Uterine transplant: new medical and ethical considerations

Summary of the ISFP congress, Brussels, 10-12 November, 2022

The 7th International Congress of the ISFP was held in Brussels in November 2022. Hundreds of attendees from all over the world had the rare opportunity to hear the most distinguished leaders discuss and debate the latest advances in the field. Participants were also able to attend workshops under the guidance of skilled practitioners. Numerous topics were considered, including a recap on fertility preservation approaches in cancer and benign pathologies and a section on male factor infertility. Other aspects covered were in vitro maturation and poor responders, the impact of chemotherapy on the ovary, and future perspectives. Participants had the chance to listen to a symposium on fertility preservation techniques, and finally, a keynote lecture on fertility preservation in gynecological cancers brought this prominent and highly influential event to a close.

The Moral Superiority of Bioengineered Wombs and Ectogenesis for Absolute Uterine Factor Infertility

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.

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.

An Ethics-Informed, Comparative Analysis of Uterus Transplantation and Gestational Surrogacy for Uterine Factor Infertility in High-Income Countries

Interest in the future, clinical implementation of uterus transplantation for uterine factor infertility was recently boosted by the demonstration of proof-of-concept for deceased uterus donation/transplantation. The ethical dimensions of living and deceased uterus transplantation are explored and addressed in the paper through their comparison to the ethical elements of an existing, legal, assisted reproduction practice in some high-income countries, i.e., gestational surrogacy. A set of six ethics lenses is used in the comparative analysis: reproductive autonomy and rights, informed choice/consent, relevant critical relational theories, health equity, theoretical application of the accepted living donation standard, and comparative benefits and burdens considerations. Gestational surrogacy, as currently practiced in some high-income countries, is the assumed, theoretical base-threshold for determination of ethical acceptability in assisted reproduction practices. The analysis demonstrates that (at the present time): 1) the ethical acceptability of living uterus donation/transplantation is less than that of gestational surrogacy in high-income countries, and 2) the ethical acceptability of deceased uterus donation/transplantation is roughly equivalent to that of gestational surrogacy. This leads to the conclusion that, at the present time, only one version of uterus transplantation practice, i.e., deceased uterus transplantation, should be considered ethically acceptable for possible clinical implementation in high-income countries.

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.

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.

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.

Framing the diagnosis and treatment of absolute uterine factor infertility: Insights from in-depth interviews with uterus transplant trial participants

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.

Uterine Transplantation: A Survey of Perceptions and Attitudes of American Reproductive Endocrinologists and Gynecologic Surgeons

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.

Uterine transplantation: Review in human research

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.

Could the female-to-male transgender population be donor candidates for uterus transplantation?

OBJECTIVE

To evaluate the eligibility of female-to-male (FtM) transgender people as donor candidates with regard to histologic, surgical, and social aspects.

MATERIALS AND METHODS

In this prospective cohort study, 31 FtM transgender people underwent standard hysterectomy and bilateral salpingo-oophorectomy for gender reassignment upon their request. The pelvic viscera of the transgender people was intraoperatively observed and the histology of the removed uteri were evaluated for fertility capacity and procurement surgery. A questionnaire was administered to explore their attitude towards uterus donation.

RESULTS

The mean ± standard deviation age was 28.5±5 years. The median duration of testosterone supplementation was 2.4 years; therefore, they all had irregular menstrual periods during this therapy. None had any previous abdominal surgery or additional morbidity. The mean uterine volume was 138±48 cm3. No adenomyosis, endometriosis, polyps, adhesions or uterine anomalies were either observed or reported. Endometrial histology was reported as proliferative (58%), atrophic (29%), and secretory (13%) pattern. Of the 31 transgender people, 30 (96.7%) had a positive attitude; only one had no opinion at the beginning. After detailed information about the procedure was given, 26 (84%) still wanted to volunteer for donation, but 4 (12%) changed their opinion to negative (p=0.12, McNemar test).

CONCLUSION

The proposal of the FtM transgender population as uterus donor is a hypothetical model that has not been experienced before. Nevertheless, our experience revealed that the FtM transgender population would be good candidates socially, legally, and biologically.

Uterus transplantation: From animal models through the first heart beating pregnancy to the first human live birth

Absolute uterine factor infertility affects 3-5% of the general population, and unfortunately this condition is untreatable. There are some available options, including surrogacy or adoption, but neither of these suits each and every woman who desires to have her own genetic child. With recent advances in surgery and transplant immunology, uterus transplantation may be a source of hope for these women with uterine infertility. In the last decade, a number of animal species including rats, mice, rabbits, pigs, sheep, and primates have been used as experimental models, and pregnancies were achieved in some of these. Human data consist of 11 subjects yielding positive pregnancy results with no live births in the second trial from Turkey and, more fortunately, live births from the latest trial from Sweden. In the light of all these studies, uterus transplantation has been proven to be a viable option for women with uterine factor infertility.

Uterus transplantation: Toward clinical application in Japan

Background

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

Methods

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

Results

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

Conclusion

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

Deceased Donor Uterine Transplantation: Innovation and Adaptation

This commentary endeavors to share our practical experience in developing and implementing the first uterine transplant clinical trial in the United States. Uterine transplant is a promising novel treatment for uterine factor infertility. After reported successful live births after uterine transplant in Sweden, research teams around the world are either embarking on or are considering the development of uterine transplant protocols. Our observations on the applied rather than theoretical aspects of uterine transplantation research in human subjects are detailed in this article. Important among these considerations are composing a broad and experienced multidisciplinary team as well as performing adequate preclinical preparations, including ideally animal studies and practice organ procurements. Ethical preparation is tantamount to clinical preparation for the complexities inherent in uterine transplant, and our suggestions for updating the current ethical criteria for uterine transplant are outlined here. We also describe our perspectives on the strengths and weaknesses of living compared with deceased donor models. Finally, we describe how a strong program can recover and adapt in the face of setbacks to continue a path toward innovation.

Deceased donor uterine transplantation

OBJECTIVE

To share our experience in performing the first-ever deceased-donor uterine transplant in the United States.

DESIGN

This video uses an animation and footage from a uterine transplantation procedure to review the steps and techniques involved in performing a uterine transplant.

SETTING

Academic, multisite medical center.

PATIENT(S)

A reproductive-age patient with Mayer-Rokitansky-Kuster-Hauser syndrome.

INTERVENTION(S)

Transplantation of a viable uterus from a deceased donor.

MAIN OUTCOME MEASURE(S)

Assessment of posttransplantation uterine graft viability.

RESULT(S)

This video article describes the essential steps in the uterine transplant process, including selecting an appropriate donor with no history of infertility or uterine malformations. Furthermore, a deceased donor should exhibit brain death but not cardiac death. We also review our inclusion criteria for suitable recipients. In this video we outline the key steps in a uterine transplantation procedure and demonstrate footage from an actual transplant procedure. These steps include establishing bilateral end-to-side vascular anastomoses between the donor uterine artery and vein and the recipient's external iliac vessels. Once this has been completed and reperfusion noted of the donor uterus, connection to the recipient vaginal cuff is then performed.

CONCLUSION(S)

Uterine transplantation, although currently experimental, has gained the potential to become the first true treatment for uterine factor infertility. This procedure can become a promising option for the approximately 1.5 million women worldwide for whom pregnancy is not possible because of the absence of the uterus or presence of a nonfunctional uterus. Deceased donor uterine transplantation will further serve to broaden accessibility for this procedure.

Duty and dilemma: Perioperative nurses hiding an objection to participate in organ procurement surgery

Perioperative nurses assist in organ procurement surgery; however, there is a dearth of information of how they encounter making conscientious objection requests or refusals to participate in organ procurement surgery. Organ procurement surgical procedures can present to the operating room ad hoc and can catch a nurse who may not desire to participate by surprise with little opportunity to refuse as a result of staffing, skill mix or organizational work demands. This paper that stems from a larger doctoral research study exploring the experiences of perioperative nurses participating in multi-organ procurement surgery used a grounded theory method to develop a substantive theory of the nurses' experiences. This current paper aimed to highlight the experiences of perioperative nurses when confronted with expressing a conscientious objection towards their participation in these procedures. A number of organizational and cultural barriers within the healthcare organization were seen to hamper their ability in expressing a conscience-based refusal, which lead to their reluctant participation. Perioperative nurses must feel safe to express a conscientious objection towards these types of surgical procedures and feel supported in doing so by their respective hospital organizations and not be forced to participate unwillingly.

The past, present and future of fertility preservation in cancer patients

Fertility preservation strategies have been developed for men and women whose fertility is compromised for medical reasons, especially in case of cancer therapy. At present, many reliable options for preserving fertility are available. However, a part of these fertility preservation methods, despite being promising, are still considered experimental. Nevertheless, there are still situations where no methods can be offered. Remarkable scientific progress is currently underway to improve available techniques and to develop new technologies to solve problems with current fertility strategies. These new options may drastically change reproductive options for young patients facing germ cell loss and hence sterility. Therefore, oncofertility counseling by a specialist is recommended for all young cancer patients having to undergo treatment that may reduce fertility potential.