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Van Dieren L, Tawa P, Coppens M, Naenen L, Dogan O, Quisenaerts T, Lancia HH, Oubari H, Dabi Y, De Fré M, Thiessen Ef F, Cetrulo CL, Lellouch AG. Acute Rejection Rates in Vascularized Composite Allografts: A Systematic Review of Case Reports. J Surg Res 2024; 298:137-148. [PMID: 38603944 DOI: 10.1016/j.jss.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/20/2024] [Accepted: 02/29/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Vascularized Composite Allografts (VCA) are usually performed in a full major histocompatibility complex mismatch setting, with a risk of acute rejection depending on factors such as the type of immunosuppression therapy and the quality of graft preservation. In this systematic review, we present the different immunosuppression protocols used in VCA and point out relationships between acute rejection rates and possible factors that might influence it. METHODS This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We systematically searched Medline (PubMed), Embase, and The Cochrane Library between November 2022 and February 2023, using following Mesh Terms: Transplant, Transplantation, Hand, Face, Uterus, Penis, Abdominal Wall, Larynx, and Composite Tissue Allografts. All VCA case reports and reviews describing multiple case reports were included. RESULTS We discovered 211 VCA cases reported. The preferred treatment was a combination of antithymocyte globulins, mycophenolate mofetil (MMF), tacrolimus, and steroids; and a combination of MMF, tacrolimus, and steroids for induction and maintenance treatment, respectively. Burn patients showed a higher acute rejection rate (P = 0.073) and were administered higher MMF doses (P = 0.020). CONCLUSIONS In contrast to previous statements, the field of VCA is not rapidly evolving, as it has encountered challenges in addressing immune-related concerns. This is highlighted by the absence of a standardized immunosuppression regimen. Consequently, more substantial data are required to draw more conclusive results regarding the immunogenicity of VCAs and the potential superiority of one immunosuppressive treatment over another. Future efforts should be made to report the VCA surgeries comprehensively, and muti-institutional long-term prospective follow-up studies should be performed to compare the number of acute rejections with influencing factors.
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Affiliation(s)
- Loïc Van Dieren
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Faculty of Medicine and Health Sciences, Antwerp, Belgium; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Pierre Tawa
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts
| | - Marie Coppens
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Laura Naenen
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Omer Dogan
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | | | - Hyshem H Lancia
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Haïzam Oubari
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Yohann Dabi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Sorbonne University, Tenon Hospital (AP-HP), Paris, France
| | - Maxime De Fré
- Department of Plastic, Reconstructive and Aesthetic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Filip Thiessen Ef
- Department of Plastic, Reconstructive and Aesthetic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Curtis L Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts
| | - Alexandre G Lellouch
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts.
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Polenz D, Sauer IM, Martin F, Reutzel-Selke A, Ashraf MI, Schirmeier A, Lippert S, Führer K, Pratschke J, Tullius SG, Moosburner S. A new bicornuate model of rat uterus transplantation. Acta Obstet Gynecol Scand 2024. [PMID: 38693698 DOI: 10.1111/aogs.14857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/20/2024] [Accepted: 04/04/2024] [Indexed: 05/03/2024]
Abstract
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.
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Affiliation(s)
- Dietrich Polenz
- Department of Surgery, Experimental Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Igor Maximilian Sauer
- Department of Surgery, Experimental Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Friederike Martin
- Department of Surgery, Experimental Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anja Reutzel-Selke
- Department of Surgery, Experimental Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Muhammad Imtiaz Ashraf
- Department of Surgery, Experimental Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anja Schirmeier
- Department of Surgery, Experimental Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Steffen Lippert
- Department of Surgery, Experimental Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kirsten Führer
- Department of Surgery, Experimental Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Experimental Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stefan Günther Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Einstein Berlin Institute of Health Visiting Fellow, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Moosburner
- Department of Surgery, Experimental Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- BIH Academy, Clinician Scientist Program, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
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Luo X, Yu S, Liu B, Zheng Q, Zhou X, An K, Zhong J, Wu L, Dai H, Qi Z, Xia J. Determination of Maximum Tolerable Cold Ischemia Time in a Mouse Model of Cervical Heterotopic Uterus Transplantation. Transplantation 2024:00007890-990000000-00693. [PMID: 38499504 DOI: 10.1097/tp.0000000000004979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND Uterus transplantation (UTx) is an emerging treatment for uterine factor infertility. Determining the maximum tolerable cold ischemia time is crucial for successful UTx. However, the limit for cold ischemia in the uterus is unclear. This study aimed to examine cold ischemia's effects on mouse uteri and identify the maximum cold ischemia duration that uteri can endure. METHODS We systematically assessed the tolerance of mouse uteri to extended cold ischemia, 24 h, 36 h, and 48 h, using the cervical heterotopic UTx model. Multiple indicators were used to evaluate ischemia-reperfusion injury, including reperfusion duration, macroscopic examination, oxidative stress, inflammation, and histopathology. The function of transplants was evaluated through estrous cycle monitoring and embryo transfer. RESULTS Mouse uteri subjected to 48 h of cold ischemia exhibited significant delays and insufficiencies in reperfusion, substantial tissue necrosis, and loss of the estrous cycle. Conversely, uteri that underwent cold ischemia within 36 h showed long survival, regular estrous cycles, and fertility. CONCLUSIONS Our study demonstrated that mouse uteri can endure at least 36 h of cold ischemia, extending the known limits for cold ischemia and providing a pivotal reference for research on the prevention and treatment of cold ischemic injury in UTx.
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Affiliation(s)
- Xin Luo
- School of Medicine, Guangxi University, Nanning, Guangxi, P. R. China
| | - Shengnan Yu
- Xiamen Key Laboratory of Regeneration Medicine, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Organ Transplantation Institute, School of Medicine, Xiamen University, Xiamen, Fujian, P. R. China
| | - Bing Liu
- School of Medicine, Guangxi University, Nanning, Guangxi, P. R. China
| | - Qisheng Zheng
- Xiamen Key Laboratory of Regeneration Medicine, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Organ Transplantation Institute, School of Medicine, Xiamen University, Xiamen, Fujian, P. R. China
| | - Xin Zhou
- Xiamen Key Laboratory of Regeneration Medicine, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Organ Transplantation Institute, School of Medicine, Xiamen University, Xiamen, Fujian, P. R. China
| | - Ke An
- Department of Physiology, Xuzhou Medical University, Xuzhou, Jiangsu, P. R. China
| | - Jiaying Zhong
- Xiamen Key Laboratory of Regeneration Medicine, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Organ Transplantation Institute, School of Medicine, Xiamen University, Xiamen, Fujian, P. R. China
| | - Licheng Wu
- School of Medicine, Xiamen University, Xiamen, Fujian, P. R. China
| | - Helong Dai
- Department of Kidney Transplantation, Center of Organ Transplantation, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, P. R. China
| | - Zhongquan Qi
- School of Medicine, Guangxi University, Nanning, Guangxi, P. R. China
| | - Junjie Xia
- Xiamen Key Laboratory of Regeneration Medicine, Fujian Provincial Key Laboratory of Organ and Tissue Regeneration, Organ Transplantation Institute, School of Medicine, Xiamen University, Xiamen, Fujian, P. R. China
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Bouko-Levy E, Vialaret C, Sallée C, Marquet P, Margueritte F, Dion L, Lavoue V, Gauthier T. Estimation of the prevalence of uterine infertility and its different causes in France according to data from a literature review. J Gynecol Obstet Hum Reprod 2023; 52:102684. [PMID: 37866776 DOI: 10.1016/j.jogoh.2023.102684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/20/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Uterine infertility (UI) is defined as the complete absence of a uterus (absolute uterine infertility or AUI) or the presence of a non functional uterus (non-absolute uterine infertility or NAUI). The exact prevalence of uterine infertility is currently unknown. Our aim was to assess the number of French women concerned by Uterine Infertility according to a recent literature review. MATERIALS AND METHODS We have previously conducted a systematic review of the literature on UI and its various causes in the world. Based on these study and demographic data of 2022 from INSEE (Institut National de la Statistique et des Études Économiques), we attempted to estimate the number of women under 40 years of age in France affected by potential UI using direct standardization. RESULTS AND DISCUSSION Based on the estimation from INSEE data, approximately 2066 women of childbearing age would have MRKH syndrome in France, 380 the Androgen Insensitivity Syndrome and 3700 had an haemostasis hysterectomy in France. We did not find data on the prevalence of hysterectomies before the age of 40 in France. For the following pathologies: uterine malformations, radiation uterus, synechiae, myomas and adenomyosis there was a huge amount of missing data, which does not allow us to estimate the number of potentially infertile patients. CONCLUSION Prevalence of UI is poorly known. UI probably concerns several thousand patients in France. The creation of a UI registry would make enable to assess the number of patients potentially eligible for adoption, uterus transplantation or even surrogacy.
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Affiliation(s)
- E Bouko-Levy
- Department of Gynecology and Obstetrics, Mother and Child Hospital, University Hospital Center of Limoges, Limoges 87000, France
| | - C Vialaret
- Department of Gynecology and Obstetrics, Mother and Child Hospital, University Hospital Center of Limoges, Limoges 87000, France
| | - C Sallée
- Department of Gynecology and Obstetrics, Mother and Child Hospital, University Hospital Center of Limoges, Limoges 87000, France
| | - P Marquet
- Pharmacology and Transplantation, INSERM U1248, Université de Limoges, 2 Rue du Pr Descottes, Limoges 87000, France
| | - F Margueritte
- Department of Gynecology and Obstetrics, Mother and Child Hospital, University Hospital Center of Limoges, Limoges 87000, France
| | - L Dion
- Department of Obstetrics and Gynecology, Hopital Universitaire de Rennes, Rennes 35000, France
| | - V Lavoue
- Department of Obstetrics and Gynecology, Hopital Universitaire de Rennes, Rennes 35000, France
| | - T Gauthier
- Department of Gynecology and Obstetrics, Mother and Child Hospital, University Hospital Center of Limoges, Limoges 87000, France; Pharmacology and Transplantation, INSERM U1248, Université de Limoges, 2 Rue du Pr Descottes, Limoges 87000, France.
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Brännström M, Racowsky C, Carbonnel M, Wu J, Gargiulo A, Adashi EY, Ayoubi JM. Uterus transplantation: from research, through human trials and into the future. Hum Reprod Update 2023; 29:521-544. [PMID: 37328434 PMCID: PMC10477946 DOI: 10.1093/humupd/dmad012] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/29/2023] [Indexed: 06/18/2023] Open
Abstract
Women suffering from absolute uterine factor infertility (AUFI) had no hope of childbearing until clinical feasibility of uterus transplantation (UTx) was documented in 2014 with the birth of a healthy baby. This landmark accomplishment followed extensive foundational work with a wide range of animal species including higher primates. In the present review, we provide a summary of the animal research and describe the results of cases and clinical trials on UTx. Surgical advances for graft removal from live donors and transplantation to recipients are improving, with a recent trend away from laparotomy to robotic approaches, although challenges persist regarding optimum immunosuppressive therapies and tests for graft rejection. Because UTx does not involve transplantation of the Fallopian tubes, IVF is required as part of the UTx process. We provide a unique focus on the intersection between these two processes, with consideration of when oocyte retrieval should be performed, whether, and for whom, preimplantation genetic testing for aneuploidy should be used, whether oocytes or embryos should be frozen and when the first embryo transfer should be performed post-UTx. We also address the utility of an international society UTx (ISUTx) registry for assessing overall UTx success rates, complications, and live births. The long-term health outcomes of all parties involved-the uterus donor (if live donor), the recipient, her partner and any children born from the transplanted graft-are also reviewed. Unlike traditional solid organ transplantation procedures, UTx is not lifesaving, but is life-giving, although as with traditional types of transplantation, costs, and ethical considerations are inevitable. We discuss the likelihood that costs will decrease as efficiency and efficacy improve, and that ethical complexities for and against acceptability of the procedure sharpen the distinctions between genetic, gestational, and social parenthood. As more programs wish to offer the procedure, we suggest a scheme for setting up a UTx program as well as future directions of this rapidly evolving field. In our 2010 review, we described the future of clinical UTx based on development of the procedure in animal models. This Grand Theme Review offers a closing loop to this previous review of more than a decade ago. The clinical feasibility of UTx has now been proved. Advancements include widening the criteria for acceptance of donors and recipients, improving surgery, shortening time to pregnancy, and improving post-UTx management. Together, these improvements catalyze the transition of UTx from experimental into mainstream clinical practice. The procedure will then represent a realistic and accessible alternative to gestational surrogacy for the treatment of AUFI and should become part of the armamentarium of reproductive specialists worldwide.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Stockholm IVF-EUGIN, Stockholm, Sweden
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
| | - Catherine Racowsky
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Marie Carbonnel
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- University Versailles, Saint-Quentin en Yvelines, France
| | - Joseph Wu
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Antonio Gargiulo
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Eli Y Adashi
- Department of Medical Science, Brown University, Providence, RI, USA
| | - Jean Marc Ayoubi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- University Versailles, Saint-Quentin en Yvelines, France
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da Graca B, Johannesson L, Testa G, Wall AE. The Ethical Evolution of Uterus Transplantation From Concept to Clinical Procedure. Clin Obstet Gynecol 2022; 65:24-36. [PMID: 35045022 DOI: 10.1097/grf.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Uterus transplantation (UTx) offers women with absolute uterine factor infertility a path to motherhood that enables them to carry their own pregnancy. Debates about the ethics of UTx have evolved in tandem with its clinical evolution: clinical trials have provided evidence regarding risks and benefits to donors and recipients that were initially uncertain; technical advances have altered the balance between risks and benefits; and the experiences of donors and recipients has revealed questions that were not anticipated. As UTx transitions to a clinical procedure, questions remain about long-term risks and benefits, applications beyond carrying a pregnancy, and cost and access.
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Affiliation(s)
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
| | - Anji E Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
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Favre-Inhofer A, Carbonnel M, Domert J, Cornet N, Chastant S, Coscas R, Vialard F, Gelin V, Galio L, Richard C, Trabelsi H, Sandra O, de Ziegler D, Chavatte-Palmer P, Ayoubi JM. Involving Animal Models in Uterine Transplantation. Front Surg 2022; 9:830826. [PMID: 35284480 PMCID: PMC8904568 DOI: 10.3389/fsurg.2022.830826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/24/2022] [Indexed: 01/15/2023] Open
Abstract
Background Absolute uterine factor infertility affects 0. 2% women of childbearing age around the world. Uterine transplantation (UTx) is a promising solution for many of them since the first birth from UTx was described by the Swedish team in 2014. The success of Utx in humans has become possible after a systematic and meticulous approach involving years of research on animal models. To date, more than 80 UTx procedures have been performed worldwide and 30 children were born. Material and Method This review summarizes the research preparation conducted in animals before beginning UTx in humans. It focuses on the advantages and limits of each animal model, their place in surgical training, and current contribution in research to improve UTx successes in humans. The different steps in the process of UTx have been analyzed, such as imaging, surgery, ischemia-reperfusion effects, rejection markers, immunosuppressive treatment, and pregnancy. Conclusion Animal models have played an essential role in the implementation of UTx, which is a highly complex procedure. While respecting the 3R requirements (replacement, refinement, and reduction), the surgical training using large animal models, such as notably ewes remain irreplaceable for teams wishing to initiate a UTx program. Furthermore, animal models are still mandatory in current research to improve the success rates of UTx in humans as well as to reduce the morbidity associated with this experimental infertility treatment.
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Affiliation(s)
- Angeline Favre-Inhofer
- Department of Gynaecology and Obstetrics, Foch Hospital, Suresnes, France
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
- *Correspondence: Angeline Favre-Inhofer
| | - Marie Carbonnel
- Department of Gynaecology and Obstetrics, Foch Hospital, Suresnes, France
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
| | | | - Nathalie Cornet
- Department of Gynaecology and Obstetrics, Foch Hospital, Suresnes, France
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
| | | | - Raphaël Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, AP-HP, Boulogne-Billancourt, France
- UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Boulogne-Billancourt, France
| | - François Vialard
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
- École Nationale Vétérinaire d'Alfort, BREED, Maisons-Alfort, France
- Département de Génétique, Laboratoire de Biologie Médicale, CHI de Poissy-St Germain en Laye, Poissy, France
| | - Valérie Gelin
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
- École Nationale Vétérinaire d'Alfort, BREED, Maisons-Alfort, France
| | - Laurent Galio
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
- École Nationale Vétérinaire d'Alfort, BREED, Maisons-Alfort, France
| | - Christophe Richard
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
- École Nationale Vétérinaire d'Alfort, BREED, Maisons-Alfort, France
| | - Héla Trabelsi
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
- École Nationale Vétérinaire d'Alfort, BREED, Maisons-Alfort, France
| | - Olivier Sandra
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
- École Nationale Vétérinaire d'Alfort, BREED, Maisons-Alfort, France
| | - Dominique de Ziegler
- Department of Gynaecology and Obstetrics, Foch Hospital, Suresnes, France
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
| | - Pascale Chavatte-Palmer
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
- École Nationale Vétérinaire d'Alfort, BREED, Maisons-Alfort, France
| | - Jean-Marc Ayoubi
- Department of Gynaecology and Obstetrics, Foch Hospital, Suresnes, France
- Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France
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Abstract
Uterus transplantation (UTx) is now a potential option to allow women with uterine factor infertility to give birth. However, UTx is still at an experimental stage, and basic animal studies, including in non-human primates, are needed for the accumulation of data prior to clinical application. Considering that UTx may provide new hope to Japanese women, we launched UTx research in 2009 and have since accumulated a large archive of results in the UTx research field. Furthermore, we have carried out various activities aimed at the implementation of clinical applications of UTx in Japan while clarifying the ethical and social issues involved. Currently, the clinical application of UTx in Japan is just around the corner, and it is expected that UTx research will develop further in the future. Herein, we summarize our basic experiences using non-human primates and our activities with the goal of future clinical applications.
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da Graca B, Johannesson L, Testa G, Wall A. Uterus transplantation: ethical considerations. Curr Opin Organ Transplant 2021; 26:664-668. [PMID: 34636768 DOI: 10.1097/mot.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Uterus transplantation (Utx) offers women with absolute uterine factor infertility the opportunity to carry their own pregnancies. As Utx transitions from an experimental to standard clinical procedure, we review the status of the ethical issues applicable to the stakeholders involved. RECENT FINDINGS With more than 65 Utx procedures reported to date, evidence is accruing that enables the chance of success - a live birth - for the recipient to be weighed against the risks the recipient incurs through the Utx process, as well as risks to living donors undergoing surgery, to children exposed in utero to immunosuppressants and the uterine graft environment, and to third parties related to uterus procurement from multiorgan deceased donors. Experience has also informed aspects of recipient and donor autonomy that must be safeguarded. SUMMARY Clinical trial results provides a basis for weighing the interests of the stakeholders implicated in Utx, and so can inform transplant centers' and regulatory bodies' development of policies and protocols that will determine access to Utx and allocation of organs, together with other considerations of justice. Additional evidence, particularly on long-term outcomes, is needed, and new questions can be expected to arise as access to and indications for Utx broaden.
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Affiliation(s)
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute
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Richards EG, Farrell RM, Ricci S, Perni U, Quintini C, Tzakis A, Falcone T. Uterus transplantation: state of the art in 2021. J Assist Reprod Genet 2021; 38:2251-2259. [PMID: 34057644 PMCID: PMC8490545 DOI: 10.1007/s10815-021-02245-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To provide a comprehensive review of uterus transplantation in 2021, including a discussion of pregnancy outcomes of all reported births to date, the donor and recipient selection process, the organ procurement and transplant surgeries, reported complications, postoperative monitoring, preimplantation preparation, and ethical considerations. METHODS Literature review and expert commentary. RESULTS Reports of thirty-one live births following uterus transplantation have been published from both living and deceased donors. The proper selection of donors and recipients is a labor-intensive process that requires advanced planning. A multidisciplinary team is critical. Reported complications in the recipient include thrombosis, infection, vaginal stricture, antenatal complications, and graft failure. Graft rejection is a common occurrence but rarely leads to graft removal. While most embryo transfers are successful, recurrent implantation failures in uterus transplant patients have been reported. Rates of preterm delivery are high but appear to be declining; more data, including long-term outcome data, is needed. CONCLUSIONS Uterus transplantation is an emerging therapy for absolute uterine factor infertility, a condition previously without direct treatment options. It is paramount that reproductive health care providers are familiar with the uterus transplantation process as more patients seek and receive this treatment.
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Affiliation(s)
- Elliott G Richards
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ruth M Farrell
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stephanie Ricci
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Uma Perni
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Cristiano Quintini
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andreas Tzakis
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tommaso Falcone
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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11
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Melatonin and Glycine Reduce Uterus Ischemia/Reperfusion Injury in a Rat Model of Warm Ischemia. Int J Mol Sci 2021; 22:ijms22168373. [PMID: 34445081 PMCID: PMC8394613 DOI: 10.3390/ijms22168373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 07/29/2021] [Accepted: 08/01/2021] [Indexed: 01/01/2023] Open
Abstract
Ischemia/reperfusion injury (IRI) remains a significant problem to be solved in uterus transplantation (UTx). Melatonin and glycine have been shown to possess direct cytoprotective activities, mainly due to their antioxidative and anti-inflammatory properties. The aim of this study was to investigate the protective effects of melatonin and glycine and their combination on IRI in a rat model of warm ischemia. In this study, Sprague-Dawley rats were assigned to eight groups, including sham and IRI (n = 80). Melatonin and glycine alone or their combination were administered prior to 1 h of uterus ischemia followed by 1 h of reperfusion. Melatonin (50 mg/kg) was administered via gavage 2 h before IRI and glycine in an enriched diet for 5 days prior to intervention. Uterus IRI was estimated by histology, including immunohistochemistry, and biochemical tissue analyses. Histology revealed that uterus IRI was significantly attenuated by pretreatment with melatonin (p = 0.019) and glycine (p = 0.044) alone as well as their combination (p = 0.003). Uterus IRI led to increased myeloperoxidase expression, which was significantly reduced by melatonin (p = 0.004), glycine (p < 0.001) or their combination (p < 0.001). The decline in superoxide dismutase activity was significantly reduced in the melatonin (p = 0.027), glycine (p = 0.038) and combined treatment groups (p = 0.015) when compared to the IRI control group. In conclusion, melatonin, glycine and their combination significantly reduced oxidative stress-induced cell damage after IRI in a small animal warm ischemia model, and, therefore, clinical studies are required to evaluate the protective effects of these well-characterized substances in uterus IRI.
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Abstract
PURPOSE To provide a comprehensive review of uterus transplantation in 2021, including a discussion of pregnancy outcomes of all reported births to date, the donor and recipient selection process, the organ procurement and transplant surgeries, reported complications, postoperative monitoring, preimplantation preparation, and ethical considerations. METHODS Literature review and expert commentary. RESULTS Reports of thirty-one live births following uterus transplantation have been published from both living and deceased donors. The proper selection of donors and recipients is a labor-intensive process that requires advanced planning. A multidisciplinary team is critical. Reported complications in the recipient include thrombosis, infection, vaginal stricture, antenatal complications, and graft failure. Graft rejection is a common occurrence but rarely leads to graft removal. While most embryo transfers are successful, recurrent implantation failures in uterus transplant patients have been reported. Rates of preterm delivery are high but appear to be declining; more data, including long-term outcome data, is needed. CONCLUSIONS Uterus transplantation is an emerging therapy for absolute uterine factor infertility, a condition previously without direct treatment options. It is paramount that reproductive health care providers are familiar with the uterus transplantation process as more patients seek and receive this treatment.
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13
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Jones BP, Ranaei-Zamani N, Vali S, Williams N, Saso S, Thum MY, Al-Memar M, Dixon N, Rose G, Testa G, Johannesson L, Yazbek J, Wilkinson S, Richard Smith J. Options for acquiring motherhood in absolute uterine factor infertility; adoption, surrogacy and uterine transplantation. THE OBSTETRICIAN & GYNAECOLOGIST : THE JOURNAL FOR CONTINUING PROFESSIONAL DEVELOPMENT FROM THE ROYAL COLLEGE OF OBSTETRICIANS & GYNAECOLOGISTS 2021; 23:138-147. [PMID: 34248417 PMCID: PMC8252631 DOI: 10.1111/tog.12729] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 11/29/2022]
Abstract
KEY CONTENT Following the diagnosis of absolute uterine factor infertility (AUFI), women may experience considerable psychological harm as a result of a loss of reproductive function and the realisation of permanent and irreversible infertility.Adoption enables women with AUFI, and their partners, to experience social and legal parenthood, also often providing benefits for the adopted child.Surrogacy offers the opportunity to have genetically related offspring. Outcomes are generally positive in both surrogates and the children born as a result.Uterine transplantation is the only option to restore reproductive anatomy and functionality. While associated with considerable risk, it allows the experience of gestation and the achievement of biological, social and legal parenthood. LEARNING OBJECTIVES To gain an understanding of the routes to parenthood available for women with AUFI experiencing involuntary childlessness, such as adoption, surrogacy and, most recently, uterine transplantationTo consider a suggested management plan to facilitate counselling in women with AUFI who experience involuntary childlessness. ETHICAL ISSUES In the UK, while the number of children requiring adoption continues to increase, the number being adopted from care is decreasing.Some cultures may hold ethical or religious beliefs that surrogacy is unacceptable, and its legal position in many jurisdictions is problematic.Restrictive selection criteria and high costs may limit future availability of uterine transplantation.
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Affiliation(s)
- Benjamin P Jones
- Clinical Research Fellow Department of Surgery and Cancer Imperial College London Du Cane Road London W12 0NN UK
| | - Niccole Ranaei-Zamani
- Clinical Research Fellow Department of Surgery and Cancer Imperial College London Du Cane Road London W12 0NN UK
| | - Saaliha Vali
- Specialty Trainee in Obstetrics and Gynaecology Queen Charlotte's & Chelsea Hospital Imperial College NHS Trust London W12 OHS UK
| | - Nicola Williams
- Research Associate in Ethics Department of Politics, Philosophy and Religion Lancaster University Lancaster LA14YQ UK
| | - Srdjan Saso
- Gynaecology Oncolology Subspecialty Trainee Hammersmith Hospital Imperial College NHS Trust London W12 OHS UK
| | - Meen-Yau Thum
- Fertility Specialist The Lister Fertility Clinic London SW1W 8RH UK
| | - Maya Al-Memar
- Specialty Trainee in Obstetrics and Gynaecology Queen Charlotte's & Chelsea Hospital Imperial College NHS Trust London W12 OHS UK
| | - Nuala Dixon
- Clinical Nurse Specialist Queen Charlotte's & Chelsea Hospital Imperial College NHS Trust London W12 OHS UK
| | - Gillian Rose
- Consultant Gynaecologist Queen Charlotte's & Chelsea Hospital Imperial College NHS Trust London W12 OHS UK
| | - Giuliano Testa
- Transplant Surgeon Baylor University Medical Center Dallas Texas 75246-2088 USA
| | - Liza Johannesson
- Gynaecology Oncology Surgeon and Medical Director of Uterus Transplant Baylor University Medical Center Dallas Texas 75246-2088 USA
| | - Joseph Yazbek
- Consultant Gynaecologist Hammersmith Hospital Imperial College NHS Trust London W12 OHS UK
| | - Stephen Wilkinson
- Professor of Bioethics Department of Politics, Philosophy and Religion Lancaster University Lancaster LA14YQ UK
| | - J Richard Smith
- Consultant Gynaecologist Hammersmith Hospital Imperial College NHS Trust London W12 OHS UK
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14
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Li X, Wang Y, Ma R, Liu X, Song B, Duan Y, Guo J, Feng G, Cui T, Wang L, Hao J, Wang H, Gu Q. Reconstruction of functional uterine tissues through recellularizing the decellularized rat uterine scaffolds by MSCs in vivo and in vitro. Biomed Mater 2021; 16:035023. [PMID: 33660616 DOI: 10.1088/1748-605x/abd116] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Infertile people who suffered from loss of uterine structures and/or functions can be treated through gestational surrogacy or uterus transplantation, which remains challenging due to the ethical and social issues, the lack of donor organs as well as technical and safety risks. One promising solution is to regenerate and reconstruct a bioartificial uterus for transplantation through the engineering of uterine architecture and appropriate cellular constituents. Here, we developed a well-defined system to regenerate a functional rat uterine through recellularization of the decellularized uterine matrix (DUM) patches reseeded with human mesenchymal stem cells (hMSCs). Engraftment of the recellularized DUMs on the partially excised uteri yielded a functional rat uterus with a pregnancy rate and number of fetuses per uterine horn comparable to that of the control group with an intact uterus. Particularly, the recellularized DUMs enhanced the regeneration of traumatic uterine in vivo because of MSC regulation. The established system here will shed light on the treatment of uterine infertility with heterogeneous DUMs/cell resources through tissue engineering in the future.
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Affiliation(s)
- Xia Li
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100049, People's Republic of China
| | - Yiming Wang
- State Key Laboratory of Membrane Biology, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100049, People's Republic of China
| | - Ruoyu Ma
- State Key Laboratory of Membrane Biology, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
| | - Xin Liu
- State Key Laboratory of Membrane Biology, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100049, People's Republic of China
| | - Biaobiao Song
- State Key Laboratory of Membrane Biology, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
- School of Life Sciences, University of Science and Technology of China, Hefei 230026, People's Republic of China
| | - Yongchao Duan
- State Key Laboratory of Membrane Biology, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100049, People's Republic of China
| | - Jia Guo
- State Key Laboratory of Membrane Biology, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100049, People's Republic of China
| | - Guihai Feng
- State Key Laboratory of Membrane Biology, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100049, People's Republic of China
- Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
| | - Tongtong Cui
- State Key Laboratory of Membrane Biology, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
| | - Liu Wang
- State Key Laboratory of Membrane Biology, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100049, People's Republic of China
- Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
| | - Jie Hao
- State Key Laboratory of Membrane Biology, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100049, People's Republic of China
- Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
| | - Hongmei Wang
- State Key Laboratory of Membrane Biology, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100049, People's Republic of China
- Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
| | - Qi Gu
- State Key Laboratory of Membrane Biology, State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing 100049, People's Republic of China
- Institute for Stem Cell and Regeneration, Chinese Academy of Sciences, Beijing 100101, People's Republic of China
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15
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Clinicopathologic Analysis of Uterine Allografts Including Proposed Scoring of Ischemia-reperfusion Injury and T Cell-mediated Rejection-Dallas UtErus Transplant Study: A Pilot Study. Transplantation 2021; 106:167-177. [PMID: 33481553 DOI: 10.1097/tp.0000000000003633] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Uterus transplantation (UTx) enables pregnancy in infertile women. This study describes the histopathological changes of ischemia reperfusion injury and mostly acute T cell-mediated rejection (TCMR) in UTx and proposes modification toward a working formulation grading system with associated treatments. METHODS Protocol and indication biopsies from 11 living and 2 deceased donor UTx recipients were analyzed. Serving as a control were 49 age-matched nontransplanted uteri. All posttransplant histopathological specimens were evaluated in a blinded fashion by 3 pathologists. Response to treatment was assessed by follow-up biopsies. Serial serum donor-specific antibody (DSA) responses were also recorded. RESULTS Changes attributed to ischemia reperfusion resolved within 2 weeks of UTx in most of the patients. For TCMR grading, perivascular inflammation, focal capillary disruption, and interstitial hemorrhage were added to interface inflammation, intercellular edema, stromal inflammation, and epithelial apoptotic bodies. Of the 173 protocol biopsies, 98 were classified as negative for TCMR; 34, indeterminate-borderline; 35, mild; 3, moderate; and 3, severe, 1 of which occurred in a DSA-positive recipient and also showed microvascular injury. Corticosteroids successfully treated all moderate to severe TCMR episodes. Mild TCMR was treated by increasing existing baseline immunosuppression. Indeterminate-borderline episodes were not treated. Neither ischemia reperfusion injury nor TCMR with DSA adversely affected embryo transfer. CONCLUSION Relying on a modified histopathological grading system, we developed a treatment strategy resulting in resolution of TCMR and successful pregnancies.
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16
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Castro-Villegas F, Canaval-Erazo GA, Rico-Juri JM, Gutiérrez-Montes JÓ, Vanin-Aguas A, Canaval-Erazo HO. [Orthotopic uterus transplantation. Sheep model experiment, Cali (Colombia)]. REVISTA COLOMBIANA DE OBSTETRICIA Y GINECOLOGÍA 2020; 71:265-274. [PMID: 33247890 DOI: 10.18597/rcog.3504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/03/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE It has been recommended that professionals who are planning to perform uterine transplantation should first carry out animal experiments. This paper describes the procedure for uterine transplant in sheep, as well as short and medium-term results. METHODS Experimental surgery study in sheep subjected to uterine explantation and transplant. Four 40-50 kg sheep received uteri transplantation (orthotopic) from four live donors. End-to-side vascular anastomosis was used, the vagina was sutured on one plane and the uterus was fixed to the pelvic wall. Complications and 180-day evolution are described. RESULTS Transplant surgery was accomplished in the 4 sheep. Surgical time in the first procedure was 240 minutes, while the last procedure lasted 185 minutes. Warm ischemia time was reduced from 42 to 22 minutes. One sheep died on the seventh postoperative day due to an intraoperative complication unrelated to the vascular anastomosis. A second sheep developed local vaginal infection treated with metronidazole and evolved satisfactorily. No transplant rejection had occurred in the remaining 3 sheep after 6 months. CONCLUSIONS The ovine model allowed surgical training in experimental uterine transplant surgery. For the authors, it offered an opportunity to gain knowledge and make progress towards future uterus transplantation in women with uterine factor infertility in Colombia.
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Affiliation(s)
- Felipe Castro-Villegas
- Médico cirujano, especialista en trasplante hepático, Centro Médico Imbanaco, Cali (Colombia)
| | | | - Juan Manuel Rico-Juri
- Médico cirujano, especialista en trasplante hepático, Centro Médico Imbanaco, Cali (Colombia)
| | - José Óscar Gutiérrez-Montes
- Profesor de Farmacología y Medicina Regenerativa, Escuela de Medicina, Facultad de Salud, Universidad del Valle, Cali (Colombia)
| | - Anabel Vanin-Aguas
- Médico cirujano, especialista en trasplante hepático, Centro Médico Imbanaco, Cali (Colombia)
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17
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Brännström M, Kvarnström N, Groth K, Akouri R, Wiman L, Enskog A, Dahm-Kähler P. Evolution of surgical steps in robotics-assisted donor surgery for uterus transplantation: results of the eight cases in the Swedish trial. Fertil Steril 2020; 114:1097-1107. [DOI: 10.1016/j.fertnstert.2020.05.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 12/30/2022]
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18
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Zhang R, Deng SL, Lian ZX, Yu K. Immunosuppression in uterine transplantation. Transpl Immunol 2020; 63:101335. [PMID: 32927095 DOI: 10.1016/j.trim.2020.101335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/09/2020] [Indexed: 11/25/2022]
Abstract
Uterine transplantation (UTx) is the only effective treatment for uterine infertility patients to become genetic mothers. After decades of research, the surgical methods of UTx are very developed. There are numerous factors that affect the results of UTx, such as selection of the donor uterus before transplantation, immunosuppressive therapy post-transplantation, rejection monitoring, and immune tolerance. Studies have shown that immune rejection is a crucial factor affecting the survival rate after organ transplantation. Unlike liver or kidney transplantation, the aim of UTx is to obtain a functional uterus that is able to support successful pregnancy and birth of a healthy fetus. Because of the unique purpose of UTx, its immunosuppressive program is relatively specialized. Some immunosuppressive agents can cause perinatal complications, and inducing immune tolerance is necessary to resolve these side effects. Further understanding of the immune mechanism of UTx and the continuous development of new immunosuppressive agents, combined with the application of assisted reproductive technology, will be more conducive to the realization of UTx to breed offspring.
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Affiliation(s)
- Rui Zhang
- College of Animal Science and Technology, China Agricultural University, Beijing 100193, China.
| | - Shou-Long Deng
- CAS Key Laboratory of Genome Sciences and Information, Beijing Institute of Genomics, Chinese Academy of Sciences, 100101 Beijing, China.
| | - Zheng-Xing Lian
- College of Animal Science and Technology, China Agricultural University, Beijing 100193, China
| | - Kun Yu
- College of Animal Science and Technology, China Agricultural University, Beijing 100193, China.
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19
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Kristek J, Johannesson L, Novotny R, Kachlik D, Fronek J. Human uterine vasculature with respect to uterus transplantation: A comprehensive review. J Obstet Gynaecol Res 2020; 46:2199-2220. [PMID: 32840043 DOI: 10.1111/jog.14428] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/28/2020] [Accepted: 07/25/2020] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Jakub Kristek
- Department of Transplantation Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Robert Novotny
- Department of Transplantation Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jiri Fronek
- Department of Transplantation Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic.,First Faculty of Medicine, Charles University, Prague, Czech Republic
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Chmel R, Pastor Z, Matecha J, Janousek L, Novackova M, Fronek J. Uterine transplantation in an era of successful childbirths from living and deceased donor uteri: Current challenges. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 164:115-120. [DOI: 10.5507/bp.2019.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 04/25/2019] [Indexed: 01/18/2023] Open
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21
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Kristek J, Kudla M, Chlupac J, Novotny R, Mirejovsky T, Janousek L, Fronek J. Acute appendicitis in a patient after a uterus transplant: A case report. World J Clin Cases 2019; 7:4270-4276. [PMID: 31911907 PMCID: PMC6940341 DOI: 10.12998/wjcc.v7.i24.4270] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/07/2019] [Accepted: 11/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acute appendicitis in a solid organ transplant recipient is a rare occurrence, and experience remains limited. Appendicitis in uterine transplant recipients has never been reported. Immunocompromised patients with acute abdomen often present late and with attenuated symptoms. The differential diagnosis in a transplanted patient is broad and challenging due to possible existing complications associated with the graft, effects of immunosuppression, and altered anatomical relations.
CASE SUMMARY A 26-year-old woman suffering from absolute uterine factor infertility received a uterus transplant. In the post-transplant period, she suffered from leukopenia and recurrent acute cellular rejection. Her compliance was suboptimal. She travelled to an exotic destination despite the physician’s recommendation not to do so. Following her vacation, she presented with abdominal discomfort, nausea and diarrhoea. There was no sign of acute abdomen; the abdominal ultrasound was negative on day 0. Clostridium difficile colitis was verified and treated with perorally administered vancomycin. On day 4, the discomfort changed to pain; the ultrasound scan revealed a finding suggestive of appendicitis. Surgical exploration revealed perforated appendicitis, and appendectomy was performed. From a surgical point of view, the patient’s follow-up was uneventful. The patient underwent a successful embryo transfer 6 months after the appendectomy. The patient gave birth to a healthy boy at the 35th week of gestation.
CONCLUSION A high index of suspicion of an atypical course and symptomatology of acute abdomen should be maintained in immunosuppressed patients.
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Affiliation(s)
- Jakub Kristek
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague 140 21, Czech Republic
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague 150 06, Czech Republic
| | - Michal Kudla
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague 140 21, Czech Republic
| | - Jaroslav Chlupac
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague 140 21, Czech Republic
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague 150 06, Czech Republic
| | - Robert Novotny
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague 140 21, Czech Republic
| | - Tomas Mirejovsky
- Department of Clinical and Transplant Pathology, Institute for Clinical and Experimental Medicine, Prague 140 21, Czech Republic
| | - Libor Janousek
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague 140 21, Czech Republic
- First Faculty of Medicine, Charles University, Prague 121 08, Czech Republic
| | - Jiri Fronek
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague 140 21, Czech Republic
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague 150 06, Czech Republic
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22
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O’Donovan L, Williams NJ, Wilkinson S. Ethical and policy issues raised by uterus transplants. Br Med Bull 2019; 131:19-28. [PMID: 31504233 PMCID: PMC6821981 DOI: 10.1093/bmb/ldz022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/09/2019] [Accepted: 06/20/2019] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Laura O’Donovan
- Department of Politics, Philosophy, & Religion, County South, Lancaster University, Lancaster, LA1 4YQ, United Kingdom
| | - Nicola Jane Williams
- Department of Politics, Philosophy, & Religion, County South, Lancaster University, Lancaster, LA1 4YQ, United Kingdom
| | - Stephen Wilkinson
- Department of Politics, Philosophy, & Religion, County South, Lancaster University, Lancaster, LA1 4YQ, United Kingdom
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Sánchez-Margallo FM, Moreno-Naranjo B, Pérez-López MDM, Abellán E, Domínguez-Arroyo JA, Mijares J, Santiago Álvarez I. Laparoscopic uterine graft procurement and surgical autotransplantation in ovine model. Sci Rep 2019; 9:8095. [PMID: 31147586 PMCID: PMC6543039 DOI: 10.1038/s41598-019-44528-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 05/16/2019] [Indexed: 11/23/2022] Open
Abstract
Currently, uterus transplantation (UTx) is a clinical option for infertile women. Over the past three decades, treating benign or malignant gynecological diseases with minimally invasive gynecological surgery has improved, providing significant advantages over conventional open surgery. This study addresses the method used for laparoscopic live-donor ovariohysterectomy and graft harvest from a sheep model. Using a microsurgical practice, ten grafts were autotransplanted after uterine perfusion. End-to-end anastomosis techniques were used to approximate veins and arteries. Follow-ups were carried out 2-months after surgery and postoperative studies included ultrasound scan, diagnostic hysteroscopy, vascular angiography, and exploratory laparoscopy. All transplants were completed without complications. After vascular anastomosis, total reperfusion of the tissue was accomplished in all animals without confirmation of arterial or venous thrombosis. Angiographic explorations did not show any statistically significant dissimilarity in the arterial diameters between the different examination times. 3-months after uterine transplantation all animals underwent assisted reproduction techniques. Patent uterine arteries were observed 4, 8 and 12 months after the transplant. 6-months after transplantation, six sheep (60%) became pregnant with assisted reproduction practices. We noticed an increase in the degree of fibrosis of the cervix samples in non-pregnant animals of the transplant group. Laparoscopic surgery can be an advantageous approach for the uterus retrieval procedure during uterine transplantation. However, larger sample sized reports are needed in order to accomplish validation, standardization and wider use of this route.
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Affiliation(s)
| | - Belén Moreno-Naranjo
- Laparoscopy Department, Jesús Usón Minimally Invasive Surgery Centre, 10071, Cáceres, Spain
| | | | - Elena Abellán
- Microsurgery Department, Jesús Usón Minimally Invasive Surgery Centre, 10071, Cáceres, Spain
| | | | - José Mijares
- Assisted Reproduction Unit, Jesús Usón Minimally Invasive Surgery Centre, 10071, Cáceres, Spain
| | - Ignacio Santiago Álvarez
- Instituto Extremeño de Reproducción Asistida (IERA), 06006 Badajoz, Spain
- Assisted Reproduction Unit, Jesús Usón Minimally Invasive Surgery Centre, 10071, Cáceres, Spain
- Anatomy and Cell Biology Department, School of Medicine, University of Extremadura, 06071, Badajoz, Spain
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Chmel R, Pastor Z, Novackova M, Matecha J, Cekal M, Fronek J. Clinical pregnancy after deceased donor uterus transplantation: Lessons learned and future perspectives. J Obstet Gynaecol Res 2019; 45:1458-1465. [DOI: 10.1111/jog.13992] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/14/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Roman Chmel
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
- Transplantation Surgery DepartmentInstitute of Clinical and Experimental Medicine Prague Czech Republic
| | - Zlatko Pastor
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
| | - Marta Novackova
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
| | - Jan Matecha
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
- Faculty of Medicine in PlzeňCharles University Czech Republic
| | - Milos Cekal
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
| | - Jiri Fronek
- Department of Obstetrics and Gynecology, 2nd Faculty of MedicineCharles University and Motol University Hospital Prague Czech Republic
- Transplantation Surgery DepartmentInstitute of Clinical and Experimental Medicine Prague Czech Republic
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Bayefsky MJ, Berkman BE. Toward the Ethical Allocation of Uterine Transplants. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:16-17. [PMID: 30040555 DOI: 10.1080/15265161.2018.1478039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Han MN, Ramirez H, Ruvalcaba L, Contreras JL, Nyachieo A, Ramirez E. Uterine Autotransplantation in the Nonhuman Primate With Preservation of the Uterine and Ovarian Vascular Pedicles. Reprod Sci 2018; 26:1329-1335. [PMID: 29576000 DOI: 10.1177/1933719118765976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE To evaluate the technical feasibility of performing a uterine autotransplantation in the nonhuman primate while preserving the uterine and ovarian vascular pedicles. METHODS Eight (n = 8) female baboons at a primate research facility underwent a uterine autotransplant procedure with preservation of the vascular pedicles. The uterine arteries were separated from their amorphous tissue and skeletonized toward the internal iliac arteries bilaterally. A segment of the internal iliac artery was removed bilaterally along with both uterine arteries. Both ovarian veins were preserved to assist with the reperfusion of the uterine organ. Due to larger vascular pedicles in one of the primates, the uterine arteries were separated and reattached directly via end-to-end anastomosis. In another baboon, the deep uterine vein was used as a vascular pedicle rather than the ovarian vein on the left side due to adequate size and visualization. RESULTS Immediate tissue reperfusion occurred intraoperatively in 5 of the animals, with slower perfusion in 3 of the animals. Average warm ischemia time was 43.8 minutes while the average cold ischemia time was 174 minutes (2 hours, 54 minutes). Average total surgical time was 5.9 hours. All animals were sheltered into separate cages and monitored for behavior changes and food and drink consumption. Three of the primates expired immediately postoperatively, 2 from severe dehydration and 1 from gastric aspiration. CONCLUSIONS This pilot study describes a modified surgical approach for uterine transplants in the nonhuman primate. This surgical technique may be applicable to living and deceased donor uterine transplantation.
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Affiliation(s)
- Michelle N Han
- Department of Obstetrics and Gynecology, University of California, Los Angeles, CA, USA
| | | | - Luis Ruvalcaba
- Instituto Mexicano de Infertilidad, Guadalajara, Jalisco, Mexico
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Use of biomedical photonics in gynecological surgery: a uterine transplantation model. Future Sci OA 2018; 4:FSO286. [PMID: 29682321 PMCID: PMC5905613 DOI: 10.4155/fsoa-2017-0129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 01/03/2018] [Indexed: 12/20/2022] Open
Abstract
Aim: Uterine transplantation (UTx) has been proposed as a treatment for permanent absolute uterine factor infertility. The study aims were to compare pulse oximetry and multispectral imaging (MSI), for intraoperative tracking of uterine oxygen saturation in animal UTx models (rabbit and sheep). Results/methodology: Imaging results confirmed the re-establishment of adequate perfusion in the transplanted organ after surgery. Comparison of oxygen saturation values between the pre-UTx donor and post-UTx recipient, and pre-UTx and post-UTx recipient reveals a statistically significant decrease in saturation levels post-UTx. Conclusion: The use of MSI is the first case in gynecology and has demonstrated promise of possible future human use. MSI technique has advantages over pulse oximetry – it provides spatial information in a real-time, noncontact manner. Transplanting wombs into women has been offered as a potential solution to treat women who have had them removed previously or who were born without one. Our aim here was to compare two techniques: pulse oximetry and multispectral imaging, for checking oxygen levels in the newly transplanted womb. The experiments were performed in two types of animals, rabbit and sheep. The use of multispectral imaging is the first case in gynecology and has demonstrated promise of possible future human use. It has advantages over pulse oximetry – it provides valuable information in a real-time, non-contact manner.
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Horsburgh CC. A Call for Empirical Research on Uterine Transplantation and Reproductive Autonomy. Hastings Cent Rep 2017; 47 Suppl 3:S46-S49. [DOI: 10.1002/hast.795] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Suganuma N, Hayashi A, Kisu I, Banno K, Hara H, Mihara M. Uterus transplantation: Toward clinical application in Japan. Reprod Med Biol 2017; 16:305-313. [PMID: 29259482 PMCID: PMC5715890 DOI: 10.1002/rmb2.12048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/03/2017] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Nobuhiko Suganuma
- Project Team for Uterus TransplantationJapan
- Department of Human Health SciencesKyoto University Graduate School of MedicineKyotoJapan
| | - Ayako Hayashi
- Project Team for Uterus TransplantationJapan
- Department of Human Health SciencesKyoto University Graduate School of MedicineKyotoJapan
| | - Iori Kisu
- Project Team for Uterus TransplantationJapan
- Department of Obstetrics and GynecologyKeio Gijuku University School of MedicineTokyoJapan
| | - Kouji Banno
- Project Team for Uterus TransplantationJapan
- Department of Obstetrics and GynecologyKeio Gijuku University School of MedicineTokyoJapan
| | - Hisako Hara
- Project Team for Uterus TransplantationJapan
- Department of Lymphatic and Reconstructive SurgerySaiseikai Kawaguchi General HospitalKawaguchiJapan
| | - Makoto Mihara
- Project Team for Uterus TransplantationJapan
- Department of Lymphatic and Reconstructive SurgerySaiseikai Kawaguchi General HospitalKawaguchiJapan
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Akouri R, Maalouf G, Abboud J, Waked A, Nakad T, Bedran F, Gjannam GA, Hajj P, Hanafy A, Brännström F, Merzah S, Gharhemani M, Dahm-Kähler P, Brännström M. Uterus transplantation: An update and the Middle East perspective. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2017. [DOI: 10.1016/j.mefs.2017.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Petrini C, Gainotti S, Morresi A, Nanni Costa A. Ethical Issues in Uterine Transplantation: Psychological Implications and Informed Consent. Transplant Proc 2017; 49:707-710. [DOI: 10.1016/j.transproceed.2017.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Brännström M. Uterus transplantation and beyond. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2017; 28:70. [PMID: 28357688 PMCID: PMC5371630 DOI: 10.1007/s10856-017-5872-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Accepted: 02/27/2017] [Indexed: 06/06/2023]
Abstract
Uterus transplantation is today the only available treatment for absolute uterine factor infertility which is caused by either congenital/surgical uterine absence or that a present uterus is non-functioning. Structured animal-based research, from rodents to nonhuman primates, was the scientific basis for a successful introduction of uterus transplantation as a clinical procedure. The patient groups for uterus transplantation, the preclinical research and data from the published human cases will be covered herein. During recent years the concept of bioengineering of organs and tissues has emerged. Creation of a bioengineered uterus is in the initial research state, with experiments performed in rodents. The research that has been performed to create a bioengineered uterus will be summarized. In conclusion, uterus transplantation is now a clinical experimental procedure for treatment of uterine factor infertility. In parallel to the establishment of this combined assisted reproduction technique and transplantation procedure as a routine clinical procedure, we predict that uterus bioengineering will develop further towards introduction within the human setting, but that this process will take several years.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden and Stockholm IVF, Stockholm, Sweden.
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Xu L, Ding L, Wang L, Cao Y, Zhu H, Lu J, Li X, Song T, Hu Y, Dai J. Umbilical cord-derived mesenchymal stem cells on scaffolds facilitate collagen degradation via upregulation of MMP-9 in rat uterine scars. Stem Cell Res Ther 2017; 8:84. [PMID: 28420433 PMCID: PMC5395893 DOI: 10.1186/s13287-017-0535-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 03/02/2017] [Accepted: 03/14/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Severe injuries of the uterus may trigger uterine scar formation, ultimately leading to infertility or obstetrical complications. To date, few methods have adequately solved the problem of collagen deposition in uterine scars. Umbilical cord-derived mesenchymal stem cells (UC-MSCs) have shown great promise in clinical applications. The objective of this study was to investigate the effect of a scaffold/UC-MSCs construct on collagen degradation and functional regeneration in rat uterine scars following full-thickness excision of uterine walls. METHODS In order to establish a rat model of uterine scars, the uterine wall of approximately 1.0 cm in length and 0.5 cm in width (one-third of the uterine circumference) was excised from each uterine horn. A total of 128 scarred uterine horns from 64 rats were randomly assigned to four groups, including a PBS group (n = 32 uterine horns), scaffold group (n = 32 uterine horns), UC-MSCs group (n = 32 uterine horns) and scaffold/UC-MSCs group (n = 32 uterine horns) to investigate the effect of different treatments on the structure and function of uterine scars. PBS, degradable collagen fibres, UC-MSCs or UC-MSCs mixed with gelatinous degradable collagen fibres were injected into four pre-marked points surrounding each uterine scar, respectively. At days 30 and 60 post-transplantation, a subset of rats (n = 8 uterine horns) from each group was euthanized and serial sections of uterine tissues containing the operative region were prepared. Haematoxylin-eosin staining, Masson's trichrome staining, and immunohistochemical staining for MMP-2, MMP-9, α-SMA and vWF were performed. Finally, another subset of rats (n = 16 uterine horns) from each group was mated with male rats at day 60 post-transplantation and euthanized 18 days after the presence of vaginal plugs to check numbers, sizes and weights of fetuses, as well as sites of implantation. RESULTS The scaffold/UC-MSCs group exhibited obvious collagen degradation compared with the other three groups. At day 60 post-transplantation, the number of MMP-9-positive cells in the scaffold/UC-MSCs group (25.96 ± 3.63) was significantly higher than that in the PBS group (8.19 ± 1.61, P < 0.01), the scaffold group (7.25 ± 2.17, P < 0.01) and the UC-MSCs group (8.31 ± 2.77, P < 0.01). The pregnancy rate in the scaffold/UC-MSCs group (10/16) was also significantly higher than that in the PBS group (2/16, P < 0.017), the scaffold group (1/16, P < 0.017) and the UC-MSCs group (3/16, P < 0.017). CONCLUSIONS The scaffold/UC-MSCs system facilitated collagen degradation in uterine scars via upregulation of MMP-9, which was secreted by transplanted UC-MSCs, and promoted regeneration of the endometrium, myometrium and blood vessels in uterine scars. Furthermore, the scaffold/UC-MSCs-treated uterine scars showed nearly complete restoration of receptive fertility.
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Affiliation(s)
- Lu Xu
- Department of Obstetrics and Gynecology, Drum Tower Clinical Medical College of Nanjing Medical University, 321 Zhongshan Road, Nanjing, 210008 China
| | - Lijun Ding
- Department of Obstetrics and Gynecology, the Drum Tower Hospital Affiliated to Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008 China
| | - Lei Wang
- Department of Obstetrics and Gynecology, Drum Tower Clinical Medical College of Nanjing Medical University, 321 Zhongshan Road, Nanjing, 210008 China
| | - Yun Cao
- Department of Obstetrics and Gynecology, the Drum Tower Hospital Affiliated to Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008 China
| | - Hui Zhu
- Department of Obstetrics and Gynecology, Drum Tower Clinical Medical College of Nanjing Medical University, 321 Zhongshan Road, Nanjing, 210008 China
| | - Jingjie Lu
- Department of Obstetrics and Gynecology, Drum Tower Clinical Medical College of Nanjing Medical University, 321 Zhongshan Road, Nanjing, 210008 China
| | - Xin’an Li
- Department of Obstetrics and Gynecology, the Drum Tower Hospital Affiliated to Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008 China
| | - Tianran Song
- Department of Obstetrics and Gynecology, the Drum Tower Hospital Affiliated to Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008 China
| | - Yali Hu
- Department of Obstetrics and Gynecology, Drum Tower Clinical Medical College of Nanjing Medical University, 321 Zhongshan Road, Nanjing, 210008 China
| | - Jianwu Dai
- Institute of Genetics and Developmental Biology, Chinese Academy of Sciences, 3 Nanyitiao, Zhongguancun, Beijing, 100190 China
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Uterus Transplantation: Current State and Future Perspectives. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2017. [DOI: 10.5301/je.5000269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Absolute uterine factor infertility (AUFI) has traditionally been regarded as untreatable. Gestational surrogacy (GS) is not permitted in most countries and societies in the world due to ethical, religious or legal reasons. The interest in uterus transplantation (UTx) as a treatment for AUFI started in the 1960s and, after some disappointing results, raised again in the new century, when our and other groups obtained live off-spring after UTx in the mouse, and here we review extensively the results of animal research. In September 2014, the first baby was born after human UTx and this proof-of-concept of UTx as an infertility treatment has been followed by several more births. All cases described in the literature are also reviewed. The overall evidence suggests that the clinical introduction of UTx as the first available treatment for AUFI has been successful. However, UTx will stay at experimental stage for several years whilst optimizing the procedure and ensuring its safety from a medical and psychological perspective.
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Clancy NT, Saso S, Stoyanov D, Sauvage V, Corless DJ, Boyd M, Noakes DE, Thum MY, Ghaem-Maghami S, Smith JR, Elson DS. Multispectral imaging of organ viability during uterine transplantation surgery in rabbits and sheep. JOURNAL OF BIOMEDICAL OPTICS 2016. [PMID: 27786342 DOI: 10.1117/12.2040518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Uterine transplantation surgery (UTx) has been proposed as a treatment for permanent absolute uterine factor infertility (AUFI) in the case of the congenital absence or surgical removal of the uterus. Successful surgical attachment of the organ and its associated vasculature is essential for the organ’s reperfusion and long-term viability. Spectral imaging techniques have demonstrated the potential for the measurement of hemodynamics in medical applications. These involve the measurement of reflectance spectra by acquiring images of the tissue in different wavebands. Measures of tissue constituents at each pixel can then be extracted from these spectra through modeling of the light–tissue interaction. A multispectral imaging (MSI) laparoscope was used in sheep and rabbit UTx models to study short- and long-term changes in oxygen saturation following surgery. The whole organ was imaged in the donor and recipient animals in parallel with point measurements from a pulse oximeter. Imaging results confirmed the re-establishment of adequate perfusion in the transplanted organ after surgery. Cornual oxygenation trends measured with MSI are consistent with pulse oximeter readings, showing decreased StO2 immediately after anastomosis of the blood vessels. Long-term results show recovery of StO2 to preoperative levels.
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Affiliation(s)
- Neil T Clancy
- Imperial College London, Institute of Global Health Innovation, Hamlyn Centre for Robotic Surgery, London SW7 2AZ, United KingdombImperial College London, Division of Surgery, Department of Surgery and Cancer, London SW7 2AZ, United Kingdom
| | - Srdjan Saso
- Imperial College London, Hammersmith Hospital Campus, Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, London W12 0NN, United Kingdom
| | - Danail Stoyanov
- University College London, Department of Computer Science, Centre for Medical Image Computing, London WC1E 6BT, United Kingdom
| | - Vincent Sauvage
- Imperial College London, Institute of Global Health Innovation, Hamlyn Centre for Robotic Surgery, London SW7 2AZ, United KingdombImperial College London, Division of Surgery, Department of Surgery and Cancer, London SW7 2AZ, United Kingdom
| | - David J Corless
- Leighton Hospital, Mid Cheshire Hospitals NHS Foundation Trust, Department of Surgery, Crewe CW1 4QJ, United Kingdom
| | - Michael Boyd
- Royal Veterinary College, Biological Services Unit, London NW1 0TU, United Kingdom
| | - David E Noakes
- Royal Veterinary College, Biological Services Unit, London NW1 0TU, United Kingdom
| | - Meen-Yau Thum
- The Lister Hospital, London SW1W 8RH, United Kingdom
| | - Sadaf Ghaem-Maghami
- Imperial College London, Hammersmith Hospital Campus, Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, London W12 0NN, United Kingdom
| | - James Richard Smith
- Imperial College London, Hammersmith Hospital Campus, Queen Charlotte's Hospital, West London Gynaecological Cancer Centre, London W12 0NN, United Kingdom
| | - Daniel S Elson
- Imperial College London, Institute of Global Health Innovation, Hamlyn Centre for Robotic Surgery, London SW7 2AZ, United KingdombImperial College London, Division of Surgery, Department of Surgery and Cancer, London SW7 2AZ, United Kingdom
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Clancy NT, Saso S, Stoyanov D, Sauvage V, Corless DJ, Boyd M, Noakes DE, Thum MY, Ghaem-Maghami S, Smith JR, Elson DS. Multispectral imaging of organ viability during uterine transplantation surgery in rabbits and sheep. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:106006. [PMID: 27786342 DOI: 10.1117/1.jbo.21.10.106006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/05/2016] [Indexed: 05/04/2023]
Abstract
Uterine transplantation surgery (UTx) has been proposed as a treatment for permanent absolute uterine factor infertility (AUFI) in the case of the congenital absence or surgical removal of the uterus. Successful surgical attachment of the organ and its associated vasculature is essential for the organ’s reperfusion and long-term viability. Spectral imaging techniques have demonstrated the potential for the measurement of hemodynamics in medical applications. These involve the measurement of reflectance spectra by acquiring images of the tissue in different wavebands. Measures of tissue constituents at each pixel can then be extracted from these spectra through modeling of the light–tissue interaction. A multispectral imaging (MSI) laparoscope was used in sheep and rabbit UTx models to study short- and long-term changes in oxygen saturation following surgery. The whole organ was imaged in the donor and recipient animals in parallel with point measurements from a pulse oximeter. Imaging results confirmed the re-establishment of adequate perfusion in the transplanted organ after surgery. Cornual oxygenation trends measured with MSI are consistent with pulse oximeter readings, showing decreased StO2 immediately after anastomosis of the blood vessels. Long-term results show recovery of StO2 to preoperative levels.
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Affiliation(s)
- Neil T Clancy
- Imperial College London, Institute of Global Health Innovation, Hamlyn Centre for Robotic Surgery, London SW7 2AZ, United KingdombImperial College London, Division of Surgery, Department of Surgery and Cancer, London SW7 2AZ, United Kingdom
| | - Srdjan Saso
- Imperial College London, Hammersmith Hospital Campus, Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, London W12 0NN, United Kingdom
| | - Danail Stoyanov
- University College London, Department of Computer Science, Centre for Medical Image Computing, London WC1E 6BT, United Kingdom
| | - Vincent Sauvage
- Imperial College London, Institute of Global Health Innovation, Hamlyn Centre for Robotic Surgery, London SW7 2AZ, United KingdombImperial College London, Division of Surgery, Department of Surgery and Cancer, London SW7 2AZ, United Kingdom
| | - David J Corless
- Leighton Hospital, Mid Cheshire Hospitals NHS Foundation Trust, Department of Surgery, Crewe CW1 4QJ, United Kingdom
| | - Michael Boyd
- Royal Veterinary College, Biological Services Unit, London NW1 0TU, United Kingdom
| | - David E Noakes
- Royal Veterinary College, Biological Services Unit, London NW1 0TU, United Kingdom
| | - Meen-Yau Thum
- The Lister Hospital, London SW1W 8RH, United Kingdom
| | - Sadaf Ghaem-Maghami
- Imperial College London, Hammersmith Hospital Campus, Department of Surgery and Cancer, Institute of Reproductive and Developmental Biology, London W12 0NN, United Kingdom
| | - James Richard Smith
- Imperial College London, Hammersmith Hospital Campus, Queen Charlotte's Hospital, West London Gynaecological Cancer Centre, London W12 0NN, United Kingdom
| | - Daniel S Elson
- Imperial College London, Institute of Global Health Innovation, Hamlyn Centre for Robotic Surgery, London SW7 2AZ, United KingdombImperial College London, Division of Surgery, Department of Surgery and Cancer, London SW7 2AZ, United Kingdom
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Adachi M, Kisu I, Nagai T, Emoto K, Banno K, Umene K, Nogami Y, Tsuchiya H, Itagaki I, Kawamoto I, Nakagawa T, Ogasawara K, Aoki D. Evaluation of allowable time and histopathological changes in warm ischemia of the uterus in cynomolgus monkey as a model for uterus transplantation. Acta Obstet Gynecol Scand 2016; 95:991-8. [DOI: 10.1111/aogs.12943] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/15/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Masataka Adachi
- Department of Obstetrics and Gynecology; Keio University School of Medicine; Tokyo Japan
| | - Iori Kisu
- Department of Obstetrics and Gynecology; Keio University School of Medicine; Tokyo Japan
| | - Toshihiro Nagai
- Electron Microscope Laboratory; Keio University School of Medicine; Tokyo Japan
| | - Katsura Emoto
- Department of Pathology; Keio University School of Medicine; Tokyo Japan
| | - Kouji Banno
- Department of Obstetrics and Gynecology; Keio University School of Medicine; Tokyo Japan
| | - Kiyoko Umene
- Department of Obstetrics and Gynecology; Keio University School of Medicine; Tokyo Japan
| | - Yuya Nogami
- Department of Obstetrics and Gynecology; Keio University School of Medicine; Tokyo Japan
| | - Hideaki Tsuchiya
- Research Center for Animal Life Science; Shiga University of Medical Science; Shiga Japan
| | - Iori Itagaki
- Research Center for Animal Life Science; Shiga University of Medical Science; Shiga Japan
- The Corporation for Production and Research of Laboratory Primates; Ibaraki Japan
| | - Ikuo Kawamoto
- Research Center for Animal Life Science; Shiga University of Medical Science; Shiga Japan
| | - Takahiro Nakagawa
- Research Center for Animal Life Science; Shiga University of Medical Science; Shiga Japan
| | - Kazumasa Ogasawara
- Research Center for Animal Life Science; Shiga University of Medical Science; Shiga Japan
- Department of Pathology; Division of Pathology and Disease Regulation; Shiga University of Medical Science; Shiga Japan
| | - Daisuke Aoki
- Department of Obstetrics and Gynecology; Keio University School of Medicine; Tokyo Japan
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Saso S, Clarke A, Bracewell-Milnes T, Saso A, Al-Memar M, Thum MY, Yazbek J, Del Priore G, Hardiman P, Ghaem-Maghami S, Smith JR. Psychological Issues Associated With Absolute Uterine Factor Infertility and Attitudes of Patients Toward Uterine Transplantation. Prog Transplant 2016; 26:28-39. [PMID: 27136247 DOI: 10.1177/1526924816634840] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
CONTEXT Uterine transplantation (UTx). OBJECTIVE To explore patients' knowledge of and attitudes toward UTx before and after a short educational intervention via a video and question and answer (Q&A) session. DESIGN Large, in-depth survey investigating patients' motivations, aims, and beliefs on UTx. SETTING Imperial College London. PARTICIPANTS Women diagnosed with absolute uterine factor infertility (AUFI) who were seeking information on UTx and had already volunteered to participate in the study. INTERVENTION A semistructured interview involving a brief baseline questionnaire before a Q&A session and a 20-minute video exploring the main risks and benefits for UTx. MAIN OUTCOME MEASURES Attitudes of self-referred patients with AUFI toward UTx before and after education focusing on UTx. Rank order of importance of key UTx-related issues. RESULTS Forty women were interviewed. Following the video presentation and Q&A session, 97.5% (n = 39) would undergo UTx ahead of surrogacy and adoption in full knowledge that the latter 2 options would be ultimately safer for their own well-being and the fact that the graft could fail even prior to conception. All felt that UTx should take place, and 92.5% saw UTx as achievable. CONCLUSION The study demonstrates a keen interest in UTx, partly because other options seem difficult to access. It is worth noting that people appear to be distancing themselves from the risk. This requires careful assessment in any clinical program. This study is the first to demonstrate a qualitative relationship between patients with AUFI and their curiosity and desire for UTx. It paves the way for forming the introduction into the psychological assessment of a potential patient.
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Affiliation(s)
- Srdjan Saso
- Division of Surgery and Cancer, Institute of Reproductive & Developmental Biology, Imperial College London, London, United Kingdom
| | - Alex Clarke
- Department of Plastic and Reconstructive Surgery, Royal Free London, NHS Foundation Trust, London, United Kingdom
| | | | - Anja Saso
- St Mary's Hospital, Imperial College London, London, United Kingdom
| | - Maya Al-Memar
- Division of Surgery and Cancer, Institute of Reproductive & Developmental Biology, Imperial College London, London, United Kingdom
| | - Meen-Yau Thum
- The Lister Hospital, Chelsea, London, United Kingdom
| | - Joseph Yazbek
- West London Gynaecological Cancer Centre, Queen Charlotte's Hospital, Hammersmith Hospital Campus, Imperial College London, London, United Kingdom
| | | | - Paul Hardiman
- Institute for Women's Health, University College London, London, United Kingdom Royal Free, University College and Whittington NHS Trusts, London, United Kingdom
| | - Sadaf Ghaem-Maghami
- Division of Surgery and Cancer, Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Hospital Campus, London, United Kingdom
| | - J Richard Smith
- West London Gynaecological Cancer Centre, Queen Charlotte's Hospital, Hammersmith Hospital Campus, Imperial College London, London, United Kingdom
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Acién P, Acién M. The presentation and management of complex female genital malformations. Hum Reprod Update 2015; 22:48-69. [DOI: 10.1093/humupd/dmv048] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 10/14/2015] [Indexed: 11/13/2022] Open
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Johannesson L, Dahm-Kähler P, Eklind S, Brännström M. The future of human uterus transplantation. ACTA ACUST UNITED AC 2015; 10:455-67. [PMID: 25259905 DOI: 10.2217/whe.14.22] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The only untreatable subgroup of female infertility is absolute uterine factor infertility (AUFI), which is due to congenital or surgical absence of a uterus or presence of a nonfunctional uterus. The solitary option for a woman with AUFI to become a biological mother today is through a gestational surrogate mother, a procedure that is prohibited in Sweden and large parts of the world. Uterus transplantation (UTx) is a potential future treatment of AUFI. After extensive animal research, also involving non-human primates, a small number of human UTx cases have recently been performed. Here, we summarize the primate UTx experiments that have paved the way for the human UTx cases, which are described and analyzed in more detail. We also estimate how many women of fertile age are affected by AUFI and describe the causes. The ethics around UTx is complex and is also addressed.
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Affiliation(s)
- Liza Johannesson
- Department of Obstetrics & Gynecology, Sahlgrenska Academy, University of Gothenburg, Women's Clinic, Carlanderska Hospital, Gothenburg
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Saso S, Clarke A, Bracewell-Milnes T, Al-Memar M, Hamed AH, Thum MY, Ghaem-Maghami S, Del Priore G, Smith JR. Survey of Perceptions of Health Care Professionals in the United Kingdom toward Uterine Transplant. Prog Transplant 2015; 25:56-63. [DOI: 10.7182/pit2015552] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Context Currently, the only 2 options that women with absolute uterine factor infertility have for managing their infertility are surragocy or adoption. These women may also benefit from a possible future third option: uterine transplant Objective To investigate the opinions and views of UK health care professionals toward uterine transplant and rank issues related to uterine transplant by importance in order to make uterine transplant transparent and understandable to colleagues. Design Large, in-depth survey investigating health care professionals' opinions on uterine transplant. Setting Analysis done at Imperial College London. Participants UK transplant professionals (surgeons, nurses, operating room staff, and donor coordinators) and obstetricians and gynecologists (trainees, members, and fellows of the Royal College of Obstetricians and Gynaecologists). Intervention Questionnaires were given out at hospital grand rounds, trainee teaching days, and conferences (national and international). Main Outcome Measures Should uterine transplant take place? Is uterine transplant achievable? What is the rank order of importance of key issues related to uterine transplant? Results The study had 528 participants. With respect to overall support for uterine transplant and as a possible future therapeutic option for absolute uterine factor infertility, 93.8% (n=495) thought that uterine transplant should take place if considered appropriate medically, surgically, and ethically and 57.2% (n= 302) thought it was an achievable objective. Issues related to immunology of uterine transplant and pregnancy after uterine transplant were unanimously thought of as most important. More effort is required to educate health care professionals about all aspects of uterine transplant.
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Affiliation(s)
- Srdjan Saso
- Imperial College London (SS, MAM, SG-M, JRS), Royal Free London, NHS Foundation Trust, London (AC), William Harvey Hospital, Ashford (TB-M), United Kingdom, Assiut University, Assiut, Egypt (AHH), The Lister Hospital, Chelsea, London, United Kingdom (M-YT), Southeastern Regional Medical Center, Georgia (GDP)
| | - Alex Clarke
- Imperial College London (SS, MAM, SG-M, JRS), Royal Free London, NHS Foundation Trust, London (AC), William Harvey Hospital, Ashford (TB-M), United Kingdom, Assiut University, Assiut, Egypt (AHH), The Lister Hospital, Chelsea, London, United Kingdom (M-YT), Southeastern Regional Medical Center, Georgia (GDP)
| | - Timothy Bracewell-Milnes
- Imperial College London (SS, MAM, SG-M, JRS), Royal Free London, NHS Foundation Trust, London (AC), William Harvey Hospital, Ashford (TB-M), United Kingdom, Assiut University, Assiut, Egypt (AHH), The Lister Hospital, Chelsea, London, United Kingdom (M-YT), Southeastern Regional Medical Center, Georgia (GDP)
| | - Maya Al-Memar
- Imperial College London (SS, MAM, SG-M, JRS), Royal Free London, NHS Foundation Trust, London (AC), William Harvey Hospital, Ashford (TB-M), United Kingdom, Assiut University, Assiut, Egypt (AHH), The Lister Hospital, Chelsea, London, United Kingdom (M-YT), Southeastern Regional Medical Center, Georgia (GDP)
| | - Ali Hassan Hamed
- Imperial College London (SS, MAM, SG-M, JRS), Royal Free London, NHS Foundation Trust, London (AC), William Harvey Hospital, Ashford (TB-M), United Kingdom, Assiut University, Assiut, Egypt (AHH), The Lister Hospital, Chelsea, London, United Kingdom (M-YT), Southeastern Regional Medical Center, Georgia (GDP)
| | - Meen-Yau Thum
- Imperial College London (SS, MAM, SG-M, JRS), Royal Free London, NHS Foundation Trust, London (AC), William Harvey Hospital, Ashford (TB-M), United Kingdom, Assiut University, Assiut, Egypt (AHH), The Lister Hospital, Chelsea, London, United Kingdom (M-YT), Southeastern Regional Medical Center, Georgia (GDP)
| | - Sadaf Ghaem-Maghami
- Imperial College London (SS, MAM, SG-M, JRS), Royal Free London, NHS Foundation Trust, London (AC), William Harvey Hospital, Ashford (TB-M), United Kingdom, Assiut University, Assiut, Egypt (AHH), The Lister Hospital, Chelsea, London, United Kingdom (M-YT), Southeastern Regional Medical Center, Georgia (GDP)
| | - Giuseppe Del Priore
- Imperial College London (SS, MAM, SG-M, JRS), Royal Free London, NHS Foundation Trust, London (AC), William Harvey Hospital, Ashford (TB-M), United Kingdom, Assiut University, Assiut, Egypt (AHH), The Lister Hospital, Chelsea, London, United Kingdom (M-YT), Southeastern Regional Medical Center, Georgia (GDP)
| | - J. Richard Smith
- Imperial College London (SS, MAM, SG-M, JRS), Royal Free London, NHS Foundation Trust, London (AC), William Harvey Hospital, Ashford (TB-M), United Kingdom, Assiut University, Assiut, Egypt (AHH), The Lister Hospital, Chelsea, London, United Kingdom (M-YT), Southeastern Regional Medical Center, Georgia (GDP)
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Brännström M, Johannesson L, Bokström H, Kvarnström N, Mölne J, Dahm-Kähler P, Enskog A, Milenkovic M, Ekberg J, Diaz-Garcia C, Gäbel M, Hanafy A, Hagberg H, Olausson M, Nilsson L. Livebirth after uterus transplantation. Lancet 2015; 385:607-616. [PMID: 25301505 DOI: 10.1016/s0140-6736(14)61728-1] [Citation(s) in RCA: 450] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Uterus transplantation is the first available treatment for absolute uterine infertility, which is caused by absence of the uterus or the presence of a non-functional uterus. Eleven human uterus transplantation attempts have been done worldwide but no livebirth has yet been reported. METHODS In 2013, a 35-year-old woman with congenital absence of the uterus (Rokitansky syndrome) underwent transplantation of the uterus in Sahlgrenska University Hospital, Gothenburg, Sweden. The uterus was donated from a living, 61-year-old, two-parous woman. In-vitro fertilisation treatment of the recipient and her partner had been done before transplantation, from which 11 embryos were cryopreserved. FINDINGS The recipient and the donor had essentially uneventful postoperative recoveries. The recipient's first menstruation occurred 43 days after transplantation and she continued to menstruate at regular intervals of between 26 and 36 days (median 32 days). 1 year after transplantation, the recipient underwent her first single embryo transfer, which resulted in pregnancy. She was then given triple immunosuppression (tacrolimus, azathioprine, and corticosteroids), which was continued throughout pregnancy. She had three episodes of mild rejection, one of which occurred during pregnancy. These episodes were all reversed by corticosteroid treatment. Fetal growth parameters and blood flows of the uterine arteries and umbilical cord were normal throughout pregnancy. The patient was admitted with pre-eclampsia at 31 full weeks and 5 days, and 16 h later a caesarean section was done because of abnormal cardiotocography. A male baby with a normal birthweight for gestational age (1775 g) and with APGAR scores 9, 9, 10 was born. INTERPRETATION We describe the first livebirth after uterus transplantation. This report is a proof-of-concept for uterus transplantation as a treatment for uterine factor infertility. Furthermore, the results show the feasibility of live uterus donation, even from a postmenopausal donor. FUNDING Jane and Dan Olsson Foundation for Science.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF, Stockholm, Sweden.
| | - Liza Johannesson
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF, Stockholm, Sweden
| | - Hans Bokström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Mölne
- Department of Clinical Pathology and Genetics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF, Stockholm, Sweden
| | - Anders Enskog
- Department of Anesthesiology and Intensive Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Milan Milenkovic
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF, Stockholm, Sweden
| | - Jana Ekberg
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Cesar Diaz-Garcia
- Department of Obstetrics and Gynecology, La Fe University Hospital, University of Valencia, Valencia, Spain
| | - Markus Gäbel
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ash Hanafy
- Department of Obstetrics and Gynecology, Griffith University, Gold Coast, QLD, Australia
| | - Henrik Hagberg
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK; King's Health Partners, St Thomas' Hospital, London, UK
| | - Michael Olausson
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Nilsson
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Stockholm IVF, Stockholm, Sweden
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Achieving an early pregnancy following allogeneic uterine transplantation in a rabbit model. Eur J Obstet Gynecol Reprod Biol 2015; 185:164-9. [DOI: 10.1016/j.ejogrb.2014.12.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 12/03/2014] [Accepted: 12/18/2014] [Indexed: 02/01/2023]
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Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome: A historical perspective. Gene 2015; 555:33-40. [DOI: 10.1016/j.gene.2014.09.045] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 09/19/2014] [Accepted: 09/21/2014] [Indexed: 12/15/2022]
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Saso S, Petts G, Thum MY, Corless D, Boyd M, Noakes D, Del Priore G, Ghaem-Maghami S, Smith JR. Achieving uterine auto-transplantation in a sheep model using iliac vessel anastomosis: a short-term viability study. Acta Obstet Gynecol Scand 2014; 94:245-52. [PMID: 25421489 DOI: 10.1111/aogs.12550] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 11/20/2014] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate, develop and evaluate anatomical, surgical and anastomotic aspects necessary for a successful uterine transplant in a large-animal model. DESIGN Sheep model; longitudinal study involving five ewes. SETTING Royal Veterinary College, London, UK. POPULATION Five ewes of proven fertility. METHODS The uterine allograft along with the internal iliacs, and uterine arterial and venous tree all intact were harvested en bloc. An end-to-side anastomosis was performed between the external iliac vessels and the internal iliac vessels of the graft using 6-0 polypropylene. Successful reperfusion of the graft was initially judged by the color shift of the uterus during reperfusion. Blood flow past the venous and arterial anastomotic sites was also ensured by visual inspection, together with pulse oximetry and multispectral imaging. MAIN OUTCOME MEASURES Operative details (retrieval, ischemic, clamping, reperfusion and recipient hysterectomy duration); physiological profiles; gross morphology and histopathology. RESULTS Five autotransplants were performed. One procedure was abandoned because of the inappropriate size of sheep model. Another procedure was halted because the animal suffered from respiratory failure in the immediate intra-operative period. Three transplants were completed. In those, at least two of four possible anastomoses were finished and the grafted uteri demonstrated immediate perfusion and appropriate viability 45 min post-operatively. CONCLUSIONS Internal to external iliac vessel anastomoses are an acceptable surgical technique that should be applied in a human model to ensure adequate subsequent uterine perfusion.
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Affiliation(s)
- Srdjan Saso
- Division of Surgery and Cancer, Institute of Reproductive & Developmental Biology, Imperial College London, Hammersmith Hospital Campus, London, UK
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Díaz-García C, Johannesson L, Shao R, Bilig H, Brännström M. Pregnancy after allogeneic uterus transplantation in the rat: perinatal outcome and growth trajectory. Fertil Steril 2014; 102:1545-52.e1. [DOI: 10.1016/j.fertnstert.2014.09.010] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/06/2014] [Accepted: 09/08/2014] [Indexed: 11/26/2022]
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Uterine allotransplantation in a rabbit model using aorto-caval anastomosis: a long-term viability study. Eur J Obstet Gynecol Reprod Biol 2014; 182:185-93. [DOI: 10.1016/j.ejogrb.2014.09.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 09/09/2014] [Accepted: 09/17/2014] [Indexed: 11/20/2022]
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Johannesson L, Kvarnström N, Mölne J, Dahm-Kähler P, Enskog A, Diaz-Garcia C, Olausson M, Brännström M. Uterus transplantation trial: 1-year outcome. Fertil Steril 2014; 103:199-204. [PMID: 25439846 DOI: 10.1016/j.fertnstert.2014.09.024] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 08/20/2014] [Accepted: 09/16/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To report the 12-month outcome of seven patients with viable uteri after uterus transplantation (UTx). DESIGN Prospective observational study. SETTING University hospital. PATIENT(S) Seven patients with absolute uterine infertility and viable uteri for 12 months after live-donor UTx. INTERVENTION(S) Predetermined immunosuppression was with tacrolimus and mychophenolate mofetil (MMF) during 6 months, whereupon MMF should be withdrawn. Frequent ultrasound examinations were performed to assess uterine appearance and uterine artery blood flow. Cervical biopsies (for histological detection of rejection) were obtained at preset time points, with temporary adjustments of immunosuppression if there were signs of rejection. Menstruations were systematically recorded. MAIN OUTCOME MEASURE(S) Menstruation, uterine artery blood flow, histology of cervical biopsies, and blood levels of tacrolimus. RESULT(S) All patients showed regular menses after 1-2 months. Uterine artery blood flow was unchanged, with a median pulsatility index of 1.9 (range, 0.5-5.4). Blood levels of tacrolimus were approximately 10, 9, and 8 (μg/L) during months 2, 9, and 12, respectively. Four recipients showed mild inflammation in biopsies after MMF withdrawal and were treated with corticosteroids and azathioprine during the remainder of the 12 months. Subclinical rejection episodes were detected on ectocervical biopsies in five recipients. Histology showed apoptotic bodies and occasional spongiosis in the squamous epithelium. Moderate infiltration of lymphocytes and neutrophils was seen in the epithelial/stromal interface. All rejection episodes were successfully treated for 2 weeks with corticosteroids or dose increments of tacrolimus. CONCLUSION(S) We demonstrate long-term uterine viability after UTx, with continued menstruation and unaltered uterine artery blood flow. Subclinical rejection episodes were effectively reversed by temporary increase of immunosuppression. CLINICAL TRIAL REGISTRATION NUMBER NCT01844362.
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Affiliation(s)
- Liza Johannesson
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Johan Mölne
- Department of Clinical Pathology and Genetics, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Anders Enskog
- Department of Anesthesiology and Intensive Care, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Cesar Diaz-Garcia
- Department of Gynecology and Obstetrics, La Fe University Hospital, University of Valencia, Valencia, Spain
| | - Michael Olausson
- Department of Transplantation, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden; Stockholm IVF, Stockholm, Sweden.
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Miyazaki K, Maruyama T. Partial regeneration and reconstruction of the rat uterus through recellularization of a decellularized uterine matrix. Biomaterials 2014; 35:8791-8800. [PMID: 25043501 DOI: 10.1016/j.biomaterials.2014.06.052] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 06/26/2014] [Indexed: 10/25/2022]
Abstract
Despite dramatic progress in infertility treatments and assisted reproduction, no effective therapies exist for complete loss of uterine structure and/or function. For such patients, genetic motherhood is possible only through gestational surrogacy or uterine transplantation. However, many ethical, social, technical and safety challenges accompany such approaches. A theoretical alternative is to generate a bioartificial uterus, which requires engineering of uterine architecture and appropriate cellular constituents. Here, rat uteri decellularization by aortic perfusion with detergents produced an underlying extracellular matrix together with an acellular, perfusable vascular architecture. Uterine-like tissues were then regenerated and maintained in vitro for up to 10 d through decellularized uterine matrix (DUM) reseeding with adult and neonatal rat uterine cells and rat mesenchymal stem cells followed by aortic perfusion in a bioreactor. Furthermore, DUM placement onto a partially excised uterus yielded recellularization and regeneration of uterine tissues and achievement of pregnancy nearly comparable to the intact uterus. These results suggest that DUM could be used for uterine regeneration, and provides insights into treatments for uterine factor infertility.
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Affiliation(s)
- Kaoru Miyazaki
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo 160-8582, Japan
| | - Tetsuo Maruyama
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Tokyo 160-8582, Japan.
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