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Walter JR, Johannesson L, Falcone T, Putnam JM, Testa G, Richards EG, O'Neill KE. In vitro fertilization practice in patients with absolute uterine factor undergoing uterus transplant in the United States. Fertil Steril 2024; 122:397-405. [PMID: 38631504 DOI: 10.1016/j.fertnstert.2024.04.017] [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: 01/26/2024] [Revised: 04/06/2024] [Accepted: 04/09/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To report detailed, pooled multicenter experiences and outcomes after in vitro fertilization (IVF) treatment among patients undergoing uterus transplantation (UTx) in the US. DESIGN Cohort study. SETTING Hospital. PATIENTS Patients undergoing UTxsfrom the three longest-running UTx clinical trials in the US. INTERVENTION In vitro fertilization treatment among patients undergoing UTx. MAIN OUTCOME MEASURES Reproductive outcomes pretransplant and posttransplant ovarian stimulation. RESULTS Thirty-one uterus transplant recipients were included in this cohort (mean [±SD] age at transplant was 31 ± 4.7 years). Before transplant, recipients completed a mean of two oocyte retrievals (range 1-4), banking a mean of eight untested embryos (range 3-24) or six euploid embryos (range 2-10). Posttransplant retrieval cycles were required in 19% (n = 6/31) of recipients, for a total of 16 cycles (range 2-4 cycles per recipient). All posttransplant retrievals were performed vaginally without complications. Preimplantation genetic testing was used by 74% (n = 23/31) of subjects. Seventy-two autologous single embryo transfers (ETs) occurred in 23 patients who completed at least one ET. Two ETs followed a fresh IVF treatment cycle, and the remainder (n = 70) were frozen ETs. Endometrial preparation was more commonly performed with programmed protocols (n = 61) (exogenous administration of estrogen and progesterone) compared with natural cycle protocols (n = 9). The overall live birth rate (LBR) for this cohort was 35% (n = 25/72) per ET. Among those patients (n = 21) who had an ET leading to a live birth, a mean of 2.2 ETs were performed. The overall LBR after the first ET was 57% (n = 13/23) and rose to 74% (n = 17/23) after a second ET. There was no difference in rate of preeclampsia, live birth, neonatal birth, or placental weights among programmed vs. natural cycle frozen ETs. There were no differences in the LBR between living or deceased donor uteri (37% vs. 32%). CONCLUSIONS Posttransplant ovarian stimulation was required in 26% (n = 6/23) of recipients undergoing at least one ET, despite high rates of preimplantation genetic testing and pretransplant embryo cryopreservation. Posttransplant retrievals were performed transvaginally, without complications. Future reporting of IVF treatment experiences will be essential to optimizing reproductive outcomes after a uterus transplant. CLINICAL TRIAL REGISTRATION NUMBERS NCT02656550 (Baylor University Medical Center); NCT03307356 (University of Pennsylvania); and NCT02573415 (Cleveland Clinic).
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Affiliation(s)
- Jessica R Walter
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Liza Johannesson
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Tommaso Falcone
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio
| | - J Michael Putnam
- Fertility Center of Dallas, Baylor University Medical Center, Dallas, Texas
| | - Giuliano Testa
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Elliott G Richards
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio
| | - Kathleen E O'Neill
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Penn Fertility Care, University of Pennsylvania, Philadelphia, Pennsylvania.
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Wu T, Wu Y, Nie K, Yan J, Chen Y, Wang S, Zhang J. Bibliometric analysis and global trends in uterus transplantation. Int J Surg 2024; 110:4932-4946. [PMID: 38626445 PMCID: PMC11326002 DOI: 10.1097/js9.0000000000001470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/31/2024] [Indexed: 04/18/2024]
Abstract
AIM The purpose of this study was to characterize publication patterns, academic influence, research trends, and the recent developments in uterus transplantation (UTx) across the globe. METHODS The Web of Science Core Collection database was searched for documents published from the time the database began to include relevant articles to 15 December 2023. With the use of VOSviewer, Citespace, BICOMB, and Incites, a cross-sectional bibliometric analysis was conducted to extract or calculate the evaluative indexes. Publications were categorized by country, institution, author, journal, highly cited papers, and keywords. The variables were compared in terms of publication and academic influence, which further included citation count, citation impact, Hirsh index, journal impact factor, total link strength, collaboration metrics, and impact relative to the world. RESULTS A total of 581 papers concerning UTx were initially identified after retrieval, and 425 documents were included. Of the 41 countries participating in relevant studies, the USA and Sweden were in leading positions in terms of publications, citations, and academic influence. The most versatile institution was the University of Gothenburg, followed by Baylor University. The most productive scholars and journals were Brännström M. and Fertility and Sterility , respectively. Five groups of cutting-edge keywords were identified: venous drainage, donors and donation, women, fertility preservation, and fertility. Topics about surgery, first live birth, risk, and in vitro fertilization remain hot in this field. CONCLUSIONS UTx is anticipated to enter a golden era in the coming years. This study provides some guidance concerning the authors involved in promoting UTx research, the current development of UTx, and journals to submit their innovative research. This also helps to reach a comprehensive insight and prospect in the near future. In order to establish recognized standards and benefit more patients who are disturbed by uterine infertility, large-scale and well-designed clinical trials are required.
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Affiliation(s)
- Tong Wu
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Yangyang Wu
- College of Animal Science and Technology, Sichuan Agricultural University, Sichuan, People's Republic of China
| | - Kebing Nie
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Jinfeng Yan
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
- School of Materials Science and Engineering, Huazhong University of Science and Technology, Wuhan
| | - Ying Chen
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Shixuan Wang
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Jinjin Zhang
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
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Pérez-Blanco A, Seoane JA, Pallás TA, Nieto-Moro M, Calonge RN, de la Fuente A, Martin DE. Uterus Transplantation as a Surgical Innovation. JOURNAL OF BIOETHICAL INQUIRY 2023; 20:367-378. [PMID: 37382845 PMCID: PMC10624705 DOI: 10.1007/s11673-023-10272-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 11/20/2022] [Indexed: 06/30/2023]
Abstract
Uterus transplantation (UTx) research has been introduced in several countries, with trials in Sweden and the United States producing successful outcomes. The growing interest in developing UTx trials in other countries, such as Spain, the Netherlands, Japan, and Australia, raises important questions regarding the ethics of surgical innovation research in the field of UTx. This paper examines the current state of UTx in the context of the surgical innovation paradigm and IDEAL framework and discusses the ethical challenges faced by those considering the introduction of new trials. We argue that UTx remains an experimental procedure at a relatively early stage of the IDEAL framework, especially in the context of de novo trials, where protocols are likely to deviate from those used previously and where researchers are likely to have limited experience of UTx. We conclude that countries considering the introduction of UTx trials should build on the strengths of the reported outcomes to consolidate the evidence base and shed light on the uncertainties of the procedure. Authorities responsible for the ethical governance of UTx trials are advised to draw on the ethical framework used in the oversight of surgical innovation.
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Affiliation(s)
| | - José-Antonio Seoane
- Philosophy, Constitution and Rationality Research Group, Faculty of Law, Universidade da Coruña, A Coruña, Spain
| | | | - Montserrat Nieto-Moro
- Paediatric Critical Care Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | | | | | - Dominique E Martin
- Geelong Waurn Ponds Campus, Locked Bag 20000, Geelong, VIC, 3220, Australia.
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Robova H, Rob L, Halaska MJ, Drozenova J, Pichlik T, Drochytek V, Hruda M. Twenty years of experience with less radical fertility-sparing surgery in early-stage cervical cancer: Pregnancy outcomes. Gynecol Oncol 2023; 174:76-79. [PMID: 37163776 DOI: 10.1016/j.ygyno.2023.04.016] [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: 11/15/2022] [Revised: 04/04/2023] [Accepted: 04/17/2023] [Indexed: 05/12/2023]
Abstract
INTRODUCTION The standard procedure in cervical cancer is radical hysterectomy and pelvic lymphadenectomy (PLND). Because of the increasing age of women bearing children, fertility has become a major challenge. We present pregnancy results after less radical fertility-sparing surgery in women with IA1, LVSI positive, IA2 and IB1 (<2 cm, infiltration less than half of the cervical stroma). MATERIALS AND METHOD All women (n = 91) underwent laparoscopic sentinel lymph node mapping with frozen section followed by PLND and "selective parametrectomy" (removal of afferent lymphatic channels from the paracervix) if sentinel nodes (SLN) are negative. If lymph nodes were verified negative by definitive histopathology, patients were treated by simple trachelectomy (IB1) or large cone (IA1/IA2) biopsy 1 week after primary surgery. RESULTS From 1999 to 2018, 91 women were enrolled in the study (median age 29.1 years, range 21-40). Fertility was spared in 76 (83.5%) women; 13 (17.1%) women did not plan future pregnancy and 63 (82.9%) had pregnancy desires. Fifty-four of 63 women conceived (pregnancy rate 85.7%) and 48 of 63 delivered 58 babies (delivery rate 76.2%). Thirty-nine women delivered in term (67.2%): 13 women between 32 and 36 + 6 weeks of pregnancy, 3 between 28 and 31 + 6 weeks and 3 between 24 and 27 + 6 weeks. Only one woman still plans pregnancy. One woman is currently pregnant. CONCLUSION The goal of fertility-sparing surgery is to produce good oncological results and promising pregnancy outcomes. Pregnancy results after less radical fertility-sparing procedures show promise (pregnancy rate 82.9% and delivery rate 76.2%).
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Affiliation(s)
- Helena Robova
- 3(rd) Medical Faculty, Charles University in Prague, Department of Obstetrics & Gynaecology, Czech Republic
| | - Lukas Rob
- 3(rd) Medical Faculty, Charles University in Prague, Department of Obstetrics & Gynaecology, Czech Republic.
| | - Michael J Halaska
- 3(rd) Medical Faculty, Charles University in Prague, Department of Obstetrics & Gynaecology, Czech Republic
| | - Jana Drozenova
- 3(rd) Medical Faculty, Charles University, Department of Pathology, Czech Republic
| | - Tomas Pichlik
- 3(rd) Medical Faculty, Charles University in Prague, Department of Obstetrics & Gynaecology, Czech Republic
| | - Vit Drochytek
- 3(rd) Medical Faculty, Charles University in Prague, Department of Obstetrics & Gynaecology, Czech Republic
| | - Martin Hruda
- 3(rd) Medical Faculty, Charles University in Prague, Department of Obstetrics & Gynaecology, Czech Republic; Faculty of Medicine in Plzeň, Charles University, Department of Obstetrics & Gynaecology, Czech Republic
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Uterine allograft removal by total laparoscopic hysterectomy after successful cesarean delivery in a living-donor uterus recipient with uterovaginal agenesis (MRKHS). Arch Gynecol Obstet 2023; 307:827-840. [PMID: 36342536 PMCID: PMC9984324 DOI: 10.1007/s00404-022-06796-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/15/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE To limit the burden of long-term immunosuppression (IS) after uterus transplantation (UTx), removal of the uterine allograft is indicated after maximum two pregnancies. Hitherto this has required graft hysterectomy by laparotomy. Our objective was to demonstrate, as a proof of concept, the feasibility of less traumatic transplantectomy by total laparoscopic hysterectomy (TLH). PATIENT A 37-year-old woman with uterovaginal agenesis due to Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) who had undergone neovaginoplasty at age 19 years prior to living-donor (LD) UTx in 10/2019 at age 35 years gave birth to a healthy boy by primary cesarean section in 06/2021. During pregnancy, she developed impaired renal function, with bilateral hydronephrosis, necessitating early allograft removal in 09/2021 to prevent chronic kidney disease, particularly during a potential second pregnancy. METHODS Transplantectomy by TLH essentially followed standard TLH procedures. We paid meticulous attention to removing as much donor tissue as possible to prevent postoperative complications from residual donor tissue after stopping IS, as well as long-term vascular damage. RESULTS TLH was performed successfully without the need to convert to open surgery. Surgical time was 90 min with minimal blood loss. No major complications occurred intra- or postoperatively and during the subsequent 9-month follow-up period. Kidney function normalized. CONCLUSIONS To our knowledge, we report the first successful TLH-based removal of a uterine allograft in a primipara after LD UTx, thus demonstrating the feasibility of TLH in uterus recipients with MRKHS.
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Twenty years of experience with less radical fertility-sparing surgery in early-stage cervical cancer: Oncological outcomes. Gynecol Oncol 2021; 163:100-104. [PMID: 34330536 DOI: 10.1016/j.ygyno.2021.07.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The standard procedure in cervical cancer is radical hysterectomy (RH) and pelvic lymphadenectomy (PLND). Because of the increasing age of women at childbirth, fertility becomes a major challenge. We present 20 years of experience with two-step less radical fertility-sparing surgery in women with IA1, LVSI positive, IA2 and IB1 (<2 cm, infiltration less than half of stromal invasions. MATERIALS AND METHOD Preoperative workout consisted of histopathological diagnosis and magnetic resonance imaging along with ultrasonographic volumetry. We then performed laparoscopic sentinel lymph node mapping (SLNM) with frozen section (FS) followed by PLND and "selective parametrectomy" (removal of afferent lymphatic channels from the paracervix) in case of a negative result. If verified by definitive histopathology, patients were treated by simple trachelectomy (IB1) or large cone (IA1/IA2) biopsy 1 week after primary surgery. RESULTS From 1999 to 2018, 91 women were enrolled in the study (median age 29.1 years, range 21-40). Of these 91 women, 51 (56.0%) were nulliparous. The detection rate of SLNs was 100% per patient and the specific side detection rate 96.7%. Positive lymph nodes were diagnosed in nine cases (9.8%). These women then underwent RH. Fertility was spared in 80 women but 4 recurred locally (5.0%). The mortality rate was 0.0%. The median follow-up was 149 months. CONCLUSION Less radical fertility-sparing surgery with SLNM is safe in cervical cancers <2 cm at the largest diameter and infiltrating less than half of the cervical stroma. The recurrence rate is acceptable with no mortality. Morbidity with this procedure is low. Extended and accurate follow-up is necessary and human papillomavirus - high risk (HPV-HR tests seem to be useful in such follow-up assessment.
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Kasaven LS, Jones BP, Keays R, Saso S. Anaesthetic considerations for fertility-sparing surgery and uterine transplantation. Anaesthesia 2021; 76 Suppl 4:46-55. [PMID: 33682092 DOI: 10.1111/anae.15389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2020] [Indexed: 12/15/2022]
Abstract
A number of benign and malignant gynaecological conditions can cause infertility. Advancements in assisted reproductive technologies have facilitated the rapidly evolving subspecialty of fertility preservation. Regardless of clinical indication, women now have the reproductive autonomy to make fully informed decisions regarding their future fertility. In particular, there has been an increasing interest and demand among patients and healthcare professionals for fertility-sparing surgery. Gynaecologists find themselves continually adapting surgical techniques and introducing novel procedures to facilitate this rapidly emerging field and anaesthetists need to manage the consequent physiological demands intra-operatively. Not only is it important to understand the surgical procedures now undertaken, but also the intra-operative management in an ever evolving field. This article reviews the methods of fertility-sparing surgery and also describes important anaesthetic challenges including peri-operative care for women undergoing complex fertility-sparing surgeries such as uterus transplantation.
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Affiliation(s)
- L S Kasaven
- Department of Cancer and Surgery, Imperial College London, London, UK
| | - B P Jones
- Department of Cancer and Surgery, Imperial College London, London, UK
| | - R Keays
- Chelsea and Westminster Hospital, London, UK
| | - S Saso
- Queen Charlotte's and Chelsea Hospital, Imperial College NHS Trust and Imperial College London, UK
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