American Society for Reproductive Medicine position statement on uterus transplantation: a committee opinion

Classification and treatment of vaginal strictures at the donor-recipient anastomosis after uterus transplant

OBJECTIVE

To describe the incidence and management of vaginal stricture after uterus transplantation (UTx) in the US, to propose a grading system to classify stricture severity, and to identify risk factors for stricture formation.

DESIGN

Prospective cohort study.

SETTING

University Hospital.

PATIENTS

Recipients undergoing UTx from 2016-2023 at Baylor University Medical Center in Dallas, Cleveland Clinic, the University of Pennsylvania, and the University of Alabama at Birmingham were monitored postoperatively with regular pelvic examinations. Stricture was defined as vaginal narrowing of <3 cm in patients with graft survival of at least 7 days.

INTERVENTION

Demographic and surgery characteristics.

MAIN OUTCOME MEASURES

Stricture development and severity (grade 1 for diameter 2-<3 cm, grade 2 for 1-<2 cm, or grade 3 for <1 cm).

RESULTS

Of the 45 UTx from 2016-2023 (16 deceased donors and 29 living donors), 3 were excluded from the analysis because of graft loss within 7 days. Of the 42 remaining recipients, 39 (92.9%) had Mayer-Rokitansky-Küster-Hauser syndrome and 3 (7.1%) had a prior hysterectomy. Twenty-eight (66.7%) UTx recipients developed postoperative vaginal strictures with a median time to stricture of 33 days (interquartile range 19-53 days). Most strictures were of moderate severity, with 4 (14.3%) strictures categorized as grade 1, 19 (67.9%) as grade 2, and 5 (17.9%) as grade 3. History of Mayer-Rokitansky-Küster-Hauser syndrome and preoperative recipient vaginal length were significant risk factors for stricture, after adjustment for donor and recipient age and body mass index, anastomosis technique, total ischemia time, center, and year. Patients with longer preoperative vaginal length had a lower risk of stricture (hazard ratio 0.45, 0.29-0.70). The severity grading of the stricture was associated with the effectiveness of a nonoperative treatment approach (grade 1 vs. grade 3). No patients with grade 3 strictures improved with self-dilation alone; all required surgical repair and/or dilation under anesthesia. Conversely, for grade 1 or 2 strictures, self-dilation alone was successful in 47.8% (11/23), and no grade 1 strictures required surgical repair.

CONCLUSIONS

Vaginal stricture is a common postoperative complication after UTx, affecting >65% of recipients. Short preoperative vaginal length and history of müllerian agenesis in the recipient are significant risk factors. Vaginal self-dilation was effective for some mild to moderate strictures, although dilation under anesthesia or surgical repair was required in most cases.

CLINICAL TRIAL REGISTRATION NUMBERS

Dallas UtErus Transplant Study (DUETS) at Baylor University Medical Center (NCT02656550), Uterine transplantation for the treatment of uterine factor infertility at the Cleveland Clinic (NCT02573415), The University of Pennsylvania Uterus Transplant for Uterine Factor Infertility Trial (UNTIL) (NCT03307356).

Long-term health-related quality-of-life and psychosocial outcomes after uterus transplantation: a 5-year follow-up of donors and recipients

STUDY QUESTION

What are the outcomes regarding health-related quality-of-life, mood, and marital relationship of recipients and donors 5 years after uterus transplantation (UTx) and uterus donation?

SUMMARY ANSWER

Both recipients and donors generally demonstrated long-term stability regarding psychosocial outcomes but with negative deviations associated with unsuccessful outcomes.

WHAT IS KNOWN ALREADY

UTx is the first infertility treatment for women with absolute uterine factor infertility. The procedure can be performed with either a uterus donation from a live donor (LD), typically a close relative, or from a deceased, multi-organ donor. There are many potential stressful events over several years after UTx both for recipients and for LDs and these events may have impacts on quality-of-life and mental well-being.

STUDY DESIGN, SIZE, DURATION

This, prospective observational cohort study includes the nine recipients and LDs of the first human UTx trial. They were assessed in 2017-2018 by questionnaires 5 years after UTx.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The nine recipients (ages 32-43 years) and their respective LDs (ages 44-67 years) were either related (n = 8) or friends (n = 1). Eight recipients had congenital uterine absence and one was hysterectomized due to cervical cancer. For two recipients, UTx resulted in early graft failures, while six of the other seven recipients gave birth to a total of eight babies over the following 5 years. Physical and mental component summaries of health-related quality-of-life were measured with the SF-36 questionnaire. Mood was assessed by the Hospital Anxiety and Depression Scale. Relationship with partner was measured with the Dyadic Adjustment Scale. Comparisons were made between the values after 5 years and the values before uterus donation/transplantation.

MAIN RESULTS AND THE ROLE OF CHANCE

Five years after primary UTx, the majority of recipients scored above the predicted value of the general population on quality-of-life, except for two women, one of whom had a viable graft but no live birth and one recipient who was strained by quality-of-life changes, possibly related to parenthood transitions. Regarding mood, only one value (anxiety) was above the threshold for further clinical assessment. Recipients showed declining satisfaction with their marital relationships, but all reported scores above the 'at risk for divorce' threshold at the time of the final assessment in our study. The LDs were all found to be stable and above the predicted value of the general population regarding mental components of quality-of-life. Three LDs showed declined physical components, possibly related to older age. Only one LD reported a value in mood (anxiety) that would need further assessment. The marital satisfaction of LDs remained stable and unchanged compared to baseline values. Notably, the two recipients with early graft failures, and their related LDs, regained their mental well-being during the first years after graft failure and remained stable after 5 years.

LIMITATIONS, REASONS FOR CAUTION

The restricted sample size and the single-centre study-design are limitations of this study. Additionally the study was limited to LD UTx, as opposed to deceased donor UTx.

WIDER IMPLICATIONS OF THE FINDINGS

Our study shows that both LDs and recipients had acceptable or favourable quality-of-life outcomes, including mood assessment, at the 5-year follow-up mark, and that failure to achieve a live birth negatively affected these modalities both for LDs and recipients. Moreover, an important finding was that LDs and recipients are not reacting with depression after hysterectomy, which is common after hysterectomy in the general population.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was provided by the Jane and Dan Olsson Foundation for Science, Knut and Alice Wallenberg Foundation, Handlanden Hjalmar Svensson Foundation, Swedish Governmental ALF Grant, and Swedish Research Council. There are no conflicts of interest to disclose.

TRIAL REGISTRATION NUMBER

NCT01844362.

Living-Donor Uterus Transplantation: A Clinical Review

Uterus transplantation (UTx) is currently the only available treatment for absolute uterine factor infertility. More than 90 uterus transplantations have been performed worldwide, mostly from living donors. Living-donor (LD) UTx is a challenging surgical procedure since it poses ethical issues, and it is a high-risk and invasive surgery with higher hysterectomy-related risks compared to conventional hysterectomy. A total of 59 living-donor hysterectomies have been reported in the literature, including 35 performed with a laparotomic approach, 20 with a robotic approach and 4 with a laparoscopic approach. The mean donor age was 45.6 ± 9.1 years, and 22 were unrelated with the recipients, 34 were emotionally related (27 mothers, 5 sisters, 2 mother's sisters). The mean recipient age was 28.8 ± 4.5 years. Mayer-Rokitansky-Küster-Hauser syndrome was the most common indication for uterus transplant. Robotic living-donor hysterectomy had the longest operative time but resulted in a lower blood loss and postoperative stay compared to laparotomic and laparoscopic approaches. Twenty-nine births from LD-UTx have been reported, four after robotic living-donor hysterectomy and twenty-five after a laparotomic procedure. UTx is now an effective treatment for women with UFI. While living-donor UTx in some cases may be considered an experimental procedure, it offers the extraordinary possibility to give women the opportunity to have a pregnancy. Many efforts should be made to reduce the potential risks for donors, including the use of mini-invasive techniques, and the efficacy of UTx in the recipients, giving the potential harm of immunosuppression in a recipient of a non-life-saving organ.

Deceased donor availability for uterus transplantation in Australia

BACKGROUND

Uterus transplantation is an emerging treatment option for uterine factor infertility. Most uterus transplantation research programs use living donors, although this comes with considerable surgical and psychological risks and not all women desiring uterus transplantation will have an available living donor. A deceased donor program eliminates donor risks; however, the availability of deceased uterus donors is currently unknown in Australia.

AIMS

To establish the feasibility of a deceased donor uterus transplantation program in Australia and consider expanded inclusion criteria for this model.

MATERIALS AND METHODS

A retrospective review of the New South Wales (NSW) Organ and Tissue Donation Service database was undertaken to identify potential deceased uterus donors, with comparison to the broad deceased donor inclusion criteria from three international uterus transplantation trials including female, brain-dead, multi-organ donation, no major abdominal surgery, and <60 years of age.

RESULTS

Between January 1, 2018, and December 31, 2022, 648 deceased donors were available in NSW. Of these, 43% (279/648) were female and 67% of the women (187/279) were also multi-organ donors. When the brain-dead donor-only and age criteria (<60 years) were applied, a total of 107 deceased donors met the available criteria for uterus transplantation, with an average of 21 deceased donors per year in NSW.

CONCLUSIONS

There appears to be adequate deceased donor organ availability to establish a deceased uterus transplantation program in NSW, Australia. Should interest in uterus transplantation increase, including criteria such as older and nulliparous donors could increase organ availability for a uterus transplantation program.

Uterus Transplantation as a Surgical Innovation

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

Pregnancy management and outcome after uterus transplantation

Uterus transplantation is a novel approach in women whose uterus is absent or severely abnormal. However, it is still an experimental procedure that poses risks to both mother and baby. To date, 32 live births after uterus transplantation have been reported in peer-reviewed journals, with several maternal, fetal and neonatal complications. The most common complications were preterm delivery, hypertensive disorders and placenta previa. Four patients experienced episodes of transplant rejection during pregnancy. The appropriate management of complicated and non-complicated pregnancies following uterus transplantation is still unresolved. In this review, obstetric outcomes after uterus transplantation and optimal management during pregnancy are discussed in light of the available data. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Who should provide the uterus? The ethics of live donor recruitment for uterus transplantation

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.

Neonatal Outcomes after Uterus Transplantation: Dallas Uterus Transplant Study

OBJECTIVE

Limited data are available on the outcome of infants born after uterus transplantation. Our aim was to describe the hospital course and laboratory findings in the first 2 months of life of the 12 infants born in the Dallas UtErus Transplant Study (DUETS).

STUDY DESIGN

Based on the trial protocol, information about infants was collected in a prospective fashion, including infant demographics, hospital course, and laboratory values.

RESULTS

Twelve infants were delivered, all by cesarean section, from 11 mothers who had undergone uterus transplantation (one mother had two pregnancies and delivered two babies). All pregnancies were singleton. The mothers received immunosuppressive therapy, and one had a rejection episode that was detected during pregnancy. The rejection episode resolved after steroid treatment. The infants had a median gestational age of 36^6/7 weeks (range: 30^6/7-38^0/7 weeks) and median birth weight of 2,920 g (range: 1,770-3,470 g). The lowest Apgar's score at 5 minutes was 8. All infants were appropriate size for gestational age. Two infants presented with bandemia but negative blood cultures. At 2 months of age, all infants achieved the developmental and behavioral milestones outlined by the American Academy of Pediatrics.

CONCLUSION

The 12 infants born from mothers with uterus transplants had a neonatal course that reflected the gestational age at delivery. No baby was born with an identified malformation or organ dysfunction. Longer follow-up and a larger number of infants are needed to confirm these observations.

KEY POINTS

· Normal fetal development after uterus transplantation.. · No baby was born with malformations or showed any organ dysfunction.. · At 2 months, all infants achieved appropriate developmental and behavioral milestones..

The First 5 Years of Uterus Transplant in the US

Importance

Uterus transplant is a viable surgical treatment for women affected by absolute uterine-factor infertility, which affects 1 in 500 women.

Objective

To review transplant and birth outcomes of uterus transplant recipients in the US since the first case in 2016.

Design, Setting, and Participants

In this cohort study, 5 years of uterus transplant outcome data were collected from the 3 centers performing uterus transplants in the US: Baylor University Medical Center, Dallas, Texas; Cleveland Clinic, Cleveland, Ohio; and University of Pennsylvania, Philadelphia. A total of 33 women with absolute uterine-factor infertility who underwent uterus transplant between February 2016 and September 2021 were included.

Main Outcomes and Measures

Graft survival, live birth, and neonatal outcome.

Results

Of the 33 included uterus transplant recipients, 2 (6%) were Asian, 1 (3%) was Black, 1 (3%) was South Asian, and 29 (88%) were White; the mean (SD) age was 31 (4.7) years; and the mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 24 (3.6). Most uterus transplant recipients (31 of 33 [94%]) had a congenitally absent uterus (Mayer-Rokitansky-Küster-Hauser syndrome), and 21 of 33 (64%) received organs from living donors. Mean (range) follow-up was 36 (1-67) months. There was no donor or recipient mortality. One-year graft survival was 74% (23 of 31 recipients). Through October 2021, 19 of 33 recipients (58%) had delivered 21 live-born children. Among recipients with a viable graft at 1 year, the proportion with a live-born child was 83% (19 of 23). The median (range) gestational age at birth of neonates was 36 weeks 6 days (30 weeks, 1 day to 38 weeks), and the median (range) birth weight was 2860 (1310-3940) g (median [range], 58th [6th-98th] percentile). No congenital malformations were detected.

Conclusions and Relevance

Uterus transplant is a surgical therapy that enables women with uterine-factor infertility to successfully gestate and deliver children. Aggregate data from US centers demonstrate safety for the recipient, living donor, and child. These data may be used to counsel women with uterine-factor infertility on treatment options.

Uterine Transplantation: Recipient Patient Populations

Uterine transplantation is an emerging treatment for patients with uterine factor infertility (UFI). In order to determine patient candidacy for transplant, it is imperative to understand how to identify, counsel and treat uterine transplant recipients. In this article, we focus on patient populations with UFI, whether congenital or acquired, including Mayer-Rokitansky-Kuster-Hauser, complete androgen insensitivity syndrome, hysterectomy, and other causes of nonabsolute UFI. Complete preoperative screening of recipients should be required to assess the candidacy of each individual prior to undergoing this extensive treatment option.

The Future of Uterus Transplantation: Cost, Regulations, and Outcomes

Uterus transplantation (UTx) has evolved rapidly since technical success was first demonstrated, and is now practiced worldwide, using both living and deceased donors. As UTx transitions from an experimental to widely available standard clinical procedure, new challenges and questions are becoming more urgent. These include issues of cost and coverage, the establishment of guidelines and registries to ensure quality of care and monitor outcomes, regulatory oversight (including for the allocation organs from deceased donors), and the extent to which indications for UTx should be expanded.

The journey from infertility to uterus transplantation: A qualitative study of the perspectives of participants in the Dallas Uterus Transplant Study

OBJECTIVE

To assess how absolute uterine factor infertility affects women who undergo uterus transplantation, how uterus transplantation impacts women with absolute uterine factor infertility and how uterus transplant recipients view uterus transplantation in terms of their reproductive autonomy.

DESIGN

Qualitative semi-structured interview study.

SETTING

Uterus transplant programme in a large academic medical centre in the USA.

POPULATION/SAMPLE

Twenty one uterus transplant recipients.

METHODS

A medical chart review was conducted to collect patient demographic information and clinical outcomes. Semi-structured interviews collected information regarding participants' experience.

MAIN OUTCOME MEASURE(S)

The outcomes of interest were participants' experience of infertility, experience with uterus transplantation and general perceptions of uterus transplantation.

RESULTS

Six participants were pregnant (one with a second child), six had experienced early graft failure and removal, five had delivered a healthy baby, and four had a viable graft and were awaiting embryo transfer. The primary themes identified were: the negative impact of absolute uterine factor infertility diagnosis on psychological wellbeing, relationships and female identity; the positive impact of uterus transplantation on healing the emotional scars of absolute uterine factor infertility, female identity and value of research trial participation and the perception of uterus transplantation as an expansion of reproductive autonomy. All participants reported that uterus transplantation was worthwhile, regardless of individual outcome.

CONCLUSION

Absolute uterine factor infertility has a negative impact on women from a young age, affects multiple relationships and challenges female identity. Uterus transplantation helps to reverse this impact, transforming women's life narrative of infertility and enhancing female identity.

TWEETABLE ABSTRACT

Absolute uterine factor infertility (AUFI) adversely affects women. Uterus transplantation helps mitigate the negative impact of AUFI, by transforming women's life narratives of infertility and enhancing female identity.

Uterus transplantation - donor and recipient work-up

PURPOSE OF REVIEW

Uterus transplantation (UTx) is transitioning from an experimental procedure to a clinical treatment for absolute uterine factor infertility (AUFI). Standardized protocols for the evaluation and selection of donors and recipients that maximize chances of success - a healthy live birth - are needed.

RECENT FINDINGS

To date, recipient eligibility has been limited to otherwise healthy women with AUFI who are of childbearing age and are good candidates for in-vitro fertilization (IVF). For donors (living or deceased), selection criteria vary, apart from basic requirements of blood-type compatibility and freedom from critical infectious diseases, but generally require a term birth and a uterus free from uterine pathologies. The stepwise evaluation process for candidate recipients and living donors moves through health screening (medical and psychosocial); initial selection committee review; IVF (recipients only); and final selection committee review. This eliminates candidates with poor chances of success before exposure to unnecessary risks.

SUMMARY

The currently stringent selection criteria for prospective recipients and donors will likely broaden, as UTx becomes more widely available. Continued research is needed to define the donor, recipient and uterine graft factors associated with successful outcomes, and to support the development of standardized selection criteria.

Psychological Characteristics of Recipients Pretransplantation in the Dallas UtErus Transplant Study (DUETS)

INTRODUCTION

Uterus transplantation is now a viable option for fertility treatment for women with absolute uterine factor infertility. Psychological assessment is recommended as a part of the perioperative evaluation process.

RESEARCH OBJECTIVE

The purpose of this study was to examine the psychological characteristics and mental health history of the 20 women who participated in the Dallas UtErus Transplant Study (DUETS) trial.

DESIGN

This retrospective observational descriptive study was part of a prospective clinical trial. Prior to transplant, 20 women completed a clinical psychological interview, 19 of whom also completed psychological assessment measures including the Hospital Anxiety and Depression Scale, Patient Health Questionnaire 9 item, Generalized Anxiety Disorder 7 item, PTSD Checklist for DSM-5, 36-Item Short Form, Connor-Davidson Resilience Scale 10 item, and Dyadic Adjustment Scale.

RESULTS

Women who participated in the trial had high health-related quality of life and minimal psychological history, with most reporting psychological distress associated with their initial infertility diagnosis (N = 13). None of the participants endorsed psychological distress to meet clinical concerns on the psychological measures used. Satisfaction with relationship adjustment with their partners was also high.

CONCLUSIONS

Women with absolute uterine factor infertility who underwent uterus transplant demonstrated low psychological distress on assessment measures, were resilient, had high health related quality of life, and strong satisfaction with the quality of relationships with their partners. Although some women reported either current or past psychological diagnosis, most reported psychological distress that occurred at the time of the infertility diagnosis and appeared to resolve over time.

Uterus transplantation in a sheep model: novel surgical technique with long-term survival and uterus vitality. First case series in Argentina

OBJECTIVE

To develop a sheep autologous uterus transplantation (UT) program with an innovative surgical technique and assess long term uterus vitality and animal survival.

METHODS

A novel surgical technique consisting of the procurement of the complete uterus and the two ovaries, back table vascular reconstruction, and subsequent implantation in the same animal, performing only two arterial and two venous anastomoses.

RESULTS

Four autologous transplantations were performed; anesthesia and surgery were well tolerated by all the animals without complications. Direct observation and Doppler US performed a week after UT and laparoscopy performed three months later confirmed uterus vitality. All animals were alive more than a year after transplantation.

CONCLUSIONS

Our study was the first to describe a novel surgical technique for sheep uterus autologous transplantation in Latin America, showing long-term survival and uterus vitality.

Uterus transplantation-questions and answers about the procedure that is expanding the field of solid organ transplantation

Uterus transplant is a new and rapidly evolving field of solid organ transplantation designed to help women with absolute uterine-factor infertility who desire to carry their own pregnancies. The advent of this procedure and human clinical trials of uterus transplantation have raised technical, clinical, and ethical questions. We address several questions about uterus transplantation based on available literature and the clinical experience at Baylor University Medical Center, which has the largest uterus transplant program in the United States.

Clinical pregnancy rates and experience with in vitro fertilization after uterus transplantation: Dallas Uterus Transplant Study

BACKGROUND

The clinical pregnancy rates among patients with uterus transplantation have been reported by only a limited number of centers, and those centers have not used preimplantation genetic testing for aneuploidy in their protocol.

OBJECTIVE

This study examined clinical pregnancy rates among women with absolute uterine-factor infertility undergoing in vitro fertilization using good-quality, expanded-blastocyst-stage, euploid embryos after uterus transplantation.

STUDY DESIGN

This cohort observational study involved 20 women who underwent uterus transplantation over 3 years. Notably, 14 of these patients had successful transplants and were followed prospectively for a median of 14.1 months (range, 11-34.8 months). In vitro fertilization was performed before subjects underwent uterus transplantation, and good-quality expanded-blastocyst-stage euploid embryos were obtained and frozen for future embryo transfer. Interventions consisted of in vitro fertilization, preimplantation genetic testing for aneuploidy, uterus transplantation, and frozen embryo transfer.

RESULTS

All 14 subjects with successful transplants underwent single embryo transfer of a warmed, good-quality, euploid, expanded blastocyst and had at least 1 documented clinical pregnancy within the uterus. In 71.4%, the first embryo transfer resulted in clinical pregnancy. The median time from successful uterus transplantation to first embryo transfer was 4.5 months; from successful uterus transplantation to first clinical pregnancy, 7.3 months; and from successful uterus transplantation to first live birth, 14.1 months. A total of 13 live births have occurred in 12 subjects.

CONCLUSION

Women with absolute uterine-factor infertility who have surgically successful uterus transplantation and in vitro fertilization using preimplantation genetic testing for aneuploidy can achieve high clinical pregnancy rates. We have reduced the time interval from uterus transplantation to embryo transfer by at least 50% and the interval from uterus transplantation to clinical pregnancy by >6 months compared with previous studies. We believe our approach may shorten the time from transplant to clinical pregnancy and therefore decrease patient exposure to immunosuppressant therapies.

Uterus transplantation and pregnancy induction: Approved protocol at the Royal Prince Alfred Hospital

Absolute uterine factor infertility (AUFI) is defined as the absence of a uterus or the presence of a non-functional uterus. Before the first live birth from a uterus transplant in 2014, the only fertility options for women with AUFI were surrogacy and adoption. In November 2019, our team was granted approval for the first uterus transplant trial in Australia using known living donors. Our program is based on that of our overseas collaborators in Dallas, Texas; this team will also be proctoring us for our first two cases.

Preimplantation genetic testing for aneuploidy in uterus transplant patients

Uterus transplantation is an emerging treatment for uterine factor infertility. In vitro fertilization with cryopreservation of embryos prior is required before a patient can be listed for transplant. Whether or not to perform universal preimplantation genetic testing for aneuploidy should be addressed by centers considering a uterus transplant program. The advantages and disadvantages of preimplantation genetic testing for aneuploidy in this unique population are presented. The available literature is reviewed to determine the utility of preimplantation genetic testing for aneuploidy in uterus transplantation protocols. Theoretical benefits of preimplantation genetic testing for aneuploidy include decreased time to pregnancy in a population that benefits from minimization of exposure to immunosuppressive agents and decreased chance of spontaneous abortion requiring a dilation and curettage. Drawbacks include increased cost per in vitro fertilization cycle, increased number of required in vitro fertilization cycles to achieve a suitable number of embryos prior to listing for transplant, and a questionable benefit to live birth rate in younger patients. Thoughtful consideration of whether or not to use preimplantation genetic testing for aneuploidy is necessary in uterus transplant trials. Age is likely a primary factor that can be useful in determining which uterus transplant recipients benefit from preimplantation genetic testing for aneuploidy.

Endometriosis and Medical Therapy: From Progestogens to Progesterone Resistance to GnRH Antagonists: A Review

Background: The first objective of this review was to present, based on recent literature, the most frequently applied medical options (oral contraceptive pills (OCPs) and progestogens) for the management of symptomatic endometriosis, and evaluate their effectiveness in treating premenopausal women with endometriosis-associated pelvic pain, dysmenorrhea, non-menstrual pelvic pain and dyspareunia. The second objective was to review the concept of progesterone resistance and newly available treatment options. Methods: We reviewed the most relevant papers (n = 73) on the efficacy of OCPs and progestogens as medical therapy for endometriosis, as well as those on progesterone resistance and new medical alternatives (oral gonadotropin-releasing hormone (GnRH) antagonist). Eleven papers, essentially reviews, were selected and scrutinized from among 94 papers discussing the concept of progesterone resistance. Results: Having reviewed the most significant papers, we can confirm that OCPs and progestogens are effective in two-thirds of women suffering from endometriosis, but that other options are required in case of failure (in one-third of women due to progesterone resistance) or intolerance to these compounds. It is clear that there is a need for effective long-term oral treatment capable of managing endometriosis symptoms, while mitigating the impact of side effects. Biochemical, histological and clinical evidence show that estrogens play a critical role in the pathogenesis of endometriosis, so lowering levels of circulating estrogens should be considered an effective medical approach. The efficacy of three oral GnRH antagonists is discussed on the basis of published studies. Conclusion: There is a place for GnRH antagonists in the management of symptomatic endometriosis and clinical trials should be conducted, taking into account the different phenotypes in order to propose novel algorithms.

The Evolution of Transplantation From Saving Lives to Fertility Treatment: DUETS (Dallas UtErus Transplant Study)

OBJECTIVE

We report the results of the first 20 uterus transplants performed in our institution.

SUMMARY BACKGROUND DATA

Uterus transplantation (UTx) aims at giving women affected by absolute uterine-factor infertility the possibility of carrying their own pregnancy. UTx has evolved from experimental to an established surgical procedure.

METHODS

The Dallas Uterus Transplant Study (DUETS) program started in 2016. The uterus was transplanted in orthotopic position with vascular anastomoses to the external iliac vessels and removed when 1 or 2 live births were achieved. Immunosuppression lasted only for the duration of the uterus graft.

RESULTS

Twenty women, median age 29.7 years, enrolled in the study, with 10 in phase 1 and 10 in phase 2. All but 2 recipients had a congenital absence of the uterus. Eighteen recipients received uteri from living donors and 2 from deceased donors. In phase 1, 50% of recipients had a technically successful uterus transplant, compared to 90% in phase 2. Four recipients with a technical success in phase 1 have delivered 1 or 2 babies, and the fifth recipient with a technical success is >30 weeks pregnant. In phase 2, 2 recipients have delivered healthy babies and 5 are pregnant.

CONCLUSIONS

UTx is a unique type of transplant; whose only true success is a healthy child birth. Based on results presented here, involving refinement of the surgical technique and donor selection process, UTx is now an established solution for absolute uterine-factor infertility.

Operative and Clinical Outcomes of Minimally Invasive Living-Donor Surgery on Uterus Transplantation: A Literature Review

BACKGROUND

The surgical approach and choice of drainage veins for uterus transplantation living-donor surgery have been investigated to reduce invasiveness.

METHODS

A thorough search of the PubMed database was conducted. The search was not limited by language or date of publication. The data were collected on 13 October 2020. Two reviewers independently assessed each article and determined eligibility for inclusion in the review article. Inclusion criteria were English peer-reviewed articles reporting surgical information or postoperative course, articles regarding animal research on UTx, UTx on deceased donors, or not original articles.

RESULTS

Of the 51 operations within 26 articles reviewed, the mean operative time was shortest in the laparoscopic approach, and longest in the robot-assisted approach. The mean blood loss was less in the laparoscopic and robot-assisted approaches than in the open approach. In cases where the uterine veins were not preserved, the mean operative time was shortened by each approach and the mean blood loss decreased with the laparoscopic and robot-assisted approaches.

CONCLUSIONS

These procedures may contribute to less invasive living-donor surgery.

Uterine Transplantation: Evolving Data, Success, and Clinical Importance

Uterine transplantation is an evolving procedure to allow for childbearing in paitents with absolute uterine factor infertility. The objective of this study was to review the existing literature using a comprehensive PubMed literature search. A systematic medical subheadings search strategy was used with the terms "uterus transplant" and "uterine transplantation". Of the 75 full-text articles assessed for eligibility, 68 were included in the qualitative synthesis. Of these, 9 were included in the meta-analysis on living donor uterine transplant, 5 on deceased donor uterine transplant, and 6 case reports of single uterine transplants. In conclusion, uterus transplant is a nascent field undergoing a rapid rate of evolution as programs mature their data and increase the number of procedures performed. The most recent publications and advances are thus summarized in this article to capture the most up-to-date information.

Human uterine vasculature with respect to uterus transplantation: A comprehensive review

Due to the novelty of uterus transplantation, data on preferable inflow and outflow of the graft are limited. This paper reviews the technique, type of vessels and the outcome. A systematic search of the PubMed database was conducted. We extracted and analyzed data on the arteries and veins utilized, types of anastomosis, types of donors, complications and the outcome. Thirty eight sources reported 51 human uterine transplantations, 10 graft thromboses and 25 live births. Inflow was established with two uterine arteries (UA) with/without the anterior division of the internal iliac artery in 62% (n = 31) of cases, two UA arteries with a segment/patch of the internal iliac artery in 34% (n = 17) of cases or two UA with a conduit in 4% of cases (n = 2). Both cases with a conduit developed thrombosis (n = 2). Arterial thrombosis/ischemia developed in 8 of the 51 cases. In 50% of cases with arterial thrombosis, atherosclerosis was identified as a possible cause. Outflow was established by two internal iliac veins with patches/segments in 27.5% of cases (n = 14) followed by two utero-ovarian veins in 25.5% (n = 13). Venous thrombosis occurred in 3 of the 51 cases. Uterine arteries with/without anterior division of the internal iliac artery were the most frequent arteries used for inflow and produced the highest patency rate. The presence of atherosclerosis and complex arterial reconstruction was associated with a high rate of arterial thrombosis. None of the veins utilized in the procedures appeared to be superior. There are insufficient data to draw a definite conclusion.

First birth from a deceased donor uterus in the United States: from severe graft rejection to successful cesarean delivery

Uterus transplantation is the only known potential treatment for absolute uterine factor infertility. It offers a unique setting for the investigation of immunologic adaptations of pregnancy in the context of the pharmacologic-induced tolerance of solid organ transplants, thus providing valuable insights into the early maternal-fetal interface. Until recently, all live births resulting from uterus transplantation involved living donors, with only 1 prior birth from a deceased donor. The Cleveland Clinic clinical trial of uterus transplantation opened in 2015. In 2017, a 35 year old woman with congenital absence of the uterus was matched to a 24 year old parous deceased brain-dead donor. Transplantation of the uterus was performed with vaginal anastomosis and vascular anastomoses bilaterally from internal iliac vessels of the donor to the external iliac vessels of the recipient. Induction and maintenance immunosuppression were achieved and subsequently modified in anticipation of pregnancy 6 months after transplant. Prior to planned embryo transfer, ectocervical biopsy revealed ulceration and a significant diffuse, plasma cell-rich mixed inflammatory cell infiltrate, with histology interpreted as grade 3 rejection suspicious for an antibody-mediated component. Aggressive immunosuppressive regimen targeting both cellular and humoral rejection was initiated. After 3 months of treatment, there was no histologic evidence of rejection, and after 3 months from complete clearance of rejection, an uneventful embryo transfer was performed and a pregnancy was established. At 21 weeks, central placenta previa with accreta was diagnosed. A healthy neonate was delivered by cesarean hysterectomy at 34 weeks' gestation. In summary, this paper highlights the first live birth in North America resulting from a deceased donor uterus transplant. This achievement underscores the capacity of the transplanted uterus to recover from a severe, prolonged rejection and yet produce a viable neonate. This is the first delivery from our ongoing clinical trial in uterus transplantation, including the first reported incidence of severe mixed cellular/humoral rejection as well as the first reported placenta accreta.

Psychosocial outcomes of uterine transplant recipients and partners up to 3 years after transplantation: results from the Swedish trial

OBJECTIVE

To assess the psychosocial outcomes of recipients and their partners 2 and 3 years after entering this first clinical uterus transplantation study.

DESIGN

Prospective observational study.

SETTING

University hospital.

PATIENT(S)

Nine women with absolute uterine factor infertility and their male partners participated.

INTERVENTION(S)

Psychosocial evaluations using questionnaires focusing on health-related quality-of-life, mood, relationship, and fertility-related quality-of-life were conducted at 2- and 3-year follow-up after transplantation.

MAIN OUTCOME MEASURE(S)

Scores were obtained on the validated questionnaires 36-Item Short Form Survey (SF-36), Hospital Anxiety and Depression Scale, Dyadic Adjustment Scale, and Fertility Quality of life measuring health-related quality-of-life, mood, relationship, and infertility-associated life quality, respectively.

RESULT(S)

There was a reversible decrease (at year 2) in the physical component of SF-36 concerning recipients, but not in partners. Negative deviations in the mental component of SF-36 were seen in four recipients, and in two of their partners at year 3, possibly related to the fact that live birth had not been achieved yet among three of these women. Childlessness also seemed to be related to reporting elevated anxiety scores. Most recipients and partners stated high satisfaction with marital relationship both at inclusion and at follow-up.

CONCLUSION(S)

The results of the present study show that even if the baseline psychosocial characteristics of the women to undergo transplantation and their partners were stable and equal or better compared with norm populations, graft failure and failure to achieve parenthood will pose psychological strains on couples in the period up to 3 years after transplantation. Psychological counseling should be offered past 3 years for recipients and their partners.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01844362.

Uterine Factor Infertility: A Clinical Review

Uterine factor infertility (UFI) may affect up to 1 in 500 reproductive age women. The uterus is an essential component of achieving pregnancy and carrying a pregnancy to term successfully. There are many etiologies of UFI which may be categorized into either congenital or acquired causes. In this review, we discuss the different causes of UFI as well as the treatment options, which now includes uterine transplant.

Provider Knowledge and Support of Uterus Transplantation: Surveying Multidisciplinary Team Members

Objective

To determine relevant provider opinions on uterus transplantation (UTx).

Patients and Methods

We invited 1933 providers in obstetrics and gynecology, transplant surgery, transplant medicine, internal medicine, and family medicine at a large, integrated health care system to complete an online survey containing a series of questions on their attitudes about the ethics and clinical utility of UTx. The survey was open from June 4, 2018, through July 2, 2018. We received 449 responses overall (23.2% response rate).

Results

Of 433 physicians who responded, 195 (45.0%) believe that UTx is ethically justified, and just over a third (160 of 446 [35.9%]) would introduce the possibility of UTx to a patient with absolute uterine factor infertility (AUFI). Respondents indicated the risks to donor, recipient, and child carried the most weight in their ethical evaluation and were most supportive of UTx in a patient with congenital uterine absence (334 of 743 [45.0%]; participants were allowed to choose more than one answer). A majority stated that a living or cadaveric donor would be an acceptable donor source (238 of 395 [60.3%]).

Conclusion

Provider support for UTx is qualified by safety concerns and its expansion to patient populations other than women with AUFI. This survey suggests that most providers limit their support of UTx to patients with the most demonstrated clinical need, childless women with AUFI.

DUETS (Dallas UtErus Transplant Study): Complete report of 6-month and initial 2-year outcomes following open donor hysterectomy

INTRODUCTION

Uterus transplantation has shown success in treating women with uterine factor infertility who want to carry their own pregnancy.

METHODS

We report the medical, sexual, and psychological outcomes of our first cohort of 13 living donor hysterectomies. As we have transitioned from open to robotically assisted hysterectomy, this report represents the complete series of open donor hysterectomies at our center, all with ≥6-month postoperative outcomes.

RESULTS

The open donor hysterectomy had a median of a 6.5-hour surgical time, 0.8 L estimated blood loss, 6-day hospital stay, and 28-day sick leave. Three donors had a grade III or IV complications, one reported new-onset psychological symptoms, and 9 experienced transient sexual discomfort. All complications were addressed and resolved, and all donors returned to their presurgical social and physical activities.

CONCLUSION

Since uterus transplantation is not life-saving or life-extending, the risks in living uterus donation must be weighed against the benefit of giving another woman the opportunity to give birth to her own child. This report provides data to support more detailed informed consent regarding the medical, psychological, and sexual complications of open living donor hysterectomy and allows for further evaluation of the ethical acceptability of this procedure.

New Frontier: Role of the Radiologist in Uterine Transplantation

Uterine transplantation (UT) is a novel treatment for absolute uterine factor infertility (AUFI) that is currently being performed under experimental protocols in multiple medical centers worldwide. At the time of this publication, there have been at least 10 live births by women with a transplanted uterus. As successful outcomes from this innovative procedure increase, it is likely that more centers will perform UT. Imaging is performed in multiple steps of the UT process, including preoperative imaging of potential donors and recipients, posttransplant surveillance, and monitoring of pregnancy. Fetal imaging is performed by maternal-fetal medicine professionals, but most imaging examinations in UT are performed by radiologists. Given the significant role of imaging in this groundbreaking surgery, radiologists must be familiar with the causes of AUFI and the role of imaging in establishing this diagnosis. Radiologists working in medical centers where UT is performed should understand the role of imaging in preoperative planning and postoperative surveillance. While data regarding complications of UT are preliminary at best, radiologists must be aware of the risk of vascular compromise and graft failure and their imaging features. The authors provide a brief history of UT and define the radiologist's role in pre- and postoperative imaging assessments.^©RSNA, 2019.

Fertility preservation for transgender adolescents and young adults: a systematic review

BACKGROUND

Many transgender individuals choose to undergo gender-affirming hormone treatment (GAHT) and/or sex reassignment surgery (SRS) to alleviate the distress that is associated with gender dysphoria. Although these treatment options often succeed in alleviating such symptoms, they can also negatively impact future reproductive potential.

OBJECTIVE AND RATIONALE

The purpose of this systematic review was to synthesize the available psychosocial and medical literature on fertility preservation (FP) for transgender adolescents and young adults (TAYAs), to identify gaps in the current research and provide suggestions for future research directions.

SEARCH METHODS

A systematic review of English peer-reviewed papers published from 2001 onwards, using the preferred reporting items for systematic reviews and meta-analyses protocols (PRISMA-P) guidelines, was conducted. Four journal databases (Ovid MEDLINE, PubMed Medline, Ovid Embase and Ovid PsychINFO) were used to identify all relevant studies exploring psychosocial or medical aspects of FP in TAYAs. The search strategy used a combination of subject headings and generic terms related to the study topic and population. Bibliographies of the selected articles were also hand searched and cross-checked to ensure comprehensive coverage. All selected papers were independently reviewed by the co-authors. Characteristics of the studies, objectives and key findings were extracted, and a systematic review was conducted.

OUTCOMES

Included in the study were 19 psychosocial-based research papers and 21 medical-based research papers that explore fertility-related aspects specific for this population. Key psychosocial themes included the desire to have children for TAYAs; FP discussions, counselling and referrals provided by healthcare providers (HCPs); FP utilization; the attitudes, knowledge and beliefs of TAYAs, HCPs and the parents/guardians of TAYAs; and barriers to accessing FP. Key medical themes included fertility-related effects of GAHT, FP options and outcomes. From a synthesis of the literature, we conclude that there are many barriers preventing TAYAs from pursuing FP, including a lack of awareness of FP options, high costs, invasiveness of the available procedures and the potential psychological impact of the FP process. The available medical data on the reproductive effects of GAHT are diverse, and while detrimental effects are anticipated, the extent to which these effects are reversible is unknown.

WIDER IMPLICATIONS

FP counselling should begin as early as possible as a standard of care before GAHT to allow time for informed decisions. The current lack of high-quality medical data specific to FP counselling practice for this population means there is a reliance on expert opinion and extrapolation from studies in the cisgender population. Future research should include large-scale cohort studies (preferably multi-centered), longitudinal studies of TAYAs across the FP process, qualitative studies of the parents/guardians of TAYAs and studies evaluating the effectiveness of different strategies to improve the attitudes, knowledge and beliefs of HCPs.

Uterus transplantation in women who are genetically XY

Uterus transplantation is an emerging technology adding to the arsenal of treatments for infertility; specifically the only available treatment for uterine factor infertility. Ethical investigations concerning risks to uteri donors and transplant recipients have been discussed in the literature. However, missing from the discourse is the potential of uterus transplantation in other groups of genetically XY women who experience uterine factor infertility. There have been philosophical inquiries concerning uterus transplantation in genetically XY women, which includes transgender women and women with complete androgen insufficiency syndrome. We discuss the potential medical steps necessary and associated risks for uterus transplantation in genetically XY women. Presently, the medical technology does not exist to make uterus transplantation a safe and effective option for genetically XY women, however this group should not be summarily excluded from participation in trials. Laboratory research is needed to better understand and reduce medical risk and widen the field to all women who face uterine factor infertility.

Ethical and policy issues raised by uterus transplants

INTRODUCTION

In 2014, Brännström and colleagues reported the first human live birth following uterine transplantation (UTx). Research into this treatment for absolute uterine factor infertility has since grown with clinical trials currently taking place across centers in at least thirteen countries worldwide.

SOURCES OF DATA

This review summarizes and critiques the academic literature on ethical and policy issues raised by UTx.

AREAS OF AGREEMENT

There is general agreement on the importance of risk reduction and, in principle, to the sharing and maintenance of patient data on an international registry.

AREAS OF CONTROVERSY

There are numerous areas of controversy ranging from whether it is ethically justified to carry out uterus transplants at all (considering the associated health risks) to how deceased donor organs for transplant should be allocated. This review focuses on three key issues: the choice between deceased and living donors, ensuring valid consent to the procedure and access to treatment.

GROWING POINTS

UTx is presently a novel and rare procedure but is likely to become more commonplace in the foreseeable future, given the large number of surgical teams working on it worldwide.

AREAS TIMELY FOR DEVELOPING RESEARCH

Uterus transplantation requires us to re-examine fundamental questions about the ethical and social value of gestation. If eventually extended to transgender women or even to men, it may also require us to reconceptualize what it is to be a 'father' or to be a 'mother', and the definition of these terms in law.

DUETS (Dallas UtErus Transplant Study): The role of imaging in uterus transplantation

Objective:

Uterus transplantation is rapidly becoming a viable clinical option for women with uterine-factor infertility and a desire for parenthood. Radiological imaging plays a central role in selecting the optimal living donors for uterus transplantation and serves to exclude any pathology and evaluate the uterine vasculature. The latter is the most important variable in the ultimate technical success of the uterus transplant. In this first report of imaging in the setting of uterus transplantation, we report our experience with living-donor selection, and the evolution of the imaging techniques that ultimately allowed a significant improvement in donor selection and transplant outcome. We also suggest a framework for preoperative imaging in uterus transplantation.

Methods:

Between 2016 and 2018, 27 potential living donors were evaluated by imaging prior to uterine donation for uterus transplantation. Predonation imaging included a screening chest radiograph, dual-phase computed tomography (CT) angiograms of the abdomen and pelvis in the arterial and venous phases and pelvic sonography with Doppler. Seventeen potential donors additionally underwent multiphasic pelvic MR angiograms. The imaging performed was meant to display features of the vascular anatomy relevant for uterus transplantation.

Results:

Out of the 27 potential live donors who were evaluated by imaging, 9 eventually donated their uterus for transplantation. The most frequent reason for exclusion was suboptimal quality of the vessels (33%), including small uterine arteries, the presence of atherosclerosis or small size/poor quality of the uterine or utero-ovarian veins, or both. The next most common reason was voluntary patient withdrawal or failure to complete the evaluation process (28%). Three potential donors (16.6%) were rejected for uterine factors, fibroids, and/or adenomyosis. Other reasons for donor rejection included ABO incompatibility and unfavorable psychological evaluation.

Conclusion:

Diagnostic imaging plays a crucial role in selecting appropriate potential donors, screening prospective recipients, planning the graft procedure, and following up on any graft or nongraft-related complications in both the donor and recipient after the transplantation procedure is performed. Contrast-enhanced CT and MR angiographies have complementary roles, especially when evaluating the donor for adequacy of the arterial and venous supply to the uterine graft and the experience gained from our series indicates that the inclusion of both modalities contributed directly to successful uterus transplant graft survival by selecting patients with favorable arterial and venous vasculature.

Fertility concerns of the transgender patient

Transgender individuals who undergo gender-affirming medical or surgical therapies are at risk for infertility. Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear. Gender-affirming surgery (GAS) that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility. It is recommended that clinicians counsel transgender patients on fertility preservation (FP) options prior to initiation of gender-affirming therapy. Transmen can choose to undergo cryopreservation of oocytes or embryos, which requires hormonal stimulation for egg retrieval. Uterus preservation allows transmen to gestate if desired. For transwomen, the option for FP is cryopreservation of sperm either through masturbation or testicular sperm extraction. Experimental and future options may include cryopreservation and in vitro maturation of ovarian or testicular tissue, which could provide prepubertal transgender youth an option for FP since they lack mature gametes. Successful uterus transplantation with subsequent live birth is a new medical breakthrough for cisgender women with uterus factor infertility. Although it has not yet been performed in transgender women, uterus transplantation is a potential solution for those who wish to get pregnant. The transgender population faces many barriers to care, such as provider discrimination, lack of information, legal barriers, scarcity of fertility centers, financial burden, and emotional cost. Further research is necessary to investigate the feasibility of experimental FP options, provide better evidence-based information to clinicians and transgender patients alike, and to improve access to and quality of reproductive services for the transgender population.

Uterine transplantation

Successful human uterine transplantation followed by subsequent pregnancy and live birth in a woman for whom this would otherwise have been impossible is a laudable goal. Research programs have been developed in several countries aimed at achieving this goal. The pioneering Swedish program has reported live births in six women, two of whom had a second pregnancy and birth. Five other live births have been reported from other countries. Most transplants were from a live donor, although recently a live birth has been reported following transplant from a deceased donor. The surgical procedure on a live donor is highly invasive, complex, hazardous, and long and may decrease her quality of life. The use of a deceased donor would partly simplify this issue and is being explored in several centers. Also explored are technical modifications to simplify the procedure and shorten the operating times. The American Society for Reproductive Medicine (ASRM) reminds us of the full array of options available to patients: 'including gestational carriers (surrogacy), adoption and child-free living'. The ASRM also recommends 55 years as the upper age limit for transfer of donor oocytes and embryos in healthy women. Would it not be more practical and less onerous for the prospective live donor to carry the pregnancy instead? Uterine transplantation remains an experimental procedure that requires the study and resolution of ethical, technical, financial, and social issues, all very important.