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Pecorino B, Scibilia G, Ferrara M, Veroux P, Chiofalo B, Scollo P. Deceased Donor Uterus Transplantation: A Narrative Review of the First 24 Published Cases. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1348. [PMID: 39202629 PMCID: PMC11356378 DOI: 10.3390/medicina60081348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 08/05/2024] [Accepted: 08/15/2024] [Indexed: 09/03/2024]
Abstract
Uterus transplantation is the surgical treatment for absolute uterine factor infertility (AUFI), a congenital or acquired condition characterized by the absence of a uterus. More than 80 transplants have been performed worldwide, resulting in more than 30 live births, originating both from living and deceased donors. The collection of published articles on deceased donor uterus transplantations was performed in PubMed and SCOPUS by searching for the terms "Uterus transplantation" AND "deceased donor"; from the 107 articles obtained, only case reports and systematic reviews of deceased donor uterus transplantations and the resulting live births were considered for the present manuscript. The extracted data included the date of surgery (year), country, recipient (age and cause of AUFI) and donor (age and parity) details, outcome of recipient surgery (hysterectomy), and live births (date and gestational age). The search of peer-reviewed publications showed 24 deceased donor uterus transplantations and 12 live births (a birth rate of 66%) with a 25% occurrence of graft loss during follow-up (6 of 24). Among this series, twelve transplants were performed in the USA (seven births), five in the Czech Republic (one birth), three in Italy (one birth), two in Turkey (two births), and two in Brazil (one birth). The median recipient age was 29.8 years (range 21-36), while the median donor age was 36.1 years (range 20-57). Of 24 recipients, 100% were affected by MRKH (Mayer-Rokitanski-Kuster-Hauser) syndrome. Two live births were reported from nulliparous donors. Deceased donor uterus transplantation birth rates are very similar to the living donor rates reported in the literature, but ethical implications could be less important in the first group. It is necessary to register every case in the International Registry for Uterus Transplantation in order to perform a systematic review and comparison with living donor rates.
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Affiliation(s)
- Basilio Pecorino
- Obstetrics and Gynecology Umberto I Hospital, Kore University of Enna, 94100 Enna, Italy;
| | - Giuseppe Scibilia
- Obstetrics and Gynecology Giovanni Paolo II Hospital, 97100 Ragusa, Italy;
| | - Martina Ferrara
- Obstetrics and Gynecology Cannizzaro Hospital, 95126 Catania, Italy;
| | - Pierfrancesco Veroux
- Vascular Surgery and Organ Transplant Unit, Department of General Surgery and Medical-Surgical Specialties, University Hospital of Catania, 95124 Catania, Italy;
| | - Benito Chiofalo
- Obstetrics and Gynecology Cannizzaro Hospital, Kore University of Enna, 95126 Catania, Italy;
| | - Paolo Scollo
- Obstetrics and Gynecology Cannizzaro Hospital, Kore University of Enna, 95126 Catania, Italy;
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Veroux M, Scollo P, Giambra MM, Roscitano G, Giaquinta A, Setacci F, Veroux P. Living-Donor Uterus Transplantation: A Clinical Review. J Clin Med 2024; 13:775. [PMID: 38337468 PMCID: PMC10856556 DOI: 10.3390/jcm13030775] [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: 01/03/2024] [Revised: 01/22/2024] [Accepted: 01/27/2024] [Indexed: 02/12/2024] Open
Abstract
Uterus transplantation (UTx) is currently the only available treatment for absolute uterine factor infertility. More than 90 uterus transplantations have been performed worldwide, mostly from living donors. Living-donor (LD) UTx is a challenging surgical procedure since it poses ethical issues, and it is a high-risk and invasive surgery with higher hysterectomy-related risks compared to conventional hysterectomy. A total of 59 living-donor hysterectomies have been reported in the literature, including 35 performed with a laparotomic approach, 20 with a robotic approach and 4 with a laparoscopic approach. The mean donor age was 45.6 ± 9.1 years, and 22 were unrelated with the recipients, 34 were emotionally related (27 mothers, 5 sisters, 2 mother's sisters). The mean recipient age was 28.8 ± 4.5 years. Mayer-Rokitansky-Küster-Hauser syndrome was the most common indication for uterus transplant. Robotic living-donor hysterectomy had the longest operative time but resulted in a lower blood loss and postoperative stay compared to laparotomic and laparoscopic approaches. Twenty-nine births from LD-UTx have been reported, four after robotic living-donor hysterectomy and twenty-five after a laparotomic procedure. UTx is now an effective treatment for women with UFI. While living-donor UTx in some cases may be considered an experimental procedure, it offers the extraordinary possibility to give women the opportunity to have a pregnancy. Many efforts should be made to reduce the potential risks for donors, including the use of mini-invasive techniques, and the efficacy of UTx in the recipients, giving the potential harm of immunosuppression in a recipient of a non-life-saving organ.
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Affiliation(s)
- Massimiliano Veroux
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Paolo Scollo
- Maternal and Child Department, Obstetrics and Gynecology, Cannizzaro Hospital, 95123 Catania, Italy;
| | - Martina Maria Giambra
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Giuseppe Roscitano
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Alessia Giaquinta
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Francesco Setacci
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
| | - Pierfrancesco Veroux
- Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, 95123 Catania, Italy; (M.M.G.); (G.R.); (A.G.); (F.S.); (P.V.)
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3
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Lee JY. Who should provide the uterus? The ethics of live donor recruitment for uterus transplantation. JOURNAL OF MEDICAL ETHICS 2023:jme-2023-109227. [PMID: 37640534 DOI: 10.1136/jme-2023-109227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
Uterus transplantation (UTx) is an experimental surgery likely to face the issue of organ shortage. In my article, I explore how this issue might be addressed by changing the prevailing practices around live uterus donor recruitment. Currently, women with children - often the mothers of recipients - tend to be overrepresented as donors. Yet, other potentially eligible groups who may have an interest in providing their uterus - such as transgender men, or cisgender women who do not wish to gestate or to have children - tend to be excluded as potential donors. Moving forward, I recommend that donor inclusion criteria for UTx be broadened to be more inclusive of these latter groups.
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Affiliation(s)
- J Y Lee
- Department of Public Health, University of Copenhagen, Kobenhavn 1172, Denmark
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Wall AE, Johannesson L, Reddy V, Warren AM, Gordon EJ, Testa G. Living uterus donors' perceptions of decision-making and informed consent: a qualitative study of the Dallas Uterus Transplant Study participants. Am J Transplant 2023; 23:265-271. [PMID: 36695701 DOI: 10.1016/j.ajt.2022.12.006] [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: 08/22/2022] [Revised: 11/15/2022] [Accepted: 12/02/2022] [Indexed: 01/03/2023]
Abstract
Uterus transplantation is a growing field, but little is known about living uterus donors' perceptions of informed consent or their decision-making processes. This study used semistructured interviews to collect information regarding uterus donors' experiences with uterus donation, perceptions of the informed consent process, and information on how they decided to pursue uterus donation. Interviews were coded for thematic analysis. Three major themes emerged in this study. First, the decision-making process was based on individuals' motivations, rationale, and considerations of alternative contributions to help other women with infertility. Second, participants described how they felt about the process of informed consent, their decision-making processes, and how their experiences compared with their expectations. Third, participants discussed how uterus donation was a valuable experience. This study found that living uterus donors are motivated to give another woman the opportunity to experience pregnancy and childbirth. They were satisfied with the informed consent process, their experiences were in line with their expectations, and the value of uterus donation was associated with the act of donation itself. Our findings suggest that living donor uterus programs should develop robust informed consent processes that provide detailed information about uterus donation and encourage shared decision-making with potential uterus donors.
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Affiliation(s)
- Anji E Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA.
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA; Division of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas, USA
| | - Vikrant Reddy
- Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Ann Marie Warren
- Division of Trauma, Acute Care, and Critical Care Surgery, Baylor University Medical Center, Dallas, Texas, USA; Department of Surgery, Division of Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Elisa J Gordon
- Department of Surgery, Division of Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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Uterus Transplantation: Revisiting the Question of Deceased Donors versus Living Donors for Organ Procurement. J Clin Med 2022; 11:jcm11154516. [PMID: 35956131 PMCID: PMC9369769 DOI: 10.3390/jcm11154516] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/26/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Uterus transplantation is a surgical treatment for women with congenital or acquired uterine factor infertility. While uterus transplantation is a life-enhancing transplant that is commonly categorized as a vascular composite allograft (e.g., face or hand), it is similar to many solid organ transplants (e.g., kidney) in that both living donors (LDs) and deceased donors (DDs) can be utilized for organ procurement. While many endpoints appear to be similar for LD and DD transplants (including graft survival, time to menses, livebirth rates), there are key medical, technical, ethical, and logistical differences between these modalities. Primary considerations in favor of a LD model include thorough screening of donors, enhanced logistics, and greater donor availability. The primary consideration in favor of a DD model is the lack of physical or psychological harm to a living donor. Other important factors, that may not clearly favor one approach over the other, are important to include in discussions of LD vs. DD models. We favor a stepwise approach to uterus transplantation, one in which programs first begin with DD procurement before attempting LD procurement to maximize successful organ recovery and to minimize potential harms to a living donor.
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Robotic Donor Hysterectomy Results in Technical Success and Live Births After Uterus Transplantation. Clin Obstet Gynecol 2021; 65:59-67. [DOI: 10.1097/grf.0000000000000678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Guntram L. May I have your uterus? The contribution of considering complexities preceding live uterus transplantation. MEDICAL HUMANITIES 2021; 47:425-437. [PMID: 33627444 PMCID: PMC8639951 DOI: 10.1136/medhum-2020-011864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/31/2020] [Indexed: 06/12/2023]
Abstract
Uterus transplantation combined with in vitro fertilisation (IVF) (henceforth called UTx-IVF) as a treatment for infertility caused by an absence or malfunction of the uterus is advancing. About 50 transplantations have been conducted worldwide and at least 14 children have been born-9 of them by women taking part in a Swedish research project on UTx-IVF. The Swedish research protocol initially stated that the potential recipient must 'have her own donor' who is preferably related to the recipient. But what does it mean to ask someone for a uterus? What challenges does this question instigate? And what norms may it enact? In this article, I explore how 10 women-who have considered, and sometimes pursued, UTx-IVF-describe their experiences of searching for a donor. I aim to show how an analysis of such accounts can help us unpack some of the specific relational and gendered dimensions of UTx-IVF and by doing so enrich discussions of risks, benefits, care and support in UTx-IVF. Drawing on research in social sciences and medical humanities that has demonstrated how assisted reproductive technologies and organ donation can provoke social and familial conundrums, with respect to such topics as embodiment and identity, I present three patterns that describe different dimensions of the interviewees' quest for a uterus donor. I discuss the negotiations that took place, how expectations unfolded and how entanglements were managed as the interviewees considered asking someone for a donation. Such an examination, I suggest, contributes to make care and support more attuned to the experiences and entanglements that UTx-IVF entails for those pursuing it. This will become increasingly important if (or when) UTx-IVF becomes part of general healthcare. To conclude, I problematise responsibilities and relational challenges in medical innovation, and in this way provide insights into how the ethical debate over UTx-IVF can broaden its scope.
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Affiliation(s)
- Lisa Guntram
- TEMA-Department of Thematic Studies, Linkopings universitet Institutionen for Tema, Linkoping, Sweden
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Almeida GHDR, Iglesia RP, Araújo MS, Carreira ACO, Dos Santos EX, Calomeno CVAQ, Miglino MA. Uterine Tissue Engineering: Where We Stand and the Challenges Ahead. TISSUE ENGINEERING PART B-REVIEWS 2021; 28:861-890. [PMID: 34476997 DOI: 10.1089/ten.teb.2021.0062] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Tissue engineering is an innovative approach to develop allogeneic tissues and organs. The uterus is a very sensitive and complex organ, which requires refined techniques to properly regenerate and even, to rebuild itself. Many therapies were developed in 20th century to solve reproductive issues related to uterus failure and, more recently, tissue engineering techniques provided a significant evolution in this issue. Herein we aim to provide a broad overview and highlights of the general concepts involved in bioengineering to reconstruct the uterus and its tissues, focusing on strategies for tissue repair, production of uterine scaffolds, biomaterials and reproductive animal models, highlighting the most recent and effective tissue engineering protocols in literature and their application in regenerative medicine. In addition, we provide a discussion about what was achieved in uterine tissue engineering, the main limitations, the challenges to overcome and future perspectives in this research field.
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Affiliation(s)
- Gustavo Henrique Doná Rodrigues Almeida
- University of São Paulo, Faculty of Veterinary and Animal Science, Professor Orlando Marques de Paiva Avenue, 87, Butantã, SP, Sao Paulo, São Paulo, Brazil, 05508-900.,University of São Paulo Institute of Biomedical Sciences, 54544, Cell and Developmental Biology, Professor Lineu Prestes Avenue, 1374, Butantã, SP, Sao Paulo, São Paulo, Brazil, 05508-900;
| | - Rebeca Piatniczka Iglesia
- University of São Paulo Institute of Biomedical Sciences, 54544, Cell and Developmental Biology, Sao Paulo, São Paulo, Brazil;
| | - Michelle Silva Araújo
- University of São Paulo, Faculty of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, SP, Brazil., São Paulo, São Paulo, Brazil;
| | - Ana Claudia Oliveira Carreira
- University of São Paulo, Faculty of Veterinary Medicine and Animal Science, University of São Paulo, SP, Brazil, São Paulo, São Paulo, Brazil;
| | - Erika Xavier Dos Santos
- State University of Maringá, 42487, Department of Morphological Sciences, State University of Maringá, Maringá, PR, Brazil, Maringa, PR, Brazil;
| | - Celso Vitor Alves Queiroz Calomeno
- State University of Maringá, 42487, Department of Morphological Sciences, State University of Maringá, Maringá, PR, Brazil, Maringa, PR, Brazil;
| | - Maria Angélica Miglino
- University of São Paulo, Faculty of Veterinary and Animal Science Professor Orlando Marques de Paiva Avenue, 87 Butantã SP Sao Paulo, São Paulo, BR 05508-900, São Paulo, São Paulo, Brazil;
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Kirby J. An Ethics-Informed, Comparative Analysis of Uterus Transplantation and Gestational Surrogacy for Uterine Factor Infertility in High-Income Countries. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:417-427. [PMID: 34383286 DOI: 10.1007/s11673-021-10114-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 03/17/2021] [Indexed: 06/13/2023]
Abstract
Interest in the future, clinical implementation of uterus transplantation for uterine factor infertility was recently boosted by the demonstration of proof-of-concept for deceased uterus donation/transplantation. The ethical dimensions of living and deceased uterus transplantation are explored and addressed in the paper through their comparison to the ethical elements of an existing, legal, assisted reproduction practice in some high-income countries, i.e., gestational surrogacy. A set of six ethics lenses is used in the comparative analysis: reproductive autonomy and rights, informed choice/consent, relevant critical relational theories, health equity, theoretical application of the accepted living donation standard, and comparative benefits and burdens considerations. Gestational surrogacy, as currently practiced in some high-income countries, is the assumed, theoretical base-threshold for determination of ethical acceptability in assisted reproduction practices. The analysis demonstrates that (at the present time): 1) the ethical acceptability of living uterus donation/transplantation is less than that of gestational surrogacy in high-income countries, and 2) the ethical acceptability of deceased uterus donation/transplantation is roughly equivalent to that of gestational surrogacy. This leads to the conclusion that, at the present time, only one version of uterus transplantation practice, i.e., deceased uterus transplantation, should be considered ethically acceptable for possible clinical implementation in high-income countries.
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Affiliation(s)
- Jeffrey Kirby
- Department of Bioethics, Faculty of Medicine, Dalhousie University, C-315 - 5849 University Avenue, Halifax, Nova Scotia, B3H 4H7, Canada.
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11
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Abstract
Uterine transplantation (UTx) is a fertility restoring treatment for women with absolute uterine factor infertility. At a time when there is no question of the procedure's feasibility, and as the number of livebirths begins to increase exponentially, various important reproductive, fetal, and maternal medicine implications have emerged. Detailed outcomes from 17 livebirths following UTx are now available, which are reviewed herein, along with contextualized extrapolation from pregnancy outcomes in other solid organ transplants. Differences in recipient demographics and reproductive aspirations between UTx and other transplant recipients make extrapolating management strategies and outcomes in other solid organ transplants inappropriate. Whereas preterm delivery remains prominent, small for gestational age or hypertensive disorders do not appear to be as prevalent following UTx when compared to other solid organ transplants. Given the primary objective of undertaking UTx is to achieve a livebirth, publication of reproductive outcomes is essential at this early stage, to reflect on and optimize the management of future cases.
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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: 13] [Impact Index Per Article: 4.3] [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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Uterine Transplantation Using Living Donation: A Cross-sectional Study Assessing Perceptions, Acceptability, and Suitability. Transplant Direct 2021; 7:e673. [PMID: 34104711 PMCID: PMC8183710 DOI: 10.1097/txd.0000000000001124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. A uterine transplantation is a nonvital, quality-of-life–enhancing solid organ transplant. Given improvements in donor risk profile and the anticipated shortage of suitable deceased donors, nondirected donation could facilitate sustainability as uterine transplantation moves from research into the clinical realm. The aim of this article is to determine perceptions and identify motivations of potential nondirected living uterus donors and assess acceptability and suitability.
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14
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Liu Y, Ding Y, Zhang X, Zhang Y, Hua K. Morphologic assessment of hypertonic citrate adenine, histidine-tryptophan-ketoglutarate, and university of Wisconsin solutions for hypothermic uterus preservation in rats. J Obstet Gynaecol Res 2021; 47:1097-1109. [PMID: 33410204 DOI: 10.1111/jog.14645] [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: 09/30/2020] [Revised: 12/06/2020] [Accepted: 12/17/2020] [Indexed: 12/11/2022]
Abstract
AIM Optimizing perfusate for static cold storage is one of the key ways of reducing organ dysfunction and rejection in organ transplantation. Here, we tested the effectiveness of the three different solutions for hypothermic uterus preservation. METHODS Twenty rats were divided into four groups, five in each group. Uterine grafts were retrieved and perfused in situ. The uteri were preserved at 4°C in normal saline as control group (group NS), hypertonic citrate adenine (group HCA), histidine-tryptophan-ketoglutarate (group HTK), or university of Wisconsin solutions (group UW) for 0, 12, 24, and 48 h, respectively. HE, electron microscopy, TUNEL staining, and Cleaved Caspase3 immunohistochemical staining were assessed at each time point. RESULTS There was no significant difference in the uterine retrieval time, perfusion time, and the amount of perfusion solution in NS, HCA, HTK, and UW groups (p > 0.05). HCA and HTK can well preserve the pathological morphology of rat uterine tissues for up to 24 h, and the apoptosis rates of the two groups are 7.2% and 7.1%, respectively, with no statistical difference (p > 0.05). Still, the protective effect of HTK on the ultrastructure of cells was much better than HCA. There was a significant difference in the apoptosis rate of UW (6.5%), HTK (8.8%), and HCA (9.4%) at 48 h, with mitochondrial and endoplasmic reticulum structure well preserved only in UW. CONCLUSION At 4°C, normal saline is not suitable to preserve rat uterus for more than 12 h. The morphologic results would favor the use of HTK rather than HCA for short-term hypothermic uterus preservation (≤24 h). UW is better than HTK and HCA for 48 h hypothermic uterus preservation.
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Affiliation(s)
- Yu Liu
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Yan Ding
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xuyin Zhang
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Ying Zhang
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Keqin Hua
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
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Uterine Transplantation: Evolving Data, Success, and Clinical Importance. J Minim Invasive Gynecol 2020; 28:502-512. [PMID: 33348011 DOI: 10.1016/j.jmig.2020.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/09/2020] [Accepted: 12/15/2020] [Indexed: 11/22/2022]
Abstract
Uterine transplantation is an evolving procedure to allow for childbearing in paitents with absolute uterine factor infertility. The objective of this study was to review the existing literature using a comprehensive PubMed literature search. A systematic medical subheadings search strategy was used with the terms "uterus transplant" and "uterine transplantation". Of the 75 full-text articles assessed for eligibility, 68 were included in the qualitative synthesis. Of these, 9 were included in the meta-analysis on living donor uterine transplant, 5 on deceased donor uterine transplant, and 6 case reports of single uterine transplants. In conclusion, uterus transplant is a nascent field undergoing a rapid rate of evolution as programs mature their data and increase the number of procedures performed. The most recent publications and advances are thus summarized in this article to capture the most up-to-date information.
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Custodiol-N Is Superior to Custodiol ® Solution in Experimental Rat Uterus Preservation. Int J Mol Sci 2020; 21:ijms21218015. [PMID: 33126511 PMCID: PMC7662817 DOI: 10.3390/ijms21218015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 01/15/2023] Open
Abstract
Uterus transplantation (UTx) is the first and only available treatment for women with absolute uterine factor infertility. However, clinical application is limited by the lack of organs, ischemia/reperfusion injury, as well as immunosuppression after UTx. Several different preservation solutions are used in experimental and clinical UTx, including Custodiol® solution. Recently, the novel Custodiol-N solution was developed with superior results in organ preservation. However, the solution was not tested yet in UTx. Therefore, the aims of this study were to evaluate the effect of Custodiol-N in uterus prolonged cold preservation time (8 and 24 h), compared to Custodiol® solution. Uterus tissue samples were obtained from adult Sprague Dawley rats (n = 10/group). Cold ischemic injury was estimated by histology, including immunohistochemistry, and biochemical tissue analyses. After 8 h of cold ischemia, higher percentage of tissue edema, necrosis signs and myeloperoxidase expression, as well as lower superoxide dismutase activity were found in Custodiol® compared to Custodiol-N (p < 0.05). These differences were more pronounced after 24 h of cold preservation time (p < 0.05). This study demonstrated that Custodiol-N protects uterus grafts from cold ischemic injury better than standard Custodiol® most likely via inhibition of oxidative stress and tissue edema. It seems that iron chelators in the composition of Custodiol-N play an important protective role against cold ischemia.
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Dion L, Jacquot Thierry L, Tardieu A, Carbonnel M, Ayoubi JM, Gauthier T, Lavoué V. [Uterus transplantation, current prospect and future indications. State of art with review of literature]. ACTA ACUST UNITED AC 2020; 49:193-203. [PMID: 32916317 DOI: 10.1016/j.gofs.2020.09.001] [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: 04/07/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of this review is to summarize the development of UT on worldwide and to develop the new questions posed by this technique in 2020. METHODS According to the PRISMA model, via Pubmed, we searched for publications containing the keywords: uterus transplantation; UT and cryopreservation from 2000 to 2020. RESULTS At least 76 UTx have been carried out around the world and 19 healthy babies were born. The main indication remains the uterine agenesis (MRKH Syndrome>85% cases) then the history of hysterectomy (hemorrhage of the delivery or cervical cancer) and the non-functional uterus (Asherman's syndrome, diffuse adenomyosis). The 2 types of donors (living and deceased) are developed representing respectively 75% and 25% of the TU; the success rate in terms of return of rules is better in the living donor group and is 79% vs 68% in the deceased donor group. The choice of donor type must take into account the constraints of both procedures. Surgical complications (grade III) for the donor are estimated to be 14% mainly represented by ureter wounds. Technical simplifications concerning the venous return of the graft but also the carrying out of robot-assisted surgery would reduce the operating time for the donor and facilitate the collection process. CONCLUSION TU is a complementary alternative to GPA and adoption allowing patients to be surrogates, legal and biological of the baby. An extension of the indications to patients with non absolute uterine infertility is in the process of democratization.
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Affiliation(s)
- L Dion
- Service de gynécologie, CHU de Rennes, hôpital Sud, 16, boulevard de Bulgarie, 35000 Rennes, France.
| | - L Jacquot Thierry
- Service de gynécologie, CHU de Rennes, hôpital Sud, 16, boulevard de Bulgarie, 35000 Rennes, France
| | - A Tardieu
- Département de gynécologie obstétrique, CHU Limoges, avenue Dominique Larrey, 87000 Limoges, France; Inserm, UMR-1248, CHU Limoges, 87000 Limoges, France
| | - M Carbonnel
- Service de gynécologie obstétrique et médecine de la reproduction, hôpital Foch, université de Versailles Saint-Quentin en Yvelines, 92150 Suresnes, France
| | - J-M Ayoubi
- Service de gynécologie obstétrique et médecine de la reproduction, hôpital Foch, université de Versailles Saint-Quentin en Yvelines, 92150 Suresnes, France
| | - T Gauthier
- Département de gynécologie obstétrique, CHU Limoges, avenue Dominique Larrey, 87000 Limoges, France; Inserm, UMR-1248, CHU Limoges, 87000 Limoges, France
| | - V Lavoué
- Service de gynécologie, CHU de Rennes, hôpital Sud, 16, boulevard de Bulgarie, 35000 Rennes, France
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18
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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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19
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Flyckt R, Falcone T, Quintini C, Perni U, Eghtesad B, Richards EG, Farrell RM, Hashimoto K, Miller C, Ricci S, Ferrando CA, D’Amico G, Maikhor S, Priebe D, Chiesa-Vottero A, Heerema-McKenney A, Mawhorter S, Feldman MK, Tzakis A. First birth from a deceased donor uterus in the United States: from severe graft rejection to successful cesarean delivery. Am J Obstet Gynecol 2020; 223:143-151. [PMID: 32151611 DOI: 10.1016/j.ajog.2020.03.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/25/2020] [Accepted: 03/01/2020] [Indexed: 01/29/2023]
Abstract
Uterus transplantation is the only known potential treatment for absolute uterine factor infertility. It offers a unique setting for the investigation of immunologic adaptations of pregnancy in the context of the pharmacologic-induced tolerance of solid organ transplants, thus providing valuable insights into the early maternal-fetal interface. Until recently, all live births resulting from uterus transplantation involved living donors, with only 1 prior birth from a deceased donor. The Cleveland Clinic clinical trial of uterus transplantation opened in 2015. In 2017, a 35 year old woman with congenital absence of the uterus was matched to a 24 year old parous deceased brain-dead donor. Transplantation of the uterus was performed with vaginal anastomosis and vascular anastomoses bilaterally from internal iliac vessels of the donor to the external iliac vessels of the recipient. Induction and maintenance immunosuppression were achieved and subsequently modified in anticipation of pregnancy 6 months after transplant. Prior to planned embryo transfer, ectocervical biopsy revealed ulceration and a significant diffuse, plasma cell-rich mixed inflammatory cell infiltrate, with histology interpreted as grade 3 rejection suspicious for an antibody-mediated component. Aggressive immunosuppressive regimen targeting both cellular and humoral rejection was initiated. After 3 months of treatment, there was no histologic evidence of rejection, and after 3 months from complete clearance of rejection, an uneventful embryo transfer was performed and a pregnancy was established. At 21 weeks, central placenta previa with accreta was diagnosed. A healthy neonate was delivered by cesarean hysterectomy at 34 weeks' gestation. In summary, this paper highlights the first live birth in North America resulting from a deceased donor uterus transplant. This achievement underscores the capacity of the transplanted uterus to recover from a severe, prolonged rejection and yet produce a viable neonate. This is the first delivery from our ongoing clinical trial in uterus transplantation, including the first reported incidence of severe mixed cellular/humoral rejection as well as the first reported placenta accreta.
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20
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Zitkute V, Kvietkauskas M, Leber B, Strupas K, Stiegler P, Schemmer P. Ischemia and reperfusion injury in uterus transplantation: A comprehensive review. Transplant Rev (Orlando) 2020; 34:100550. [PMID: 32498979 DOI: 10.1016/j.trre.2020.100550] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/19/2020] [Accepted: 04/21/2020] [Indexed: 01/26/2023]
Abstract
Uterus transplantation (UTx) is the only available treatment for human beings who cannot carry children out to term. However, despite several clinical studies with a very limited number of UTx many issues have to be addressed. Up to date, there is a limited number of successful UTx with livebirth and the majority was achieved with live donors. Wide clinical application is inherently limited by the lack of organs, ischemia/reperfusion injury (IRI) as well as immunosuppression after UTx. The objective of this comprehensive literature review is to discuss these arising limitations of UTx with main focus on strategies to reduce IRI. This review showed, that usage of immunosuppressants, opioids or supplements, like amino acids, protects uterus from IRI, improving rising level of antioxidants and decreasing level of oxidative stress markers. The available data of experimental and clinical studies was compiled and will be discussed.
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Affiliation(s)
- Viktorija Zitkute
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria; Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Mindaugas Kvietkauskas
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria; Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Bettina Leber
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | | | - Philipp Stiegler
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.
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21
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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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22
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Peters HE, Juffermans LJM, Lambalk CB, Dekker JJML, Fernhout T, Groenman FA, de Groot CJM, Hoksbergen AWJ, Huirne JAF, de Leeuw RA, van Mello NM, Nederhoed JH, Schats R, Verhoeven MO, Hehenkamp WJK. Feasibility study for performing uterus transplantation in the Netherlands. Hum Reprod Open 2020; 2020:hoz032. [PMID: 32128452 PMCID: PMC7048682 DOI: 10.1093/hropen/hoz032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/10/2019] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION Is it feasible to perform uterus transplantations (UTx) in a tertiary centre in the Netherlands? SUMMARY ANSWER Considering all ethical principles, surgical risks and financial aspects, we have concluded that at this time, it is not feasible to establish the UTx procedure at our hospital. WHAT IS KNOWN ALREADY UTx is a promising treatment for absolute uterine factor infertility. It is currently being investigated within several clinical trials worldwide and has resulted in the live birth of 19 children so far. Most UTx procedures are performed in women with the Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, a congenital disorder characterized by absence of the uterus. In the Netherlands, the only possible option for these women for having children is adoption or surrogacy. STUDY DESIGN SIZE DURATION We performed a feasibility study to search for ethical, medical and financial support for performing UTx at the Amsterdam UMC, location VUmc. PARTICIPANTS/MATERIALS SETTING METHODS For this feasibility study, we created a special interest group, including gynaecologists, transplant surgeons, researchers and a financial advisor. Also, in collaboration with the patients' association for women with MRKH, a questionnaire study was performed to research the decision-making in possible recipients. In this paper, we present an overview of current practices and literature on UTx and discuss the results of our feasibility study. MAIN RESULTS AND THE ROLE OF CHANCE A high level of interest from the possible recipients became apparent from our questionnaire amongst women with MRKH. The majority (64.8%) positively considered UTx with a live donor, with 69.6% having a potential donor available. However, this 'non-life-saving transplantation' requires careful balancing of risks and benefits. The UTx procedure includes two complex surgeries and unknown consequences for the unborn child. The costs for one UTx are calculated to be around €100 000 and will not be compensated by medical insurance. The Clinical Ethics Committee places great emphasis on the principle of non-maleficence and the 'fair distribution of health services'. LIMITATIONS REASONS FOR CAUTION In the Netherlands, alternatives for having children are available and future collaboration with experienced foreign clinics that offer the procedure is a possibility not yet investigated. WIDER IMPLICATIONS OF THE FINDINGS The final assessment of this feasibility study is that that there are not enough grounds to support this procedure at our hospital at this point in time. We will closely follow the developments and will re-evaluate the feasibility in the future. STUDY FUNDING/COMPETING INTERESTS This feasibility study was funded by the VU Medical Center (Innovation grant 2017). No conflicts of interest have been reported relevant to the subject of all authors. TRIAL REGISTRATION NUMBER n.a.
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Affiliation(s)
- H E Peters
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - L J M Juffermans
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - C B Lambalk
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J J M L Dekker
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - T Fernhout
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - F A Groenman
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - C J M de Groot
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - A W J Hoksbergen
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J A F Huirne
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - R A de Leeuw
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - N M van Mello
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J H Nederhoed
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - R Schats
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - M O Verhoeven
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - W J K Hehenkamp
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
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23
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Ramani A, Testa G, Ghouri Y, Koon EC, Di Salvo M, McKenna GJ, Bayer J, Marie Warren A, Wall A, Johannesson L. DUETS (Dallas UtErus Transplant Study): Complete report of 6-month and initial 2-year outcomes following open donor hysterectomy. Clin Transplant 2019; 34:e13757. [PMID: 31758566 DOI: 10.1111/ctr.13757] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/12/2019] [Accepted: 11/17/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Uterus transplantation has shown success in treating women with uterine factor infertility who want to carry their own pregnancy. METHODS We report the medical, sexual, and psychological outcomes of our first cohort of 13 living donor hysterectomies. As we have transitioned from open to robotically assisted hysterectomy, this report represents the complete series of open donor hysterectomies at our center, all with ≥6-month postoperative outcomes. RESULTS The open donor hysterectomy had a median of a 6.5-hour surgical time, 0.8 L estimated blood loss, 6-day hospital stay, and 28-day sick leave. Three donors had a grade III or IV complications, one reported new-onset psychological symptoms, and 9 experienced transient sexual discomfort. All complications were addressed and resolved, and all donors returned to their presurgical social and physical activities. CONCLUSION Since uterus transplantation is not life-saving or life-extending, the risks in living uterus donation must be weighed against the benefit of giving another woman the opportunity to give birth to her own child. This report provides data to support more detailed informed consent regarding the medical, psychological, and sexual complications of open living donor hysterectomy and allows for further evaluation of the ethical acceptability of this procedure.
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Affiliation(s)
- Azaan Ramani
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Yumna Ghouri
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Eric C Koon
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX, USA
| | - Marco Di Salvo
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Greg J McKenna
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Johanna Bayer
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Ann Marie Warren
- Division of Trauma, Acute Care, and Critical Care Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
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24
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Abstract
Absolute uterine factor infertility is the final hurdle for assisted reproductive treatments. Uterus transplant trials are happening worldwide; to advance the debate around uterine transplantation (UTx), this article considers selection criteria for clinical trials from a UK perspective and makes recommendations for future selection criteria for UTx treatment. Recommendations advanced include the use of donor eggs, access for single women and women in same-sex relationships, prohibiting participation of women who are already mothers, and a preference for deceased donors and bioengineered uteri. With UTx treatment on the horizon, it is important to proactively consider future selection criteria. TWEETABLE ABSTRACT: Review of UK selection criteria for clinical trials for uterus transplantation; recommendations for the future.
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25
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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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26
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The Key Role of Warm and Cold Ischemia in Uterus Transplantation: A Review. J Clin Med 2019; 8:jcm8060760. [PMID: 31146406 PMCID: PMC6616576 DOI: 10.3390/jcm8060760] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 05/20/2019] [Accepted: 05/22/2019] [Indexed: 01/29/2023] Open
Abstract
Introduction: Uterus transplantation (UTx) is a promising treatment for uterine infertility that has resulted in several births since 2014. Ischemia is a key step in organ transplantation because it may lead to changes jeopardizing graft viability. Method: We performed a systematic review of animal and human studies relating to uterine ischemia. Results: We retained 64 studies published since 2000. There were 35 studies in animals, 24 in humans, and five literature reviews. Modest preliminary results in large animals and humans are limited but encouraging. In small animals, pregnancies have been reported to occur after 24 h of cold ischemia (CI). In ewes, uterine contractions have been detected after 24 h of CI. Furthermore, it has been shown in animals that uterine tolerance to CI and to warm ischemia (WI) can be increased by pharmacological products. In women, mean CI time in studies of births from uteri obtained from live donors was between 2 h 47 min and 6 h 20 min from a deceased donor; with only one birth in this case. Muscle contractions have also been demonstrated in myometrial samples from women, after six or more hours of CI. Conclusion: The uterus seems to be able to tolerate a prolonged period of CI, of at least six hours. Studies of the ischemia tolerance of the uterus and ways to improve it are essential for the development of UTx, particularly for procedures using grafts from deceased donors.
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27
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Tardieu A, Chazelas P, Faye PA, Favreau F, Nadal-Desbarats L, Sallée C, Margueritte F, Couquet CY, Marquet P, Guellec CBL, Gauthier T. Changes in the metabolic composition of storage solution with prolonged cold ischemia of the uterus. J Assist Reprod Genet 2019; 36:1169-1178. [PMID: 31079269 DOI: 10.1007/s10815-019-01477-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/03/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The development of uterine transplantation (UTx) from deceased donors requires knowledge of the tolerance of the uterus to prolonged cold ischemia (CI). This can be evaluated through the use of biological parameters to assess degradation of the organ between its procurement and transplantation. The objective of this study was to analyze changes in the metabolic composition of the storage solution in cases of prolonged CI in uteri from ewes. METHODS Eighteen uterine auto-transplantations were performed in ewes. CI time was 1 h (T1) or 24 h (T24). Samples of Celsior® were taken when the explanted uterus was flushed (T0) and at the end of CI. A dual approach to metabolic analyses was followed: targeted biochemical analyses targeting several predefined metabolites and non-targeted metabolomics analyses based on nuclear magnetic resonance (NMR). RESULTS Metabolic analyses were performed on 16 explanted uteri. Metabolomic profiles differed significantly between T1 and T24 (p = 0.003). Hypoxia-associated degradation of the organ was demonstrated by the significantly higher lactate levels at T24 than at T1 (p < 0.05), accompanied by cell lysis, and significantly higher levels of creatine kinase activity in T24 than in T1 uteri (p < 0.05). Oxidative stress increased over time, with a significantly higher oxidized glutathione/glutathione ratio for T24 than for T1 uteri (p < 0.05). CONCLUSION The metabolic results indicate a significant degradation of the uterus during 24 h of CI. Metabolic analysis of the storage solution could be used as a non-invasive tool for evaluating uterine degradation during CI before transplantation.
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Affiliation(s)
- Antoine Tardieu
- INSERM, Inserm Unit U1248, 87000, Limoges, France. .,Department of Gynecologic and Obstetric, Hospital of Limoges, 87000, Limoges, France.
| | - P Chazelas
- Faculty of Medicine, EA 6309 "Maintenance Myélinique et Neuropathies Périphériques", University of Limoges, 87000, Limoges, France.,Laboratory of Biochemistry and Molecular genetics, Hospital of Limoges, 87000, Limoges, France
| | - P-A Faye
- Faculty of Medicine, EA 6309 "Maintenance Myélinique et Neuropathies Périphériques", University of Limoges, 87000, Limoges, France.,Laboratory of Biochemistry and Molecular genetics, Hospital of Limoges, 87000, Limoges, France
| | - F Favreau
- Faculty of Medicine, EA 6309 "Maintenance Myélinique et Neuropathies Périphériques", University of Limoges, 87000, Limoges, France.,Laboratory of Biochemistry and Molecular genetics, Hospital of Limoges, 87000, Limoges, France
| | | | - C Sallée
- Department of Gynecologic and Obstetric, Hospital of Limoges, 87000, Limoges, France
| | - F Margueritte
- Department of Gynecologic and Obstetric, Hospital of Limoges, 87000, Limoges, France
| | - C-Y Couquet
- Platform of Medicine, Imagery and experimental surgery (MICE), Hospital of Limoges, 87000, Limoges, France
| | - P Marquet
- INSERM, Inserm Unit U1248, 87000, Limoges, France
| | - C Barin-Le Guellec
- INSERM, Inserm Unit U1248, 87000, Limoges, France.,Faculty of Medicine, University of Tours, 37000, Tours, France
| | - T Gauthier
- INSERM, Inserm Unit U1248, 87000, Limoges, France.,Department of Gynecologic and Obstetric, Hospital of Limoges, 87000, Limoges, France
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Taneja A, Das S, Hussain SA, Madadin M, Lobo SW, Fatima H, Menezes RG. Uterine Transplant: A Risk to Life or a Chance for Life? SCIENCE AND ENGINEERING ETHICS 2019; 25:635-642. [PMID: 29423621 DOI: 10.1007/s11948-018-0018-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 01/09/2018] [Indexed: 06/08/2023]
Abstract
Being inherently different from any other lifesaving organ transplant, uterine transplantation does not aim at saving lives but supporting the possibility to generate life. Unlike the kidneys or the liver, the uterus is not specifically a vital organ. Given the non-lifesaving nature of this procedure, questions have been raised about its feasibility. The ethical dilemma revolves around whether it is worth placing two lives at risk related to surgery and immunosuppression, amongst others, to enable a woman with absolute uterine factor infertility to experience the presence of an organ enabling childbirth. In the year 2000, the first uterine transplantation, albeit unsuccessful, was performed in Saudi Arabia from where it has spread to the rest of the world including Sweden, the United States and now recently India. The procedure is, however, still in the preclinical stages and several ethical, legal, social and religious concerns are yet to be addressed before it can be integrated into the clinical setting as standard of care for women with absolute uterine factor infertility.
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Affiliation(s)
| | - Siddhartha Das
- Department of Forensic Medicine and Toxicology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Syed Ather Hussain
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Mohammed Madadin
- Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | | | - Huda Fatima
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Ritesh G Menezes
- Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
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First Healthy Baby After Deceased Donor Uterus Transplantation: Birth to a New Era? Transplantation 2019; 103:652-653. [PMID: 30907853 DOI: 10.1097/tp.0000000000002627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dion L, Tardieu A, Garbin O, Ayoubi JM, Agostini A, Collinet P, Yves A, Pascal P, Tristan G, Lavoué V. Should brain-dead or living donors be used for uterus transplantation? A statement by the CNGOF French Uterus Transplantation Committee (CETUF). J Gynecol Obstet Hum Reprod 2019; 48:9-10. [DOI: 10.1016/j.jogoh.2018.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 01/20/2023]
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Lavoué V, Dion L, Tardieu A, Garbin O, Ayoubi JM, Agostini A, Collinet P, Piver P, Aubard Y, Gauthier T. Organizing a uterus transplantation programme: The designation of Uterus Transplantation Centres in France. J Gynecol Obstet Hum Reprod 2019; 48:15-18. [DOI: 10.1016/j.jogoh.2018.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 01/18/2023]
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Wall A, Testa G. Living Donation, Listing, and Prioritization in Uterus Transplantation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:20-22. [PMID: 30040574 DOI: 10.1080/15265161.2018.1478026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Bruno B, Arora KS. Uterus Transplantation: The Ethics of Using Deceased Versus Living Donors. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:6-15. [PMID: 30040550 PMCID: PMC6296249 DOI: 10.1080/15265161.2018.1478018] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Research teams have made considerable progress in treating absolute uterine factor infertility through uterus transplantation, though studies have differed on the choice of either deceased or living donors. While researchers continue to analyze the medical feasibility of both approaches, little attention has been paid to the ethics of using deceased versus living donors as well as the protections that must be in place for each. Both types of uterus donation also pose unique regulatory challenges, including how to allocate donated organs; whether the donor / donor's family has any rights to the uterus and resulting child; how to manage contact between the donor / donor's family, recipient, and resulting child; and how to track outcomes moving forward.
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Affiliation(s)
- Bethany Bruno
- a Cleveland Clinic Lerner College of Medicine, Case Western Reserve University
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Abstract
PURPOSE OF REVIEW As the techniques of uterus transplantation have evolved, culminating in a birth in 2014, the ethical debate has been enriched by several considerations. Uterus transplantation raises issues because of its unique features of being temporary, nonlifesaving, experimental, and expensive, with established alternatives. RECENT FINDINGS Uterus transplantation entails risks for the recipient related to multiple surgeries and immunosuppression, yet studies have shown that women see infertility as a distressing element in their lives, justifying the risks. The alternative of surrogacy has its own ethical issues, and adoption does not provide for genetic progeny. Although patient decisions are susceptible to inconsistent reasoning, misconception of risks or wishful thinking, a carefully drafted and clearly explained informed consent can represent a valid ethical response in balancing risks and benefits. There is no evidence of increased risks for children born from uterus transplant. For living donors, the risks of hysterectomy are known and can be explained to facilitate proper informed consent. Allocation of deceased donor organs needs to be determined, as guidelines for other organs cannot readily be applied. Cost is an issue, as the procedure is expensive and not covered by insurance. SUMMARY In this rapidly advancing field, a strong ethical foundation is needed to guide regulations and legislation.
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Flyckt R, Davis A, Farrell R, Zimberg S, Tzakis A, Falcone T. Uterine Transplantation: Surgical Innovation in the Treatment of Uterine Factor Infertility. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:86-93. [DOI: 10.1016/j.jogc.2017.06.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 06/07/2017] [Indexed: 12/11/2022]
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