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Brännström M, Adashi EY, Wu JH, Tsiartas P, Racowsky C. Uterus Transplantation: the Translational Evolution of a Clinical Breakthrough. Physiology (Bethesda) 2024; 39:0. [PMID: 38954427 DOI: 10.1152/physiol.00011.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 07/01/2024] [Accepted: 07/01/2024] [Indexed: 07/04/2024] Open
Abstract
Women suffering from absolute uterine factor infertility (AUFI), due to either lack of a uterus or one unable to sustain neonatal viability, presented as one of the last frontiers in conquering infertility. Following systematic animal research for over a decade, uterus transplantation was tested as a treatment for AUFI in 2012, which culminated in the first human live birth in 2014. The development of uterus transplantation from mouse to human has followed both the Moore criteria for introduction of a surgical innovation and the IDEAL concept for evaluation of a novel major surgical procedure. In this article we review the important preclinical animal and human studies that paved the way for the successful introduction of human uterus transplantation a decade ago. We discuss this in the context of the Moore criteria and describe the different procedures of preparation, surgeries, postoperative monitoring, and use of assisted reproduction in human uterus transplantation. We review the worldwide activities and associated results in the context of the IDEAL concept for evaluation of surgical innovation and appraise the ethical considerations relevant to uterus transplantation. We conclude that rigorous application of the Moore criteria and strict alignment with the IDEAL concept have resulted in the establishment of uterus transplantation as a novel, safe, and effective infertility therapy that is now being used worldwide for the treatment of women suffering from AUFI.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Stockholm IVF-EUGIN, Stockholm, Sweden
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
| | - Eli Y Adashi
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States
| | - Joseph H Wu
- Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Panagiotis Tsiartas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Obstetrics and Gynecology, Karolinska Institute, Stockholm, Sweden
- Nordic IVF-EUGIN, Solna, Sweden
| | - Catherine Racowsky
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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Broecker V, Toulza F, Brännström M, Ernst A, Roufosse C, Carbonnel M, Alkattan Z, Mölne J. Transcript analysis of uterus transplant cervical biopsies using the Banff Human Organ Transplant panel. Am J Transplant 2024:S1600-6135(24)00536-7. [PMID: 39216690 DOI: 10.1016/j.ajt.2024.08.027] [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: 04/17/2024] [Revised: 08/10/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024]
Abstract
Uterus transplantation is being more widely implemented in clinical practice. Monitoring of rejection is routinely done for cervical biopsies and is dependent on histopathological assessment, as rejections are clinically silent and nonhistological biomarkers are missing. Until this gap is filled, it is important to corroborate the histopathological diagnosis of rejection through independent methods such as gene expression analysis. In this study, we compared our previously published scoring system for grading rejection in uterus transplant cervical biopsies to the gene expression profile in the same biopsy. For this, we used the Banff Human Organ Transplant gene panel to analyze the expression of 788 genes in 75 paraffin-embedded transplant cervical biopsies with a spectrum of histologic findings, as well as in 24 cervical biopsies from healthy controls. We found that gene expression in borderline changes did not differ from normal transplants, whereas the genes with increased expression in mild rejections overlapped with previously published rejection-associated transcripts. Moderate/severe rejection samples showed a gene expression pattern characterized by a mixture of rejection-associated and tissue injury-associated genes and a decrease in epithelial transcripts. In summary, our findings support our proposed scoring system for rejection but argue against the treatment of borderline changes.
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Affiliation(s)
- Verena Broecker
- Department of Clinical Pathology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Frederic Toulza
- Department of Immunology and Inflammation, Imperial College, Centre for Inflammatory Disease, London, United Kingdom
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - Angela Ernst
- Institute of Medical Statistics and Computational Biology, University Hospital of Cologne, Germany; Institute for AI and Informatics in Medicine, Technical University of Munich, Germany
| | - Candice Roufosse
- Department of Immunology and Inflammation, Imperial College, Centre for Inflammatory Disease, London, United Kingdom
| | - Marie Carbonnel
- Department of Obstetrics and Gynecology, Foch Hospital, University of Versailles-Saint-Quentin-en-Yvelines Paris Saclay, Suresnes, France
| | - Zeinab Alkattan
- Department of Obstetrics and Gynecology, Halland Hospital, Varberg, Region Halland, Sweden
| | - Johan Mölne
- Department of Clinical Pathology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Institute of Biomedicine, Department of Laboratory Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
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Johannesson L, Wood-Trageser MA, Lesniak D, Punar M, Klingman L, Naziruddin B, Askar M, Demetris AJ, Testa G. Unique Lessons From the Natural Progression of Rejection in Human Uterine Allografts. Clin Transplant 2024; 38:e15434. [PMID: 39166465 DOI: 10.1111/ctr.15434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 08/06/2024] [Accepted: 08/07/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION Uterus transplantation (UTx) is a novel treatment for absolute uterine infertility. Acute T cell-mediated rejection (TCMR) can be monitored only through serial cervical biopsies. METHODS This study, the first of its kind in human transplantation, evaluated clinical, serological, and pathophysiological manifestations of allograft rejection from immunosuppression withdrawal (ISW) to graft hysterectomy (Hx). RESULTS Following live birth, immunosuppression was abruptly withdrawn from six living-donor UTx recipients. ISW occurred at a median of 7.4 weeks before graft Hx. Post-ISW signs of rejection included: (1) discoloration of the cervix; (2) increased uterine size compared to day of ISW; (3) serological evidence of eosinophilia and progressive development of donor-specific antibodies (DSA) or child-specific antibodies (CSA); (4) histopathological evidence of TCMR in cervical biopsies preceding the development of antibodies in serum; and (5) C4d deposition in tissue before formation of DSA or CSA in all but two recipients. At graft Hx, endometrial glands were preferentially targeted for destruction over stroma while parametrial arteries displayed variable arteritis and fibrointimal hyperplasia. CONCLUSION Recognition of the progression of uterine allograft rejection may be important for other human organ recipients and drive research on modulation of immunosuppression and the paradoxical relationship between adaptive cellular and humoral immunity in natural pregnancies. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02656550.
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Affiliation(s)
- Liza Johannesson
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Michelle A Wood-Trageser
- Department of Pathology, Division of Hepatic and Transplantation Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Drew Lesniak
- Department of Pathology, Division of Hepatic and Transplantation Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Metin Punar
- Department of Pathology, Baylor University Medical Center, Dallas, Texas, USA
| | - Lynne Klingman
- Transplant Immunology Laboratory, Baylor University Medical Center, Dallas, Texas, USA
| | - Bashoo Naziruddin
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Medhat Askar
- Department of Pathology, Baylor University Medical Center, Dallas, Texas, USA
- College of Medicine & Qatar University Health, Qatar University, Doha, Qatar
| | - Anthony J Demetris
- Department of Pathology, Division of Hepatic and Transplantation Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Giuliano Testa
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
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Carbonnel M, Petit M, Tarantino N, Morin V, Corneau A, Tourne M, Gueguan J, Mölne J, Akouri R, Broecker V, Vinit A, Racowsky C, Brännström M, Ayoubi JM, Vieillard V. Analysis of Immunological Biomarkers Associated With Rejection After Uterus Transplantation in Human. Transplantation 2024:00007890-990000000-00821. [PMID: 39020469 DOI: 10.1097/tp.0000000000005126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
BACKGROUND Uterus transplantation (UTx) is an emerging therapy for women with uterine infertility. However, critical questions remain with this procedure including the mechanisms involved in graft rejection. METHODS In this study, we analyzed the immune profile of ectocervical biopsies from 5 patients after UTx before and during their first episode of rejection using RNA sequencing, quantitative polymerase chain reaction, and imaging mass cytometry. RESULTS We identified 530 upregulated and 207 downregulated genes associated with graft rejection. Enrichment databases revealed abnormalities of skin-associated genes and the immune system, in particular activation of T and B lymphocytes, and macrophages. Imaging mass cytometry confirmed these observations; in cervical biopsies of 3 women, rejection was associated with the presence of B-cell structures linked to tertiary lymphoid structures, and 2 biopsies from 1 woman with severe rejection episodes and poor prognosis of graft function (repeated miscarriage and implantation failures) were associated with an accumulation of HLA-DR- macrophages, producing granzyme B at the surface of the epithelium. CONCLUSIONS We showed that rejection of a UTx graft was associated with major alterations of immune markers including the involvement of tertiary lymphoid structures, the most organized of which may be a sign of chronic rejection, and with an increase in HLA-DR- macrophages expressing granzyme B in the case of grade 3 rejection episodes according Mölne's classification. We identified potential emerging biomarkers to predict or diagnose graft rejection (Keratin 1 granzyme B, IL1β). These findings could lead to development of improved strategies for the identification, prevention, and/or treatment of uterus graft rejection.
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Affiliation(s)
- Marie Carbonnel
- Department of Obstetrics and Gynecology, Foch Hospital, Suresnes, France
- University of Versailles-Saint-Quentin-en-Yvelines, Montigny-Le-Bretonneux, France
- Sorbonne Université, Inserm U1135, CNRS EMR 8255, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Maxime Petit
- Pitié-Salpétrière Cytometry Platform (CyPS), UMS037-PASS, Sorbonne Université-Faculté de Médecine, Paris, France
| | - Nadine Tarantino
- Sorbonne Université, Inserm U1135, CNRS EMR 8255, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Veronique Morin
- Sorbonne Université, Inserm U1135, CNRS EMR 8255, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
| | - Aurélien Corneau
- Pitié-Salpétrière Cytometry Platform (CyPS), UMS037-PASS, Sorbonne Université-Faculté de Médecine, Paris, France
| | - Morgan Tourne
- Department of Pathology, Foch Hospital, Suresnes, France
| | - Justine Gueguan
- Institut du Cerveau, Bioinformatics/Biostatistics iCONICS Facility, Sorbonne Université, INSERM, Paris, France
| | - Johann Mölne
- Department of Laboratory Medicine, Sahlgrenska Academy, Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden
| | - Randa Akouri
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg; Göteborg, Sweden
| | - Verena Broecker
- Department of Laboratory Medicine, Sahlgrenska Academy, Institute of Biomedicine, University of Gothenburg, Göteborg, Sweden
| | - Angélique Vinit
- Pitié-Salpétrière Cytometry Platform (CyPS), UMS037-PASS, Sorbonne Université-Faculté de Médecine, Paris, France
| | - Catherine Racowsky
- Department of Obstetrics and Gynecology, Foch Hospital, Suresnes, France
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg; Göteborg, Sweden
- Stockholm IVF-EUGIN, Stockholm, Sweden
| | - Jean-Marc Ayoubi
- Department of Obstetrics and Gynecology, Foch Hospital, Suresnes, France
- University of Versailles-Saint-Quentin-en-Yvelines, Montigny-Le-Bretonneux, France
| | - Vincent Vieillard
- Sorbonne Université, Inserm U1135, CNRS EMR 8255, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
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Jones BP, Vali S, Saso S, Devaney A, Bracewell-Milnes T, Nicopoullos J, Thum MY, Kaur B, Roufosse C, Stewart V, Bharwani N, Ogbemudia A, Barnardo M, Dimitrov P, Klucniks A, Katz R, Johannesson L, Diaz Garcia C, Udupa V, Friend P, Quiroga I, Smith JR. Living donor uterus transplant in the UK: A case report. BJOG 2024; 131:372-377. [PMID: 37607687 DOI: 10.1111/1471-0528.17639] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 08/24/2023]
Affiliation(s)
- Benjamin P Jones
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Saaliha Vali
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Cutrale Perioperative and Ageing Group, Sir Michael Uren Hub, Imperial College London, London, UK
| | - Srdjan Saso
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Andrea Devaney
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Timothy Bracewell-Milnes
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Lister Fertility Clinic, The Lister Hospital, London, UK
| | - James Nicopoullos
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Lister Fertility Clinic, The Lister Hospital, London, UK
| | - Meen-Yau Thum
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Lister Fertility Clinic, The Lister Hospital, London, UK
| | - Baljeet Kaur
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- North West London Pathology, Charing Cross Hospital, Imperial College NHS Trust, London, UK
| | - Candice Roufosse
- North West London Pathology, Charing Cross Hospital, Imperial College NHS Trust, London, UK
- Centre for Inflammatory Disease, Department Immunology and Inflammation, Faculty of Medicine, Imperial College London, London, UK
| | - Victoria Stewart
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - Nishat Bharwani
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Division of Surgery and Cancer, Imperial College London, London, UK
| | - Ann Ogbemudia
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Martin Barnardo
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Peter Dimitrov
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Andris Klucniks
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Richard Katz
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | - Cesar Diaz Garcia
- IVI London, IVIRMA Global, London, UK
- EGA Institute for Women's Health, University College London, London, UK
| | - Venkatesha Udupa
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Peter Friend
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Isabel Quiroga
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - J Richard Smith
- West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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Järvholm S, Kättström A, Kvarnström N, Dahm-Kähler P, Brännström M. Long-term health-related quality-of-life and psychosocial outcomes after uterus transplantation: a 5-year follow-up of donors and recipients. Hum Reprod 2024; 39:374-381. [PMID: 37995381 PMCID: PMC10833084 DOI: 10.1093/humrep/dead245] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/29/2023] [Indexed: 11/25/2023] Open
Abstract
STUDY QUESTION What are the outcomes regarding health-related quality-of-life, mood, and marital relationship of recipients and donors 5 years after uterus transplantation (UTx) and uterus donation? SUMMARY ANSWER Both recipients and donors generally demonstrated long-term stability regarding psychosocial outcomes but with negative deviations associated with unsuccessful outcomes. WHAT IS KNOWN ALREADY UTx is the first infertility treatment for women with absolute uterine factor infertility. The procedure can be performed with either a uterus donation from a live donor (LD), typically a close relative, or from a deceased, multi-organ donor. There are many potential stressful events over several years after UTx both for recipients and for LDs and these events may have impacts on quality-of-life and mental well-being. STUDY DESIGN, SIZE, DURATION This, prospective observational cohort study includes the nine recipients and LDs of the first human UTx trial. They were assessed in 2017-2018 by questionnaires 5 years after UTx. PARTICIPANTS/MATERIALS, SETTING, METHODS The nine recipients (ages 32-43 years) and their respective LDs (ages 44-67 years) were either related (n = 8) or friends (n = 1). Eight recipients had congenital uterine absence and one was hysterectomized due to cervical cancer. For two recipients, UTx resulted in early graft failures, while six of the other seven recipients gave birth to a total of eight babies over the following 5 years. Physical and mental component summaries of health-related quality-of-life were measured with the SF-36 questionnaire. Mood was assessed by the Hospital Anxiety and Depression Scale. Relationship with partner was measured with the Dyadic Adjustment Scale. Comparisons were made between the values after 5 years and the values before uterus donation/transplantation. MAIN RESULTS AND THE ROLE OF CHANCE Five years after primary UTx, the majority of recipients scored above the predicted value of the general population on quality-of-life, except for two women, one of whom had a viable graft but no live birth and one recipient who was strained by quality-of-life changes, possibly related to parenthood transitions. Regarding mood, only one value (anxiety) was above the threshold for further clinical assessment. Recipients showed declining satisfaction with their marital relationships, but all reported scores above the 'at risk for divorce' threshold at the time of the final assessment in our study. The LDs were all found to be stable and above the predicted value of the general population regarding mental components of quality-of-life. Three LDs showed declined physical components, possibly related to older age. Only one LD reported a value in mood (anxiety) that would need further assessment. The marital satisfaction of LDs remained stable and unchanged compared to baseline values. Notably, the two recipients with early graft failures, and their related LDs, regained their mental well-being during the first years after graft failure and remained stable after 5 years. LIMITATIONS, REASONS FOR CAUTION The restricted sample size and the single-centre study-design are limitations of this study. Additionally the study was limited to LD UTx, as opposed to deceased donor UTx. WIDER IMPLICATIONS OF THE FINDINGS Our study shows that both LDs and recipients had acceptable or favourable quality-of-life outcomes, including mood assessment, at the 5-year follow-up mark, and that failure to achieve a live birth negatively affected these modalities both for LDs and recipients. Moreover, an important finding was that LDs and recipients are not reacting with depression after hysterectomy, which is common after hysterectomy in the general population. STUDY FUNDING/COMPETING INTEREST(S) Funding was provided by the Jane and Dan Olsson Foundation for Science, Knut and Alice Wallenberg Foundation, Handlanden Hjalmar Svensson Foundation, Swedish Governmental ALF Grant, and Swedish Research Council. There are no conflicts of interest to disclose. TRIAL REGISTRATION NUMBER NCT01844362.
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Affiliation(s)
- Stina Järvholm
- Department of Obstetrics & Gynecology, Institue of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Alva Kättström
- Department of Obstetrics & Gynecology, Institue of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Niclas Kvarnström
- Transplantation, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics & Gynecology, Institue of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Mats Brännström
- Department of Obstetrics & Gynecology, Institue of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
- Stockholm IVF-EUGIN, Stockholm, Sweden
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Tian S, Han Y, Wei Q, Liu M, Zhang J, Wang Y. Endometrium procurement and transplantation restores fertility in rats. Reprod Biomed Online 2024; 48:103370. [PMID: 38096630 DOI: 10.1016/j.rbmo.2023.103370] [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: 06/03/2023] [Revised: 08/09/2023] [Accepted: 08/23/2023] [Indexed: 02/12/2024]
Abstract
RESEARCH QUESTION Can rat endometrium be successfully procured and transplanted, and can a similar method be used to procure human endometrium? DESIGN Rat endometrium was procured using an endometrium stripping method and transplanted into female Sprague-Dawley rats. Macroscopic and histological changes, endometrial receptivity-related protein concentrations and fertility were assessed. Additionally, a preliminary experiment was conducted to procure human endometrium using a similar method. RESULTS Endometrium was successfully procured from both rats and humans, which contained intact endometrium and parts of the adjacent inner annulus myometrium. Endometrium auto-transplantation was conducted in rats and the procedure lasted a total of 41.3 ± 5.7 min with a mean blood loss of 0.09 ± 0.04 g. The transplanted endometrium survived well, but a fibrotic zone formed between the transplant and recipient tissue. Compared with sham rats, those with endometrium transplantation had similar endometrial thickness and endometrial gland numbers but reduced vascular density at 8 weeks after surgery. Endometrium transplantation also retained expression of the endometrial receptivity-related proteins leukaemia inhibitory factor and vascular endothelial growth factor. In contrast to non-pregnancy in the stripped horn, a mean of 5.0 ± 2.7 fetuses developed in the transplanted horn, and full-term live fetuses were conceived in the horns with transplanted endometrium. CONCLUSIONS Endometrium procurement by stripping method can obtain an intact and functional endometrium, and endometrium transplantation can reconstruct the uterine cavity and restore fertility in rats.
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Affiliation(s)
- Shiyu Tian
- Center for Reproductive Medicine, Department of Gynaecology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yongshu Han
- Center for Reproductive Medicine, Department of Gynaecology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Qianqian Wei
- Center for Reproductive Medicine, Department of Gynaecology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Miaomiao Liu
- Center for Reproductive Medicine, Department of Gynaecology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Jing Zhang
- Center for Reproductive Medicine, Department of Obstetrics, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China.
| | - Yanpeng Wang
- Center for Reproductive Medicine, Department of Gynaecology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China.
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8
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Dube R, Kar SS, Jhancy M, George BT. Molecular Basis of Müllerian Agenesis Causing Congenital Uterine Factor Infertility-A Systematic Review. Int J Mol Sci 2023; 25:120. [PMID: 38203291 PMCID: PMC10778982 DOI: 10.3390/ijms25010120] [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: 10/17/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Infertility affects around 1 in 5 couples in the world. Congenital absence of the uterus results in absolute infertility in females. Müllerian agenesis is the nondevelopment of the uterus. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a condition of uterovaginal agenesis in the presence of normal ovaries and the 46 XX Karyotype. With advancements in reproductive techniques, women with MA having biological offspring is possible. The exact etiology of MA is unknown, although several genes and mechanisms affect the development of Müllerian ducts. Through this systematic review of the available literature, we searched for the genetic basis of MA. The aims included identification of the genes, chromosomal locations, changes responsible for MA, and fertility options, in order to offer proper management and counseling to these women with MA. A total of 85 studies were identified through searches. Most of the studies identified multiple genes at various locations, although the commonest involved chromosomes 1, 17, and 22. There is also conflicting evidence of the involvement of various candidate genes in the studies. The etiology of MA seems to be multifactorial and complex, involving multiple genes and mechanisms including various mutations and mosaicism.
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Affiliation(s)
- Rajani Dube
- Department of Obstetrics and Gynaecology, RAK College of Medical Sciences, RAK Medical & Health Sciences University, Ras al Khaimah P.O. Box 11172, United Arab Emirates
| | - Subhranshu Sekhar Kar
- Department of Paediatrics and Neonatology, RAK College of Medical Sciences, RAK Medical & Health Sciences University, Ras al Khaimah P.O. Box 11172, United Arab Emirates; (S.S.K.); (M.J.)
| | - Malay Jhancy
- Department of Paediatrics and Neonatology, RAK College of Medical Sciences, RAK Medical & Health Sciences University, Ras al Khaimah P.O. Box 11172, United Arab Emirates; (S.S.K.); (M.J.)
| | - Biji Thomas George
- Department of General Surgery, RAK College of Medical Sciences, RAK Medical & Health Sciences University, Ras al Khaimah P.O. Box 11172, United Arab Emirates;
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Janota J, Orlova E, Novackova M, Chmel R, Brabec R, Pastor Z, Chmel R. Three-year follow-up results of two children born from a transplanted uterus. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:370-375. [PMID: 37901926 DOI: 10.5507/bp.2023.042] [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: 08/03/2023] [Accepted: 10/17/2023] [Indexed: 10/31/2023] Open
Abstract
AIMS To evaluate the 3-year follow-up results of two children delivered at our institution in 2019 from mothers with a transplanted uterus. METHODS Observational data on pregnancy outcomes, neonatal course, and growth trajectory in two children born to mothers after uterus transplantation, including 3-year follow-up and neurodevelopmental status assessed using the Bayley Scales of Infant and Toddler Development, third edition (Bayley-III). RESULTS Both children were born prematurely via uneventful caesarean sections, to mothers with Mayer-Rokitansky-Küster-Hauser syndrome and a transplanted uterus. An acute caesarean section was performed in one mother because of the onset of regular uterine contractions at 34 weeks and 6 days of pregnancy; in the other mother, an elective caesarean section was performed at 36 weeks and 2 days of gestation. The children were born healthy with no congenital malformations. They had an uneventful postnatal course and showed a normal growth trajectory during 3 years of follow-up. The Bayley-III neurodevelopmental scores of both children were within the normal ranges at ages 2 and 3 years. CONCLUSION Though pregnancy after uterus transplantation is associated with the risk of premature delivery, no abnormalities were observed in the neonatal course and 3-year follow-up results, including the neurodevelopmental status, of two children born prematurely to mothers with a transplanted uterus. This is the first report on neurodevelopmental outcomes in children born after uterus transplantation. More data on children born after this radical procedure of uterine factor infertility treatment are required to support our promising results.
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Affiliation(s)
- Jan Janota
- Department of Neonatology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Ekaterina Orlova
- Department of Neonatology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Marta Novackova
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Roman Chmel
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
- Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Radim Brabec
- Department of Neonatology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Zlatko Pastor
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Roman Chmel
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
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10
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Broecker V, Brännström M, Bösmüller H, Sticová E, Malušková J, Chiesa-Vottero A, Mölne J. Reproducibility of Rejection Grading in Uterus Transplantation: A Multicenter Study. Transplant Direct 2023; 9:e1535. [PMID: 37745947 PMCID: PMC10513355 DOI: 10.1097/txd.0000000000001535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/27/2023] [Accepted: 08/09/2023] [Indexed: 09/26/2023] Open
Abstract
Background Diagnosis of rejection after uterus transplantation is based on histopathological examination of ectocervical biopsies. Inflammation at the stromal-epithelial interface is the backbone of the histopathological classification proposed by our group in 2017. However, the reproducibility of this grading scheme has not been tested, and it is unclear whether it covers the full morphological spectrum of rejection. Methods We present a multicenter study in which 5 pathologists from 4 uterus transplantation centers performed 2 rounds of grading on 145 and 48 cervical biopsies, respectively. Three of the centers provided biopsies. Additionally, the presence of perivascular stromal inflammation was recorded. During discussions after the first round, further histological lesions (venous endothelial inflammation and apoptosis) were identified for closer evaluation and added to the panel of lesions to score in the second round. All participants completed a questionnaire to explore current practices in handling and reporting uterus transplant biopsies. Results Cervical biopsies were commonly performed in all centers to monitor rejection. Intraobserver reproducibility of rejection grading (performed by 1 rater) was excellent, whereas interobserver reproducibility was moderate and did not improve in the second round. Reproducibility of perivascular stromal inflammation was moderate but unsatisfactory for venous endothelial inflammation and apoptosis. All lesions were more frequent in, but not restricted to, biopsies with rejection patterns. Conclusions Grading of rejection in cervical biopsies is reproducible and applicable to biopsies from different centers. Diagnosis of rejection may be improved by adding further histological lesions to the grading system; however, lesions require rigorous consensus definition.
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Affiliation(s)
- Verena Broecker
- Department of Clinical Pathology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Bösmüller
- Institute of Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Eva Sticová
- Clinical and Transplant Pathology Department, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | - Jana Malušková
- Clinical and Transplant Pathology Department, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czech Republic
| | | | - Johan Mölne
- Department of Clinical Pathology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Sweden
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11
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Brännström M, Racowsky C, Carbonnel M, Wu J, Gargiulo A, Adashi EY, Ayoubi JM. Uterus transplantation: from research, through human trials and into the future. Hum Reprod Update 2023; 29:521-544. [PMID: 37328434 PMCID: PMC10477946 DOI: 10.1093/humupd/dmad012] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/29/2023] [Indexed: 06/18/2023] Open
Abstract
Women suffering from absolute uterine factor infertility (AUFI) had no hope of childbearing until clinical feasibility of uterus transplantation (UTx) was documented in 2014 with the birth of a healthy baby. This landmark accomplishment followed extensive foundational work with a wide range of animal species including higher primates. In the present review, we provide a summary of the animal research and describe the results of cases and clinical trials on UTx. Surgical advances for graft removal from live donors and transplantation to recipients are improving, with a recent trend away from laparotomy to robotic approaches, although challenges persist regarding optimum immunosuppressive therapies and tests for graft rejection. Because UTx does not involve transplantation of the Fallopian tubes, IVF is required as part of the UTx process. We provide a unique focus on the intersection between these two processes, with consideration of when oocyte retrieval should be performed, whether, and for whom, preimplantation genetic testing for aneuploidy should be used, whether oocytes or embryos should be frozen and when the first embryo transfer should be performed post-UTx. We also address the utility of an international society UTx (ISUTx) registry for assessing overall UTx success rates, complications, and live births. The long-term health outcomes of all parties involved-the uterus donor (if live donor), the recipient, her partner and any children born from the transplanted graft-are also reviewed. Unlike traditional solid organ transplantation procedures, UTx is not lifesaving, but is life-giving, although as with traditional types of transplantation, costs, and ethical considerations are inevitable. We discuss the likelihood that costs will decrease as efficiency and efficacy improve, and that ethical complexities for and against acceptability of the procedure sharpen the distinctions between genetic, gestational, and social parenthood. As more programs wish to offer the procedure, we suggest a scheme for setting up a UTx program as well as future directions of this rapidly evolving field. In our 2010 review, we described the future of clinical UTx based on development of the procedure in animal models. This Grand Theme Review offers a closing loop to this previous review of more than a decade ago. The clinical feasibility of UTx has now been proved. Advancements include widening the criteria for acceptance of donors and recipients, improving surgery, shortening time to pregnancy, and improving post-UTx management. Together, these improvements catalyze the transition of UTx from experimental into mainstream clinical practice. The procedure will then represent a realistic and accessible alternative to gestational surrogacy for the treatment of AUFI and should become part of the armamentarium of reproductive specialists worldwide.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Stockholm IVF-EUGIN, Stockholm, Sweden
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
| | - Catherine Racowsky
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Marie Carbonnel
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- University Versailles, Saint-Quentin en Yvelines, France
| | - Joseph Wu
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Antonio Gargiulo
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Eli Y Adashi
- Department of Medical Science, Brown University, Providence, RI, USA
| | - Jean Marc Ayoubi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch, Suresnes, France
- University Versailles, Saint-Quentin en Yvelines, France
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12
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Mendilcioglu I, Dogan NU, Ozkan O, Bahceci M, Boynukalin K, Dogan S, Ozkan O. Pregnancy management and outcome after uterus transplantation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:328-335. [PMID: 36468688 DOI: 10.1002/uog.26134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 10/30/2022] [Accepted: 11/18/2022] [Indexed: 06/17/2023]
Abstract
Uterus transplantation is a novel approach in women whose uterus is absent or severely abnormal. However, it is still an experimental procedure that poses risks to both mother and baby. To date, 32 live births after uterus transplantation have been reported in peer-reviewed journals, with several maternal, fetal and neonatal complications. The most common complications were preterm delivery, hypertensive disorders and placenta previa. Four patients experienced episodes of transplant rejection during pregnancy. The appropriate management of complicated and non-complicated pregnancies following uterus transplantation is still unresolved. In this review, obstetric outcomes after uterus transplantation and optimal management during pregnancy are discussed in light of the available data. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- I Mendilcioglu
- Department of Obstetrics and Gynecology, Akdeniz University, Antalya, Turkey
| | - N U Dogan
- Department of Obstetrics and Gynecology, Akdeniz University, Antalya, Turkey
| | - O Ozkan
- Department of Plastic and Reconstructive Surgery, Akdeniz University, Antalya, Turkey
| | - M Bahceci
- Bahçeci IVF Center, Istanbul, Turkey
| | | | - S Dogan
- Department of Obstetrics and Gynecology, Akdeniz University, Antalya, Turkey
| | - O Ozkan
- Department of Plastic and Reconstructive Surgery, Akdeniz University, Antalya, Turkey
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13
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Houeis L, Dolmans MM. Summary of the ISFP congress, Brussels, 10-12 November, 2022. J Assist Reprod Genet 2023; 40:433-442. [PMID: 36765026 PMCID: PMC10033808 DOI: 10.1007/s10815-023-02720-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 02/12/2023] Open
Abstract
The 7th International Congress of the ISFP was held in Brussels in November 2022. Hundreds of attendees from all over the world had the rare opportunity to hear the most distinguished leaders discuss and debate the latest advances in the field. Participants were also able to attend workshops under the guidance of skilled practitioners. Numerous topics were considered, including a recap on fertility preservation approaches in cancer and benign pathologies and a section on male factor infertility. Other aspects covered were in vitro maturation and poor responders, the impact of chemotherapy on the ovary, and future perspectives. Participants had the chance to listen to a symposium on fertility preservation techniques, and finally, a keynote lecture on fertility preservation in gynecological cancers brought this prominent and highly influential event to a close.
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Affiliation(s)
- Lara Houeis
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.
- Department of Gynecology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
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14
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D'Amico G, Del Prete L, Eghtesad B, Hashimoto K, Miller C, Tzakis A, Quintini C, Falcone T. Immunosuppression in uterus transplantation: from transplant to delivery. Expert Opin Pharmacother 2023; 24:29-35. [PMID: 35723045 DOI: 10.1080/14656566.2022.2090243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Uterus transplantation introduces unique challenges regarding immunosuppression, including the effects of immunosuppressive drugs on the fetus and graft rejection during pregnancy. Although immunosuppressive regimens are based on protocols used after solid organ transplantation, in recipients of uterus grafts, the physician must consider therapy modifications based on the phase of the transplant, from the intra-operative period through to delivery. AREAS COVERED This review discusses the current immunosuppressive rationale in uterus transplantation, focusing on the therapy in each phase of the transplant. The authors present an overview of the already approved immunosuppressive medications for solid organ transplantation, their application in uterus transplant prior to pregnancy, during pregnancy and as rejection treatment. EXPERT OPINION Most medications used for uterus transplant are adopted from solid organ transplantation experience, especially kidney transplantation, and rejection is treated in standard fashion. Research is needed to clarify the drugs' effects on fetal and neonatal well-being and to develop new medications to achieve better tolerance. Early markers of uterus graft rejection need to be identified, and prior rejection episodes should no longer be a cause to remove the graft during delivery in a recipient who wants a further pregnancy.
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Affiliation(s)
- Giuseppe D'Amico
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Luca Del Prete
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA.,General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Bijan Eghtesad
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Koji Hashimoto
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Charles Miller
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andreas Tzakis
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Cristiano Quintini
- Departments of General Surgery, Digestive Disease and Surgery Institute, Liver and Uterus Transplant Unit, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tommaso Falcone
- Cleveland Clinic, Obstetrics and Gynecology and Women's Health Institute, Cleveland, Ohio, USA
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15
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Chen N, Song S, Bao X, Zhu L. Update on Mayer-Rokitansky-Küster-Hauser syndrome. Front Med 2022; 16:859-872. [PMID: 36562950 DOI: 10.1007/s11684-022-0969-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/12/2022] [Indexed: 12/24/2022]
Abstract
This review presents an update of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome on its etiologic, clinical, diagnostic, psychological, therapeutic, and reproductive aspects. The etiology of MRKH syndrome remains unclear due to its intrinsic heterogeneity. Nongenetic and genetic causes that may interact during the embryonic development have been proposed with no definitive etiopathogenesis identified. The proportion of concomitant extragenital malformations varies in different studies, and the discrepancies may be explained by ethnic differences. In addition to physical examination and pelvic ultrasound, the performance of pelvic magnetic resonance imaging is crucial in detecting the presence of rudimentary uterine endometrium. MRKH syndrome has long-lasting psychological effects on patients, resulting in low esteem, poor coping strategies, depression, and anxiety symptoms. Providing psychological counseling and peer support to diagnosed patients is recommended. Proper and timely psychological intervention could significantly improve a patient's outcome. Various nonsurgical and surgical methods have been suggested for treatment of MRKH syndrome. Due to the high success rate and minimal risk of complications, vaginal dilation has been proven to be the first-line therapy. Vaginoplasty is the second-line option for patients experiencing dilation failure. Uterine transplantation and gestational surrogacy are options for women with MRKH syndrome to achieve biological motherhood.
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Affiliation(s)
- Na Chen
- National Clinical Research Center for Obstetric and Gynecologic Diseases, Department of Obstetrics and Gynecology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Shuang Song
- National Clinical Research Center for Obstetric and Gynecologic Diseases, Department of Obstetrics and Gynecology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xinmiao Bao
- National Clinical Research Center for Obstetric and Gynecologic Diseases, Department of Obstetrics and Gynecology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
- Peking Union Medical College, M.D. Program, Beijing, 100730, China
| | - Lan Zhu
- National Clinical Research Center for Obstetric and Gynecologic Diseases, Department of Obstetrics and Gynecology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
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16
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Cacciottola L, Dolmans MM, Schattman GL. A synopsis of the 2021 International Society of Fertility Preservation bi-annual meeting. J Assist Reprod Genet 2022; 39:1727-1732. [PMID: 35849256 PMCID: PMC9428092 DOI: 10.1007/s10815-022-02568-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 01/19/2023] Open
Abstract
On November 19, 2021, the first virtual meeting of the International Society for Fertility Preservation (ISFP) took place. Eight experts in the field of reproductive medicine presented important updates on their research in the field of fertility preservation and reproductive surgery for absolute uterine factor infertility. Presentations included talks on ovarian stem cell therapy for premature ovarian insufficiency, practical aspects of oocyte vitrification, ovarian stimulation for patients with breast cancer, in vitro maturation of oocytes at the time of ovarian tissue harvesting, male fertility preservation, and uterine transplantation. These presentations are summarized below and can be viewed in their entirety at www.isfp-fertility.org.
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Affiliation(s)
- Luciana Cacciottola
- Gynecology Research Unit, Institut de Recherche Expérimentale Et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | | | - Glenn L. Schattman
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Medical College of Cornell University, New York, NY USA
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17
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Ayoubi JM, Carbonnel M, Kvarnström N, Revaux A, Poulain M, Vanlieferinghen S, Coatantiec Y, Le Marchand M, Tourne M, Pirtea P, Snanoudj R, Le Guen M, Dahm-Kähler P, Racowsky C, Brännström M. Case Report: Post-Partum SARS-CoV-2 Infection After the First French Uterus Transplantation. Front Surg 2022; 9:854225. [PMID: 35836605 PMCID: PMC9273879 DOI: 10.3389/fsurg.2022.854225] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/11/2022] [Indexed: 12/15/2022] Open
Abstract
Absolute uterus factor infertility, whether congenital or acquired, renders the woman unable to carry a child. Although uterus transplantation (UTx) is being increasingly performed as a non-vital procedure to address this unfortunate condition, the immunosuppression required presents risks that are further compounded by pregnancy and during the puerperium period. These vulnerabilities require avoidance of SARS-CoV-2 infection in pregnant UTx recipients especially during the third trimester, as accumulating evidence reveals increased risks of morbidity and mortality. Here we describe a successful UTx case with delivery of a healthy child, but in which both mother and neonate developed asymptomatic SARS-CoV-2 infection seven days after RNA vaccination, on day 35 post-partum. Although the patient was successfully treated with a combination therapy comprised of two monoclonal antibodies, this case highlights the challenges associated with performing UTx in the era of Covid-19. More broadly, the risks of performing non-vital organ transplantation during a pandemic should be discussed among team members and prospective patients, weighing the risks against the benefits in improving the quality of life, which were considerable for our patient who achieved motherhood with the birth of a healthy child.
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Affiliation(s)
- Jean Marc Ayoubi
- Department of Obstetrics Gynecology and Reproductive Medicine, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Marie Carbonnel
- Department of Obstetrics Gynecology and Reproductive Medicine, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Aurelie Revaux
- Department of Obstetrics Gynecology and Reproductive Medicine, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Marine Poulain
- Department of Obstetrics Gynecology and Reproductive Medicine, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Sarah Vanlieferinghen
- Department of Obstetrics Gynecology and Reproductive Medicine, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | | | | | - Morgan Tourne
- Department of Pathology, Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Paul Pirtea
- Department of Obstetrics Gynecology and Reproductive Medicine, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Renaud Snanoudj
- Department of Nephrology and Transplantation, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Morgan Le Guen
- Department of Anesthesiology, Foch Hospital - Paris Ouest Medicine University (UVSQ), Suresnes, France
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Catherine Racowsky
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA
| | - Mats Brännström
- Neonatal Care Unit, Foch Hospital, Suresnes, France.,Stockholm IVF-EUGIN, Stockholm, Sweden
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18
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Ayoubi JM, Carbonnel M, Racowsky C, de Ziegler D, Gargiulo A, Kvarnström N, Dahm-Kähler P, Brännström M. Evolving clinical challenges in uterus transplantation. Reprod Biomed Online 2022; 45:947-960. [DOI: 10.1016/j.rbmo.2022.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
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19
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Porrett PM, Nellore A. Immunologic and Infectious Concerns in Uterus Transplantation. Clin Obstet Gynecol 2022; 65:37-43. [PMID: 35045023 DOI: 10.1097/grf.0000000000000686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pharmacologic immunosuppression is required for the success of uterus transplantation but can provoke several complications for the transplant recipient. In this review, we discuss the immunologic complications that can occur in the uterus transplant recipient. First, we provide the latest update on immunosuppression regimens used by programs throughout the world. Next, we discuss the prevalence, mechanisms, treatment, and outcome of rejection in uterus transplant recipients. Finally, we discuss infectious complications of varying severity alongside their treatment and impact.
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Affiliation(s)
| | - Anoma Nellore
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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20
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Uterus Transplantation: Lessons Learned From a Psychological Perspective. Clin Obstet Gynecol 2022; 65:52-58. [DOI: 10.1097/grf.0000000000000673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Antepartum Care of the Uterus Transplant Patient: The Experience of 3 Successful US Centers. Clin Obstet Gynecol 2022; 65:84-91. [DOI: 10.1097/grf.0000000000000682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Karlsson CC, Dahm-Kähler P, Kvarnström N, Mölne J, Broecker V, Brännström M. Hysterectomy after uterus transplantation and detailed analyses of graft failures. Acta Obstet Gynecol Scand 2021; 101:355-363. [PMID: 34907538 DOI: 10.1111/aogs.14304] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/25/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The first live birth after uterus transplantation occurred in Sweden in 2014. Uterus transplantation has repeatedly, and at many centers worldwide, proven to be a feasible treatment for absolute uterine factor infertility. Hysterectomy in live donors and transplantation are well described in numerous reports. However, there are no reports of hysterectomy in the recipient after uterus transplantation, which will occur at either graft failure, after childbirth, or after numerous failed pregnancy attempts. We present the first report of hysterectomy in recipients after uterus transplantation with detailed analyses of findings in conjunction with graft failures. MATERIAL AND METHODS An analysis of recipient hysterectomies (n = 10), performed in 2012-2020, was conducted. Data from the international uterus transplantation registry (ISUTx registry) were extracted, and medical records were systematically reviewed, to collect and compile characteristics of recipients and donors, as well as pre-, per-, and postoperative data, including clinical course of graft failures. RESULTS Hysterectomy in recipients was performed in conjunction with cesarean section (n = 3), 3-6 months after cesarean section (n = 3), or after failed pregnancy attempts (n = 1) or graft failure (n = 3). The durations of anesthesia (2 h 36 min to 7 h 35 min) and hysterectomy surgery (1 h 42 min to 5 h 52 min) ranged widely, with long perioperative interruptions for insertion of ureteral catheters in two cases. Adhesions to the uterus were abundant, the majority being mild. Three uteri that subsequently showed graft failure (hysterectomy at 1, 3, and 8 months post transplantation) showed histological signs of ischemia in biopsies taken 1-week post-transplant and early signs of central hypoperfusion by Doppler ultrasound. In these graft failure explants, there were no epithelial linings in the uterine cavity or in the cervix. The inner uterine wall was severely ischemic and/or necrotic, whereas outer parts were partly viable. There were signs of moderate atherosclerosis of uterine arteries but no rejection. Mild postoperative complications were frequent (6/10), with one supravaginal hematoma requiring surgical drainage. CONCLUSIONS Hysterectomy after uterus transplantation is a complex and time-consuming procedure, and perioperative ureteral catheters may be helpful. Histopathology of early cervical biopsies showing ischemic signs may indicate subsequent irreversible damage, leading to graft failure.
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Affiliation(s)
- Camilla C Karlsson
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Mölne
- Department of Clinical Pathology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Verena Broecker
- Department of Clinical Pathology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Stockholm IVF-Eugin, Stockholm, Sweden
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Järvholm S, Bokström H, Enskog A, Hammarling C, Dahm-Kähler P, Brännström M. Striving for motherhood after uterus transplantation: a qualitative study concerning pregnancy attempts, and the first years of parenthood after transplantation. Hum Reprod 2021; 37:274-283. [PMID: 34865019 DOI: 10.1093/humrep/deab260] [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: 04/10/2021] [Revised: 10/31/2021] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION How do women experience attempts to become pregnant, and the first years of motherhood, after uterus transplantation (UTx)? SUMMARY ANSWER Women who try to become pregnant after UTx experience the general strains typically associated with infertility and childlessness, such as failure of embryo transfer (ET), and specific worries about graft survival but when they become mothers they essentially feel like other mothers, with the associated rewards and stresses. WHAT IS KNOWN ALREADY UTx has proven to be a successful treatment for absolute uterine factor infertility (AUFI). Although UTx seems to have a positive effect on self-image there is a lack of knowledge about how women who have received uterine grafts experience pregnancy attempts, pregnancy itself and the first years of motherhood. STUDY DESIGN, SIZE, DURATION This prospective cohort study included the seven participants in the first UTx trial who had experienced surgically successful grafts. Pregnancy was attempted using ET 12 months after transplantation. Structured interviews were performed once a year for 5 years after transplantation. PARTICIPANTS/MATERIALS, SETTING, METHODS Six of the seven participants (mean age 29.3 years at UTx) had AUFI owing to the congenital absence of the uterus, while the seventh woman had undergone a hysterectomy. Post-transplantation, yearly interviews (2013-2018) were performed, comprising a total of 34 interviews. Interview data were analysed thematically. MAIN RESULTS AND THE ROLE OF CHANCE All seven participants achieved pregnancy during the study period and six became mothers. Experiencing the previously unimaginable was classed as an overarching theme with the following underlying themes: The yoke of childlessness; Going through the impossible and Motherhood as surreal and normal. The results showed that the women who try to achieve motherhood after UTx generally describe their situation as manageable and present strains comparable to other women undergoing infertility treatments. LIMITATIONS, REASONS FOR CAUTION The fact that all participants came from one centre is a limitation. WIDER IMPLICATIONS OF THE FINDINGS There are real psychological strains in motherhood after UTx, such as the concern the women expressed relating to health of the child and the effects of immunosuppressants. These findings are in line with those of other women who became pregnant after transplantation of organs other than the uterus. The results show that extra psychological support and attention should be given to those with repeated pregnancy failures or unsuccessful outcomes. In the cases where women became mothers, attention needs to be given to the possible worries connected to the UTx, but in other respects, they should be treated like any mother-to-be. STUDY FUNDING/COMPETING INTEREST(S) Funding was received from the Jane and Dan Olsson Foundation for Science; Knut and Alice Wallenberg Foundation. A.L.F. grant from the Swedish state under an agreement between the government and the county councils; Swedish Research Council. The authors have no competing interests. TRIAL REGISTRATION NUMBER NCT01844362.
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Affiliation(s)
- Stina Järvholm
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Bokström
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Enskog
- Department of Anaesthesia and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Catrina Hammarling
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Stockholm IVF-EUGIN, Stockholm, Sweden
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24
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Martin F, Tullius SG. Immunosuppression after uterus transplantation. Curr Opin Organ Transplant 2021; 26:627-633. [PMID: 34581290 DOI: 10.1097/mot.0000000000000925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Clinical uterus transplantation (UTx) is growing rapidly. The procedure represents the only therapy for women with absolute uterine factor infertility to give birth to a biological baby. Immunosuppression after UTx needs to carefully balance effects with the healthy mother and baby. Unique for UTx is the 'temporary' character of the procedure with a transplant hysterectomy being performed after delivery. Most of the practice on immunosuppression in UTx is currently based on the experience in solid organ transplantation (SOT). RECENT FINDINGS Clinical UTx-trials have been performed in centers worldwide during the recent years and experience on immunosuppression has accumulated. SUMMARY Immunosuppression in UTx has been successfully applied as maintenance treatment in addition to effectively treating acute T- and B-cell mediated rejections. Understanding the biology of UTx in more detail is expected to refine future approaches.
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Affiliation(s)
- Friederike Martin
- Department of General, Visceral and Transplant Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan G Tullius
- Division of Transplant Surgery and Transplant Surgery Research Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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25
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Abstract
PURPOSE OF REVIEW Donor hysterectomy for live donor uterus transplantation was from the start performed by laparotomy, but minimal invasive surgery has entered the scene. In particular robotic-assisted laparoscopy is used since robotics is advantageous in the complex donor hysterectomy surgery in narrow space. This review covers the development and benefits of robotics and the published robotic donor hysterectomy experiences. RECENT FINDINGS Robotic donor hysterectomy publications are scarce with eight cases in Sweden, five in USA, and one each in China and Spain. Robotics have been performed for either the entire donor hysterectomy or with conversion to laparotomy for the last steps of the surgical procedure. The total operative times are in line with open surgery, although a decrease is expected in the future. The estimated blood loss and hospital stays are less than at open surgery. The complication panorama includes hydronephrosis, ureteric fistula and pressure alopecia. Live births with healthy babies have been reported. SUMMARY In uterus transplantation, robotic live donor hysterectomy has proven to be feasible, safe and associated with successful live births. The robotic donor hysterectomy is a low-volume procedure and an international registry to gather collective information is crucial for further evaluation and development.
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Affiliation(s)
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy at University of Gothenburg, Gothenburg
| | - Mats Brännström
- Department of Obstetrics and Gynecology
- Stockholm IVF-EUGIN, Stockholm, Sweden
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26
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Brännström M, Belfort MA, Ayoubi JM. Uterus transplantation worldwide: clinical activities and outcomes. Curr Opin Organ Transplant 2021; 26:616-626. [PMID: 34636769 DOI: 10.1097/mot.0000000000000936] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Women with absolute uterine factor infertility, because of uterine absence, or the presence of a nonfunctional uterus, were regarded as being untreatable until 2014 when the first birth following uterus transplantation (UTx) took place in Sweden. This proof-of-concept occurred in a woman with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHs) with congenital uterine absence, who received a uterus from a 61-year-old live donor (LD). Since then, several births after UTx have occurred in Sweden and subsequently in other countries, including both LD and deceased donor (DD) transplants. A great majority of the recipients were women with MRKHs. The efficiency and safety of UTx can be determined only when a complete study cohort of transplanted women have reached the definitive endpoint of graft hysterectomy. The different outcomes of transplanted women include graft failure, as well as graft survival with failure to achieve livebirth, or livebirth(s). Published data from a completed trial are not yet available. The results that we have to rely on are reports of completed surgeries and interim outcomes that may be as early as a few months after surgery and up to several years after UTx. The purpose of this review is to give an update on all published clinical UTx data and major results, including live births up to mid 2021. RECENT FINDINGS The interim results of a number of UTx studies have been published. LD UTx procedures have been reported from four European countries (Sweden, the Czech Republic, Germany, Spain), four Asian nations (Saudi Arabia, India, China, Lebanon), as well as some from the USA. DD UTx procedures have been reported from Turkey, the Czech Republic, the USA and Brazil. To our knowledge, there also exist unpublished UTx cases from some of the countries mentioned above and from at least four other countries (Serbia, France, Mexico, Italy). We estimate that at least 80 UTx procedures have been performed, resulting in more than 40 births. The present study includes only data from published, peer-reviewed, research papers. The results of 62 UTx cases show an overall surgical success rate, as defined by a technically successful transplantation with a subsequent regular menstrual pattern, of 76%. The success rates for LD and DD UTx procedures were 78% and 64%, respectively. The rate of serious postsurgical complications requiring invasive or radiological intervention was 18% for LDs and 19% for recipients. The cumulative live birth rate in successful UTx procedures is estimated to be above 80%. Twenty-four births after UTx have been reported and the results show a high rate of preterm birth, with an associated high proportion of respiratory distress syndrome. SUMMARY UTx has proven to be a successful treatment for uterine factor infertility at several centers around the world. The modest success rate and the fairly high complication rate among LDs, indicate that further research and development under strict governance are needed before this option should be widely offered.
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Affiliation(s)
- Mats Brännström
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborg
- Stockholm IVF-EUGIN, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch - Faculté de Medicine Paris Ouest (UVSQ), Suresnes, France
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Jean Marc Ayoubi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Hospital Foch - Faculté de Medicine Paris Ouest (UVSQ), Suresnes, France
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27
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Leonhardt H, Thilander-Klang A, Båth J, Johannesson M, Kvarnström N, Dahm-Kähler P, Brännström M. Imaging evaluation of uterine arteries in potential living donors for uterus transplantation: a comparative study of MRA, CTA, and DSA. Eur Radiol 2021; 32:2360-2371. [PMID: 34767069 PMCID: PMC8921132 DOI: 10.1007/s00330-021-08350-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/08/2021] [Accepted: 09/20/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate uterine arteries (UA) of potential living donors for uterus transplantation (UTx) by comparison of CT angiography (CTA), digital subtraction angiography (DSA), and MR angiography (MRA) with care taken to minimize radiation doses. METHODS Prospective donors for a clinical UTx trial were included. CTA, DSA, and MRA measurements in three predefined segments of the UAs were evaluated. Radiation doses were estimated and 1-year graft survival was recorded. RESULTS Twelve potential donors (age 37-62 years) were investigated. There was no difference in visualized average UA lumen diameter when comparing CTA (mean 2.0 mm, SD 0.4), DSA (mean 2.1 mm, SD 0.6), and MRA (mean 2.0 mm, SD 0.3). MRA was not able to fully evaluate 10 (43%) out of 23 UA that proved to be patent on DSA. One UA was not identified by any of the modalities, and three MRA-absent UAs were identified by both CTA and DSA. The estimated mean effective dose was lower for DSA (5.1 mSv, SD 2.8) than CTA (7.1 mSv, SD 2.0), but not significantly (p value = 0.06). Three potential donors were excluded due to UA pathology and one due to adenomyosis. Eight donors underwent hysterectomy, with 1-year graft survival in six women. CONCLUSION MRI including MRA should be the initial modality to examine potential UTx donors to acquire valuable details of uterine anatomy, and if UAs are fully visualized, there is no need for further angiographic methods with radiation. If UAs are not visualized by MRA, CTA may be performed and in selective cases with addition of the invasive modality DSA. KEY POINTS • For uterine transplantation, pelvic MRI with MRA provides information of the uterine structure and of the diameters of uterine arteries in living donors. • Failure of MRA to demonstrate uterine arteries could be followed by CTA which will visualize the uterine arteries in a majority of cases. If MRA and additional CTA provide inconclusive results, the uterine arteries should be further evaluated by DSA. • Information of CTA can be used in the angio-system for DSA settings to minimize the radiation and contrast media doses.
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Affiliation(s)
- Henrik Leonhardt
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Sahlgrenska Academy at University of Gothenburg, Bruna stråket 11B, SE-413 45, Gothenburg, Sweden.
| | - Anne Thilander-Klang
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - John Båth
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Sahlgrenska Academy at University of Gothenburg, Bruna stråket 11B, SE-413 45, Gothenburg, Sweden
| | - Marit Johannesson
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Sahlgrenska Academy at University of Gothenburg, Bruna stråket 11B, SE-413 45, Gothenburg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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28
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Balko J, Novackova M, Skapa P, Pastor Z, Chmel R, Zamecnik J, Chmel R. Histopathological examination of the ectocervical biopsy in non-transplanted uteri: A study contributing to the provisional scoring system of subclinical graft rejection after uterus transplantation. Acta Obstet Gynecol Scand 2021; 101:37-45. [PMID: 34693986 DOI: 10.1111/aogs.14280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 09/14/2021] [Accepted: 10/03/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Uterus transplantation is a causal treatment for absolute uterine factor infertility. Assessing rejection signs using a histopathological examination of the ectocervical biopsy from the transplanted uterus is common practice in all human uterus transplants worldwide to date. A provisional scoring system was used for the histopathological assessment of subclinical rejection signs in uterus recipients. Here we hypothesized that histopathological and immunohistochemical findings in the normal uteri would differ from the borderline category of subclinical rejection in uterine transplants. MATERIAL AND METHODS This prospective observational study included ectocervical biopsies of 54 women who underwent hysterectomy for benign reasons. All biopsy samples were assessed histopathologically and immunohistochemically. RESULTS Most of the ectocervical biopsies showed clustering lymphocytic infiltrates affecting the stromal-epithelial interface with the epithelial influx of lymphocytes, primarily CD45RO-positive activated T-cells with CD8 T-lymphocyte predominance. CD4-positive T-lymphocytes and B-cells were rarely detected in the ectocervix. These morphological findings and immunoprofiles of lymphocytic populations overlapped with the so-called borderline changes defined in the provisional scoring system for rejection in the transplanted uteri. The immunoprofiles of ectocervical and endocervical lymphocytic populations differed, with strikingly prominent B-cell participation in the endocervix vs the rare detection of B-cells in the ectocervix. CONCLUSIONS The histopathological and immunohistochemical findings in the uteri of premenopausal women were similar to the borderline category of the currently used provisional scoring system of subclinical uterine rejection utilized in all uterine transplant studies. However, future similar studies are required to validate our findings.
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Affiliation(s)
- Jan Balko
- Department of Pathology and Molecular Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Marta Novackova
- Department of Obstetrics and Gynecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Petr Skapa
- Department of Pathology and Molecular Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Zlatko Pastor
- Department of Obstetrics and Gynecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Roman Chmel
- Department of Obstetrics and Gynecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
- Faculty of Medicine in Plzeň, Charles University, Prague, Czech Republic
| | - Josef Zamecnik
- Department of Pathology and Molecular Medicine, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Roman Chmel
- Department of Obstetrics and Gynecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
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29
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Vali S, Jones BP, Saso S, Fertleman M, Testa G, Johanesson L, Alghrani A, Smith JR. Uterine transplantation: legal and regulatory implications in England. BJOG 2021; 129:590-596. [PMID: 34532958 DOI: 10.1111/1471-0528.16927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 12/01/2022]
Abstract
Uterus transplantation (UTx) is fast evolving from an experimental to a clinical procedure, combining solid organ transplantation with assisted reproductive technology. The commencement of the first human uterus transplant trial in the United Kingdom leads us to examine and reflect upon the legal and regulatory aspects closely intertwined with UTx from the process of donation to potential implications for fertility treatment and the birth of the resultant child. As the world's first ephemeral transplant, the possibility of organ restitution requires consideration and is discussed herein. TWEETABLE ABSTRACT: Uterine transplantation warrants a closer look at the legal frameworks on fertility treatment and transplantation in England.
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Affiliation(s)
- S Vali
- Department of Surgery and Cancer, Hammersmith Hospital, Imperial College London, London, UK.,Cutrale Perioperative and Ageing Research Group, Imperial College London, London, UK
| | - B P Jones
- Department of Surgery and Cancer, Hammersmith Hospital, Imperial College London, London, UK.,West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - S Saso
- Department of Surgery and Cancer, Hammersmith Hospital, Imperial College London, London, UK.,West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - M Fertleman
- Cutrale Perioperative and Ageing Research Group, Imperial College London, London, UK
| | - G Testa
- Baylor University Medical Centre, Dallas, TX, USA
| | - L Johanesson
- Baylor University Medical Centre, Dallas, TX, USA
| | - A Alghrani
- School of Law and Social Justice, University of Liverpool, Liverpool, UK
| | - J R Smith
- Department of Surgery and Cancer, Hammersmith Hospital, Imperial College London, London, UK.,West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial College NHS Trust, London, UK
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30
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Richards EG, Farrell RM, Ricci S, Perni U, Quintini C, Tzakis A, Falcone T. Uterus transplantation: state of the art in 2021. J Assist Reprod Genet 2021; 38:2251-2259. [PMID: 34057644 PMCID: PMC8490545 DOI: 10.1007/s10815-021-02245-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To provide a comprehensive review of uterus transplantation in 2021, including a discussion of pregnancy outcomes of all reported births to date, the donor and recipient selection process, the organ procurement and transplant surgeries, reported complications, postoperative monitoring, preimplantation preparation, and ethical considerations. METHODS Literature review and expert commentary. RESULTS Reports of thirty-one live births following uterus transplantation have been published from both living and deceased donors. The proper selection of donors and recipients is a labor-intensive process that requires advanced planning. A multidisciplinary team is critical. Reported complications in the recipient include thrombosis, infection, vaginal stricture, antenatal complications, and graft failure. Graft rejection is a common occurrence but rarely leads to graft removal. While most embryo transfers are successful, recurrent implantation failures in uterus transplant patients have been reported. Rates of preterm delivery are high but appear to be declining; more data, including long-term outcome data, is needed. CONCLUSIONS Uterus transplantation is an emerging therapy for absolute uterine factor infertility, a condition previously without direct treatment options. It is paramount that reproductive health care providers are familiar with the uterus transplantation process as more patients seek and receive this treatment.
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Affiliation(s)
- Elliott G Richards
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ruth M Farrell
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stephanie Ricci
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Uma Perni
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Cristiano Quintini
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andreas Tzakis
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tommaso Falcone
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Desk A-81, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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31
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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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32
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Abstract
PURPOSE To provide a comprehensive review of uterus transplantation in 2021, including a discussion of pregnancy outcomes of all reported births to date, the donor and recipient selection process, the organ procurement and transplant surgeries, reported complications, postoperative monitoring, preimplantation preparation, and ethical considerations. METHODS Literature review and expert commentary. RESULTS Reports of thirty-one live births following uterus transplantation have been published from both living and deceased donors. The proper selection of donors and recipients is a labor-intensive process that requires advanced planning. A multidisciplinary team is critical. Reported complications in the recipient include thrombosis, infection, vaginal stricture, antenatal complications, and graft failure. Graft rejection is a common occurrence but rarely leads to graft removal. While most embryo transfers are successful, recurrent implantation failures in uterus transplant patients have been reported. Rates of preterm delivery are high but appear to be declining; more data, including long-term outcome data, is needed. CONCLUSIONS Uterus transplantation is an emerging therapy for absolute uterine factor infertility, a condition previously without direct treatment options. It is paramount that reproductive health care providers are familiar with the uterus transplantation process as more patients seek and receive this treatment.
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33
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Davidson T, Ekberg J, Sandman L, Brännström M. The costs of human uterus transplantation: a study based on the nine cases of the initial Swedish live donor trial. Hum Reprod 2021; 36:358-366. [PMID: 33247912 DOI: 10.1093/humrep/deaa301] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/08/2020] [Indexed: 01/08/2023] Open
Abstract
STUDY QUESTION What are the costs of live donor uterus transplantation in a European setting? SUMMARY ANSWER The total costs for preoperative investigations, including IVF, and live donor uterus transplantation including postoperative costs for 2 months, were calculated to be €74 564 (mean), with the costs of recipient being somewhat higher than for donor and the cost components of total costs distributed between sick leave (25.7%), postoperative hospitalization (17.8%), surgery (17.1%), preoperative investigations (15.7%), anaesthesia (9.7%), drugs (7.8%), tests after surgery (4.0%) and for re-hospitalization (2.2%). WHAT IS KNOWN ALREADY Uterus transplantation has proved to be successful by demonstrations of live births, both after live donor and deceased donor procedures. The transplantation is considered as a complex and expensive infertility treatment. There exist no analyses of costs involved in uterus transplantation. STUDY DESIGN, SIZE, DURATION This prospective cohort study included nine uterus transplantations procedures, performed in Sweden in 2013. Study duration of this health economic study included 6-12 months of pre-transplantation investigations and the time interval from transplantation to 2 months after. PARTICIPANTS/MATERIALS, SETTING, METHODS Nine triads of uterus recipient, partner of recipient and uterus donor participated. All prospective recipients were in stable relationships and performed IVF with their partners before transplantation. The nine donors were relatives or family friends. The recipients and donors underwent pre-transplantation investigations with imaging, laboratory tests and psychological/medical screening prior to transplantation. Transplantation was by laparotomy in both donor and recipient. Standard immunosuppression and postoperative medication were used. After discharge from the hospital, the recipients were followed frequently with laboratory tests and examinations. MAIN RESULTS AND THE ROLE OF CHANCE The mean costs for preoperative investigations, including IVF, and live donor uterus transplantation with postoperative costs for 2 months, were calculated to be €74 564 (range €50 960-€99 658), from a societal perspective. The four largest components were cost of sick leave (€19 164), cost of postoperative hospitalization (€13 246), surgery cost (€12 779) and costs for preoperative investigations, including IVF (€11 739). Smaller components were costs for anaesthesia (€7207), costs for drugs (€5821), costs for post-surgical tests (€2985) and costs for re-hospitalization (€1623). The costs of the recipient (€42 984) were somewhat higher than the costs of the donor (€31 580), but in terms of costs, they should be viewed as one entity. By using a health care perspective, excluding cost for productivity loss, the total costs would be reduced by 26%. LIMITATIONS, REASONS FOR CAUTION A limitation is the restricted sample size and that this is in the experimental, clinical stage of development. WIDER IMPLICATIONS OF THE FINDINGS The results provide the first information concerning the costs for pre-transplantation investigations and uterus transplantation procedures with postoperative follow-up. We consider the total estimate to be in the higher interval, because of the extensive research protocol. It is likely that the cost of live donor uterus transplantation will vary between countries and that the costs will be lower in a future clinical setting. STUDY FUNDING/COMPETING INTEREST(S) Funding was received from the Jane and Dan Olsson Foundation for Science; the Knut and Alice Wallenberg Foundation; an ALF grant from the Swedish state under an agreement between the government and the county councils; and the Swedish Research Council. None of the authors have a conflict of interest with regard to the study. TRIAL REGISTRATION NUMBER NCT01844362.
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Affiliation(s)
- Thomas Davidson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jana Ekberg
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Lars Sandman
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.,Stockholm IVF-EUGIN, Stockholm, Sweden
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Abstract
PURPOSE OF REVIEW Uterus transplantation (UTx) is the first existing infertility treatment for women with no uterus and for women with a present nonfunctional uterus, which is unable to carry a pregnancy. This type of transplantation is a novel addition within the field of vascularized composite allografts and is the first ephemeral kind of transplantation, with the graft intended for only a restricted number of years, until the desired numbers of children have been born and with subsequent graft removal. The proof-of-concept of UTx, as an infertility treatment for women with uterine factor infertility, came with the report of the first live birth after UTx, occurring in Sweden in 2014. This UTx live birth has been followed by around 30 births, taking place in four continents. Despite the initial clinical success, UTx should still be regarded as an experimental procedure, at a developmental phase. The clinical UTx activities at several centers around the globe take place within scientific clinical trials and aim to advance UTx further. This review describes certain developmental areas around UTx. These relate to surgery, donor selection, assisted reproduction, and inclusion of new recipient groups. RECENT FINDINGS Successful UTx procedures, with live births, have been reported both after live and deceased donor transplantation. There exist developments in the areas of robotic surgery for live donor hysterectomy, of alternate vascular connections to the graft, modifications of inclusion criteria/investigations of donors, assisted reproduction in conjunction with UTx, as well as discussions concerning expanding the pool of eligible recipients. SUMMARY Uterus transplantation has repeatedly proven to be a feasible infertility treatment for women with absolute uterine factor infertility. Ongoing studies aim to increase safety and efficiency of the procedure as well as to better define suitable donors and recipients.
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Jones BP, Saso S, Yazbek J, Thum MY, Quiroga I, Ghaem-Maghami S, Smith JR. Uterine Transplantation: Scientific Impact Paper No. 65 April 2021. BJOG 2021; 128:e51-e66. [PMID: 33913235 DOI: 10.1111/1471-0528.16697] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
A uterine transplant, or womb transplant, provides a potential treatment for women who cannot become pregnant or carry a pregnancy because they do not have a womb, or have a womb that is unable to maintain a pregnancy. This is estimated to affect one in 500 women. Options for those who wish to start a family include adoption and surrogacy, but these are associated with legal, cultural, ethical and religious implications that may not be appropriate for some women and their families. A womb transplant is undertaken when the woman is ready to start a family, and is removed following the completion of their family. Womb transplants have been performed all over the world, with more than 70 procedures carried out so far. At least 23 babies have been born as a result, demonstrating that womb transplants can work. While the procedure offers a different option to adoption and surrogacy, it is associated with significant risks, including multiple major surgeries and the need to take medications that help to dampen the immune system to prevent rejection of the womb. To date there has been a 30% risk of a transplant being unsuccessful. Although the number of transplants to date is still relatively small, the number being performed globally is growing, providing an opportunity to learn from the experience gained so far. This paper looks at the issues that have been encountered, which may arise at each step of the process, and proposes a framework for the future. However, long term follow-up of cases will be essential to draw reliable conclusions about any overall benefits of this procedure.
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Affiliation(s)
- B P Jones
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - S Saso
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - J Yazbek
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - M-Y Thum
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - I Quiroga
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - S Ghaem-Maghami
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - J R Smith
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
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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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Iske J, Elkhal A, Tullius SG. The Fetal-Maternal Immune Interface in Uterus Transplantation. Trends Immunol 2021; 41:213-224. [PMID: 32109373 DOI: 10.1016/j.it.2020.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 01/10/2020] [Accepted: 01/11/2020] [Indexed: 12/16/2022]
Abstract
Uterus transplants (UTxs) have been performed worldwide. Overall frequencies have been low, but globally initiated UTx programs are expected to increase clinical implementation. The uterus constitutes a unique immunological environment with specific features of tissue renewal and a receptive endometrium. Decidual immune cells facilitate embryo implantation and placenta development. Although UTx adds to the complexity of immunity during pregnancy and transplantation, the procedure provides a unique clinical and experimental model. We posit that understanding the distinct immunological properties at the interface of the transplanted uterus, the fetus and maternal circulation might provide valuable novel insights while improving outcomes for UTx. Here, we discuss immunological challenges and opportunities of UTx affecting mother, pregnancy and healthy livebirths.
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Affiliation(s)
- Jasper Iske
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Institute of Transplant Immunology, Integrated Research and Treatment Center Transplantation, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Abdallah Elkhal
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefan G Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Dahm-Kähler P, Kvarnström N, Alfonzo Rodriguez E, Skogsberg Dahlgren U, Brännström M. Uterus transplantation for fertility preservation in patients with gynecologic cancer. Int J Gynecol Cancer 2021; 31:371-378. [PMID: 33649004 DOI: 10.1136/ijgc-2020-001804] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 11/04/2022] Open
Abstract
Cervical and endometrial cancer may impact women interested in future fertility in approximately 5-25% of cases. The recommended treatment for patients with early stage disease is hysterectomy and/or radiation leading to infertility. This is referred to as absolute uterine factor infertility. Such infertility was considered untreatable until 2014, when the first child was born after uterus transplantation. Thereafter, multiple births have been reported, mainly from women with Mayer-Rokitansky-Küster-Hauser syndrome, with congenital uterine absence, although also from a patient with iatrogenic uterine factor infertility caused by radical hysterectomy secondary to an early stage cervical cancer 7 years before uterus transplantation. A live birth after uterus transplantation may be considered promising for many who may not otherwise have this option.Uterus transplantation is a complex process including careful patient selection in both recipients and donors, in vitro fertilization, and complex surgery in the organ procurement procedure including harvesting the vessel pedicles with the thin-walled veins. Thereafter, the transplantation surgery with anastomosis to ensure optimal blood inflow and outflow of the transplanted organ. Knowledge regarding immunosuppression and pregnancy is essential. Lastly there is the hysterectomy component as the uterus must be removed. Multidisciplinary teams working closely are essential to achieve successful uterus transplantation and, ultimately, delivery of a healthy child. Both the living and deceased donor concept may be considered and we address both the advantages and disadvantages. This review summarizes the animal research thus far published on uterus transplantation, the suggested recipient selections including former gynecologic cancer patients, the living and deceased donor uterus transplantation concepts with reported results, and updated fertility outcomes.
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Affiliation(s)
- Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Niclas Kvarnström
- Department of Transplantation, Sahlgrenska Academy, Goteborg, Sweden
| | | | | | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, Gothenburg, Sweden
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Human Uterus Transplantation from Living and Deceased Donors: The Interim Results of the First 10 Cases of the Czech Trial. J Clin Med 2021; 10:jcm10040586. [PMID: 33557282 PMCID: PMC7916074 DOI: 10.3390/jcm10040586] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 01/16/2023] Open
Abstract
Introduction: Uterus transplantation (UTx) is a rapidly evolving treatment of uterine-factor infertility. We report the results of the first 10 UTx procedures performed at our institution. Methods: The program started in April 2016 as a two-arm study comparing the efficacy of UTx from live donors (LD) and deceased donors (DD). Results: Between April 2016 and April 2018, we performed five DD UTx and five LD UTx. Two grafts had to be removed early due to thrombosis. One graft was removed due to chronic rejection and previous herpes simplex infection at month 7. Graft survival is 70% at one year. Recipient survival is 100% at two years. Live donor survival is 100% at three years. Three live-births have been achieved, two from a LD and one from a graft from a nulliparous DD. Vaginal anastomotic stenosis occurred in 63% (5/8) of grafts. Self-expanding stents have shown preliminary suitability for the treatment of vaginal stenosis. Three recipients developed severe acute rejection. Conclusion: The interim results of our study demonstrate mid-term viability in 70% of grafts. The LD UTx produced two live births and the DD UTx produced one live birth. Nulliparous donors should be considered for donation.
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Broecker V, Brännström M, Ekberg J, Dahm-Kähler P, Mölne J. Uterus transplantation: Histological findings in explants at elective hysterectomy. Am J Transplant 2021; 21:798-808. [PMID: 32659865 DOI: 10.1111/ajt.16213] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/10/2020] [Accepted: 07/07/2020] [Indexed: 01/25/2023]
Abstract
Uterus transplantation has enabled women with absolute uterine factor infertility to carry a pregnancy. The first human uterus transplantation trial was initiated in 2013 in Gothenburg, Sweden. It was completed with 7 transplantations with long-term allograft survival and 9 children born from 6 women. In the present study we describe the histopathology of these 7 allografts, which were removed at 22-83 months after transplantation, and compare findings to control cases. Morphological findings in a subset of explants included linear subepithelial inflammation and perivascular stromal inflammation in the cervix, small inflammatory foci in the myometrium, and intimal inflammation in larger arteries. The average number of T cells, B cells, and macrophages was higher in transplants compared to normal controls, but variability was high among transplants. Chronic-active vascular rejection was seen in 2 of 7 transplants, both showed also inflammation in the cervix. Further, the inflammation seen in the cervix reflected the inflammation in the myometrium, suggesting that cervical biopsies are suitable to monitor rejection. However, the degree of inflammation and signs of rejection in explants did not reflect on the possibility to become pregnant in this limited series.
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Affiliation(s)
- Verena Broecker
- Department of Clinical Pathology, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Brännström
- Institute of Clinical Sciences, Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Stockholm IVF-Eugin, Stockholm, Sweden
| | - Jana Ekberg
- Institute of Clinical Sciences, Transplantation Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pernilla Dahm-Kähler
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Mölne
- Department of Clinical Pathology, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Clinicopathologic Analysis of Uterine Allografts Including Proposed Scoring of Ischemia-reperfusion Injury and T Cell-mediated Rejection-Dallas UtErus Transplant Study: A Pilot Study. Transplantation 2021; 106:167-177. [PMID: 33481553 DOI: 10.1097/tp.0000000000003633] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Uterus transplantation (UTx) enables pregnancy in infertile women. This study describes the histopathological changes of ischemia reperfusion injury and mostly acute T cell-mediated rejection (TCMR) in UTx and proposes modification toward a working formulation grading system with associated treatments. METHODS Protocol and indication biopsies from 11 living and 2 deceased donor UTx recipients were analyzed. Serving as a control were 49 age-matched nontransplanted uteri. All posttransplant histopathological specimens were evaluated in a blinded fashion by 3 pathologists. Response to treatment was assessed by follow-up biopsies. Serial serum donor-specific antibody (DSA) responses were also recorded. RESULTS Changes attributed to ischemia reperfusion resolved within 2 weeks of UTx in most of the patients. For TCMR grading, perivascular inflammation, focal capillary disruption, and interstitial hemorrhage were added to interface inflammation, intercellular edema, stromal inflammation, and epithelial apoptotic bodies. Of the 173 protocol biopsies, 98 were classified as negative for TCMR; 34, indeterminate-borderline; 35, mild; 3, moderate; and 3, severe, 1 of which occurred in a DSA-positive recipient and also showed microvascular injury. Corticosteroids successfully treated all moderate to severe TCMR episodes. Mild TCMR was treated by increasing existing baseline immunosuppression. Indeterminate-borderline episodes were not treated. Neither ischemia reperfusion injury nor TCMR with DSA adversely affected embryo transfer. CONCLUSION Relying on a modified histopathological grading system, we developed a treatment strategy resulting in resolution of TCMR and successful pregnancies.
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Histopathologic Grading of Uterine Allograft Rejection: The Beginning of a Long Journey. Transplantation 2021; 106:22-23. [PMID: 33481555 DOI: 10.1097/tp.0000000000003634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Matoba Y, Kisu I, Banno K, Aoki D. Operative and Clinical Outcomes of Minimally Invasive Living-Donor Surgery on Uterus Transplantation: A Literature Review. J Clin Med 2021; 10:349. [PMID: 33477593 PMCID: PMC7831297 DOI: 10.3390/jcm10020349] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/11/2021] [Accepted: 01/15/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The surgical approach and choice of drainage veins for uterus transplantation living-donor surgery have been investigated to reduce invasiveness. METHODS A thorough search of the PubMed database was conducted. The search was not limited by language or date of publication. The data were collected on 13 October 2020. Two reviewers independently assessed each article and determined eligibility for inclusion in the review article. Inclusion criteria were English peer-reviewed articles reporting surgical information or postoperative course, articles regarding animal research on UTx, UTx on deceased donors, or not original articles. RESULTS Of the 51 operations within 26 articles reviewed, the mean operative time was shortest in the laparoscopic approach, and longest in the robot-assisted approach. The mean blood loss was less in the laparoscopic and robot-assisted approaches than in the open approach. In cases where the uterine veins were not preserved, the mean operative time was shortened by each approach and the mean blood loss decreased with the laparoscopic and robot-assisted approaches. CONCLUSIONS These procedures may contribute to less invasive living-donor surgery.
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Affiliation(s)
| | - Iori Kisu
- Department of Obstetrics and Gynecology, Keio University School of Medicine 35 Shinanomachi, Shinjku-Ku, Tokyo 160-8582, Japan; (Y.M.); (K.B.); (D.A.)
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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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Kisu I, Kato Y, Masugi Y, Ishigaki H, Yamada Y, Matsubara K, Obara H, Emoto K, Matoba Y, Adachi M, Banno K, Saiki Y, Sasamura T, Itagaki I, Kawamoto I, Iwatani C, Nakagawa T, Murase M, Tsuchiya H, Urano H, Ema M, Ogasawara K, Aoki D, Nakagawa K, Shiina T. First Successful Delivery after Uterus Transplantation in MHC-Defined Cynomolgus Macaques. J Clin Med 2020; 9:jcm9113694. [PMID: 33213083 PMCID: PMC7698480 DOI: 10.3390/jcm9113694] [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: 09/27/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 12/25/2022] Open
Abstract
Delivery following uterus transplantation (UTx)—an approach for treating uterine factor infertility—has not been reported in nonhuman primate models. Here, six female major histocompatibility complex (MHC)-defined cynomolgus macaques that underwent allogeneic UTx were evaluated. Antithymocyte globulin and rituximab were administered to induce immunosuppression and a triple maintenance regimen was used. Menstruation resumed in all animals with long-term survival, except one, which was euthanized due to infusion associated adverse reaction to antithymocyte globulin. Donor-specific antibodies (DSA) were detected in cases 2, 4, and 5, while humoral rejection occurred in cases 4 and 5. Post-transplant lymphoproliferative disorder (PTLD) developed in cases 2 and 3. Pregnancy was attempted in cases 1, 2, and 3 but was achieved only in case 2, which had haploidentical donor and recipient MHCs. Pregnancy was achieved in case 2 after recovery from graft rejection coincident with DSA and PTLD. A cesarean section was performed at full-term. This is the first report of a successful livebirth following allogeneic UTx in nonhuman primates, although the delivery was achieved via UTx between a pair carrying haploidentical MHCs. Experimental data from nonhuman primates may provide important scientific knowledge needed to resolve unsolved clinical issues in UTx.
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Affiliation(s)
- Iori Kisu
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo 1608582, Japan; (Y.M.); (M.A.); (K.B.); (D.A.)
- Correspondence: or ; Tel.: +81-333-531-211; Fax: +81-333-530-249
| | - Yojiro Kato
- Department of Surgery, Division of Gastroenterological and General Surgery, School of Medicine, Showa University, Tokyo 1428555, Japan;
| | - Yohei Masugi
- Department of Pathology, Keio University School of Medicine, Tokyo 1608582, Japan; (Y.M.); (K.E.)
| | - Hirohito Ishigaki
- Department of Pathology, Shiga University of Medical Science, Shiga 5202192, Japan; (H.I.); (T.S.); (K.O.)
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo 1608582, Japan;
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan; (K.M.); (H.O.)
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo 1608582, Japan; (K.M.); (H.O.)
| | - Katsura Emoto
- Department of Pathology, Keio University School of Medicine, Tokyo 1608582, Japan; (Y.M.); (K.E.)
| | - Yusuke Matoba
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo 1608582, Japan; (Y.M.); (M.A.); (K.B.); (D.A.)
| | - Masataka Adachi
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo 1608582, Japan; (Y.M.); (M.A.); (K.B.); (D.A.)
| | - Kouji Banno
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo 1608582, Japan; (Y.M.); (M.A.); (K.B.); (D.A.)
| | - Yoko Saiki
- Department of Anesthesiology, Saiseikai Kanagawaken Hospital, Kanagawa 2210821, Japan;
| | - Takako Sasamura
- Department of Pathology, Shiga University of Medical Science, Shiga 5202192, Japan; (H.I.); (T.S.); (K.O.)
| | - Iori Itagaki
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga 5202192, Japan; (I.I.); (I.K.); (C.I.); (T.N.); (M.M.); (H.T.); (M.E.)
| | - Ikuo Kawamoto
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga 5202192, Japan; (I.I.); (I.K.); (C.I.); (T.N.); (M.M.); (H.T.); (M.E.)
| | - Chizuru Iwatani
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga 5202192, Japan; (I.I.); (I.K.); (C.I.); (T.N.); (M.M.); (H.T.); (M.E.)
| | - Takahiro Nakagawa
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga 5202192, Japan; (I.I.); (I.K.); (C.I.); (T.N.); (M.M.); (H.T.); (M.E.)
| | - Mitsuru Murase
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga 5202192, Japan; (I.I.); (I.K.); (C.I.); (T.N.); (M.M.); (H.T.); (M.E.)
| | - Hideaki Tsuchiya
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga 5202192, Japan; (I.I.); (I.K.); (C.I.); (T.N.); (M.M.); (H.T.); (M.E.)
| | - Hiroyuki Urano
- Safety Research Center, Ina Research Inc., Nagano 3994501, Japan; (H.U.); (K.N.)
| | - Masatsugu Ema
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga 5202192, Japan; (I.I.); (I.K.); (C.I.); (T.N.); (M.M.); (H.T.); (M.E.)
| | - Kazumasa Ogasawara
- Department of Pathology, Shiga University of Medical Science, Shiga 5202192, Japan; (H.I.); (T.S.); (K.O.)
| | - Daisuke Aoki
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo 1608582, Japan; (Y.M.); (M.A.); (K.B.); (D.A.)
| | - Kenshi Nakagawa
- Safety Research Center, Ina Research Inc., Nagano 3994501, Japan; (H.U.); (K.N.)
| | - Takashi Shiina
- Department of Molecular Life Science, Division of Basic Medical Science and Molecular Medicine, Tokai University School of Medicine, Kanagawa 2591193, Japan;
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Akouri R, Maalouf G, Abboud J, Nakad T, Bedran F, Hajj P, Beaini C, Cricu LM, Aftimos G, El Hajj C, Eid G, Waked A, Hallit R, Gerges C, Rached EA, Matta M, El Khoury M, Barakat A, Kvarnström N, Dahm-Kähler P, Brännström M. First live birth after uterus transplantation in the Middle East. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2020. [DOI: 10.1186/s43043-020-00041-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Abstract
Background
The first live birth after uterus transplantation took place in Sweden in 2014. It was the first ever cure for absolute uterine factor infertility. We report the surgery, assisted reproduction, and pregnancy behind the first live birth after uterus transplantation in the Middle East, North Africa, and Turkey (MENAT) region.
A 24-year old woman with congenital absence of the uterus underwent transplantation of the uterus donated by her 50-year-old multiparous mother. In vitro fertilization was performed to cryopreserve embryos. Both graft retrieval and transplantation were performed by laparotomy. Donor surgery included isolation of the uterus, together with major uterine arteries and veins on segments of the internal iliac vessels bilaterally, the round ligaments, and the sacrouterine ligaments, as well as with bladder peritoneum. Recipient surgery included preparation of the vaginal vault, end-to-side anastomosis to the external iliac arteries and veins on each side, and then fixation of the uterus.
Results
One in vitro fertilization cycle prior to transplantation resulted in 11 cryopreserved embryos. Surgical time of the donor was 608 min, and blood loss was 900 mL. Cold ischemia time was 85 min. Recipient surgical time was 363 min, and blood loss was 700 mL. Anastomosis time was 105 min. Hospital stay was 7 days for both patients. Ten months after the transplantation, one previously cryopreserved blastocyst was transferred which resulted in viable pregnancy, which proceeded normally (except for one episode of minor vaginal bleeding in the 1st trimester) until cesarean section at 35 + 1 weeks due to premature contractions and shortened cervix. A healthy girl (Apgar 9-10-10) weighing 2620 g was born in January 2020, and her development has been normal during the first 6 months.
Conclusions
This is the first report of a healthy live birth after uterus transplantation in the MENAT region. We hope that this will motivate further progress and additional clinical trials in this area in the Middle East Region, where the first uterus transplantation attempt ever, however unsuccessful, was performed already three decades ago.
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47
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Kisu I, Banno K, Obara H, Kato Y, Yamada Y, Matsubara K, Matoba Y, Adachi M, Emoto K, Masugi Y, Saiki Y, Ishigaki H, Itagaki I, Kawamoto I, Iwatani C, Nakagawa T, Murase M, Tsuchiya H, Nakagawa K, Shiina T, Aoki D. Experimental techniques for the development of a uterus transplantation model in cynomolgus macaques. J Obstet Gynaecol Res 2020; 46:2251-2260. [PMID: 32924267 DOI: 10.1111/jog.14477] [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: 07/28/2020] [Accepted: 08/30/2020] [Indexed: 01/02/2023]
Abstract
Uterus transplantation (UTx) is now a treatment for women with uterine factor infertility to have a child. However, UTx is still largely at the experimental stage, and many medical issues remain unsolved. Therefore, adequate studies in large animals including non-human primates are required for validation of these issues. UTx research, especially in non-human primates, can provide important information for its full establishment in humans due to the anatomical and physiological similarities between the two. We accumulated data from UTx studies using cynomolgus macaques since 2009 and established autologous and allogeneic UTx models which led to deliveries after performing the procedure. In this paper, we summarized key points to develop UTx models in cynomolgus macaques based on our experience. UTx models in non-human primates can surely contribute new and beneficial knowledge in this field and can be useful for the further development of UTx in humans.
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Affiliation(s)
- Iori Kisu
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Kouji Banno
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yojiro Kato
- Department of Surgery, Division of Gastroenterological and General Surgery, School of Medicine, Showa University, Tokyo, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yusuke Matoba
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Masataka Adachi
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Katsura Emoto
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Masugi
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Saiki
- Department of Anesthesiology, Saiseikai Kanagawaken Hospital, Kanagawa, Japan
| | - Hirohito Ishigaki
- Department of Pathology, Shiga University of Medical Science, Shiga, Japan
| | - Iori Itagaki
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga, Japan
| | - Ikuo Kawamoto
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga, Japan
| | - Chizuru Iwatani
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga, Japan
| | - Takahiro Nakagawa
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga, Japan
| | - Mitsuru Murase
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga, Japan
| | - Hideaki Tsuchiya
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga, Japan
| | | | - Takashi Shiina
- Department of Molecular Life Science, Division of Basic Medical Science and Molecular Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Daisuke Aoki
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
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Herlin MK, Petersen MB, Brännström M. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome: a comprehensive update. Orphanet J Rare Dis 2020; 15:214. [PMID: 32819397 PMCID: PMC7439721 DOI: 10.1186/s13023-020-01491-9] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/05/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, also referred to as Müllerian aplasia, is a congenital disorder characterized by aplasia of the uterus and upper part of the vagina in females with normal secondary sex characteristics and a normal female karyotype (46,XX). MAIN BODY The diagnosis is often made during adolescence following investigations for primary amenorrhea and has an estimated prevalence of 1 in 5000 live female births. MRKH syndrome is classified as type I (isolated uterovaginal aplasia) or type II (associated with extragenital manifestations). Extragenital anomalies typically include renal, skeletal, ear, or cardiac malformations. The etiology of MRKH syndrome still remains elusive, however increasing reports of familial clustering point towards genetic causes and the use of various genomic techniques has allowed the identification of promising recurrent genetic abnormalities in some patients. The psychosexual impact of having MRKH syndrome should not be underestimated and the clinical care foremost involves thorough counselling and support in careful dialogue with the patient. Vaginal agenesis therapy is available for mature patients following therapeutical counselling and education with non-invasive vaginal dilations recommended as first-line therapy or by surgery. MRKH syndrome involves absolute uterine factor infertility and until recently, the only option for the patients to achieve biological motherhood was through gestational surrogacy, which is prohibited in most countries. However, the successful clinical trial of uterus transplantation (UTx) by a Swedish team followed by the first live-birth in September, 2014 in Gothenburg, proofed the first available fertility treatment in MRKH syndrome and UTx is now being performed in other countries around the world allowing women with MRKH syndrome to carry their own child and achieve biological motherhood. CONCLUSION Several advances in research across multiple disciplines have been made in the recent years and this kaleidoscopic review provides a current status of various key aspects in MRKH syndrome and provides perspectives for future research and improved clinical care.
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Affiliation(s)
- Morten Krogh Herlin
- Department of Clinical Genetics, Aalborg University Hospital, Aalborg, Denmark.
- Department of Clinical Genetics, Aarhus University Hospital, Brendstrupgårdsvej 21C, DK-8200, Aarhus N, Denmark.
| | - Michael Bjørn Petersen
- Department of Clinical Genetics, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, Gothenburg, Sweden
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49
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Kisu I, Emoto K, Masugi Y, Yamada Y, Matsubara K, Obara H, Matoba Y, Banno K, Kato Y, Saiki Y, Itagaki I, Kawamoto I, Iwatani C, Murase M, Nakagawa T, Tsuchiya H, Ishigaki H, Urano H, Ema M, Ogasawara K, Aoki D, Nakagawa K, Shiina T. Clinical features of irreversible rejection after allogeneic uterus transplantation in cynomolgus macaques. Sci Rep 2020; 10:13910. [PMID: 32807830 PMCID: PMC7431528 DOI: 10.1038/s41598-020-70914-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 07/22/2020] [Indexed: 11/30/2022] Open
Abstract
Uterus transplantation (UTx) is a potential option for women with uterine factor infertility to have a child. The clinical features indicating irreversible rejection of the uterus are unknown. In our experimental series of allogeneic UTx in cynomolgus macaques, six female macaques were retrospectively examined, which were unresponsive to treatment with immunosuppressants (i.e. irreversible rejection). Clinical features including general condition, hematology, uterine size, indocyanine green (ICG) fluorescence imaging by laparotomy, and histopathological findings of the removed uterus were evaluated. In all cases, general condition was good at the time of diagnosis of irreversible rejection and thereafter. Laboratory evaluation showed temporary increases in white blood cells, lactate dehydrogenase and C-reactive protein, then these levels tended to decrease gradually. In transabdominal ultrasonography, the uterus showed time-dependent shrinkage after transient swelling at the time of diagnosis of irreversible rejection. In laparotomy, a whitish transplanted uterus was observed and enhancement of the transplanted uterus was absent in ICG fluorescence imaging. Histopathological findings in each removed uterus showed hyalinized fibrosis, endometrial deficit, lymphocytic infiltration and vasculitis. These findings suggest that uterine transplantation rejection is not fatal, in contrast to rejection of life-supporting organs. Since the transplanted uterus with irreversible rejection atrophies naturally, hysterectomy may be unnecessary.
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Affiliation(s)
- Iori Kisu
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi , Shinjuku-ku, Tokyo, 1608582, Japan.
| | - Katsura Emoto
- Department of Pathology, Keio University School of Medicine, Shinjuku, Tokyo, 1608582, Japan
| | - Yohei Masugi
- Department of Pathology, Keio University School of Medicine, Shinjuku, Tokyo, 1608582, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Shinjuku, Tokyo, 1608582, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, 1608582, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Shinjuku, Tokyo, 1608582, Japan
| | - Yusuke Matoba
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi , Shinjuku-ku, Tokyo, 1608582, Japan
| | - Kouji Banno
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi , Shinjuku-ku, Tokyo, 1608582, Japan
| | - Yojiro Kato
- Department of Surgery, Division of Gastroenterological and General Surgery, School of Medicine, Showa University, Shinagawa, Tokyo, 1428666, Japan
| | - Yoko Saiki
- Department of Anesthesiology, Saiseikai Kanagawaken Hospital, Yokohama, Kanagawa, 2210821, Japan
| | - Iori Itagaki
- Research Center for Animal Life Science, Shiga University of Medical Science, Ōtsu, Shiga, 5202192, Japan.,The Corporation for Production and Research of Laboratory Primates, Tsukuba, Ibaraki, 3050003, Japan
| | - Ikuo Kawamoto
- Research Center for Animal Life Science, Shiga University of Medical Science, Ōtsu, Shiga, 5202192, Japan
| | - Chizuru Iwatani
- Research Center for Animal Life Science, Shiga University of Medical Science, Ōtsu, Shiga, 5202192, Japan
| | - Mitsuru Murase
- Research Center for Animal Life Science, Shiga University of Medical Science, Ōtsu, Shiga, 5202192, Japan
| | - Takahiro Nakagawa
- Research Center for Animal Life Science, Shiga University of Medical Science, Ōtsu, Shiga, 5202192, Japan
| | - Hideaki Tsuchiya
- Research Center for Animal Life Science, Shiga University of Medical Science, Ōtsu, Shiga, 5202192, Japan
| | - Hirohito Ishigaki
- Department of Pathology, Shiga University of Medical Science, Ōtsu, Shiga, 5202192, Japan
| | - Hiroyuki Urano
- Safety Research Center, Ina Research Inc., Ina, Nagano, 3994501, Japan
| | - Masatsugu Ema
- Research Center for Animal Life Science, Shiga University of Medical Science, Ōtsu, Shiga, 5202192, Japan
| | - Kazumasa Ogasawara
- Research Center for Animal Life Science, Shiga University of Medical Science, Ōtsu, Shiga, 5202192, Japan.,Department of Pathology, Shiga University of Medical Science, Ōtsu, Shiga, 5202192, Japan
| | - Daisuke Aoki
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi , Shinjuku-ku, Tokyo, 1608582, Japan
| | - Kenshi Nakagawa
- Safety Research Center, Ina Research Inc., Ina, Nagano, 3994501, Japan
| | - Takashi Shiina
- Department of Molecular Life Science, Division of Basic Medical Science and Molecular Medicine, Tokai University School of Medicine, Hiratsuka, Kanagawa, 2591193, Japan
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50
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Living-Donor Uterus Transplantation: Pre-, Intra-, and Postoperative Parameters Relevant to Surgical Success, Pregnancy, and Obstetrics with Live Births. J Clin Med 2020; 9:jcm9082485. [PMID: 32756295 PMCID: PMC7464820 DOI: 10.3390/jcm9082485] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 01/10/2023] Open
Abstract
Uterus transplantation (UTx) can provide a route to motherhood for women with Mayer–Rokitansky–Küster–Hauser syndrome (MRKHS), a congenital disorder characterized by uterovaginal aplasia, but with functional ovaries. Based on our four successful living-donor transplantations and two resulting births, this analysis presents parameters relevant to standardizing recipient/donor selection, UTx surgery, and postoperative treatment, and their implementation in routine settings. We descriptively analyzed prospectively collected observational data from our four uterus recipients, all with MRKHS, their living donors, and the two newborns born to two recipients, including 1-year postnatal follow-ups. Analysis included only living-donor/recipient pairs with completed donor/recipient surgery. Two recipients, both requiring ovarian restimulation under immunosuppression after missed pregnancy loss in one case and no pregnancy in the other, each delivered a healthy boy by cesarean section. We conclude that parameters crucial to successful transplantation, pregnancy, and childbirth include careful selection of donor/recipient pairs, donor organ quality, meticulous surgical technique, a multidisciplinary team approach, and comprehensive follow-up. Surgery duration and blood vessel selection await further optimization, as do the choice and duration of immunosuppression, which are crucial to timing the first embryo transfer. Data need to be collected in an international registry due to the low prevalence of MRKHS.
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