayar E, Williams NJ, Alghrani A, Murugesu S, Saso S, Bracewell-Milnes T, Thum MY, Nicopoullos J, Sangster P, Yasmin E, Smith JR, Wilkinson S, Pacey A, Jones BP. Fertility preservation and realignment in transgender women. HUM FERTIL 2023; 26:463-482. [PMID: 36799335 DOI: 10.1080/14647273.2022.2163195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 09/01/2022] [Indexed: 02/18/2023]
Abstract
Medical care for transgender people is multi-faceted and attention to individual reproductive aspirations and planning are an essential, yet often overlooked aspect of care. Given the impact of hormonal therapy and other gender affirmation procedures on reproductive function, extensive counselling and consideration of fertility preservation is recommended prior to their commencement. This review article explores the reproductive aspirations of transgender women and considers the current disparity between stated desires regarding utilisation of fertility preservation services. Current fertility preservation options and prospective treatments currently showing promise in the research arena are explored.
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Affiliation(s)
- Erna Bayar
- Department of Gynaecology, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nicola J Williams
- Department of Politics, Philosophy and Religion, Lancaster University, Lancaster, UK
| | - Amel Alghrani
- School of Law and Social Justice, University of Liverpool, Liverpool, UK
| | - Sughashini Murugesu
- Department of Gynaecology, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Srdjan Saso
- Department of Gynaecology, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Meen-Yau Thum
- Lister Fertility Clinic, The Lister Hospital, Chelsea Bridge Road, London, UK
| | - James Nicopoullos
- Lister Fertility Clinic, The Lister Hospital, Chelsea Bridge Road, London, UK
| | - Philippa Sangster
- Reproductive Medicine Unit, University College London Hospital, London, UK
| | - Ephia Yasmin
- Reproductive Medicine Unit, University College London Hospital, London, UK
| | - J Richard Smith
- Department of Gynaecology, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Stephen Wilkinson
- Department of Politics, Philosophy and Religion, Lancaster University, Lancaster, UK
| | - Allan Pacey
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK
| | - Benjamin P Jones
- Department of Gynaecology, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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5
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Johannesson L, Testa G, Beshara MM, da Graca B, Walter JR, Quintini C, Latif N, Hashimoto K, Richards EG, O’Neill K. Awareness and Interest in Uterus Transplantation over Time: Analysis of Those Seeking Surgical Correction for Uterine-Factor Infertility in the US. J Clin Med 2023; 12:4201. [PMID: 37445236 PMCID: PMC10342774 DOI: 10.3390/jcm12134201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/07/2023] [Accepted: 06/15/2023] [Indexed: 07/15/2023] Open
Abstract
This study describes the characteristics of women who contacted an active program performing uterus transplantation (UTx) in the US, expressing interest in becoming a uterus transplant recipient or a living donor. Basic demographic and self-reported clinical information was collected from women who contacted any of the three US UTx programs from 2015 to July 2022. The three centers received 5194 inquiries about becoming a UTx recipient during the study timeframe. Among those reporting a cause of infertility, almost all of the reports (4066/4331, 94%) were absence of a uterus, either congenitally (794/4066, 20%) or secondary to hysterectomy (3272/4066, 80%). The mean age was 34 years, and 49% (2545/5194) had at least one child at the time of application. The two centers using living donors received 2217 inquiries about becoming living donors. The mean age was 34 years, and 60% (1330/2217) had given birth to ≥1 child. While most of the UTx clinical trial evidence has focused on young women with congenital absence of the uterus, these results show interest from a much broader patient population in terms of age, cause of infertility, and parity. These results raise questions about whether and to what extent the indications and eligibility criteria for UTx should be expanded as the procedure transitions from the experimental phase to being offered as a clinical treatment.
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Affiliation(s)
- Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75246, USA
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Menas M. Beshara
- TX A&M College of Medicine, Texas A&M University, Dallas, TX 75231, USA
| | - Briget da Graca
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Jessica R. Walter
- Department of Obstetrics & Gynecology, Northwestern University, Chicago, IL 60611, USA
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Nawar Latif
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19107, USA
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH 44103, USA
| | - Elliott G. Richards
- Obstetrics and Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, OH 44103, USA
| | - Kathleen O’Neill
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19107, USA
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6
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Uterus Transplantation: Revisiting the Question of Deceased Donors versus Living Donors for Organ Procurement. J Clin Med 2022; 11:jcm11154516. [PMID: 35956131 PMCID: PMC9369769 DOI: 10.3390/jcm11154516] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/26/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Uterus transplantation is a surgical treatment for women with congenital or acquired uterine factor infertility. While uterus transplantation is a life-enhancing transplant that is commonly categorized as a vascular composite allograft (e.g., face or hand), it is similar to many solid organ transplants (e.g., kidney) in that both living donors (LDs) and deceased donors (DDs) can be utilized for organ procurement. While many endpoints appear to be similar for LD and DD transplants (including graft survival, time to menses, livebirth rates), there are key medical, technical, ethical, and logistical differences between these modalities. Primary considerations in favor of a LD model include thorough screening of donors, enhanced logistics, and greater donor availability. The primary consideration in favor of a DD model is the lack of physical or psychological harm to a living donor. Other important factors, that may not clearly favor one approach over the other, are important to include in discussions of LD vs. DD models. We favor a stepwise approach to uterus transplantation, one in which programs first begin with DD procurement before attempting LD procurement to maximize successful organ recovery and to minimize potential harms to a living donor.
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7
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Ayoubi JM, Carbonnel M, Racowsky C, de Ziegler D, Gargiulo A, Kvarnström N, Dahm-Kähler P, Brännström M. Evolving clinical challenges in uterus transplantation. Reprod Biomed Online 2022; 45:947-960. [DOI: 10.1016/j.rbmo.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
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8
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Dorafshar AH, Hamidian Jahromi A, Horen SR, Schechter LS, Johannesson L, Testa G, Hertl M, Dewdney S, Aschkenasy J, Wood-Molo M, Brincat C, Cherullo E, Behel JM, Hebert C, Shulman R, Bassi S, Alecci AT, Konety B. Strategic Planning and Essential Steps for Establishing a Uterine Transplant and Rehabilitation Program: From Idea to Reality. Ann Surg 2022; 276:74-80. [PMID: 34793341 DOI: 10.1097/sla.0000000000005301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UTx is performed to address absolute uterine infertility in the presence of uterine agenesis, a nonfunctional uterus, or after a prior hysterectomy. After the initial success of UTx resulting in a livebirth (2014) in Sweden, there are over 70 reported UTx surgeries resulting in more than 40 livebirths worldwide. Currently, UTx has been performed in over 10 countries. As UTx is transitioning from an "experimental procedure" to a clinical option, an increasing number of centers may contemplate a UTx program. This article discusses essential steps for establishment of a successful UTx program. These principles may be implemented in cis- and transgender UTx candidates.
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Affiliation(s)
- Amir H Dorafshar
- Division of Plastic & Reconstructive Surgery, Rush University Medical Center, Chicago, IL
| | | | - Sydney R Horen
- Division of Plastic & Reconstructive Surgery, Rush University Medical Center, Chicago, IL
| | - Loren S Schechter
- Division of Plastic & Reconstructive Surgery, Rush University Medical Center, Chicago, IL
- The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, Chicago, IL
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Martin Hertl
- Division of Transplant Surgery, Rush University Medical Center, Chicago, IL
| | - Summer Dewdney
- Division of Gynecologic Oncology, Rush University Medical Center, Chicago, IL
| | | | - Mary Wood-Molo
- Division of Reproductive Endocrinology and Infertility, Rush University Medical Center, Chicago, IL
| | - Cynthia Brincat
- Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL
| | - Edward Cherullo
- Department of Urology, Rush University Medical Center, Chicago, IL
| | - Jay M Behel
- Department of Psychiatry, Rush University Medical Center, Chicago, IL
- Rush Center for Gender, Sexuality & Reproductive Health, Chicago, IL
| | - Charles Hebert
- Department of Psychiatry, Rush University Medical Center, Chicago, IL
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL
| | - Robert Shulman
- Department of Psychiatry, Rush University Medical Center, Chicago, IL
| | - Shruti Bassi
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL
| | | | - Badrinath Konety
- Department of Surgery, Rush University Medical Center, Chicago, IL
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da Graca B, Johannesson L, Testa G, Wall AE. The Ethical Evolution of Uterus Transplantation From Concept to Clinical Procedure. Clin Obstet Gynecol 2022; 65:24-36. [PMID: 35045022 DOI: 10.1097/grf.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Uterus transplantation (UTx) offers women with absolute uterine factor infertility a path to motherhood that enables them to carry their own pregnancy. Debates about the ethics of UTx have evolved in tandem with its clinical evolution: clinical trials have provided evidence regarding risks and benefits to donors and recipients that were initially uncertain; technical advances have altered the balance between risks and benefits; and the experiences of donors and recipients has revealed questions that were not anticipated. As UTx transitions to a clinical procedure, questions remain about long-term risks and benefits, applications beyond carrying a pregnancy, and cost and access.
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Affiliation(s)
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
| | - Anji E Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
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10
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The Moral Superiority of Bioengineered Wombs and Ectogenesis for Absolute Uterine Factor Infertility. Camb Q Healthc Ethics 2022; 31:73-82. [PMID: 35049456 DOI: 10.1017/s0963180121000827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This paper argues that uterine transplants are a potentially dangerous distraction from the development of alternative methods of providing reproductive options for women with absolute uterine factor infertility (AUFI). We consider two alternatives in particular: the bioengineering of wombs using stem cells (which would carry fewer risks than uterine transplants) and ectogenesis (which would not require surgical intervention for either the prospective mother with AUFI or a womb donor). Whether biologically or mechanically engineered, these womb replacements could provide a way for women to have children, including genetically related offspring for those who would value this possibility. Most importantly, this alternative would avoid the challenge of sourcing wombs for transplant, a practice that we argue would likely be exploitative and unethical. Continued research into bioengineering and ectogenesis will therefore remain morally important despite the recent development of uterine transplantation, even if the procedure reaches routine clinical application.
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12
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da Graca B, Johannesson L, Testa G, Wall A. Uterus transplantation: ethical considerations. Curr Opin Organ Transplant 2021; 26:664-668. [PMID: 34636768 DOI: 10.1097/mot.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Uterus transplantation (Utx) offers women with absolute uterine factor infertility the opportunity to carry their own pregnancies. As Utx transitions from an experimental to standard clinical procedure, we review the status of the ethical issues applicable to the stakeholders involved. RECENT FINDINGS With more than 65 Utx procedures reported to date, evidence is accruing that enables the chance of success - a live birth - for the recipient to be weighed against the risks the recipient incurs through the Utx process, as well as risks to living donors undergoing surgery, to children exposed in utero to immunosuppressants and the uterine graft environment, and to third parties related to uterus procurement from multiorgan deceased donors. Experience has also informed aspects of recipient and donor autonomy that must be safeguarded. SUMMARY Clinical trial results provides a basis for weighing the interests of the stakeholders implicated in Utx, and so can inform transplant centers' and regulatory bodies' development of policies and protocols that will determine access to Utx and allocation of organs, together with other considerations of justice. Additional evidence, particularly on long-term outcomes, is needed, and new questions can be expected to arise as access to and indications for Utx broaden.
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Affiliation(s)
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute
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13
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Richards EG, Farrell RM, Ricci S, Perni U, Quintini C, Tzakis A, Falcone T. Uterus transplantation: state of the art in 2021. J Assist Reprod Genet 2021; 38:2251-2259. [PMID: 34057644 PMCID: PMC8490545 DOI: 10.1007/s10815-021-02245-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To provide a comprehensive review of uterus transplantation in 2021, including a discussion of pregnancy outcomes of all reported births to date, the donor and recipient selection process, the organ procurement and transplant surgeries, reported complications, postoperative monitoring, preimplantation preparation, and ethical considerations. METHODS Literature review and expert commentary. RESULTS Reports of thirty-one live births following uterus transplantation have been published from both living and deceased donors. The proper selection of donors and recipients is a labor-intensive process that requires advanced planning. A multidisciplinary team is critical. Reported complications in the recipient include thrombosis, infection, vaginal stricture, antenatal complications, and graft failure. Graft rejection is a common occurrence but rarely leads to graft removal. While most embryo transfers are successful, recurrent implantation failures in uterus transplant patients have been reported. Rates of preterm delivery are high but appear to be declining; more data, including long-term outcome data, is needed. CONCLUSIONS Uterus transplantation is an emerging therapy for absolute uterine factor infertility, a condition previously without direct treatment options. It is paramount that reproductive health care providers are familiar with the uterus transplantation process as more patients seek and receive this treatment.
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Affiliation(s)
- Elliott G Richards
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ruth M Farrell
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stephanie Ricci
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Uma Perni
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Cristiano Quintini
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andreas Tzakis
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tommaso Falcone
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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14
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Abstract
Uterine transplantation (UTx) is a fertility restoring treatment for women with absolute uterine factor infertility. At a time when there is no question of the procedure's feasibility, and as the number of livebirths begins to increase exponentially, various important reproductive, fetal, and maternal medicine implications have emerged. Detailed outcomes from 17 livebirths following UTx are now available, which are reviewed herein, along with contextualized extrapolation from pregnancy outcomes in other solid organ transplants. Differences in recipient demographics and reproductive aspirations between UTx and other transplant recipients make extrapolating management strategies and outcomes in other solid organ transplants inappropriate. Whereas preterm delivery remains prominent, small for gestational age or hypertensive disorders do not appear to be as prevalent following UTx when compared to other solid organ transplants. Given the primary objective of undertaking UTx is to achieve a livebirth, publication of reproductive outcomes is essential at this early stage, to reflect on and optimize the management of future cases.
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Abstract
PURPOSE To provide a comprehensive review of uterus transplantation in 2021, including a discussion of pregnancy outcomes of all reported births to date, the donor and recipient selection process, the organ procurement and transplant surgeries, reported complications, postoperative monitoring, preimplantation preparation, and ethical considerations. METHODS Literature review and expert commentary. RESULTS Reports of thirty-one live births following uterus transplantation have been published from both living and deceased donors. The proper selection of donors and recipients is a labor-intensive process that requires advanced planning. A multidisciplinary team is critical. Reported complications in the recipient include thrombosis, infection, vaginal stricture, antenatal complications, and graft failure. Graft rejection is a common occurrence but rarely leads to graft removal. While most embryo transfers are successful, recurrent implantation failures in uterus transplant patients have been reported. Rates of preterm delivery are high but appear to be declining; more data, including long-term outcome data, is needed. CONCLUSIONS Uterus transplantation is an emerging therapy for absolute uterine factor infertility, a condition previously without direct treatment options. It is paramount that reproductive health care providers are familiar with the uterus transplantation process as more patients seek and receive this treatment.
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Jahromi AH, Horen SR, Dorafshar AH, Seu ML, Radix A, Anderson E, Green J, Fraser L, Johannesson L, Testa G, Schechter LSM, Schechter L. Uterine transplantation and donation in transgender individuals; proof of concept. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2021; 22:349-359. [PMID: 37808528 PMCID: PMC10553376 DOI: 10.1080/26895269.2021.1915635] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Loren Schechter
- Division of Plastic & Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
- The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, The University of Illinois at, Chicago, IL, USA
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18
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Carbonnel M, Revaux A, Menzhulina E, Karpel L, Snanoudj R, Le Guen M, De Ziegler D, Ayoubi JM. Uterus Transplantation with Live Donors: Screening Candidates in One French Center. J Clin Med 2020; 9:E2001. [PMID: 32630524 PMCID: PMC7356518 DOI: 10.3390/jcm9062001] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 12/20/2022] Open
Abstract
We report our experience regarding the profile and screening process of potential recipients (R) and their live donors (D) in our Uterus transplantation (UTx) trial from 2014 to 2020. The initial screening was performed using medical questionnaires and consultations. The second step of the screening consisted of two individual interviews with an independent multidisciplinary committee. Then, a complete medical, biological and imaging assessment of the directed living D, the R, and her partner was performed over a two-day hospitalization. A total of 239 women contacted our department: 165 potentials R and 74 potentials D. During the first step of screening, 141 R and 45 D were excluded. Only 12 R/D pairs were pursued. During inclusion, 10 R/D pairs were excluded. One R/D pair is still under evaluation. Finally, only 1 R/D pair was definitively included (0.6%), which led us to perform the first French UTx in March 2019 with a successful graft. The primary limiting factors of inclusion were due to very strict criteria and difficulty of having a suitable directed living D. The International Society of UTx (ISUTx) guidelines based on worldwide results of trials can help ease our inclusion criteria in the future while remaining safe for patients.
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Affiliation(s)
- Marie Carbonnel
- Department of Obstetrics and Gynecology, Hospital Foch, University of Versailles, Saint-Quentin-en-Yvelines, 55, avenue de Paris, 78000 Versailles, France; (A.R.); (E.M.); (L.K.); (D.D.Z.); (J.M.A.)
| | - Aurelie Revaux
- Department of Obstetrics and Gynecology, Hospital Foch, University of Versailles, Saint-Quentin-en-Yvelines, 55, avenue de Paris, 78000 Versailles, France; (A.R.); (E.M.); (L.K.); (D.D.Z.); (J.M.A.)
| | - Elena Menzhulina
- Department of Obstetrics and Gynecology, Hospital Foch, University of Versailles, Saint-Quentin-en-Yvelines, 55, avenue de Paris, 78000 Versailles, France; (A.R.); (E.M.); (L.K.); (D.D.Z.); (J.M.A.)
| | - Lea Karpel
- Department of Obstetrics and Gynecology, Hospital Foch, University of Versailles, Saint-Quentin-en-Yvelines, 55, avenue de Paris, 78000 Versailles, France; (A.R.); (E.M.); (L.K.); (D.D.Z.); (J.M.A.)
| | - Renaud Snanoudj
- Department of Nephrology and Transplantation, University of Versailles, Saint-Quentin-en-Yvelines, 55, avenue de Paris, 78000 Versailles, France;
| | - Morgan Le Guen
- Department of Anesthesiology, Hospital Foch, University of Versailles, Saint-Quentin-en-Yvelines, 55, avenue de Paris, 78000 Versailles, France;
| | - Dominique De Ziegler
- Department of Obstetrics and Gynecology, Hospital Foch, University of Versailles, Saint-Quentin-en-Yvelines, 55, avenue de Paris, 78000 Versailles, France; (A.R.); (E.M.); (L.K.); (D.D.Z.); (J.M.A.)
| | - Jean Marc Ayoubi
- Department of Obstetrics and Gynecology, Hospital Foch, University of Versailles, Saint-Quentin-en-Yvelines, 55, avenue de Paris, 78000 Versailles, France; (A.R.); (E.M.); (L.K.); (D.D.Z.); (J.M.A.)
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19
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Chmel R, Pastor Z, Matecha J, Janousek L, Novackova M, Fronek J. Uterine transplantation in an era of successful childbirths from living and deceased donor uteri: Current challenges. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 164:115-120. [DOI: 10.5507/bp.2019.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 04/25/2019] [Indexed: 01/18/2023] Open
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20
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Peters HE, Juffermans LJM, Lambalk CB, Dekker JJML, Fernhout T, Groenman FA, de Groot CJM, Hoksbergen AWJ, Huirne JAF, de Leeuw RA, van Mello NM, Nederhoed JH, Schats R, Verhoeven MO, Hehenkamp WJK. Feasibility study for performing uterus transplantation in the Netherlands. Hum Reprod Open 2020; 2020:hoz032. [PMID: 32128452 PMCID: PMC7048682 DOI: 10.1093/hropen/hoz032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/10/2019] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION Is it feasible to perform uterus transplantations (UTx) in a tertiary centre in the Netherlands? SUMMARY ANSWER Considering all ethical principles, surgical risks and financial aspects, we have concluded that at this time, it is not feasible to establish the UTx procedure at our hospital. WHAT IS KNOWN ALREADY UTx is a promising treatment for absolute uterine factor infertility. It is currently being investigated within several clinical trials worldwide and has resulted in the live birth of 19 children so far. Most UTx procedures are performed in women with the Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, a congenital disorder characterized by absence of the uterus. In the Netherlands, the only possible option for these women for having children is adoption or surrogacy. STUDY DESIGN SIZE DURATION We performed a feasibility study to search for ethical, medical and financial support for performing UTx at the Amsterdam UMC, location VUmc. PARTICIPANTS/MATERIALS SETTING METHODS For this feasibility study, we created a special interest group, including gynaecologists, transplant surgeons, researchers and a financial advisor. Also, in collaboration with the patients' association for women with MRKH, a questionnaire study was performed to research the decision-making in possible recipients. In this paper, we present an overview of current practices and literature on UTx and discuss the results of our feasibility study. MAIN RESULTS AND THE ROLE OF CHANCE A high level of interest from the possible recipients became apparent from our questionnaire amongst women with MRKH. The majority (64.8%) positively considered UTx with a live donor, with 69.6% having a potential donor available. However, this 'non-life-saving transplantation' requires careful balancing of risks and benefits. The UTx procedure includes two complex surgeries and unknown consequences for the unborn child. The costs for one UTx are calculated to be around €100 000 and will not be compensated by medical insurance. The Clinical Ethics Committee places great emphasis on the principle of non-maleficence and the 'fair distribution of health services'. LIMITATIONS REASONS FOR CAUTION In the Netherlands, alternatives for having children are available and future collaboration with experienced foreign clinics that offer the procedure is a possibility not yet investigated. WIDER IMPLICATIONS OF THE FINDINGS The final assessment of this feasibility study is that that there are not enough grounds to support this procedure at our hospital at this point in time. We will closely follow the developments and will re-evaluate the feasibility in the future. STUDY FUNDING/COMPETING INTERESTS This feasibility study was funded by the VU Medical Center (Innovation grant 2017). No conflicts of interest have been reported relevant to the subject of all authors. TRIAL REGISTRATION NUMBER n.a.
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Affiliation(s)
- H E Peters
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - L J M Juffermans
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - C B Lambalk
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J J M L Dekker
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - T Fernhout
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - F A Groenman
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - C J M de Groot
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - A W J Hoksbergen
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J A F Huirne
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - R A de Leeuw
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - N M van Mello
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J H Nederhoed
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - R Schats
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - M O Verhoeven
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - W J K Hehenkamp
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
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21
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Liu Y, Zhang Y, Ding Y, Chen G, Zhang X, Wang Y, Hua K. Clinical applications of uterus transplantation in China: Issues to take into consideration. J Obstet Gynaecol Res 2020; 46:357-368. [PMID: 31997549 DOI: 10.1111/jog.14199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 12/31/2019] [Indexed: 01/02/2023]
Affiliation(s)
- Yu Liu
- Department of GynecologyThe Obstetrics and Gynecology Hospital of Fudan University Shanghai China
| | - Ying Zhang
- Department of GynecologyThe Obstetrics and Gynecology Hospital of Fudan University Shanghai China
| | - Yan Ding
- Department of GynecologyThe Obstetrics and Gynecology Hospital of Fudan University Shanghai China
| | - Gaowen Chen
- Department of Obstetrics and GynecologyZhujiang Hospital, Southern Medical University Guangzhou China
| | - Xuyin Zhang
- Department of GynecologyThe Obstetrics and Gynecology Hospital of Fudan University Shanghai China
| | - Yifeng Wang
- Department of Obstetrics and GynecologyZhujiang Hospital, Southern Medical University Guangzhou China
| | - Keqin Hua
- Department of GynecologyThe Obstetrics and Gynecology Hospital of Fudan University Shanghai China
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22
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Mookerjee VG, Kwan D. Uterus transplantation as a fertility option in transgender healthcare. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2020; 21:122-124. [PMID: 33005906 PMCID: PMC7430417 DOI: 10.1080/15532739.2019.1599764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Vikram G Mookerjee
- Department of Plastic Surgery, Rhode Island Hospital, Brown University Alpert Medical School, Providence, RI, USA
| | - Daniel Kwan
- Department of Plastic Surgery, Rhode Island Hospital, Brown University Alpert Medical School, Providence, RI, USA
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23
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Ngaage LM, Ike S, Elegbede A, Vercler CJ, Gebran S, Liang F, Rada EM, Cooney C, Brandacher G, Redett RJ, Johannesson L, Rasko YM. The changing paradigm of ethics in uterus transplantation: a systematic review. Transpl Int 2019; 33:260-269. [PMID: 31674693 DOI: 10.1111/tri.13548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/03/2019] [Accepted: 10/28/2019] [Indexed: 11/27/2022]
Abstract
The first uterus transplantation was performed in 2000. As key milestones are reached (long-lasting graft survival in 2011, and first birth from a transplanted womb in 2014), the ethical debate around uterus transplant evolves. We performed a systematic review of articles on uterus transplantation. Ethical themes were extracted and categorized according to four bioethical principles. Papers were divided into time periods separated by key events in uterus transplant history: Phase I (first technical achievement, 2002-2011), Phase II (clinical achievement, 2012-2014), and Phase III (after the first childbirth, 2015-2018). Eighty-one articles were included. The majority of ethics papers were published in Phase III (65%, P < 0.0001), that is after the first birth. Eighty percent of papers discussed nonmaleficence making it the most discussed principle. The first birth acted as a pivotal point: nonmaleficence was discussed by a lower proportion of articles (P = 0.0073), as was beneficence (P = 0.0309). However, discussion of justice increased to become the most discussed principle of the time period (P = 0.0085). The ethical debate surrounding uterus transplantation has evolved around landmark events that signify scientific progress. As safety and efficacy become evident, the focus of ethical debate shifts from clinical equipoise to socioeconomic challenges and equitable access to uterus transplantation.
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Affiliation(s)
- Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Samantha Ike
- London North West University Healthcare Trust, London, UK
| | - Adekunle Elegbede
- Department of Plastic & Reconstructive Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian J Vercler
- Plastic Surgery Section, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Selim Gebran
- Division of Plastic & Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Fan Liang
- Division of Plastic & Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Erin M Rada
- Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Carisa Cooney
- Department of Plastic & Reconstructive Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gerald Brandacher
- Department of Plastic & Reconstructive Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic & Reconstructive Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
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24
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Ngaage LM, Elegbede A, Sugarman J, Nam AJ, Cooney CM, Cooney DS, Rasko YM, Brandacher G, Redett RJ. The Baltimore Criteria for an ethical approach to penile transplantation: a clinical guideline. Transpl Int 2019; 33:471-482. [PMID: 31646681 DOI: 10.1111/tri.13545] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 09/20/2019] [Accepted: 10/18/2019] [Indexed: 12/20/2022]
Abstract
Significant advances and increasing acceptance of vascularized composite allotransplantation (VCA) have contributed to emerging success of penile transplantation. The aims of penile transplantation are fourfold: adequate urinary function, enabling natural erections, restoration of erogenous sensation and appearance of external male genitalia. Successful penile transplantation also requires limiting risks and managing complications of lifelong immunosuppression. Given the limited experience with this procedure, potential recipients must understand that penile transplantation is not currently standard of care and long-term functional outcomes are unknown. Moreover, these transplants are associated with complex ethical issues. Nevertheless, as the efficacy and safety of penile transplantation are being evaluated, clear indications for transplant are needed. Although preliminary recommendations have been proposed, a more comprehensive framework is needed. We performed a literature review for English language publications related to penile transplantation and ethics. Based on the results of the search, a review of prior recommendations, and our experience performing the first whole male genital allotransplantation including penis, scrotum and abdominal wall; screening and identifying potential donors and recipients for the procedure; and addressing the associated ethical issues, we propose guidelines for responsible penile transplantation: The Baltimore Criteria for an Ethical Approach to Penile Transplantation.
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Affiliation(s)
- Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Adekunle Elegbede
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeremy Sugarman
- Department of Medicine, Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Arthur J Nam
- Division of Plastic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Damon S Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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25
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Chmel R, Pastor Z, Novackova M, Matecha J, Cekal M, Fronek J. Clinical pregnancy after deceased donor uterus transplantation: Lessons learned and future perspectives. J Obstet Gynaecol Res 2019; 45:1458-1465. [DOI: 10.1111/jog.13992] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/14/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Roman Chmel
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
- Transplantation Surgery DepartmentInstitute of Clinical and Experimental Medicine Prague Czech Republic
| | - Zlatko Pastor
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
| | - Marta Novackova
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
| | - Jan Matecha
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
- Faculty of Medicine in PlzeňCharles University Czech Republic
| | - Milos Cekal
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
| | - Jiri Fronek
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
- Transplantation Surgery DepartmentInstitute of Clinical and Experimental Medicine Prague Czech Republic
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26
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Richards EG, Agatisa PK, Davis AC, Flyckt R, Mabel H, Falcone T, Tzakis A, Farrell RM. Framing the diagnosis and treatment of absolute uterine factor infertility: Insights from in-depth interviews with uterus transplant trial participants. AJOB Empir Bioeth 2019; 10:23-35. [PMID: 30855220 DOI: 10.1080/23294515.2019.1572672] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Despite procedural innovations and increasing numbers of uterus transplant attempts worldwide, the perspectives of uterus transplant (UTx) trial participants are lacking. METHODS We conducted a mixed-methods study with women with absolute uterine factor infertility (AUFI). Participants included women who had previously contacted the Cleveland Clinic regarding the Uterine Transplant Trial and met the initial eligibility criteria for participation. In-depth interviews were conducted in conjunction with FertiQoL, a validated and widely used tool to measure the impact of infertility on the quality of life of infertility patients. RESULTS All (n = 19) rated their overall health as good; some experienced grief and social isolation. AUFI is a life-framing experience that influences acceptance by family, partners, peers, and one's self. UTx is a means to gain control of reproductive autonomy. UTx allows family-building and the ability to play an active role in prenatal health and well-being. Establishing and maintaining a supportive relationship is a key issue of AUFI and when considering UTx. Risks of UTx are perceived relative to risks to self/child/family posed by adoption/surrogacy. Participants had no overall preference regarding living or deceased donor. CONCLUSIONS The ways in which women with AUFI conceptualize this condition in their lives and choices around UTx and participating in a study of the procedure are multifaceted and textured. These perspectives are critical to understanding its ethical, legal, and social implications.
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Affiliation(s)
- Elliott G Richards
- a Department of Ob/Gyn & Women's Health Institute , Cleveland Clinic , Cleveland , Ohio
| | - Patricia K Agatisa
- a Department of Ob/Gyn & Women's Health Institute , Cleveland Clinic , Cleveland , Ohio
| | - Anne C Davis
- a Department of Ob/Gyn & Women's Health Institute , Cleveland Clinic , Cleveland , Ohio
| | - Rebecca Flyckt
- a Department of Ob/Gyn & Women's Health Institute , Cleveland Clinic , Cleveland , Ohio
| | - Hilary Mabel
- b Center for Bioethics Cleveland Clinic , Cleveland , Ohio
| | - Tommaso Falcone
- a Department of Ob/Gyn & Women's Health Institute , Cleveland Clinic , Cleveland , Ohio
| | - Andreas Tzakis
- c Transplantation Center , Cleveland Clinic Florida , Weston , Florida
| | - Ruth M Farrell
- a Department of Ob/Gyn & Women's Health Institute , Cleveland Clinic , Cleveland , Ohio.,b Center for Bioethics Cleveland Clinic , Cleveland , Ohio
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27
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Puntambekar S, Puntambekar S, Telang M, Kulkarni P, Date S, Panse M, Sathe R, Agarkhedkar N, Warty N, Kade S, Manchekar M, Chitale M, Parekh H, Parikh K, Mehta M, Kinholkar B, Jana JS, Pare A, Kanade S, Sadre A, Hardikar S, Jathar A, Bakre T, Chate M, Tiruke R. Novel Anastomotic Technique for Uterine Transplant Using Utero-ovarian Veins for Venous Drainage and Internal Iliac Arteries for Perfusion in Two Laparoscopically Harvested Uteri. J Minim Invasive Gynecol 2018; 26:628-635. [PMID: 30599196 DOI: 10.1016/j.jmig.2018.11.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/29/2018] [Accepted: 11/05/2018] [Indexed: 12/22/2022]
Abstract
STUDY OBJECTIVE To evaluate 2 cases of uterine transplant surgery that used utero-ovarian veins as outflow channels, internal iliac arteries for perfusion, and the organ harvest surgery performed laparoscopically. DESIGN Case study (Canadian Task Force Classification III). SETTING An urban, private, tertiary care hospital. PATIENTS Two patients, ages 30 and 24years, diagnosed with absolute uterine factor infertility secondary to Mayer-Rokitansky-Küster-Hauser syndrome underwent related living donor uterine transplants; donors were their mothers with normal menses. INTERVENTIONS Retrieval of organs through minilaparotomy and laparoscopic harvest of donor internal iliac arteries and ovarian veins. MEASUREMENTS AND MAIN RESULTS Anastomosis was completed with bilateral donor internal iliac arteries to recipient internal iliac arteries in an end-to-end manner and with bilateral donor ovarian veins to recipient external iliac veins in an end-to-side manner. The lengths of utero-ovarian veins of both donors were 11 and 11cm on both sides; the lengths of the internal iliac arteries of both donors were 10 and 7.5cm on the left side and 10 and 6cm on the right side. The operative times for harvest surgery, bench surgery and transplant surgery were 2:40 and 3:20 hours, 34:32 and 33:30 min and 4:00 and 4:30 hours respectively for recipients 1 and 2. Daily postoperative uterine Doppler was completed through day 8 and then every other day and showed good intrauterine blood flow (i.e., low resistance arcuate vessel flow; resistance index < .5). Cervical biopsies on postoperative days 7 and 14 showed no evidence of rejection in either recipient. Both recipients started menstruating within 2 months of surgery. CONCLUSION By using ovarian veins as outflow channels, the challenges involved in dissection along the internal iliac vein are avoided, and harvesting the donor internal iliac artery reduces the tension on vascular anastomosis. The selection of vessels to be harvested could make the technique reproducible, although larger studies are warranted to confirm results.
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Affiliation(s)
- Shailesh Puntambekar
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar).
| | - Seema Puntambekar
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Milind Telang
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Pankaj Kulkarni
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | | | - Mangesh Panse
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | - Ravindra Sathe
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | | | - Neeta Warty
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Sandesh Kade
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Manoj Manchekar
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | - Mihir Chitale
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | - Hirav Parekh
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | - Kajal Parikh
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Mehul Mehta
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | | | | | | | | | | | - Shirish Hardikar
- Radiology (Dr. Hardikar), Galaxy CARE Laparoscopy Institute, Pune, India
| | - Advait Jathar
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | - Tejashree Bakre
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Meenakshi Chate
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Raviraj Tiruke
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
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Balayla J, Tulandi T. Provider Perceptions, Opinions, and Insights Into Uterine Transplantation in Canada. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:428-435. [PMID: 30514611 DOI: 10.1016/j.jogc.2018.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/30/2018] [Accepted: 09/03/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study sought to evaluate perceptions and insights regarding uterine transplantation among members of a women's health care national specialty organization in Canada. METHODS The investigators obtained permission and used an electronic survey developed by Bortoletto et al. to conduct a cross-sectional study of members of the SOGC between April and May 2018. Participants were requested to answer a total of 29 questions grouped into four different categories: personal opinions and attitudes, medical opinions, ethical opinions, and demographics. The investigators compared answers with a published survey of members of the American Society for Reproductive Medicine (ASRM) and the American Association of Gynecologic Laparoscopists (AAGL). RESULTS Of a total 247 responses, 230 were complete, for a completion rate of 93%. Respondents were primarily female, White, obstetrician-gynaecologists within 15 years of starting practice. Statements viewed favourably by most of respondents (strongly agree or agree) included "Women should be allowed to donate or receive a transplanted uterus" (53.5%), "Uterine transplantation should be considered a potential treatment option for infertile women with severe uterine factor infertility" (42.4%), and "Uterine transplantation is ethical" (39.9%). Statements that were viewed unfavourably by the majority of respondents (strongly disagree or disagree) included "Uterine transplantation carries an acceptable risk for recipients" (43.7%) and "Uterine transplantation for severe uterine factor infertility should be covered by health insurance" (59.1%). When compared with members of the ASRM and AAGL, the degree of agreement was similar, except with regards to "Uterine transplantation carries an acceptable risk for donors" (50.0% vs. 65.3% ASRM/67.8% AAGL; P < 0.001), and "In countries or states where gestational surrogacy is illegal, uterine transplantation is a more permissible ethical option" (42.0% vs. 65.0% ASRM/51.4% AAGL; P < 0.001). CONCLUSION Most respondents either felt that uterine transplantation was ethical or were neutral to the subject. However, only a small minority would currently recommend the procedure to their patients. As advances in uterine transplants are made, future studies should re-evaluate providers' perceptions towards this procedure before it is introduced into clinical practice.
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Affiliation(s)
- Jacques Balayla
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC; Department of Obstetrics and Gynecology, Faculty of Medicine, McGill University, Montréal, QC
| | - Togas Tulandi
- Department of Obstetrics and Gynecology, Faculty of Medicine, McGill University, Montréal, QC.
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Chmel R, Novackova M, Pastor Z, Fronek J. The Interest of Women with Mayer-Rokitansky-Küster-Hauser Syndrome and Laparoscopic Vecchietti Neovagina in Uterus Transplantation. J Pediatr Adolesc Gynecol 2018; 31:480-484. [PMID: 29751094 DOI: 10.1016/j.jpag.2018.04.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 02/21/2018] [Accepted: 04/30/2018] [Indexed: 01/20/2023]
Abstract
STUDY OBJECTIVE The goal of this study was to assess a group of women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome with surgically created neovaginas in the interest of uterus transplantation (UTx) and to recruit the first group of applicants for a UTx trial. DESIGN AND SETTING This was an original prospective study using semistructured interviews. PARTICIPANTS A study group of 50 women with MRKH syndrome with Vecchietti neovaginas was recruited via letter of invitation. INTERVENTIONS AND MAIN OUTCOME MEASURES Interest of MRKH women in obtaining experimental UTx for the treatment of absolute uterine factor infertility. RESULTS A total of 50 women responded via e-mail and 31 (62% [31 of 50] of the study group) expressed serious interest in UTx after complete information about its risks and benefits was provided during the first semistructured interview. They subsequently agreed to participate in additional interviews and further examinations. Because of various reasons, only 9 women were prepared to enter our UTx trial (18% [9 of 50] of the study group). Three recipients/donors were accepted into the living donor arm and 6 into the deceased brain donor arm of the trial. CONCLUSION Nearly two-thirds of our MRKH syndrome study group women with surgically created neovaginas were interested in UTx and motivated to undergo this method of absolute uterine factor infertility treatment. Therefore, this group of women might be approached to participate in ongoing and future UTx trials. Future studies of women with MRKH syndrome might confirm or disprove the results of our survey.
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Affiliation(s)
- Roman Chmel
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic.
| | - Marta Novackova
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Zlatko Pastor
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Jiri Fronek
- Transplant Surgery Department, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Bortoletto P, Hariton E, Farland LV, Goldman RH, Gargiulo AR. Uterine Transplantation: A Survey of Perceptions and Attitudes of American Reproductive Endocrinologists and Gynecologic Surgeons. J Minim Invasive Gynecol 2018; 25:974-979. [PMID: 29501812 DOI: 10.1016/j.jmig.2018.02.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/20/2018] [Accepted: 02/24/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine whether reproductive endocrinologists and minimally invasive surgeons support uterine transplantation as a treatment option for absolute uterine factor infertility (AUFI). DESIGN A cross-sectional study (Canadian Task Force classification II-2). SETTING A Web-based survey. PATIENTS Physician members of the American Society of Reproductive Medicine (ASRM) and the American Association of Gynecologic Laparoscopists (AAGL). INTERVENTIONS A Web-based questionnaire administered between January and February 2017. MEASUREMENTS AND MAIN RESULTS Support for (strongly agree or agree) or opposition to (strongly disagree or disagree) various aspects of uterine transplantation were described using descriptive statistics and analyzed using chi-square tests. A total of 414 physicians (ASRM: 49.5%, AAGL: 50.5%) responded to the Web-based survey; 43.7% were female, 52.4% were between the ages of 45 and 65 years, and 73.4% were white. Nearly fifty-six percent supported women being allowed to donate or receive a transplanted uterus. Fifty-four percent strongly agreed or agreed that uterine transplantation carried an acceptable risk for donors, 28.0% for the recipient and 21.0% for the infant. Forty-two percent agreed that uterine transplantation should be considered a therapeutic option for women with AUFI, whereas 19.6% felt it should be covered by insurance. Nearly 45% of respondents felt uterine transplantation to be ethical. The most common ethical concerns regarding uterine transplantation were related to medical or surgical complications to the recipient (48.8%). CONCLUSION Just under half of the reproductive endocrinologists and minimally invasive surgeons surveyed find uterine transplantation to be an ethical option for patients with AUFI. Important concerns remain regarding the risk to donors, recipients, and resulting infants, all contributing to only a minority currently recommending it as a therapeutic option.
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Affiliation(s)
- Pietro Bortoletto
- Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Eduardo Hariton
- Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leslie V Farland
- Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Randi H Goldman
- Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Antonio R Gargiulo
- Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Shapiro ME, Ward FR. Uterus Transplantation: A Step Too Far. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:36-37. [PMID: 30040573 DOI: 10.1080/15265161.2018.1478027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Bruno B, Arora KS. Uterus Transplantation: The Ethics of Using Deceased Versus Living Donors. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:6-15. [PMID: 30040550 PMCID: PMC6296249 DOI: 10.1080/15265161.2018.1478018] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Research teams have made considerable progress in treating absolute uterine factor infertility through uterus transplantation, though studies have differed on the choice of either deceased or living donors. While researchers continue to analyze the medical feasibility of both approaches, little attention has been paid to the ethics of using deceased versus living donors as well as the protections that must be in place for each. Both types of uterus donation also pose unique regulatory challenges, including how to allocate donated organs; whether the donor / donor's family has any rights to the uterus and resulting child; how to manage contact between the donor / donor's family, recipient, and resulting child; and how to track outcomes moving forward.
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Affiliation(s)
- Bethany Bruno
- a Cleveland Clinic Lerner College of Medicine, Case Western Reserve University
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Han MN, Ramirez H, Ruvalcaba L, Contreras JL, Nyachieo A, Ramirez E. Uterine Autotransplantation in the Nonhuman Primate With Preservation of the Uterine and Ovarian Vascular Pedicles. Reprod Sci 2018; 26:1329-1335. [PMID: 29576000 DOI: 10.1177/1933719118765976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE To evaluate the technical feasibility of performing a uterine autotransplantation in the nonhuman primate while preserving the uterine and ovarian vascular pedicles. METHODS Eight (n = 8) female baboons at a primate research facility underwent a uterine autotransplant procedure with preservation of the vascular pedicles. The uterine arteries were separated from their amorphous tissue and skeletonized toward the internal iliac arteries bilaterally. A segment of the internal iliac artery was removed bilaterally along with both uterine arteries. Both ovarian veins were preserved to assist with the reperfusion of the uterine organ. Due to larger vascular pedicles in one of the primates, the uterine arteries were separated and reattached directly via end-to-end anastomosis. In another baboon, the deep uterine vein was used as a vascular pedicle rather than the ovarian vein on the left side due to adequate size and visualization. RESULTS Immediate tissue reperfusion occurred intraoperatively in 5 of the animals, with slower perfusion in 3 of the animals. Average warm ischemia time was 43.8 minutes while the average cold ischemia time was 174 minutes (2 hours, 54 minutes). Average total surgical time was 5.9 hours. All animals were sheltered into separate cages and monitored for behavior changes and food and drink consumption. Three of the primates expired immediately postoperatively, 2 from severe dehydration and 1 from gastric aspiration. CONCLUSIONS This pilot study describes a modified surgical approach for uterine transplants in the nonhuman primate. This surgical technique may be applicable to living and deceased donor uterine transplantation.
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Affiliation(s)
- Michelle N Han
- Department of Obstetrics and Gynecology, University of California, Los Angeles, CA, USA
| | | | - Luis Ruvalcaba
- Instituto Mexicano de Infertilidad, Guadalajara, Jalisco, Mexico
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Favre-Inhofer A, Rafii A, Carbonnel M, Revaux A, Ayoubi JM. Uterine transplantation: Review in human research. J Gynecol Obstet Hum Reprod 2018; 47:213-221. [PMID: 29574054 DOI: 10.1016/j.jogoh.2018.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 12/18/2022]
Abstract
Uterine transplantation is the solution to treat absolute uterine fertility. In this review, we present the historical, medical, technical, psychological and ethical perspectives in human uterine transplantation research. We reviewed the PubMed database following PRISMA guidelines and added data presented by several research teams during the first international congress on uterine transplantation.
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Affiliation(s)
- A Favre-Inhofer
- Department of Gynecology and Obstetrics, Hospital Foch, Suresnes, France
| | - A Rafii
- Department of Gynecology and Obstetrics, Hospital Foch, Suresnes, France
| | - M Carbonnel
- Department of Gynecology and Obstetrics, Hospital Foch, Suresnes, France
| | - A Revaux
- Department of Gynecology and Obstetrics, Hospital Foch, Suresnes, France
| | - J M Ayoubi
- Department of Gynecology and Obstetrics, Hospital Foch, Suresnes, France.
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Puntambekar S, Telang M, Kulkarni P, Puntambekar S, Jadhav S, Panse M, Sathe R, Agarkhedkar N, Warty N, Kade S, Manchekar M, Parekh H, Parikh K, Desai R, Mehta M, Chitale M, Kinholkar B, Jana JS, Pare A, Sadre A, Karnik S, Mane A, Gandhi G, Kanade S, Phadke U. Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for Uterine Transplant: Our Experience of Two Patients. J Minim Invasive Gynecol 2018; 25:622-631. [PMID: 29366966 DOI: 10.1016/j.jmig.2018.01.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/09/2018] [Accepted: 01/11/2018] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVE To report the first ever laparoscopic-assisted live donor uterus retrieval in 2 patients for uterus transplant. DESIGN Case study (Canadian Task Force classification III). SETTING Galaxy CARE Laparoscopy Institute, Pune, India. PATIENTS Two patients with absolute uterine factor infertility with their mothers as donors. INTERVENTIONS In vitro fertilization and uterine transplant. MEASUREMENTS AND MAIN RESULTS A 12-member team was formed, and approval for transplant was obtained from the institutional review board. Pretransplant, in vitro fertilization for both patients was done. Two consecutive uterine transplants were done on 2 successive days. Vessels were harvested laparoscopically in both donors. Uterus and harvested vessels were retrieved by a small abdominal incision to prevent injury and infection. The uterus was transplanted in the recipients by end to side anastomosis of the harvested vessels to external iliac vessels, followed by anchoring of supports of the donor uterus to those of the recipients. Surgical intra- and postoperative parameters, postoperative investigations, and follow-up data of 6 months were measured. Operative time for laparoscopic donor surgery was 4 hours. Bench surgery took 45 minutes. Recipient surgery time was 4 hours. There were no intraoperative or immediate postoperative complications. Both the recipients started menstruating after 34 days and 48 days, respectively, and have had 6 cycles of menses at regular intervals. Uterine artery Doppler showed good flow in both patients. Hysteroscopy-guided cervical biopsies were used as a method of surveillance of graft rejection after uterine transplant. Office hysteroscopy was done after 2 months in both patients, and hysteroscopy-guided endometrial and cervical biopsies were taken. Minimal slough was seen on the endometrium in the patient with Mayer-Rokitansky-Küster-Hauser syndrome, which was removed. Repeat hysteroscopy after 10 days showed a healthy endometrium. CONCLUSIONS Laparoscopic-assisted uterus donor retrieval is feasible and affords all the advantages of a minimally invasive technique, thereby reducing the morbidity of the procedure. It helps in better dissection of the vessels, shortens the operative time, and helps to minimize tissue handling of the harvested uterus and vessels.
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Affiliation(s)
| | - Milind Telang
- Department of Obstetrics and Gynaecology, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Pankaj Kulkarni
- Department of Obstetrics and Gynaecology, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Seema Puntambekar
- Department of Obstetrics and Gynaecology, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Sanjeev Jadhav
- Department of Plastic Surgery, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Mangesh Panse
- Department of General Surgery, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Ravindra Sathe
- Department of General Surgery, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Nikhil Agarkhedkar
- Department of Plastic Surgery, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Neeta Warty
- Department of Obstetrics and Gynaecology, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Sandesh Kade
- Department of Obstetrics and Gynaecology, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Manoj Manchekar
- Department of General Surgery, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Hirav Parekh
- Department of General Surgery, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Kajal Parikh
- Department of Obstetrics and Gynaecology, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Riddhi Desai
- Department of Obstetrics and Gynaecology, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Mehul Mehta
- Department of General Surgery, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Mihir Chitale
- Department of General Surgery, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Bhushan Kinholkar
- Department of Medicine, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Joy Shankar Jana
- Department of Anaesthesia, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Avinash Pare
- Department of Anaesthesia, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Abhay Sadre
- Department of Nephrology, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Swapnil Karnik
- Department of Pathology, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Abhay Mane
- Department of Medicine, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Giriraj Gandhi
- Department of Plastic Surgery, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Shailendra Kanade
- Department of Anaesthesia, Galaxy CARE Laparoscopy Institute, Pune, India
| | - Uday Phadke
- Department of Anaesthesia, Galaxy CARE Laparoscopy Institute, Pune, India
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Surgical Decision-Making in Pediatric and Adolescent Gynecology: Just Because You Can, Doesn't Mean You Should. J Pediatr Adolesc Gynecol 2017; 30:601-602. [PMID: 28923750 DOI: 10.1016/j.jpag.2017.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Petrini C, Gainotti S, Morresi A, Nanni Costa A. Ethical Issues in Uterine Transplantation: Psychological Implications and Informed Consent. Transplant Proc 2017; 49:707-710. [DOI: 10.1016/j.transproceed.2017.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Choussein S, Nasioudis D, Schizas D, Economopoulos KP. Mullerian dysgenesis: a critical review of the literature. Arch Gynecol Obstet 2017; 295:1369-1381. [DOI: 10.1007/s00404-017-4372-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 04/18/2017] [Indexed: 01/02/2023]
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Balayla J. Uterine Transplants in the Canadian Setting: A Theoretical Framework. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:955-960. [DOI: 10.1016/j.jogc.2016.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 04/18/2016] [Indexed: 12/17/2022]
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Balayla J. Public funding of uterine transplantation. JOURNAL OF MEDICAL ETHICS 2016; 42:568-569. [PMID: 26858308 DOI: 10.1136/medethics-2015-103232] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/15/2016] [Indexed: 06/05/2023]
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Kumnig M, Jowsey-Gregoire SG. Key psychosocial challenges in vascularized composite allotransplantation. World J Transplant 2016; 6:91-102. [PMID: 27011907 PMCID: PMC4801807 DOI: 10.5500/wjt.v6.i1.91] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 12/16/2015] [Accepted: 01/08/2016] [Indexed: 02/05/2023] Open
Abstract
Psychosocial factors are important elements in the assessment and follow-up care for vascularized composite allotransplantation (VCA) and require multidisciplinary evaluation protocols. This review will highlight differences between VCA with solid organ transplantation (SOT), provide information on the psychosocial selection of VCA candidates, ethical issues, psychological outcomes, and on the need for multicenter research. VCA is primarily a life-enhancing procedure to improve recipients' quality of life and psychological well-being and it represents a potential option to provide reproduction in case of penile or uterine transplantation. The risk benefit ratio is distinctly different than SOT with candidates desiring life enhancing outcomes including improved body image, return to occupations, restored touch, and for uterine transplant, pregnancy. The Chauvet Workgroup has been convened with membership from a number of transplant centers to address these issues and to call for multicenter research. A multicenter research network would share similar evaluation approaches so that meaningful research on psychosocial variables could inform the transplant community and patients about factors that increase risk of non-adherence and other adverse psychosocial and medical outcomes.
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Abstract
Abstract:In September 2014, a healthy male child was born in Sweden following a successful uterine transplantation (UTx). The event brought hope to many women without functional uteruses around the world. Having a child with a transplanted uterus is now possible, and as knowledge of the procedure proliferates and interest in UTx grows, it is important to begin thinking about how a scarce supply of uteruses will be allocated. This article represents a first discussion of the range of factors that must be considered in answering the allocation question. The primary issues addressed are (1) the motivation to seek treatment, (2) allocation by age, (3) child-rearing capacity, and (4) the amount of infertility treatment required. A set of eligibility and ranking criteria are presented. These criteria are not exhaustive but are intended to spark discussion about how uteruses can be allocated in a just manner.
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Kisu I, Banno K, Mihara M, Hara H, Umene K, Adachi M, Nogami Y, Aoki D. A surgical technique using the ovarian vein in non-human primate models of potential living-donor surgery of uterus transplantation. Acta Obstet Gynecol Scand 2015; 94:942-8. [PMID: 26095999 DOI: 10.1111/aogs.12701] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 06/14/2015] [Indexed: 01/25/2023]
Abstract
AIM Living donor surgery in organ transplantation should be performed in a minimally invasive manner under conditions that are as safe as possible. The objective of this study is to examine whether the procedure for using the ovarian vein makes donor surgery less invasive in a cynomolgus monkey model of potential living-donor surgery of uterus transplantation. MATERIAL AND METHODS Twenty-two female cynomolgus monkeys aged 6-9 years and with body weights of 3.55 ± 1.28 kg were used in the study. Vessels and tissues surrounding the uterus were dissected while preserving the uterine artery/vein. The deep uterine vein was used as a venous pedicle in four monkeys (Group 1), and the ovarian vein was used instead of the deep uterine vein in 18 monkeys (Group 2). With the uterine artery/vein and deep uterine vein (Group 1) or ovarian vein (Group 2) connected to the uterus, the vaginal canal was cut. The vessels were then clamped to produce a donor surgery model. Surgical time, intraoperative organ and vascular injury were examined in each animal. RESULTS The average surgical time from laparotomy to clamping of vessels was 230 ± 112 min in all 22 cynomolgus monkeys, and significantly longer in Group 1 (n = 4) than in Group 2 (n = 18) (393 ± 71 vs. 194 ± 84 min, p < 0.05). Surgical time in Group 2 showed a tendency to decrease in animals treated later in the study, with a significantly longer time in the first 10 monkeys compared with the last 8 (253 ± 65 vs. 120 ± 26 min, p < 0.05). All monkeys had no complications, including no injuries to other organs and no unanticipated vascular injury. CONCLUSION The procedure using the ovarian vein was less invasive than that using the deep uterine vein in mimicking living-donor surgery in a cynomolgus monkey model of uterus transplantation.
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Affiliation(s)
- Iori Kisu
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Kouji Banno
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Mihara
- Department of Vascular Surgery, Saiseikai General Hospital, Saitama, Japan
| | - Hisako Hara
- Department of Plastic and Reconstructive Surgery, Graduates School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoko Umene
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Masataka Adachi
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Yuya Nogami
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Aoki
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
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Affiliation(s)
- Jacques Balayla
- Department of Obstetrics and Gynecology, University of Montreal, Montreal H3C 3J7, Canada.
| | - Elias M Dahdouh
- Assisted Reproduction Center, Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Canada
| | - Ariel Lefkowitz
- Department of Internal Medicine, University of Toronto, Toronto, Canada
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Altawil Z, Arawi T. Uterine Transplantation: Ethical Considerations within Middle Eastern Perspectives. Dev World Bioeth 2015; 16:91-7. [DOI: 10.1111/dewb.12085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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