Uterus transplantation: from research, through human trials and into the future

Standardizing decellularization protocols for optimized uterine tissue bioengineering

Bioengineering is applied in different areas, including women's infertility management. Among other approaches, decellularized tissues are being used to treat uterine disorders causing infertility. Biomaterials made from decellularized tissue consist of tissue-specific extracellular matrix and, as acellular scaffolds, are thought to be immune inert. Hence, they are good grafting candidates to replace and regenerate excised damaged uterine tissue to cure infertility. However, decellularization approaches differ among species and research groups, posing challenges for comparison and standardization. The diversity in data reporting and studied properties of the resulting decellularized scaffold make it even more difficult, especially when the ultimate goal is clinical translation. Thus, this review aims to critically assess whole uterus decellularization studies, extracting and comparing their main results and conclusions. After carefully evaluating the reviewed studies, we noticed that the vast majority base the uterus decellularization success and resulting scaffold efficacy on the DNA removal efficacy, while other crucial aspects, including the extracellular matrix integrity or immunogenicity, are underestimated. Thus, this review further proposes practical points for what should be considered and how results can be reported in studies involving whole uterus decellularization to facilitate comparison between studies and translational progress.

Analysis of Immunological Biomarkers Associated With Rejection After Uterus Transplantation in Human

BACKGROUND

Uterus transplantation (UTx) is an emerging therapy for women with uterine infertility. However, critical questions remain with this procedure including the mechanisms involved in graft rejection.

METHODS

In this study, we analyzed the immune profile of ectocervical biopsies from 5 patients after UTx before and during their first episode of rejection using RNA sequencing, quantitative polymerase chain reaction, and imaging mass cytometry.

RESULTS

We identified 530 upregulated and 207 downregulated genes associated with graft rejection. Enrichment databases revealed abnormalities of skin-associated genes and the immune system, in particular activation of T and B lymphocytes, and macrophages. Imaging mass cytometry confirmed these observations; in cervical biopsies of 3 women, rejection was associated with the presence of B-cell structures linked to tertiary lymphoid structures, and 2 biopsies from 1 woman with severe rejection episodes and poor prognosis of graft function (repeated miscarriage and implantation failures) were associated with an accumulation of HLA-DR - macrophages, producing granzyme B at the surface of the epithelium.

CONCLUSIONS

We showed that rejection of a UTx graft was associated with major alterations of immune markers including the involvement of tertiary lymphoid structures, the most organized of which may be a sign of chronic rejection, and with an increase in HLA-DR - macrophages expressing granzyme B in the case of grade 3 rejection episodes according Mölne's classification. We identified potential emerging biomarkers to predict or diagnose graft rejection (Keratin 1 granzyme B, IL1β). These findings could lead to development of improved strategies for the identification, prevention, and/or treatment of uterus graft rejection.

Transcript analysis of uterus transplant cervical biopsies using the Banff Human Organ Transplant panel

Uterus transplantation is being more widely implemented in clinical practice. Monitoring of rejection is routinely done for cervical biopsies and is dependent on histopathological assessment, as rejections are clinically silent and nonhistological biomarkers are missing. Until this gap is filled, it is important to corroborate the histopathological diagnosis of rejection through independent methods such as gene expression analysis. In this study, we compared our previously published scoring system for grading rejection in uterus transplant cervical biopsies to the gene expression profile in the same biopsy. For this, we used the Banff Human Organ Transplant gene panel to analyze the expression of 788 genes in 75 paraffin-embedded transplant cervical biopsies with a spectrum of histologic findings, as well as in 24 cervical biopsies from healthy controls. We found that gene expression in borderline changes did not differ from normal transplants, whereas the genes with increased expression in mild rejections overlapped with previously published rejection-associated transcripts. Moderate/severe rejection samples showed a gene expression pattern characterized by a mixture of rejection-associated and tissue injury-associated genes and a decrease in epithelial transcripts. In summary, our findings support our proposed scoring system for rejection but argue against the treatment of borderline changes.

Living donor uterus transplant research project in Singapore: Progress of the first case

INTRODUCTION

To report the progress of the human living uterus transplant research project in Singapore.

MATERIAL AND METHODS

The uterus transplant research project began in 2012 with a collaboration between the Swedish and Singapore teams. Ethics approval was obtained from the SingHealth Centralised Institutional Review Board, the SingHealth Transplant and the Singapore General Hospital Biomedical Ethics Committee to perform 5 uterus transplant procedures in a collaborative multi-site research study at the Singapore General Hospital. Regulatory approval was obtained from the Ministry of Health, Singapore. A suitable recipient-donor pair was identified. The living donor was the perimenopausal mother-in-law of the recipient who had Mayer-Rokitansky-Kuster-Hauser syndrome. They underwent the requisite matching process as well as robust medical, psychiatric and psychosocial assessments. The recipient then underwent in vitro fertilization (IVF) treatment resulting in 6 frozen blastocysts. Preparations were made for the transplant surgery on 25 November 2023 in Singapore General Hospital, aided by the 3 Uterus transplant experts from the Swedish Team, for whom temporary registration was granted by the Singapore Medical Council.

RESULTS

This first uterus transplant procedure involved an operative time of 10 h and 30 min for the donor. The synchronized recipient surgery lasted 6 h and 20 min. Surgery was by midline laparotomy in both the living donor and recipient. The total warm ischemic time of the graft was 45 min, and the cold ischemic time was 1 h 45 min (total ischemic time 2 h 30 min). The patient's first menstruation occurred 38 days after the uterus transplant procedure. Cytomegalovirus infection was detected 6 weeks postoperatively for which she was aggressively treated. Serial cervical biopsies showed no rejection and Doppler ultrasound of the transplanted uterus showed good uterine blood flow.

CONCLUSIONS

To date the Living Donor Uterus Transplant Research Project in Singapore has progressed with a uterus transplant surgery involving a living donor performed by a multidisciplinary team. The recipient had a menstrual period 38 days postoperatively. Further study of the outcomes from this procedure will inform the safety and efficacy of uterus transplant in the Singapore context.

Psychological Assessment and Motivations of Potential Donors Within the First Australian Uterine Transplant Trial

OBJECTIVE

This study aims to investigate the psychological characteristics, motivations and experiences of potential living donors assessed for the first uterus transplant (UTx) clinical trial in Australia.

DESIGN

Mixed methods study.

SETTING

Tertiary hospital.

PATIENT(S)

Seven female potential UTx donors.

INTERVENTION(S)

A mixed-methods design was used to evaluate seven self-referred potential uterus donors for the UTx program. Potential donors underwent rigorous clinical and psychological screening, including self-reported psychological assessments. Additionally, five potential donors participated in semi-structured interviews conducted by the study social worker.

MAIN OUTCOME MEASURE(S)

Scores from measures of quality of life, depression, anxiety and stress, along with thematic analysis from semi-structured interviews.

RESULT(S)

Thematic analysis identified six key themes: feelings about donating a uterus, health history, informed consent, impact of donation, relationships, and access to educational resources. Several sub-themes were also identified, including awareness of surgical complications and dynamics of relationships and sexuality. Quantitative results indicated clinical levels of depression, anxiety, and stress in some donors. Overall, the quality-of-life scores of the donors were comparable to those of the general Australian female population.

CONCLUSION(S)

The study provides a deeper understanding of the psychological profiles and motivations of potential UTx donors in Australia. It reveals the complexity of donor motivations, which include altruistic desires to help others experience pregnancy, and practical considerations. The findings emphasise the need for rigorous psychological screening and continuous support to address potential mental health challenges. These insights are valuable for developing future UTx protocols and support systems to ensure donor wellbeing.

How do women with Rokitansky syndrome and healthcare professionals reflect on the provision of uterine transplantation? Insights from an interview study in France, Norway, and Sweden

INTRODUCTION

Uterine transplantation is currently intended for women with absolute uterine infertility. Since proof of the concept in 2014, many countries have started research programs and clinical activities. However, access to uterine transplantation remains limited given that only a few hundred transplants have been described worldwide compared with the 1.5 million women of childbearing age who suffer from absolute uterine infertility. The aim of this study was to investigate how limited access to uterine transplantation is perceived by women with Mayer-Rokitansky-Küster-Hauser syndrome and health professionals involved in uterus transplantation programs.

MATERIAL AND METHODS

We conducted a qualitative study with semistructured interviews in France, Norway, and Sweden with women with Mayer-Rokitansky-Küster-Hauser syndrome and health professional involved in uterine transplantation programs. The interviews were analyzed manually using thematic content analysis. The research questions were: How do (a) women with Mayer-Rokitansky-Küster-Hauser syndrome and (b) healthcare professionals involved in uterus transplantation programs perceive uterus transplantation and its accessibility 10 years after proof of concept?

RESULTS

The interviews enabled us to highlight a number of themes addressed by doctors and women with Mayer-Rokitansky-Küster-Hauser syndrome, the main ones being the hope raised by this technique and the disappointment for those who do not have access to it, the lack of perception of the risks associated with the technique, and finally, an inequity of access and the training difficulties this entails for the teams.

CONCLUSIONS

Access to uterine transplantation varies widely across Europe owing to legislative restrictions and limited access due to resources or competence. The result is a feeling of injustice/misunderstanding and despair for these women who had planned to become parents and cannot benefit from a transplant. They appear to be poorly supported. Women who are ultimately unable to access a transplant program should perhaps be given psychological support to deal with this disappointment, whereas the minority who finally have had access to transplant programs are supervised by well-trained multidisciplinary teams.

Uterine Transplant Optimization From a Preclinical Donor Model With Controlled Cardiocirculatory Arrest

Background

Uterus transplantation from deceased donors offers a promising solution to the organ shortage, but optimal preservation methods are crucial for successful outcomes. Our primary objective is to conduct an initial assessment of the contribution of oxygenated hypothermic perfusion in uterine transplantation.

Methods

We performed a preclinical study on a porcine model of controlled donation after circulatory death (60 min warm ischemia). Ten uterus grafts were preserved for 12 h using static cold storage or hypothermic machine perfusion (VitaSmart device, perfusion pressure at 15 mm Hg). Subsequently, they were reperfused using ex vivo normothermic machine perfusion (Liverassist, perfusion pressure at 30 mm Hg) with oxygenated autologous blood to assess early ischemia/reperfusion injury. Not only resistance index assessment and oxygenation evaluation but also immunochemistry and gene expression analysis were performed.

Results

This study demonstrates the feasibility of using hypothermic machine perfusion for uterine graft preservation, showing improvements in reperfusion capacity (decrease of resistance indexes; P < 0.0001) and tissue oxygenation (higher oxygen level) compared with static cold storage.

Conclusions

These findings provide valuable insights for further research and refinement of uterine transplantation procedures.

The costs per live birth after uterus transplantation: results of the Swedish live donor trial

STUDY QUESTION

What is the cost per live birth after live donor uterus transplantation in a Swedish clinical trial setting?

SUMMARY ANSWER

The total cost per child, from a health care perspective, was calculated to be €124 894 and if only surgically successful transplants are considered, the total cost per live birth was €107 120.

WHAT IS KNOWN ALREADY

Uterus transplantation has proved to be a feasible treatment for uterine factor infertility by accomplished live births, both after live donor and deceased donor transplantation procedures. Our previous study, the only existing cost analysis of uterus transplantation, found that the initial (up to 2 months after surgeries) societal costs of preoperative interventions, live donor uterus transplantation surgeries, and postoperative care were between €50 000 and €100 000 (mean €74 000) in Year 2020 values per uterus transplantation. That study also included costs of sick leave for both donors and recipients.

STUDY DESIGN, SIZE, DURATION

This real-data health economic cost study is based on a prospective cohort study, which included nine live donor uterus transplantation procedures. Study duration included the time from the first pre-transplantation investigation until postoperative controls after graft removal.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Recipients, live donors, and neonates of nine uterus transplantation procedures participated. The recipients and donors underwent pre-transplantation investigations with imaging, laboratory tests, and psychological/medical screening. In vitro fertilization with embryo cryopreservation was performed in advance of transplantation. Donor hysterectomy and transplantation were by laparotomy and the recipient received immunosuppression. Pregnancy attempts by ET started 1 year after transplantation and delivery was by caesarean section. Hysterectomy was performed either after birth of one or two children, after graft failure, or after multiple pregnancy failures. Nine transplantation procedures resulted in seven surgically successful (adequate blood flow and regular menstruations) grafts and six women delivered a total of nine children.

MAIN RESULTS AND THE ROLE OF CHANCE

The total cost of preoperative investigations, live donor uterus transplantation, postoperative care, immunosuppression, IVF, follow-up, pregnancy care, delivery, and graft removal after completed childbirth(s) or failure to achieve live birth was calculated, based on inclusion of cost for six women, giving birth to a total of nine children, and three women, with no childbirth. Cost for live donors was also included in the analysis. The total cost per child was calculated to be €124 894. However, if only surgical successful transplants (seven out of nine transplants) are considered, the cost per live birth was €107 120. The cost for preoperative preparations with IVF, surgeries, and postoperative follow-up during the initial 2 months was around 53% of total costs. Smaller sub-costs were those for monitoring, ETs with additional IVF (14%), immunosuppression and other drugs from Month 3 until hysterectomy (13%), and pregnancy care with delivery and neonatal care (13%).

LIMITATIONS, REASONS FOR CAUTION

Limitations are the restricted sample size, the experimental phase of the procedure and that the results only reflect the cost in one country (Sweden).

WIDER IMPLICATIONS OF THE FINDINGS

The results provide the first information concerning the cost per child of the uterus transplantation intervention. In the future, the cost per child will most likely decrease due to predicted increase in the rate of surgical success, decreased surgical durations, decreased graft duration to achieve live birth(s), and increased rate of transplantations giving not only one, but two or three singletons.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was received from the Jane and Dan Olsson Foundation for Science, the Knut and Alice Wallenberg Foundation, the Swedish Research Council, and an ALF grant from the Swedish state under an agreement between the government and the county councils. There are no conflicts of interest for any of the authors.

TRIAL REGISTRATION NUMBER

NCT01844362.

[Vascularized composite allografts in France: An update]

Vascularized composite allografts (VCA) encompass the face, upper limb, trachea, penis, abdominal wall, and, more recently, uterus transplants. They offer unique reconstructive possibilities to overcome the limitations of traditional reconstructive techniques. Unlike solid organ transplants (heart, liver, kidney, lung, etc.), VCA is not generally performed in a life-threatening situation but aims to improve quality of life, at the cost of a major constraint to its expansion: the need for lifelong immunosuppressive treatment. Nevertheless, VCA is considered one of the five most important innovations of the modern era of the discipline, and a worldwide survey of plastic surgeons has confirmed that significant changes in reconstructive surgery will be related to VCA in the future. France pioneered this type of transplantation by successfully performing the first VCA (unilateral hand transplant), the first double hand transplant, the first face transplant, the first face retransplant, and the first bilateral shoulder and arm transplant, and continues to demonstrate unprecedented surgical prowess. This activity continues to expand across the country, with active VCA programs notably in the upper limb, face, uterus and penis. This article aims to provide an update on the clinical advances made in France in the field of composite tissue allografts.

Maternal and perinatal outcomes of live births after uterus transplantation: A systematic review

INTRODUCTION

Uterus transplantation (UTx) is a treatment for absolute uterine factor infertility. The results of pregnancies of this complex infertility treatment should be established. The aim of the study was to systematically review maternal and neonatal outcomes in the pregnancies of women who have undergone UTx.

MATERIAL AND METHODS

The population of this review were women that have undergone UTx and delivered child(ren). Cesarean delivery after UTx were planned to be compared with studies reporting maternal mortality/morbidity and perinatal mortality/morbidity after delivery by elective cesarean section without UTx. Systematic literature searches were performed utilizing Medline, Embase, the Cochrane Library, Cinahl, PsycInfo, Web of Science, and clinicaltrials.gov for studies written in English language and published between January 1, 2010, and November 08, 2023. No study design limitation was applied. If no comparative studies were identified, we planned to report the outcomes from the case reports and case series. Included studies were assessed for risk of bias using a checklist for case series. The study protocol was registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols (registration number: INPLASY202310052).

RESULTS

Twenty-four articles were identified, containing data on 40 unique live births. Multiple publications including same cases were identified and clearly indicated. No comparative studies were identified. The certainty of evidence was very low, as all studies were either case reports (n = 15) or case series (n = 9). All deliveries were by cesarean section and 47.5% of them resulted in emergency cesarean sections. Out of the 21 elective cesarean sections, 52.4% were performed before 37 weeks' gestation. Historical comparison to population data on pregnancies delivered by cesarean section found a markedly increased risk for both the mother and child following cesarean section for UTx. Risks for placenta previa and preterm birth were notably high after UTx; however, some of the later may reflect the results of provider-initiated births.

CONCLUSIONS

The maternal and perinatal outcomes of 40 live births post-UTx indicate that these pregnancies may be at high risk of maternal and perinatal complications. Aiming to delay elective cesarean section beyond 37 weeks' gestation could potentially reduce some of these risks. Registration of maternal and perinatal outcomes after UTx through quality registries are essential and obstetrical care guidelines for these women should be established.

Uterus transplantation: A bibliometric review of six-decade study from 1960 to 2024

INTRODUCTION

Some women are unable to become pregnant because they do not have a functional uterus. Over the last decade, it has become possible for these women to get pregnant through uterus transplantation, which has been the subject of numerous research studies. Therefore, the purpose of this study is to review published articles in the uterus transplantation area.

MATERIAL AND METHODS

We conducted a cross-sectional bibliometric review to study the 100 highly cited papers in the Web of Science and Scopus databases from 1960 to 2024. Our research applied bibliometric analysis to these top 100 highly cited papers. Document citation and co-occurrence analysis were used for the data study. VOSviewer along with Bibliometrix® software was used to design the maps.

RESULTS

The trend of uterus transplantation publications increased exponentially after 2010. Sweden is the leading country, followed by the USA and Spain. Fertility and Sterility, Lancet, American Journal of Transplantation, and Human Reproduction were the highly cited journals. Collaboration among countries showed that the most collaboration took place between Sweden and Spain (18), Sweden and the USA (14), the USA and Spain (8), Sweden and Australia (6), and the USA and the United Kingdom (6). Furthermore, the results found that more than one-third of the highly cited papers were review papers (39%) and 27% were clinical trial studies.

CONCLUSIONS

This bibliometric review provides a valuable contribution to the literature on uterine transplantation by synthesizing and analyzing existing research findings. It offers insights into current trends, key themes, geographic distribution, and potential areas for future research within this rapidly evolving field.

Uterus Transplantation from Deceased Donors: First Italian Experience

Background: Uterus transplantation (UTx) is currently the only available treatment for absolute uterine factor infertility. Deceased donors have recently emerged as a valid alternative to living donors for uterus transplantation, with similar results. Methods: We report the first experience in Italy of uterus transplantation from deceased donors. Three uterus transplantations from deceased donors were performed at the Organ Transplant Unit of the University Hospital of Catania, Italy, between August 2020 and January 2022. Results: Two patients underwent UTx due to Mayer-Rokitansky-Küster-Hauser syndrome, while one patient had a previous hysterectomy due to benign disease. The donors' ages were between 25 and 43 years and the mean cold ischemia time was 18.3 h. The mean age of the recipients was 31.6 years, and the mean recipient surgery duration was 5.3 h, with a mean blood loss of 766.66 mL. Two recipients developed a post-transplant hematoma, which was treated conservatively. No uterus recipient needed a re-operation during the first 30 days after transplantation. No histological signs of acute rejection were detected at the cervical biopsies performed at 1, 3, and 6 months after transplantation. First menstruation occurred in all recipients after 39 ± 12 days after transplantation. One live birth was reported 15 months after UTx. One graft was lost three months after UTx due to graft thrombosis. Conclusions: Uterus transplantation from deceased donors is emerging as a valid alternative to living donors in order to increase the donor pool.

Assisted reproductive technology outcomes in women with congenital uterine anomalies: a systematic review

PURPOSE

The present systematic review aimed to assess the fecundity of women with congenital uterine anomalies (CUAs) undergoing assisted reproductive technology (ART).

METHODS

The present systematic review of the literature was reported according to the PRISMA guidelines. We systematically searched PubMed, MEDLINE, Embase and Scopus, from database inception to 17th October 2023. Studies were deemed eligible only if they included women with CUAs clearly fitting into one of the categories of the ASRM Müllerian anomalies classification 2021.

RESULTS

Data relevant to the reproductive outcomes of women with CUAs who underwent ART were extracted from 55 studies. Regarding Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, studies on gestational surrogacy reported a live birth rate (LBR) ranging from 37 to 54%. Uterus transplant, although still experimental, showed promising results. Most studies reported a negative impact of unicornuate uterus and partial or complete septate uterus on both the miscarriage rate (MR) and the live birth rate (LBR). The reproductive prognosis of women with unicornuate uterus was shown to be particularly poor in case of twin pregnancy. Uterus didelphys, bicornuate and arcuate uterus seem not to negatively impact the ART reproductive outcomes. Uterus didelphys was associated with an increased risk of preterm birth (PTB), cesarean section and low birth weight (LBW).

CONCLUSION

Women with CUAs should be informed regarding the impact (if any) of their congenital anomaly on both the chances of success of ART and on pregnancy-related complications. Elective single embryo transfer (eSET) should always be the first choice in patients with an increased baseline obstetric risk.

Permanently infertile couples and family building-a cross-sectional survey in Denmark

STUDY QUESTION

Which decision-making factors influence family building among permanently infertile couples?

SUMMARY ANSWER

Ethical, legal, and financial considerations outweigh genetic relatedness in decision-making, favouring domestic gestational surrogacy, if this were possible, over international options.

WHAT IS KNOWN ALREADY

Permanent infertility affects 4-5% of people in the fertile age. Their family-building options include adoption, surrogacy, uterus transplantation, foster care, and intentional multiple parenthood. However, in most countries, including Denmark, legal barriers constrain these methods due to surrogacy restrictions, suspended international adoptions, and the experimental status of uterus transplantation. Despite existing research on surrogacy, adoption, and specific causes of permanent infertility, a significant gap remains in our understanding of how couples with permanent infertility make family-building decisions within these limited frameworks.

STUDY DESIGN, SIZE, DURATION

This cross-sectional study with 150 permanently infertile Danish participants was conducted from June to November 2023 using an online questionnaire. Multiple strategies, such as online forums, fertility clinics, hospital departments, and snowballing, were used to recruit a diverse sample.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study included couples aged 26-50 years facing permanent infertility due to the following primary causes: women without a uterus (15%), women with a non-functional uterus (47%) or women for whom pregnancy would be life-threatening (9%), male couples (16%), transgender partner couples (2%), and other causes (11%). The survey collected data on demographics, reproductive history, family-building choices, and communication strategies. Closed questions were analysed using descriptive statistics.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 150 respondents, 41% had used transnational surrogacy, 27% adoption, 14% chose to remain childless, and 19% were undecided. Critical factors on family-building decisions were ethical, legal, and financial concerns which ranked higher than genetic relatedness. Despite the complexity of family building, most participants were open about their child's origin and received social support. If all family-building methods were legal and available in Denmark, domestic gestational surrogacy would be the preferred method, with uterus transplantation and remaining childless being least popular.

LIMITATIONS, REASONS FOR CAUTION

The sample size is relatively small, despite the use of a variety of recruitment strategies. Nevertheless, this has ensured a diverse cohort representing the different reasons for infertility and family-building choices. It is important to note that the strategies may have favoured individuals achieving parenthood.

WIDER IMPLICATIONS OF THE FINDINGS

The finding of our study reveals a notable gap between available family-building options in Denmark and the preferences of couples facing permanent infertility. These insights could be instrumental for organizations reviewing and developing family-building frameworks. Furthermore, for healthcare professionals guiding couples experiencing infertility issues in their attempts to build a family, an understanding of these preferences is essential to facilitate informed decisions about their future family plans.

STUDY FUNDING/COMPETING INTEREST(S)

The project was financed by the Independent Research Fund Denmark. The authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Biomimicking trilayer scaffolds with controlled estradiol release for uterine tissue regeneration

Scaffold-based tissue engineering provides an efficient approach for repairing uterine tissue defects and restoring fertility. In the current study, a novel trilayer tissue engineering scaffold with high similarity to the uterine tissue in structure was designed and fabricated via 4D printing, electrospinning and 3D bioprinting for uterine regeneration. Highly stretchable poly(l-lactide-co-trimethylene carbonate) (PLLA-co-TMC, "PTMC" in short)/thermoplastic polyurethane (TPU) polymer blend scaffolds were firstly made via 4D printing. To improve the biocompatibility, porous poly(lactic acid-co-glycolic acid) (PLGA)/gelatin methacryloyl (GelMA) fibers incorporated with polydopamine (PDA) particles were produced on PTMC/TPU scaffolds via electrospinning. Importantly, estradiol (E2) was encapsulated in PDA particles. The bilayer scaffolds thus produced could provide controlled and sustained release of E2. Subsequently, bone marrow derived mesenchymal stem cells (BMSCs) were mixed with gelatin methacryloyl (GelMA)-based inks and the formulated bioinks were used to fabricate a cell-laden hydrogel layer on the bilayer scaffolds via 3D bioprinting, forming ultimately biomimicking trilayer scaffolds for uterine tissue regeneration. The trilayer tissue engineering scaffolds thus formed exhibited a shape morphing ability by transforming from the planar shape to tubular structures when immersed in the culture medium at 37°C. The trilayer tissue engineering scaffolds under development would provide new insights for uterine tissue regeneration.

Psychological and emotional profiles of Australian uterine transplant potential recipients: A comparison with international trials

INTRODUCTION

Uterus transplant (UTx) has emerged as a groundbreaking solution for individuals with uterine factor infertility (UFI). This study is the first in Australia to explore the psychosocial functioning of potential recipients assessed for the nation's initial UTx clinical trial and to compare their psychological profiles with those from international UTx trials.

MATERIAL AND METHODS

This is a mixed methods prospective study incorporating standardized psychological measures and semi-structured interviews. Conducted at a tertiary hospital in Sydney, Australia, the study involved 10 female Australian UTx potential recipients with UFI undergoing assessment for UTx surgery. Participants underwent comprehensive psychological evaluation using validated measures and in-depth semi-structured interviews. Quantitative measurement tools included the Hospital Anxiety and Depression Scale, Short Form-36 Health Survey, Fertility Quality of Life, and the Stanford Integrated Psychosocial Assessment for Transplantation. Thematic analysis was conducted on qualitative data from semi-structured interviews.

RESULTS

The Australian UTx potential recipients reported significantly higher Short Form-36 (SF-36) scores compared to the Australian general population in general health (p < 0.04), bodily pain (p < 0.02), social functioning (p < 0.02), and emotional well-being (p < 0.01). Compared with international UTx cohorts, the Australian UTx group showed comparable SF-36 outcomes, with minor variations observed for general health and physical function domains. Hospital Anxiety and Depression Scale scores revealed lower anxiety, but slightly higher depression levels compared to international UTx trial cohorts. Fertility quality-of-life scores were significantly higher in the Australian UTx group compared to women experiencing primary infertility across four domains (p < 0.001). Thematic analysis of interviews highlighted the complex emotional impact of infertility, strong family and social support, and the perception of UTx as a transformative opportunity to achieve wholeness and motherhood.

CONCLUSIONS

UTx represents a novel treatment option for women with UFI. This is the first qualitative study in Australia, it demonstrates the connection between women with UFI and their motivations for parenthood. These findings highlight the importance of tailored psychological assessments and establish a foundation for future research exploring the psychological characteristics of patient candidacy for UTxs.

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).

Deceased Donor Uterus Transplantation: A Narrative Review of the First 24 Published Cases

Uterus transplantation is the surgical treatment for absolute uterine factor infertility (AUFI), a congenital or acquired condition characterized by the absence of a uterus. More than 80 transplants have been performed worldwide, resulting in more than 30 live births, originating both from living and deceased donors. The collection of published articles on deceased donor uterus transplantations was performed in PubMed and SCOPUS by searching for the terms "Uterus transplantation" AND "deceased donor"; from the 107 articles obtained, only case reports and systematic reviews of deceased donor uterus transplantations and the resulting live births were considered for the present manuscript. The extracted data included the date of surgery (year), country, recipient (age and cause of AUFI) and donor (age and parity) details, outcome of recipient surgery (hysterectomy), and live births (date and gestational age). The search of peer-reviewed publications showed 24 deceased donor uterus transplantations and 12 live births (a birth rate of 66%) with a 25% occurrence of graft loss during follow-up (6 of 24). Among this series, twelve transplants were performed in the USA (seven births), five in the Czech Republic (one birth), three in Italy (one birth), two in Turkey (two births), and two in Brazil (one birth). The median recipient age was 29.8 years (range 21-36), while the median donor age was 36.1 years (range 20-57). Of 24 recipients, 100% were affected by MRKH (Mayer-Rokitanski-Kuster-Hauser) syndrome. Two live births were reported from nulliparous donors. Deceased donor uterus transplantation birth rates are very similar to the living donor rates reported in the literature, but ethical implications could be less important in the first group. It is necessary to register every case in the International Registry for Uterus Transplantation in order to perform a systematic review and comparison with living donor rates.

A study protocol for live and deceased donor uterus transplantation as a treatment for women with uterine factor infertility

AIM

Uterus transplantation (UTx) is an emerging treatment option for women with uterine factor infertility (UFI) or the absence of a functional uterus. This is the study protocol for the first human UTx clinical trial in Australia.

MATERIALS AND METHODS

This protocol outlines the approved training program used to plan, diagnose, screen, and treat patients who may be eligible for UTx using living and deceased donors. This multi-site clinical research study includes three tertiary hospital sites within New South Wales (NSW), Australia - Prince of Wales, Royal Hospital for Women and Westmead Hospitals. Our UTx protocol is based on that used by our collaborative partner, the inaugural UTx team in Gothenburg, Sweden. The Swedish UTx team provides ongoing preceptorship for the Australian UTx team. Ethics approval for six UTx procedures using living or deceased donors (Western Sydney Local Health District Human Research Ethics Committee: 2019/ETH138038) was granted in 2020.

RESULTS

Results from surgeries and live births will be published. Data will be prospectively entered into the registry of the International Society of Uterus Transplantation (ISUTx), a sub-section of The Transplantation Society (TTS).

TRIAL ID

ACTRN12622000917730.

DISCUSSION

A multidisciplinary research team has been formed between three tertiary hospitals in Sydney - The Royal Hospital for Women, Prince of Wales and Westmead Hospitals; and with the Swedish UTx, University of Gothenburg. The Swedish team pioneered animal and human UTx studies since 1998, including publishing the first live birth after UTx. (1) This Australian trial commenced in January 2023.

CONCLUSION

Uterus transplantation gives women with UFI the opportunity to be gestational and genetic mothers. It is a complex procedure for both the donor and recipient, with medical and surgical risks. An extensive multidisciplinary approach is required to optimise patient safety and graft outcomes. This protocol outlines our Australian UTx team strategy for screening, recruitment, surgical approach, and clinical management of UTx recipients and donors.

Bibliometric analysis and global trends in uterus transplantation

AIM

The purpose of this study was to characterize publication patterns, academic influence, research trends, and the recent developments in uterus transplantation (UTx) across the globe.

METHODS

The Web of Science Core Collection database was searched for documents published from the time the database began to include relevant articles to 15 December 2023. With the use of VOSviewer, Citespace, BICOMB, and Incites, a cross-sectional bibliometric analysis was conducted to extract or calculate the evaluative indexes. Publications were categorized by country, institution, author, journal, highly cited papers, and keywords. The variables were compared in terms of publication and academic influence, which further included citation count, citation impact, Hirsh index, journal impact factor, total link strength, collaboration metrics, and impact relative to the world.

RESULTS

A total of 581 papers concerning UTx were initially identified after retrieval, and 425 documents were included. Of the 41 countries participating in relevant studies, the USA and Sweden were in leading positions in terms of publications, citations, and academic influence. The most versatile institution was the University of Gothenburg, followed by Baylor University. The most productive scholars and journals were Brännström M. and Fertility and Sterility , respectively. Five groups of cutting-edge keywords were identified: venous drainage, donors and donation, women, fertility preservation, and fertility. Topics about surgery, first live birth, risk, and in vitro fertilization remain hot in this field.

CONCLUSIONS

UTx is anticipated to enter a golden era in the coming years. This study provides some guidance concerning the authors involved in promoting UTx research, the current development of UTx, and journals to submit their innovative research. This also helps to reach a comprehensive insight and prospect in the near future. In order to establish recognized standards and benefit more patients who are disturbed by uterine infertility, large-scale and well-designed clinical trials are required.

A new bicornuate model of rat uterus transplantation

INTRODUCTION

Uterus transplantation has revolutionized reproductive medicine for women with absolute uterine factor infertility, resulting in more than 40 reported successful live births worldwide to date. Small animal models are pivotal to refine this surgical and immunological challenging procedure aiming to enhance safety for both the mother and the child.

MATERIAL AND METHODS

We established a syngeneic bicornuate uterus transplantation model in young female Lewis rats. All surgical procedures were conducted by an experienced and skilled microsurgeon who organized the learning process into multiple structured steps. Animals underwent meticulous preoperative preparation and postoperative care. Transplant success was monitored by sequential biopsies, monitoring graft viability and documenting histological changes long-term.

RESULTS

Bicornuate uterus transplantation were successfully established achieving an over 70% graft survival rate with the passage of time. The bicornuate model demonstrated safety and feasibility, yielding outcomes comparable to the unicornuate model in terms of ischemia times and complications. Longitudinal biopsies were well-tolerated, enabling comprehensive monitoring throughout the study.

CONCLUSIONS

Our novel bicornuate rat uterus transplantation model provides a distinctive opportunity for sequential biopsies at various intervals after transplantation and, therefore, comprehensive monitoring of graft health, viability, and identification of potential signs of rejection. Furthermore, this model allows for different interventions in each horn for comparative studies without interobserver differences contrary to the established unicornuate model. By closely replicating the clinical setting, this model stands as a valuable tool for ongoing research in the field of uterus transplantation, promoting further innovation and deeper insights into the intricacies of the uterus transplant procedure.

Genetics of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome: advancements and implications

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital anomaly characterized by agenesis/aplasia of the uterus and upper part of the vagina in females with normal external genitalia and a normal female karyotype (46,XX). Patients typically present during adolescence with complaints of primary amenorrhea where the diagnosis is established with significant implications including absolute infertility. Most often cases appear isolated with no family history of MRKH syndrome or related anomalies. However, cumulative reports of familial recurrence suggest genetic factors to be involved. Early candidate gene studies had limited success in their search for genetic causes of MRKH syndrome. More recently, genomic investigations using chromosomal microarray and genome-wide sequencing have been successful in detecting promising genetic variants associated with MRKH syndrome, including 17q12 (LHX1, HNF1B) and 16p11.2 (TBX6) deletions and sequence variations in GREB1L and PAX8, pointing towards a heterogeneous etiology with various genes involved. With uterus transplantation as an emerging fertility treatment in MRKH syndrome and increasing evidence for genetic etiologies, the need for genetic counseling concerning the recurrence risk in offspring will likely increase. This review presents the advancements in MRKH syndrome genetics from early familial occurrences and candidate gene searches to current genomic studies. Moreover, the review provides suggestions for future genetic investigations and discusses potential implications for clinical practice.

Utero-ovarian transposition before pelvic radiation in a patient with rectal cancer: a case report and systemic literature review

Objective

To describe a case of utero-ovarian transposition (UOT) before pelvic radiation in a patient with rectal cancer and provide a systematic literature review on all reported cases of UOT.

Methods

We performed a prospective collection and revision of clinical, intraoperative, and postoperative data from a patient who underwent UOT. In addition, a systematic review of the literature available to date on all cases of UOT was realized, and 14 patients from 10 articles were included.

Results

We reported the case of a 28-year-old nulligravida patient who was diagnosed with a low-grade rectal adenocarcinoma and underwent neoadjuvant chemoradiotherapy, followed by transanal total mesorectal excision (TaTME). Before starting neoadjuvant oncological therapies, the patient underwent laparoscopic UOT. The intervention was performed without complications, and the patient received neoadjuvant oncological treatments as planned. TaTME and uterus repositioning were completed six weeks after the end of radiotherapy. No complications were observed during the first 9 postoperative months. Adequate utero-ovarian perfusion was assessed by Doppler ultrasound, cervicovaginal anastomosis appeared to have healed correctly, and the patient experienced menstrual bleeding. Data from the literature review of all reported cases of UOT were presented and discussed.

Conclusions

UOT represents a valuable option to preserve fertility in patients requiring pelvic radiotherapy. This study provides additional evidence on the feasibility and safety of performing UOT.

Multilayered Shape-Morphing Scaffolds with a Hierarchical Structure for Uterine Tissue Regeneration

Owing to dysfunction of the uterus, millions of couples around the world suffer from infertility. Different from conventional treatments, tissue engineering provides a new and promising approach to deal with difficult problems such as human tissue or organ failure. Adopting scaffold-based tissue engineering, three-dimensional (3D) porous scaffolds in combination with stem cells and appropriate biomolecules may be constructed for uterine tissue regeneration. In this study, a hierarchical tissue engineering scaffold, which mimicked the uterine tissue structure and functions, was designed, and the biomimicking scaffolds were then successfully fabricated using solvent casting, layer-by-layer assembly, and 3D bioprinting techniques. For the multilayered, hierarchical structured scaffolds, poly(l-lactide-co-trimethylene carbonate) (PLLA-co-TMC, "PLATMC" in short) and poly(lactic acid-co-glycolic acid) (PLGA) blends were first used to fabricate the shape-morphing layer of the scaffolds, which was to mimic the function of myometrium in uterine tissue. The PLATMC/PLGA polymer blend scaffolds were highly stretchable. Subsequently, after etching of the PLATMC/PLGA surface and employing estradiol (E2), polydopamine (PDA), and hyaluronic acid (HA), PDA@E2/HA multilayer films were formed on PLATMC/PLGA scaffolds to build an intelligent delivery platform to enable controlled and sustained release of E2. The PDA@E2/HA multilayer films also improved the biological performance of the scaffold. Finally, a layer of bone marrow-derived mesenchymal stem cell (BMSC)-laden hydrogel [which was a blend of gelatin methacryloyl (GelMA) and gelatin (Gel)] was 3D printed on the PDA@E2/HA multilayer films of the scaffold, thereby completing the construction of the hierarchical scaffold. BMSCs in the GelMA/Gel hydrogel layer exhibited excellent cell viability and could spread and be released eventually upon biodegradation of the GelMA/Gel hydrogel. It was shown that the hierarchically structured scaffolds could evolve from the initial flat shape into the tubular structure completely in an aqueous environment at 37 °C, fulfilling the requirement for curved scaffolds for uterine tissue engineering. The biomimicking scaffolds with a hierarchical structure and curved shape, high stretchability, and controlled and sustained E2 release appear to be very promising for uterine tissue regeneration.

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.

Attitudes, knowledge, and perceptions among women toward uterus transplantation and donation in the United Kingdom

Objective

To assess the motivations and perceptions of the general public in the United Kingdom toward donating their uterus for Uterus Transplantation after death (UTx).

Design

A cross sectional study.

Setting

A 32-item electronic questionnaire.

Population

One hundred fifty nine females over the age of 16 living in the United Kingdom, consented and took part in the study.

Main outcome measures

The motivations and perceptions toward UTx among the general public including the willingness to donate and barriers preventing donation.

Results

One hundred fifty nine women completed the questionnaire. The majority had never heard of UTx (n = 107, 71%) and most were not aware the uterus could be donated after death (n = 130, 92%). 43% of the cohort were willing to donate their uterus after death (n = 57). 8% stated they wished to donate their organs but not their uterus (n = 10). 30% of women (n = 42) believed the child born following UTx would have genetic links to the donor. Over half of the respondents (n = 65, 51%) strongly agreed or agreed they would feel joy in the knowledge that donation would lead to bringing a new life into the world. A quarter of respondents strongly agreed or agreed (n = 45, 25%) that the use of their uterus by another woman would feel like an extension of life.

Conclusion

The findings indicate a favorable opinion toward UTx and a positive attitude toward donation of the uterus after death among the general public in the United Kingdom. The findings also highlight the need for education around UTx now this therapeutic option is available.