1
|
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.
Collapse
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
| |
Collapse
|
2
|
Johannesson L, Testa G, Beshara MM, da Graca B, Walter JR, Quintini C, Latif N, Hashimoto K, Richards EG, O’Neill K. Awareness and Interest in Uterus Transplantation over Time: Analysis of Those Seeking Surgical Correction for Uterine-Factor Infertility in the US. J Clin Med 2023; 12:4201. [PMID: 37445236 PMCID: PMC10342774 DOI: 10.3390/jcm12134201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/07/2023] [Accepted: 06/15/2023] [Indexed: 07/15/2023] Open
Abstract
This study describes the characteristics of women who contacted an active program performing uterus transplantation (UTx) in the US, expressing interest in becoming a uterus transplant recipient or a living donor. Basic demographic and self-reported clinical information was collected from women who contacted any of the three US UTx programs from 2015 to July 2022. The three centers received 5194 inquiries about becoming a UTx recipient during the study timeframe. Among those reporting a cause of infertility, almost all of the reports (4066/4331, 94%) were absence of a uterus, either congenitally (794/4066, 20%) or secondary to hysterectomy (3272/4066, 80%). The mean age was 34 years, and 49% (2545/5194) had at least one child at the time of application. The two centers using living donors received 2217 inquiries about becoming living donors. The mean age was 34 years, and 60% (1330/2217) had given birth to ≥1 child. While most of the UTx clinical trial evidence has focused on young women with congenital absence of the uterus, these results show interest from a much broader patient population in terms of age, cause of infertility, and parity. These results raise questions about whether and to what extent the indications and eligibility criteria for UTx should be expanded as the procedure transitions from the experimental phase to being offered as a clinical treatment.
Collapse
Affiliation(s)
- Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75246, USA
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Menas M. Beshara
- TX A&M College of Medicine, Texas A&M University, Dallas, TX 75231, USA
| | - Briget da Graca
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX 75246, USA
| | - Jessica R. Walter
- Department of Obstetrics & Gynecology, Northwestern University, Chicago, IL 60611, USA
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Nawar Latif
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19107, USA
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH 44103, USA
| | - Elliott G. Richards
- Obstetrics and Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland, OH 44103, USA
| | - Kathleen O’Neill
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA 19107, USA
| |
Collapse
|
3
|
Hartman N, James C, Barrera EP, Grimstad FW, El-Arabi AM. Effects on Fertility and the Preservation of Fertility in the Transgender Patient. CURRENT SEXUAL HEALTH REPORTS 2023. [DOI: 10.1007/s11930-023-00355-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
|
4
|
Uterus Transplantation: Revisiting the Question of Deceased Donors versus Living Donors for Organ Procurement. J Clin Med 2022; 11:jcm11154516. [PMID: 35956131 PMCID: PMC9369769 DOI: 10.3390/jcm11154516] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/26/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Uterus transplantation is a surgical treatment for women with congenital or acquired uterine factor infertility. While uterus transplantation is a life-enhancing transplant that is commonly categorized as a vascular composite allograft (e.g., face or hand), it is similar to many solid organ transplants (e.g., kidney) in that both living donors (LDs) and deceased donors (DDs) can be utilized for organ procurement. While many endpoints appear to be similar for LD and DD transplants (including graft survival, time to menses, livebirth rates), there are key medical, technical, ethical, and logistical differences between these modalities. Primary considerations in favor of a LD model include thorough screening of donors, enhanced logistics, and greater donor availability. The primary consideration in favor of a DD model is the lack of physical or psychological harm to a living donor. Other important factors, that may not clearly favor one approach over the other, are important to include in discussions of LD vs. DD models. We favor a stepwise approach to uterus transplantation, one in which programs first begin with DD procurement before attempting LD procurement to maximize successful organ recovery and to minimize potential harms to a living donor.
Collapse
|
5
|
Chung RK, Salari S, Findley J, Richards EG, Flyckt RLR. Uterine Transplantation: Recipient Patient Populations. Clin Obstet Gynecol 2022; 65:15-23. [PMID: 35045021 DOI: 10.1097/grf.0000000000000672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Uterine transplantation is an emerging treatment for patients with uterine factor infertility (UFI). In order to determine patient candidacy for transplant, it is imperative to understand how to identify, counsel and treat uterine transplant recipients. In this article, we focus on patient populations with UFI, whether congenital or acquired, including Mayer-Rokitansky-Kuster-Hauser, complete androgen insensitivity syndrome, hysterectomy, and other causes of nonabsolute UFI. Complete preoperative screening of recipients should be required to assess the candidacy of each individual prior to undergoing this extensive treatment option.
Collapse
Affiliation(s)
- Rebecca K Chung
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Beachwood
| | - Salomeh Salari
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Beachwood
| | - Joseph Findley
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Beachwood
| | | | - Rebecca L R Flyckt
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Beachwood
| |
Collapse
|
6
|
Polk H, Johannesson L, Testa G, Wall AE. The Future of Uterus Transplantation: Cost, Regulations, and Outcomes. Clin Obstet Gynecol 2022; 65:101-107. [PMID: 35045031 DOI: 10.1097/grf.0000000000000685] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Uterus transplantation (UTx) has evolved rapidly since technical success was first demonstrated, and is now practiced worldwide, using both living and deceased donors. As UTx transitions from an experimental to widely available standard clinical procedure, new challenges and questions are becoming more urgent. These include issues of cost and coverage, the establishment of guidelines and registries to ensure quality of care and monitor outcomes, regulatory oversight (including for the allocation organs from deceased donors), and the extent to which indications for UTx should be expanded.
Collapse
Affiliation(s)
| | - Liza Johannesson
- Obstetrics and Gynecology
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Anji E Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| |
Collapse
|
7
|
da Graca B, Johannesson L, Testa G, Wall AE. The Ethical Evolution of Uterus Transplantation From Concept to Clinical Procedure. Clin Obstet Gynecol 2022; 65:24-36. [PMID: 35045022 DOI: 10.1097/grf.0000000000000687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Uterus transplantation (UTx) offers women with absolute uterine factor infertility a path to motherhood that enables them to carry their own pregnancy. Debates about the ethics of UTx have evolved in tandem with its clinical evolution: clinical trials have provided evidence regarding risks and benefits to donors and recipients that were initially uncertain; technical advances have altered the balance between risks and benefits; and the experiences of donors and recipients has revealed questions that were not anticipated. As UTx transitions to a clinical procedure, questions remain about long-term risks and benefits, applications beyond carrying a pregnancy, and cost and access.
Collapse
Affiliation(s)
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
| | - Anji E Wall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center
| |
Collapse
|
8
|
da Graca B, Johannesson L, Testa G, Wall A. Uterus transplantation: ethical considerations. Curr Opin Organ Transplant 2021; 26:664-668. [PMID: 34636768 DOI: 10.1097/mot.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Uterus transplantation (Utx) offers women with absolute uterine factor infertility the opportunity to carry their own pregnancies. As Utx transitions from an experimental to standard clinical procedure, we review the status of the ethical issues applicable to the stakeholders involved. RECENT FINDINGS With more than 65 Utx procedures reported to date, evidence is accruing that enables the chance of success - a live birth - for the recipient to be weighed against the risks the recipient incurs through the Utx process, as well as risks to living donors undergoing surgery, to children exposed in utero to immunosuppressants and the uterine graft environment, and to third parties related to uterus procurement from multiorgan deceased donors. Experience has also informed aspects of recipient and donor autonomy that must be safeguarded. SUMMARY Clinical trial results provides a basis for weighing the interests of the stakeholders implicated in Utx, and so can inform transplant centers' and regulatory bodies' development of policies and protocols that will determine access to Utx and allocation of organs, together with other considerations of justice. Additional evidence, particularly on long-term outcomes, is needed, and new questions can be expected to arise as access to and indications for Utx broaden.
Collapse
Affiliation(s)
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas, USA
| | | | - Anji Wall
- Annette C. and Harold C. Simmons Transplant Institute
| |
Collapse
|
9
|
Xun H, Fadavi D, Darrach H, Fischer N, Yesantharao P, Kraenzlin F, Nickles Fader A, Segars JH, Sacks JM. Recognizing the Vulnerable: Perspectives, Attitudes, and Interests of Women With Uterine Factor Infertility Towards Uterus Allotransplantation. Cureus 2021; 13:e18891. [PMID: 34804735 PMCID: PMC8599396 DOI: 10.7759/cureus.18891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Uterine allotransplantation (UTx) is a novel therapy to allow women with uterine factor infertility (UFI) to bear their own children. To date, over 60 UTx have been performed, resulting in 15 live births. Our study investigates the attitudes, perspectives, and interests of women with UFI towards UTx. METHODS Anonymous questionnaires were distributed electronically to women diagnosed with UFI at Johns Hopkins Hospital between the years 2003 and 2018. RESULTS Thirty-one women with UFI were identified, resulting in 10 completed surveys. The average age was 31.7 ± 6.31 years, and the average age of diagnosis was 20 years (range 14-31); all 10 surveyed women had congenital UFI. Of note, 80% of women agreed that UTx should be an option for women with UFI, and 90% would consider receiving a UTx. The majority of the nine (90%) women who had previously heard of UTx learned about it from the news (5, 50%). When asked to rank the risks related to UTx in order of personal importance, only two women ranked themselves most important; the other woman ranked fetus and donor as more important. All women had health insurance (70% had private insurance), and 90% believed that UTx should be covered by health insurance. CONCLUSIONS We surveyed women with UFI and found that the majority are willing to have UTx, despite the associated risks of the procedure. Taking into consideration the responses for ranking the importance of risks of the procedure, women with UFI should be considered a vulnerable population, requiring special considerations for UTx informed consents.
Collapse
Affiliation(s)
- Helen Xun
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Darya Fadavi
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Halley Darrach
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Nicole Fischer
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Pooja Yesantharao
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Franca Kraenzlin
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Amanda Nickles Fader
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - James H Segars
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, USA
| |
Collapse
|
10
|
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.
Collapse
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.
| |
Collapse
|
11
|
Aljerian K. Uterine transplant: an ethical framework analysis from a Middle Eastern perspective. Curr Med Res Opin 2021; 37:1049-1060. [PMID: 33705236 DOI: 10.1080/03007995.2021.1902296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Significant advances in infertility treatment have been achieved over the past several decades, but women with uterine dysfunction, anomaly, or agenesis still need support to carry a pregnancy to term. Recently, advancements in surgical, anesthetic and immunosuppressive therapy have brought the idea of successful uterine transplant closer to reality, but many challenges must be overcome before uterine transplant can become more common, including ethical challenges related to the study and the conduct of this procedure. METHODS This was an updated ethical analysis of uterine transplant from a Middle Eastern perspective, using an established ethical framework that has been adapted for the analysis of research in non-Western cultures and developing countries. RESULTS Using the ethical framework, this analysis explored research developments in uterine transplant to date, using the following categories: collaborative partnership, social value, scientific validity, a fair selection of study population, favorable risk-benefit ratio, independent review, informed consent, and respect for recruited participants. The analysis revealed a significant need for region- and religion-specific ethical guidelines for uterine transplant procedures. CONCLUSIONS The horizons of research need to expand by addressing and researching the ethical issues related to uterine transplant trials and clinical procedures. LIMITATIONS Limitations included the challenges related to applying ethical analyses to work in developing countries, and the fact that this analysis was based on the views and interpretations of a single researcher.
Collapse
Affiliation(s)
- Khaldoon Aljerian
- Forensic and Legal Medicine Unit, Department of Pathology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
12
|
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.
Collapse
|
13
|
Georgevsky D, Li Y, Pather S, Tejada-Berges T, Robinson D, Laurence J, Campbell N, Wyburn K, Liyanagama K, Narayan R, Lutz T, Chan A, Heaney SA, Kitzing YX, Anderson L, Testa G, Johannesson L, Marren A. Uterus transplantation and pregnancy induction: Approved protocol at the Royal Prince Alfred Hospital. Aust N Z J Obstet Gynaecol 2021; 61:621-624. [PMID: 33956989 DOI: 10.1111/ajo.13364] [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: 11/10/2020] [Revised: 03/24/2021] [Accepted: 04/02/2021] [Indexed: 12/21/2022]
Abstract
Absolute uterine factor infertility (AUFI) is defined as the absence of a uterus or the presence of a non-functional uterus. Before the first live birth from a uterus transplant in 2014, the only fertility options for women with AUFI were surrogacy and adoption. In November 2019, our team was granted approval for the first uterus transplant trial in Australia using known living donors. Our program is based on that of our overseas collaborators in Dallas, Texas; this team will also be proctoring us for our first two cases.
Collapse
Affiliation(s)
- Dana Georgevsky
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Institute for Women, Children and their Families, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Ying Li
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Selvan Pather
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Trevor Tejada-Berges
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - David Robinson
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Jerome Laurence
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
| | - Neil Campbell
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Kate Wyburn
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Keith Liyanagama
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Rajit Narayan
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Tracey Lutz
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Agnes Chan
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Sally-Ann Heaney
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Yu Xuan Kitzing
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Lyndal Anderson
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute at Baylor University Medical Centre Dallas, Dallas, Texas, USA
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute at Baylor University Medical Centre Dallas, Dallas, Texas, USA
| | - Anthony Marren
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Institute for Women, Children and their Families, Sydney Local Health District, Camperdown, New South Wales, Australia.,Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
| |
Collapse
|
14
|
Kamranpour B, Noroozi M, Bahrami M. Termination of Pregnancy for Fetal Anomalies: A Qualitative Study of the Informational and Educational Needs of Women. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2021; 26:97-103. [PMID: 34036055 PMCID: PMC8132862 DOI: 10.4103/ijnmr.ijnmr_94_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/03/2020] [Accepted: 01/03/2021] [Indexed: 11/21/2022]
Abstract
Background: Diagnosing congenital fetal anomalies before birth is considered an emotionally devastating experience. To facilitate the process of compatibility with this event, healthcare providers should determine various needs of these women. The present study was conducted to explore the informational and educational needs of women who have experienced pregnancy termination because of fetal anomalies. Materials and Methods: The present study was a qualitative content analysis. Forty participants (women, their spouses, and healthcare providers) in Rasht city, Iran, were selected using purposive sampling method with maximum variety and their data were gathered using in-depth interviews and field notes. Data were analyzed using conventional qualitative content analysis with Graneheim and Lundman approach. Results: After analyzing the text of the interviews, the informational and educational needs of women who have experienced pregnancy termination because of fetal anomalies were categorized in three main categories of “receiving information tailored to the client's circumstances,” “learning life skills to cope,” and “getting prepared for the next pregnancy.” Conclusions: The results, by exploring and magnifying the informational and educational needs of these women, could present an appropriate context for providing principal care and cultural-based interventions with an emphasis on comprehensive education and counseling. Also, proper implementation of the process of obtaining informed consent from the women to terminate the pregnancy is essential. These could facilitate the conditions for their return to normal life and ultimately promote their health.
Collapse
Affiliation(s)
- Bahareh Kamranpour
- Department of Midwifery, College of Nursing and Midwifery, Rasht Branch, Islamic Azad University, Rasht, Iran
| | - Mahnaz Noroozi
- Department of Midwifery and Reproductive Health, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoud Bahrami
- Department of Adult Health Nursing, Nursing an Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
15
|
|
16
|
Mayhew AC, Gomez-Lobo V. Fertility Options for the Transgender and Gender Nonbinary Patient. J Clin Endocrinol Metab 2020; 105:5892794. [PMID: 32797184 PMCID: PMC7455280 DOI: 10.1210/clinem/dgaa529] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
Comprehensive care for transgender and gender nonbinary patients has been a priority established by the World Professional Association for Transgender Health. Because pubertal suppression, gender-affirming hormone therapy, and antiandrogen therapy used alone or in combination during medical transition can affect gonadal function, understanding the effects these treatments have on fertility potential is important for practitioners caring for transgender and gender nonbinary patients. In this review, we outline the impacts of gender-affirming treatments on fertility potential and discuss the counseling and the treatment approach for fertility preservation and/or family building in transgender and gender nonbinary individuals.
Collapse
Affiliation(s)
- Allison C Mayhew
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Children’s National Medical Center, Washington, DC
| | - Veronica Gomez-Lobo
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
- Children’s National Medical Center, Washington, DC
- Correspondence and Reprint Requests: Veronica Gomez-Lobo, MD, National Institute of Child Health and Human Development, Children’s National Medical Center, Division of Pediatric and Adolescent Gynecology, 10 Central Dr, Bldg 10, Rm 8N248, Bethesda, MD 20892, USA. E-mail:
| |
Collapse
|
17
|
Tholance Y, Tricard J, Chianea T, Marquet P, Ponsonnard S, Sturtz F, Piccardo A, Gauthier T. Metabolic alterations of uterine grafts after extended cold ischemic storage: experimental study in ewes. Mol Hum Reprod 2020; 25:647-659. [PMID: 31323687 DOI: 10.1093/molehr/gaz041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/06/2019] [Accepted: 07/10/2019] [Indexed: 01/14/2023] Open
Abstract
Uterine transplantation from a deceased donor could become an available option for widely treating uterine infertility. However, this procedure requires more precise knowledge about the graft's tolerance to extended cold ischemia. Here, we sought to assess the uterine metabolic alterations after extended cold ischemic storage in a model of auto-transplantation in ewe. A total of 14 uterine auto-transplantations were performed, divided into 2 groups: 7 after 3 h of cold ischemia time (CIT) and 7 after 24 h. Venous uterine blood was collected before uterus retrieval and during reperfusion (30, 60 and 90 min); thereafter, blood gases, lactate, glucose and amino acids (AAs) were analyzed. Apoptosis analyses were performed before uterus retrieval and following reperfusion in uterus biopsies. A total of 12 uterine auto-transplantations were successfully performed and 7 ewes were alive ≥8 days after transplantation. After reperfusion, a decrease in pH, a rise of lactate and lactate/glucose ratio and a delayed decrease of pO2 were found in the 3 h CIT group. No significant variation of these parameters was observed in the 24 h CIT group. Significant decreases of AAs were observed during reperfusion and these decreases were more pronounced and concerned a larger number of compounds in the 24 h CIT group than in the 3 h CIT group. There was no significant uterine apoptotic signal in either group. Overall, these results suggest that extended CIT storage delayed restoration of aerobic glycolysis and induced an increase in AA requirements of the uterus after reperfusion. However, this biochemical alteration did not reduce success rate for uterine transplantation.
Collapse
Affiliation(s)
- Yannick Tholance
- Department of Biochemistry and Molecular Genetics, Dupuytren University Hospital, F-87000 Limoges, France.,Synaptopathies and Autoantibodies, Institut NeuroMyoGene Institut national de la santé et de la recherche médicale (INSERM) U1217/Centre national de la recherche scientifique (CNRS) Unités Mixtes de Recherche (UMR) 5310, University of Lyon, University Jean-Monnet, F-42270 Saint-Priest-en-Jarez, France
| | - Jeremy Tricard
- Department of Thoracic and Cardiovascular Surgery and Angiology, Dupuytren University Hospital, F-87000 Limoges, France.,Individual Profiling and Prevention of Risks with Immunosuppressive Therapies and Transplantation, UMR 1248 INSERM, School of Medicine, University of Limoges, F-87000 Limoges, France
| | - Thierry Chianea
- Department of Biochemistry and Molecular Genetics, Dupuytren University Hospital, F-87000 Limoges, France
| | - Pierre Marquet
- Individual Profiling and Prevention of Risks with Immunosuppressive Therapies and Transplantation, UMR 1248 INSERM, School of Medicine, University of Limoges, F-87000 Limoges, France.,Department of Pharmacology and Toxicology, Dupuytren University Hospital, F-87000 Limoges, France
| | | | - Franck Sturtz
- Department of Biochemistry and Molecular Genetics, Dupuytren University Hospital, F-87000 Limoges, France.,EA 6309-Myelin Maintenance and Peripheral Neuropathies, School of Medicine, University of Limoges, F-87000 Limoges, France
| | - Alessandro Piccardo
- Department of Thoracic and Cardiovascular Surgery and Angiology, Dupuytren University Hospital, F-87000 Limoges, France
| | - Tristan Gauthier
- Individual Profiling and Prevention of Risks with Immunosuppressive Therapies and Transplantation, UMR 1248 INSERM, School of Medicine, University of Limoges, F-87000 Limoges, France.,Department of Gynecology and Obstetrics, Dupuytren University Hospital, F-87000 Limoges, France
| |
Collapse
|
18
|
Farrell RM, Johannesson L, Flyckt R, Richards EG, Testa G, Tzakis A, Falcone T. Evolving ethical issues with advances in uterus transplantation. Am J Obstet Gynecol 2020; 222:584.e1-584.e5. [PMID: 31981513 DOI: 10.1016/j.ajog.2020.01.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 12/12/2022]
Abstract
While uterus transplantation was once considered only a theoretical possibility for patients with uterine factor infertility, researchers have now developed methods of transplantation that have led to successful pregnancies with multiple children born to date. Because of the unique and significant nature of this type of research, it has been undertaken with collaboration not only with scientists and physicians but also with bioethicists, who paved the initial path for research of uterus transplantation to take place. As the science of uterus transplantation continues to advance, so too must the public dialogue among obstetrician/gynecologists, transplant surgeons, bioethicists, and other key stakeholders in defining the continued direction of research in addition to planning for the clinical implementation of uterus transplantation as a therapeutic option. Given the rapid advances in this field, the time has come to revisit the fundamental questions raised at the inception of uterus transplantation and, looking forward, determine the future of this approach given emerging data on the procedure's impact on individuals, families, and society.
Collapse
|
19
|
Peters HE, Juffermans LJM, Lambalk CB, Dekker JJML, Fernhout T, Groenman FA, de Groot CJM, Hoksbergen AWJ, Huirne JAF, de Leeuw RA, van Mello NM, Nederhoed JH, Schats R, Verhoeven MO, Hehenkamp WJK. Feasibility study for performing uterus transplantation in the Netherlands. Hum Reprod Open 2020; 2020:hoz032. [PMID: 32128452 PMCID: PMC7048682 DOI: 10.1093/hropen/hoz032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/10/2019] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION Is it feasible to perform uterus transplantations (UTx) in a tertiary centre in the Netherlands? SUMMARY ANSWER Considering all ethical principles, surgical risks and financial aspects, we have concluded that at this time, it is not feasible to establish the UTx procedure at our hospital. WHAT IS KNOWN ALREADY UTx is a promising treatment for absolute uterine factor infertility. It is currently being investigated within several clinical trials worldwide and has resulted in the live birth of 19 children so far. Most UTx procedures are performed in women with the Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, a congenital disorder characterized by absence of the uterus. In the Netherlands, the only possible option for these women for having children is adoption or surrogacy. STUDY DESIGN SIZE DURATION We performed a feasibility study to search for ethical, medical and financial support for performing UTx at the Amsterdam UMC, location VUmc. PARTICIPANTS/MATERIALS SETTING METHODS For this feasibility study, we created a special interest group, including gynaecologists, transplant surgeons, researchers and a financial advisor. Also, in collaboration with the patients' association for women with MRKH, a questionnaire study was performed to research the decision-making in possible recipients. In this paper, we present an overview of current practices and literature on UTx and discuss the results of our feasibility study. MAIN RESULTS AND THE ROLE OF CHANCE A high level of interest from the possible recipients became apparent from our questionnaire amongst women with MRKH. The majority (64.8%) positively considered UTx with a live donor, with 69.6% having a potential donor available. However, this 'non-life-saving transplantation' requires careful balancing of risks and benefits. The UTx procedure includes two complex surgeries and unknown consequences for the unborn child. The costs for one UTx are calculated to be around €100 000 and will not be compensated by medical insurance. The Clinical Ethics Committee places great emphasis on the principle of non-maleficence and the 'fair distribution of health services'. LIMITATIONS REASONS FOR CAUTION In the Netherlands, alternatives for having children are available and future collaboration with experienced foreign clinics that offer the procedure is a possibility not yet investigated. WIDER IMPLICATIONS OF THE FINDINGS The final assessment of this feasibility study is that that there are not enough grounds to support this procedure at our hospital at this point in time. We will closely follow the developments and will re-evaluate the feasibility in the future. STUDY FUNDING/COMPETING INTERESTS This feasibility study was funded by the VU Medical Center (Innovation grant 2017). No conflicts of interest have been reported relevant to the subject of all authors. TRIAL REGISTRATION NUMBER n.a.
Collapse
Affiliation(s)
- H E Peters
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - L J M Juffermans
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - C B Lambalk
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J J M L Dekker
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - T Fernhout
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - F A Groenman
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - C J M de Groot
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - A W J Hoksbergen
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J A F Huirne
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - R A de Leeuw
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - N M van Mello
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - J H Nederhoed
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - R Schats
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - M O Verhoeven
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - W J K Hehenkamp
- Department of Obstetrics & Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| |
Collapse
|
20
|
Provider Knowledge and Support of Uterus Transplantation: Surveying Multidisciplinary Team Members. Mayo Clin Proc Innov Qual Outcomes 2020; 4:150-158. [PMID: 32280925 PMCID: PMC7140015 DOI: 10.1016/j.mayocpiqo.2019.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 10/21/2019] [Accepted: 11/13/2019] [Indexed: 01/23/2023] Open
Abstract
Objective To determine relevant provider opinions on uterus transplantation (UTx). Patients and Methods We invited 1933 providers in obstetrics and gynecology, transplant surgery, transplant medicine, internal medicine, and family medicine at a large, integrated health care system to complete an online survey containing a series of questions on their attitudes about the ethics and clinical utility of UTx. The survey was open from June 4, 2018, through July 2, 2018. We received 449 responses overall (23.2% response rate). Results Of 433 physicians who responded, 195 (45.0%) believe that UTx is ethically justified, and just over a third (160 of 446 [35.9%]) would introduce the possibility of UTx to a patient with absolute uterine factor infertility (AUFI). Respondents indicated the risks to donor, recipient, and child carried the most weight in their ethical evaluation and were most supportive of UTx in a patient with congenital uterine absence (334 of 743 [45.0%]; participants were allowed to choose more than one answer). A majority stated that a living or cadaveric donor would be an acceptable donor source (238 of 395 [60.3%]). Conclusion Provider support for UTx is qualified by safety concerns and its expansion to patient populations other than women with AUFI. This survey suggests that most providers limit their support of UTx to patients with the most demonstrated clinical need, childless women with AUFI.
Collapse
|
21
|
Ngaage LM, Ike S, Elegbede A, Vercler CJ, Gebran S, Liang F, Rada EM, Cooney C, Brandacher G, Redett RJ, Johannesson L, Rasko YM. The changing paradigm of ethics in uterus transplantation: a systematic review. Transpl Int 2019; 33:260-269. [PMID: 31674693 DOI: 10.1111/tri.13548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/03/2019] [Accepted: 10/28/2019] [Indexed: 11/27/2022]
Abstract
The first uterus transplantation was performed in 2000. As key milestones are reached (long-lasting graft survival in 2011, and first birth from a transplanted womb in 2014), the ethical debate around uterus transplant evolves. We performed a systematic review of articles on uterus transplantation. Ethical themes were extracted and categorized according to four bioethical principles. Papers were divided into time periods separated by key events in uterus transplant history: Phase I (first technical achievement, 2002-2011), Phase II (clinical achievement, 2012-2014), and Phase III (after the first childbirth, 2015-2018). Eighty-one articles were included. The majority of ethics papers were published in Phase III (65%, P < 0.0001), that is after the first birth. Eighty percent of papers discussed nonmaleficence making it the most discussed principle. The first birth acted as a pivotal point: nonmaleficence was discussed by a lower proportion of articles (P = 0.0073), as was beneficence (P = 0.0309). However, discussion of justice increased to become the most discussed principle of the time period (P = 0.0085). The ethical debate surrounding uterus transplantation has evolved around landmark events that signify scientific progress. As safety and efficacy become evident, the focus of ethical debate shifts from clinical equipoise to socioeconomic challenges and equitable access to uterus transplantation.
Collapse
Affiliation(s)
- Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Samantha Ike
- London North West University Healthcare Trust, London, UK
| | - Adekunle Elegbede
- Department of Plastic & Reconstructive Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian J Vercler
- Plastic Surgery Section, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Selim Gebran
- Division of Plastic & Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Fan Liang
- Division of Plastic & Reconstructive Surgery, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Erin M Rada
- Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Carisa Cooney
- Department of Plastic & Reconstructive Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gerald Brandacher
- Department of Plastic & Reconstructive Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic & Reconstructive Surgery, John Hopkins University School of Medicine, Baltimore, MD, USA
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| |
Collapse
|
22
|
Ngaage LM, Elegbede A, Sugarman J, Nam AJ, Cooney CM, Cooney DS, Rasko YM, Brandacher G, Redett RJ. The Baltimore Criteria for an ethical approach to penile transplantation: a clinical guideline. Transpl Int 2019; 33:471-482. [PMID: 31646681 DOI: 10.1111/tri.13545] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 09/20/2019] [Accepted: 10/18/2019] [Indexed: 12/20/2022]
Abstract
Significant advances and increasing acceptance of vascularized composite allotransplantation (VCA) have contributed to emerging success of penile transplantation. The aims of penile transplantation are fourfold: adequate urinary function, enabling natural erections, restoration of erogenous sensation and appearance of external male genitalia. Successful penile transplantation also requires limiting risks and managing complications of lifelong immunosuppression. Given the limited experience with this procedure, potential recipients must understand that penile transplantation is not currently standard of care and long-term functional outcomes are unknown. Moreover, these transplants are associated with complex ethical issues. Nevertheless, as the efficacy and safety of penile transplantation are being evaluated, clear indications for transplant are needed. Although preliminary recommendations have been proposed, a more comprehensive framework is needed. We performed a literature review for English language publications related to penile transplantation and ethics. Based on the results of the search, a review of prior recommendations, and our experience performing the first whole male genital allotransplantation including penis, scrotum and abdominal wall; screening and identifying potential donors and recipients for the procedure; and addressing the associated ethical issues, we propose guidelines for responsible penile transplantation: The Baltimore Criteria for an Ethical Approach to Penile Transplantation.
Collapse
Affiliation(s)
- Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Adekunle Elegbede
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeremy Sugarman
- Department of Medicine, Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Arthur J Nam
- Division of Plastic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Damon S Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
23
|
Sampson A, Kimberly LL, Goldman KN, Keefe DL, Quinn GP. Uterus transplantation in women who are genetically XY. JOURNAL OF MEDICAL ETHICS 2019; 45:687-689. [PMID: 30803984 DOI: 10.1136/medethics-2018-105222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/08/2019] [Accepted: 02/04/2019] [Indexed: 06/09/2023]
Abstract
Uterus transplantation is an emerging technology adding to the arsenal of treatments for infertility; specifically the only available treatment for uterine factor infertility. Ethical investigations concerning risks to uteri donors and transplant recipients have been discussed in the literature. However, missing from the discourse is the potential of uterus transplantation in other groups of genetically XY women who experience uterine factor infertility. There have been philosophical inquiries concerning uterus transplantation in genetically XY women, which includes transgender women and women with complete androgen insufficiency syndrome. We discuss the potential medical steps necessary and associated risks for uterus transplantation in genetically XY women. Presently, the medical technology does not exist to make uterus transplantation a safe and effective option for genetically XY women, however this group should not be summarily excluded from participation in trials. Laboratory research is needed to better understand and reduce medical risk and widen the field to all women who face uterine factor infertility.
Collapse
Affiliation(s)
- Amani Sampson
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York City, New York, USA
| | - Laura L Kimberly
- Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York City, New York, USA
- Division of Medical Ethics, Department of Population Health, New York University School of Medicine, New York City, New York, USA
| | - Kara N Goldman
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York City, New York, USA
| | - David L Keefe
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York City, New York, USA
| | - Gwendolyn P Quinn
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York City, New York, USA
- Division of Medical Ethics, Department of Population Health, New York University School of Medicine, New York City, New York, USA
| |
Collapse
|
24
|
O’Donovan L, Williams NJ, Wilkinson S. Ethical and policy issues raised by uterus transplants. Br Med Bull 2019; 131:19-28. [PMID: 31504233 PMCID: PMC6821981 DOI: 10.1093/bmb/ldz022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/09/2019] [Accepted: 06/20/2019] [Indexed: 12/15/2022]
Abstract
INTRODUCTION In 2014, Brännström and colleagues reported the first human live birth following uterine transplantation (UTx). Research into this treatment for absolute uterine factor infertility has since grown with clinical trials currently taking place across centers in at least thirteen countries worldwide. SOURCES OF DATA This review summarizes and critiques the academic literature on ethical and policy issues raised by UTx. AREAS OF AGREEMENT There is general agreement on the importance of risk reduction and, in principle, to the sharing and maintenance of patient data on an international registry. AREAS OF CONTROVERSY There are numerous areas of controversy ranging from whether it is ethically justified to carry out uterus transplants at all (considering the associated health risks) to how deceased donor organs for transplant should be allocated. This review focuses on three key issues: the choice between deceased and living donors, ensuring valid consent to the procedure and access to treatment. GROWING POINTS UTx is presently a novel and rare procedure but is likely to become more commonplace in the foreseeable future, given the large number of surgical teams working on it worldwide. AREAS TIMELY FOR DEVELOPING RESEARCH Uterus transplantation requires us to re-examine fundamental questions about the ethical and social value of gestation. If eventually extended to transgender women or even to men, it may also require us to reconceptualize what it is to be a 'father' or to be a 'mother', and the definition of these terms in law.
Collapse
Affiliation(s)
- Laura O’Donovan
- Department of Politics, Philosophy, & Religion, County South, Lancaster University, Lancaster, LA1 4YQ, United Kingdom
| | - Nicola Jane Williams
- Department of Politics, Philosophy, & Religion, County South, Lancaster University, Lancaster, LA1 4YQ, United Kingdom
| | - Stephen Wilkinson
- Department of Politics, Philosophy, & Religion, County South, Lancaster University, Lancaster, LA1 4YQ, United Kingdom
| |
Collapse
|
25
|
Abstract
OBJECTIVE We describe the first successful penis transplant in the United States in a patient with a history of subtotal penectomy for penile cancer. BACKGROUND Penis transplantation represents a new paradigm in restoring anatomic appearance, urine conduit, and sexual function after genitourinary tissue loss. To date, only 2 penis transplants have been performed worldwide. METHODS After institutional review board approval, extensive medical, surgical, and radiological evaluations of the patient were performed. His candidacy was reviewed by a multidisciplinary team of surgeons, physicians, psychiatrists, social workers, and nurse coordinators. After appropriate donor identification and recipient induction with antithymocyte globulin, allograft procurement and recipient preparation took place concurrently. Anastomoses of the urethra, corpora, cavernosal and dorsal arteries, dorsal vein, and dorsal nerves were performed, and also inclusion of a donor skin pedicle as the composite allograft. Maintenance immunosuppression consisted of mycophenolate mofetil, tacrolimus, and methylprednisolone. RESULTS Intraoperative, the allograft had excellent capillary refill and strong Doppler signals after revascularization. Operative reinterventions on postoperative days (PODs) 2 and 13 were required for hematoma evacuation and skin eschar debridement. At 3 weeks, no anastomotic leaks were detected on urethrogram, and the catheter was removed. Steroid resistant-rejection developed on POD 28 (Banff I), progressed by POD 32 (Banff III), and required a repeat course of methylprednisolone and antithymocyte globulin. At 7 months, the patient has recovered partial sensation of the penile shaft and has spontaneous penile tumescence. Our patient reports increased overall health satisfaction, dramatic improvement of self-image, and optimism for the future. CONCLUSIONS We have shown that it is feasible to perform penile transplantation with excellent results. Furthermore, this experience demonstrates that penile transplantation can be successfully performed with conventional immunosuppression. We propose that our successful penile transplantation pilot experience represents a proof of concept for an evolution in reconstructive transplantation.
Collapse
|
26
|
Abstract
Absolute uterine factor infertility is the final hurdle for assisted reproductive treatments. Uterus transplant trials are happening worldwide; to advance the debate around uterine transplantation (UTx), this article considers selection criteria for clinical trials from a UK perspective and makes recommendations for future selection criteria for UTx treatment. Recommendations advanced include the use of donor eggs, access for single women and women in same-sex relationships, prohibiting participation of women who are already mothers, and a preference for deceased donors and bioengineered uteri. With UTx treatment on the horizon, it is important to proactively consider future selection criteria. TWEETABLE ABSTRACT: Review of UK selection criteria for clinical trials for uterus transplantation; recommendations for the future.
Collapse
|
27
|
Cheng PJ, Pastuszak AW, Myers JB, Goodwin IA, Hotaling JM. Fertility concerns of the transgender patient. Transl Androl Urol 2019; 8:209-218. [PMID: 31380227 DOI: 10.21037/tau.2019.05.09] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Transgender individuals who undergo gender-affirming medical or surgical therapies are at risk for infertility. Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear. Gender-affirming surgery (GAS) that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility. It is recommended that clinicians counsel transgender patients on fertility preservation (FP) options prior to initiation of gender-affirming therapy. Transmen can choose to undergo cryopreservation of oocytes or embryos, which requires hormonal stimulation for egg retrieval. Uterus preservation allows transmen to gestate if desired. For transwomen, the option for FP is cryopreservation of sperm either through masturbation or testicular sperm extraction. Experimental and future options may include cryopreservation and in vitro maturation of ovarian or testicular tissue, which could provide prepubertal transgender youth an option for FP since they lack mature gametes. Successful uterus transplantation with subsequent live birth is a new medical breakthrough for cisgender women with uterus factor infertility. Although it has not yet been performed in transgender women, uterus transplantation is a potential solution for those who wish to get pregnant. The transgender population faces many barriers to care, such as provider discrimination, lack of information, legal barriers, scarcity of fertility centers, financial burden, and emotional cost. Further research is necessary to investigate the feasibility of experimental FP options, provide better evidence-based information to clinicians and transgender patients alike, and to improve access to and quality of reproductive services for the transgender population.
Collapse
Affiliation(s)
- Philip J Cheng
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Alexander W Pastuszak
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Jeremy B Myers
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Isak A Goodwin
- Division of Plastic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - James M Hotaling
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA.,Department of Obstetrics & Gynecology, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
28
|
Taran FA, Schöller D, Rall K, Nadalin S, Königsrainer A, Henes M, Bösmüller H, Fend F, Nikolaou K, Notohamiprodjo M, Grasshoff C, Heim E, Zipfel S, Schäffeler N, Bakchoul T, Heyne N, Guthoff M, Krämer B, Reisenauer C, Hoopmann M, Kagan KO, Brännström M, Wallwiener D, Brucker SY. Screening and evaluation of potential recipients and donors for living donor uterus transplantation: results from a single-center observational study. Fertil Steril 2019; 111:186-193. [PMID: 30611405 DOI: 10.1016/j.fertnstert.2018.09.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 09/12/2018] [Accepted: 09/13/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To report our experience with the screening and selection of potential recipients and living donors of our uterus transplantation (UTx) program. DESIGN Part of an observational program. SETTING University hospital. PATIENT(S) Patients with absolute uterine factor infertility (AUFI). INTERVENTION(S) Screening by e-mail and telephone, selection during surgical consultation, and preoperative investigations according to a multistep procedure for living donation. MAIN OUTCOME MEASURE(S) Age, cause of AUFI, exclusion reasons, and preoperative workup. RESULT(S) A total of 212 potential recipients expressed interest in participation. Among the 46 potential recipients and 49 directed donors were 4 potential recipients, each with 2 directed donors. Mean (range) age of potential recipients was 29.6 (19-41) years. Of the potential recipients, 39 (84.8%) had congenital AUFI and 7 (17.3%) had acquired AUFI. Ultimately, 15 potential recipients with 16 directed donors were selected for participation, with 1 potential recipient having 2 directed donors. Mean age of included potential recipients was 28.9 (22-35) years, and mean donor age was 51.3 (37-62) years. Fourteen potential recipients (93.3%) had congenital AUFI, and one potential recipient (6.7%) had undergone hysterectomy for obstetric complications. CONCLUSION(S) The number of potential candidates for UTx is not inconsiderable, with congenital AUFI being the leading cause of AUFI in our cohort. However, our findings highlight that large numbers of AUFI patients need to be screened, considering our exclusion rates were >50%, owing to ABO incompatibility, unavailability of a directed donor, and self-withdrawal. Moreover, meticulous preoperative screening, including in-depth psychological assessment, is mandatory to maximize living donor safety and UTx success.
Collapse
Affiliation(s)
- Florin-Andrei Taran
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany.
| | - Dorit Schöller
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - Katharina Rall
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral, and Transplant Surgery, University of Tübingen, Tübingen, Germany
| | - Alfred Königsrainer
- Department of General, Visceral, and Transplant Surgery, University of Tübingen, Tübingen, Germany
| | - Melanie Henes
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - Hans Bösmüller
- Department of Pathology, University of Tübingen, Tübingen, Germany
| | - Falko Fend
- Department of Pathology, University of Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University of Tübingen, Tübingen, Germany
| | - Mike Notohamiprodjo
- Department of Diagnostic and Interventional Radiology, University of Tübingen, Tübingen, Germany
| | - Christian Grasshoff
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Eckhard Heim
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Stephan Zipfel
- Department of Psychosomatic Medicine, University of Tübingen, Tübingen, Germany
| | - Norbert Schäffeler
- Department of Psychosomatic Medicine, University of Tübingen, Tübingen, Germany
| | - Tamam Bakchoul
- Center for Transfusion Medicine, University of Tübingen, Tübingen, Germany
| | - Nils Heyne
- Department of Endocrinology and Diabetology, Angiology, Nephrology, and Clinical Chemistry, University of Tübingen, Tübingen, Germany
| | - Martina Guthoff
- Department of Endocrinology and Diabetology, Angiology, Nephrology, and Clinical Chemistry, University of Tübingen, Tübingen, Germany
| | - Bernhard Krämer
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - Christl Reisenauer
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - Markus Hoopmann
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - Karl-Oliver Kagan
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - Mats Brännström
- Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden; Stockholm IVF, Stockholm, Sweden
| | - Diethelm Wallwiener
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| | - Sara Y Brucker
- Department of Obstetrics and Gynecology, University of Tübingen, Tübingen, Germany
| |
Collapse
|
29
|
Taneja A, Das S, Hussain SA, Madadin M, Lobo SW, Fatima H, Menezes RG. Uterine Transplant: A Risk to Life or a Chance for Life? SCIENCE AND ENGINEERING ETHICS 2019; 25:635-642. [PMID: 29423621 DOI: 10.1007/s11948-018-0018-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 01/09/2018] [Indexed: 06/08/2023]
Abstract
Being inherently different from any other lifesaving organ transplant, uterine transplantation does not aim at saving lives but supporting the possibility to generate life. Unlike the kidneys or the liver, the uterus is not specifically a vital organ. Given the non-lifesaving nature of this procedure, questions have been raised about its feasibility. The ethical dilemma revolves around whether it is worth placing two lives at risk related to surgery and immunosuppression, amongst others, to enable a woman with absolute uterine factor infertility to experience the presence of an organ enabling childbirth. In the year 2000, the first uterine transplantation, albeit unsuccessful, was performed in Saudi Arabia from where it has spread to the rest of the world including Sweden, the United States and now recently India. The procedure is, however, still in the preclinical stages and several ethical, legal, social and religious concerns are yet to be addressed before it can be integrated into the clinical setting as standard of care for women with absolute uterine factor infertility.
Collapse
Affiliation(s)
| | - Siddhartha Das
- Department of Forensic Medicine and Toxicology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Syed Ather Hussain
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Mohammed Madadin
- Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | | | - Huda Fatima
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Ritesh G Menezes
- Department of Pathology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| |
Collapse
|
30
|
Shared Decision Making bei seltenen Erkrankungen. Ethik Med 2019. [DOI: 10.1007/s00481-019-00522-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
31
|
|
32
|
Richards EG, Agatisa PK, Davis AC, Flyckt R, Mabel H, Falcone T, Tzakis A, Farrell RM. Framing the diagnosis and treatment of absolute uterine factor infertility: Insights from in-depth interviews with uterus transplant trial participants. AJOB Empir Bioeth 2019; 10:23-35. [PMID: 30855220 DOI: 10.1080/23294515.2019.1572672] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Despite procedural innovations and increasing numbers of uterus transplant attempts worldwide, the perspectives of uterus transplant (UTx) trial participants are lacking. METHODS We conducted a mixed-methods study with women with absolute uterine factor infertility (AUFI). Participants included women who had previously contacted the Cleveland Clinic regarding the Uterine Transplant Trial and met the initial eligibility criteria for participation. In-depth interviews were conducted in conjunction with FertiQoL, a validated and widely used tool to measure the impact of infertility on the quality of life of infertility patients. RESULTS All (n = 19) rated their overall health as good; some experienced grief and social isolation. AUFI is a life-framing experience that influences acceptance by family, partners, peers, and one's self. UTx is a means to gain control of reproductive autonomy. UTx allows family-building and the ability to play an active role in prenatal health and well-being. Establishing and maintaining a supportive relationship is a key issue of AUFI and when considering UTx. Risks of UTx are perceived relative to risks to self/child/family posed by adoption/surrogacy. Participants had no overall preference regarding living or deceased donor. CONCLUSIONS The ways in which women with AUFI conceptualize this condition in their lives and choices around UTx and participating in a study of the procedure are multifaceted and textured. These perspectives are critical to understanding its ethical, legal, and social implications.
Collapse
Affiliation(s)
- Elliott G Richards
- a Department of Ob/Gyn & Women's Health Institute , Cleveland Clinic , Cleveland , Ohio
| | - Patricia K Agatisa
- a Department of Ob/Gyn & Women's Health Institute , Cleveland Clinic , Cleveland , Ohio
| | - Anne C Davis
- a Department of Ob/Gyn & Women's Health Institute , Cleveland Clinic , Cleveland , Ohio
| | - Rebecca Flyckt
- a Department of Ob/Gyn & Women's Health Institute , Cleveland Clinic , Cleveland , Ohio
| | - Hilary Mabel
- b Center for Bioethics Cleveland Clinic , Cleveland , Ohio
| | - Tommaso Falcone
- a Department of Ob/Gyn & Women's Health Institute , Cleveland Clinic , Cleveland , Ohio
| | - Andreas Tzakis
- c Transplantation Center , Cleveland Clinic Florida , Weston , Florida
| | - Ruth M Farrell
- a Department of Ob/Gyn & Women's Health Institute , Cleveland Clinic , Cleveland , Ohio.,b Center for Bioethics Cleveland Clinic , Cleveland , Ohio
| |
Collapse
|
33
|
Matoba Y, Kisu I, Sera A, Yanokura M, Banno K, Aoki D. Current status of uterine regenerative medicine for absolute uterine factor infertility. Biomed Rep 2019; 10:79-86. [PMID: 30675350 PMCID: PMC6341411 DOI: 10.3892/br.2019.1182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/16/2018] [Indexed: 12/12/2022] Open
Abstract
Though assisted reproduction technology has been developed, a treatment for absolute uterine factor infertility (AUFI), such as defects in the uterus, has not yet been established. Regenerative medicine has been developed and applied clinically over recent years; however, whole solid organs still cannot be produced. Though uterine regeneration has the potential to be a treatment for AUFI, there have been only a few studies on uterine regeneration involving the myometrium in vivo. In the present report, those relevant articles are reviewed. A literature search was conducted in PubMed with a combination of key words, and 10 articles were found, including nine in rat models and one in a mouse model. Of these studies, eight used scaffolds and two were performed without scaffolds. In four of these studies, scaffolds were re-cellularized with various cells. In the remaining four studies, scaffolds were transplanted alone, or other structures were used. Though the methods differed, the injured uterus recovered well, morphologically and functionally, in every study. Only 10 articles were relevant to our investigation, but the results were favorable, if limited to partial regeneration. Recently, uterus transplantation (UTx) has been investigated as a treatment for AUFI. However, UTx has many problems in the medical, ethical and social fields. Though the artificial uterus was also researched and some improvements in this technology were reported, it will take long time for this to reach a clinically applicable stage. Though the results of uterine regeneration studies were promising, these studies were conducted using animal models, so further human studies and trials are needed.
Collapse
Affiliation(s)
- Yusuke Matoba
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Iori Kisu
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Asako Sera
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Megumi Yanokura
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Kouji Banno
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Daisuke Aoki
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo 160-8582, Japan
| |
Collapse
|
34
|
Lavoué V, Dion L, Tardieu A, Garbin O, Ayoubi JM, Agostini A, Collinet P, Piver P, Aubard Y, Gauthier T. Organizing a uterus transplantation programme: The designation of Uterus Transplantation Centres in France. J Gynecol Obstet Hum Reprod 2019; 48:15-18. [DOI: 10.1016/j.jogoh.2018.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 01/18/2023]
|
35
|
Puntambekar S, Puntambekar S, Telang M, Kulkarni P, Date S, Panse M, Sathe R, Agarkhedkar N, Warty N, Kade S, Manchekar M, Chitale M, Parekh H, Parikh K, Mehta M, Kinholkar B, Jana JS, Pare A, Kanade S, Sadre A, Hardikar S, Jathar A, Bakre T, Chate M, Tiruke R. Novel Anastomotic Technique for Uterine Transplant Using Utero-ovarian Veins for Venous Drainage and Internal Iliac Arteries for Perfusion in Two Laparoscopically Harvested Uteri. J Minim Invasive Gynecol 2018; 26:628-635. [PMID: 30599196 DOI: 10.1016/j.jmig.2018.11.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/29/2018] [Accepted: 11/05/2018] [Indexed: 12/22/2022]
Abstract
STUDY OBJECTIVE To evaluate 2 cases of uterine transplant surgery that used utero-ovarian veins as outflow channels, internal iliac arteries for perfusion, and the organ harvest surgery performed laparoscopically. DESIGN Case study (Canadian Task Force Classification III). SETTING An urban, private, tertiary care hospital. PATIENTS Two patients, ages 30 and 24years, diagnosed with absolute uterine factor infertility secondary to Mayer-Rokitansky-Küster-Hauser syndrome underwent related living donor uterine transplants; donors were their mothers with normal menses. INTERVENTIONS Retrieval of organs through minilaparotomy and laparoscopic harvest of donor internal iliac arteries and ovarian veins. MEASUREMENTS AND MAIN RESULTS Anastomosis was completed with bilateral donor internal iliac arteries to recipient internal iliac arteries in an end-to-end manner and with bilateral donor ovarian veins to recipient external iliac veins in an end-to-side manner. The lengths of utero-ovarian veins of both donors were 11 and 11cm on both sides; the lengths of the internal iliac arteries of both donors were 10 and 7.5cm on the left side and 10 and 6cm on the right side. The operative times for harvest surgery, bench surgery and transplant surgery were 2:40 and 3:20 hours, 34:32 and 33:30 min and 4:00 and 4:30 hours respectively for recipients 1 and 2. Daily postoperative uterine Doppler was completed through day 8 and then every other day and showed good intrauterine blood flow (i.e., low resistance arcuate vessel flow; resistance index < .5). Cervical biopsies on postoperative days 7 and 14 showed no evidence of rejection in either recipient. Both recipients started menstruating within 2 months of surgery. CONCLUSION By using ovarian veins as outflow channels, the challenges involved in dissection along the internal iliac vein are avoided, and harvesting the donor internal iliac artery reduces the tension on vascular anastomosis. The selection of vessels to be harvested could make the technique reproducible, although larger studies are warranted to confirm results.
Collapse
Affiliation(s)
- Shailesh Puntambekar
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar).
| | - Seema Puntambekar
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Milind Telang
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Pankaj Kulkarni
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | | | - Mangesh Panse
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | - Ravindra Sathe
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | | | - Neeta Warty
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Sandesh Kade
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Manoj Manchekar
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | - Mihir Chitale
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | - Hirav Parekh
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | - Kajal Parikh
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Mehul Mehta
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | | | | | | | | | | | - Shirish Hardikar
- Radiology (Dr. Hardikar), Galaxy CARE Laparoscopy Institute, Pune, India
| | - Advait Jathar
- Departments of General Surgery (Drs. Puntambekar, Panse, Sathe, Manchekar, Chitale, Parekh, Mehta, and Jathar)
| | - Tejashree Bakre
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Meenakshi Chate
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| | - Raviraj Tiruke
- Obstetrics and Gynaecology (Drs. Puntambekar, Telang, Kulkarni, Warty, Kade, Parikh, Bakre, Chate, and Tiruke)
| |
Collapse
|
36
|
Balayla J, Tulandi T. Provider Perceptions, Opinions, and Insights Into Uterine Transplantation in Canada. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:428-435. [PMID: 30514611 DOI: 10.1016/j.jogc.2018.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/30/2018] [Accepted: 09/03/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study sought to evaluate perceptions and insights regarding uterine transplantation among members of a women's health care national specialty organization in Canada. METHODS The investigators obtained permission and used an electronic survey developed by Bortoletto et al. to conduct a cross-sectional study of members of the SOGC between April and May 2018. Participants were requested to answer a total of 29 questions grouped into four different categories: personal opinions and attitudes, medical opinions, ethical opinions, and demographics. The investigators compared answers with a published survey of members of the American Society for Reproductive Medicine (ASRM) and the American Association of Gynecologic Laparoscopists (AAGL). RESULTS Of a total 247 responses, 230 were complete, for a completion rate of 93%. Respondents were primarily female, White, obstetrician-gynaecologists within 15 years of starting practice. Statements viewed favourably by most of respondents (strongly agree or agree) included "Women should be allowed to donate or receive a transplanted uterus" (53.5%), "Uterine transplantation should be considered a potential treatment option for infertile women with severe uterine factor infertility" (42.4%), and "Uterine transplantation is ethical" (39.9%). Statements that were viewed unfavourably by the majority of respondents (strongly disagree or disagree) included "Uterine transplantation carries an acceptable risk for recipients" (43.7%) and "Uterine transplantation for severe uterine factor infertility should be covered by health insurance" (59.1%). When compared with members of the ASRM and AAGL, the degree of agreement was similar, except with regards to "Uterine transplantation carries an acceptable risk for donors" (50.0% vs. 65.3% ASRM/67.8% AAGL; P < 0.001), and "In countries or states where gestational surrogacy is illegal, uterine transplantation is a more permissible ethical option" (42.0% vs. 65.0% ASRM/51.4% AAGL; P < 0.001). CONCLUSION Most respondents either felt that uterine transplantation was ethical or were neutral to the subject. However, only a small minority would currently recommend the procedure to their patients. As advances in uterine transplants are made, future studies should re-evaluate providers' perceptions towards this procedure before it is introduced into clinical practice.
Collapse
Affiliation(s)
- Jacques Balayla
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montréal, QC; Department of Obstetrics and Gynecology, Faculty of Medicine, McGill University, Montréal, QC
| | - Togas Tulandi
- Department of Obstetrics and Gynecology, Faculty of Medicine, McGill University, Montréal, QC.
| | | |
Collapse
|
37
|
A Survey of Public Opinion in the United States Regarding Uterine Transplantation. J Minim Invasive Gynecol 2018. [DOI: 10.1016/j.jmig.2018.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
|
38
|
Shapiro ME, Ward FR. Uterus Transplantation: A Step Too Far. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:36-37. [PMID: 30040573 DOI: 10.1080/15265161.2018.1478027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
|
39
|
Rogers A. Allocating Uterus Transplants-Who Gets to Be a Gestational Mother? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:38-39. [PMID: 30040575 DOI: 10.1080/15265161.2018.1478025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
|
40
|
Allyse M. "Whole Again": Why Are Penile Transplants Less Controversial Than Uterine? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:34-35. [PMID: 30040581 DOI: 10.1080/15265161.2018.1478044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
|
41
|
Han MN, Ramirez H, Ruvalcaba L, Contreras JL, Nyachieo A, Ramirez E. Uterine Autotransplantation in the Nonhuman Primate With Preservation of the Uterine and Ovarian Vascular Pedicles. Reprod Sci 2018; 26:1329-1335. [PMID: 29576000 DOI: 10.1177/1933719118765976] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE To evaluate the technical feasibility of performing a uterine autotransplantation in the nonhuman primate while preserving the uterine and ovarian vascular pedicles. METHODS Eight (n = 8) female baboons at a primate research facility underwent a uterine autotransplant procedure with preservation of the vascular pedicles. The uterine arteries were separated from their amorphous tissue and skeletonized toward the internal iliac arteries bilaterally. A segment of the internal iliac artery was removed bilaterally along with both uterine arteries. Both ovarian veins were preserved to assist with the reperfusion of the uterine organ. Due to larger vascular pedicles in one of the primates, the uterine arteries were separated and reattached directly via end-to-end anastomosis. In another baboon, the deep uterine vein was used as a vascular pedicle rather than the ovarian vein on the left side due to adequate size and visualization. RESULTS Immediate tissue reperfusion occurred intraoperatively in 5 of the animals, with slower perfusion in 3 of the animals. Average warm ischemia time was 43.8 minutes while the average cold ischemia time was 174 minutes (2 hours, 54 minutes). Average total surgical time was 5.9 hours. All animals were sheltered into separate cages and monitored for behavior changes and food and drink consumption. Three of the primates expired immediately postoperatively, 2 from severe dehydration and 1 from gastric aspiration. CONCLUSIONS This pilot study describes a modified surgical approach for uterine transplants in the nonhuman primate. This surgical technique may be applicable to living and deceased donor uterine transplantation.
Collapse
Affiliation(s)
- Michelle N Han
- Department of Obstetrics and Gynecology, University of California, Los Angeles, CA, USA
| | | | - Luis Ruvalcaba
- Instituto Mexicano de Infertilidad, Guadalajara, Jalisco, Mexico
| | | | | | | |
Collapse
|
42
|
Favre-Inhofer A, Rafii A, Carbonnel M, Revaux A, Ayoubi JM. Uterine transplantation: Review in human research. J Gynecol Obstet Hum Reprod 2018; 47:213-221. [PMID: 29574054 DOI: 10.1016/j.jogoh.2018.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/16/2018] [Accepted: 03/20/2018] [Indexed: 12/18/2022]
Abstract
Uterine transplantation is the solution to treat absolute uterine fertility. In this review, we present the historical, medical, technical, psychological and ethical perspectives in human uterine transplantation research. We reviewed the PubMed database following PRISMA guidelines and added data presented by several research teams during the first international congress on uterine transplantation.
Collapse
Affiliation(s)
- A Favre-Inhofer
- Department of Gynecology and Obstetrics, Hospital Foch, Suresnes, France
| | - A Rafii
- Department of Gynecology and Obstetrics, Hospital Foch, Suresnes, France
| | - M Carbonnel
- Department of Gynecology and Obstetrics, Hospital Foch, Suresnes, France
| | - A Revaux
- Department of Gynecology and Obstetrics, Hospital Foch, Suresnes, France
| | - J M Ayoubi
- Department of Gynecology and Obstetrics, Hospital Foch, Suresnes, France.
| |
Collapse
|
43
|
Selecting living donors for uterus transplantation: lessons learned from two transplantations resulting in menstrual functionality and another attempt, aborted after organ retrieval. Arch Gynecol Obstet 2017; 297:675-684. [PMID: 29270725 DOI: 10.1007/s00404-017-4626-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/11/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE To contribute to establishing donor selection criteria based on our experience with two successful living-donor human uterus transplantations (UTx) and an aborted attempt. METHODS This interventional study included three patients with uterine agenesis, aged 23, 34, and 23 years, scheduled for UTx, and their uterus-donating mothers, aged 46, 61, and 46 years, respectively. Interventions included preoperative investigations, donor surgery, back-table preparation, and recipient surgery. Preoperative imaging, surgical data, histopathology, menstrual pattern, and uterine blood flow were the main outcome measures. RESULTS In the first case (46-year-old mother/23-year-old daughter), donor/recipient surgery took 12.12/5.95 h. Regular spontaneous menstruations started 6-week post-transplantation, continuing at 24-28-day intervals throughout the 6-month observation period. Repeated follow-up cervical biopsies showed no signs of rejection. In the second case (61-year-old donor), surgery lasted 13.10 h; attempts to flush the retrieved uterus failed due to extreme resistance of the left uterine artery (UA) and inability to perfuse the right UA. Transplantation was aborted to avoid graft vessel thrombosis or insufficient blood flow during potential pregnancy. Histopathology revealed intimal fibrosis and initial sclerosis (right UA), extensive intimal fibrosis (parametric arterial segments), and subtotal arterial stenosis (myometrial vascular network). In the third case (46-year-old mother/23-year-old daughter), donor/recipient surgery took 9.05/4.52 h. Menstruations started 6-week post-transplantation. Repeated cervical biopsies showed no signs of rejection during the initial 12-week follow-up period. CONCLUSIONS Meticulous preoperative evaluation of potential living uterus donors is essential. This may include selective contrast-enhanced UA angiograms and limitation of donor age, at least in donors with risk factors for atherosclerosis. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03048396.
Collapse
|
44
|
Horsburgh CC. A Call for Empirical Research on Uterine Transplantation and Reproductive Autonomy. Hastings Cent Rep 2017; 47 Suppl 3:S46-S49. [DOI: 10.1002/hast.795] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
45
|
Suganuma N, Hayashi A, Kisu I, Banno K, Hara H, Mihara M. Uterus transplantation: Toward clinical application in Japan. Reprod Med Biol 2017; 16:305-313. [PMID: 29259482 PMCID: PMC5715890 DOI: 10.1002/rmb2.12048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/03/2017] [Indexed: 12/27/2022] Open
Abstract
Background In recent years, uterus transplantation (UTx) has been applied as the treatment for patients with uterine factor infertility worldwide. Thus, the clinical application of UTx in Japan should be considered through both the history of UTx technology development in the world and future prospects. Methods Recent information on UTx was collected via a literature survey and the Internet. Results Basic research using various animals has been done mainly since 2000. In 2014, the world's first UTx baby was born in Sweden. In total, 24 UTx procedures have been performed at 10 institutes in nine countries and five births were obtained (as of May, 2017). In Japan, the "Project Team for Uterus Transplantation" initiated UTx experiments in 2008 and the "Japan Society for Uterus Transplantation" was organized in March, 2014. In the rest of the world, the "International Society for Uterus Transplantation" was established in January, 2016. Conclusion Uterus transplantation is still under development as a reproductive medicine tool and organ transplant procedure. A collaborative system that is not limited by facilities and specialties should strive to build an "all-Japan" team.
Collapse
Affiliation(s)
- Nobuhiko Suganuma
- Project Team for Uterus TransplantationJapan
- Department of Human Health SciencesKyoto University Graduate School of MedicineKyotoJapan
| | - Ayako Hayashi
- Project Team for Uterus TransplantationJapan
- Department of Human Health SciencesKyoto University Graduate School of MedicineKyotoJapan
| | - Iori Kisu
- Project Team for Uterus TransplantationJapan
- Department of Obstetrics and GynecologyKeio Gijuku University School of MedicineTokyoJapan
| | - Kouji Banno
- Project Team for Uterus TransplantationJapan
- Department of Obstetrics and GynecologyKeio Gijuku University School of MedicineTokyoJapan
| | - Hisako Hara
- Project Team for Uterus TransplantationJapan
- Department of Lymphatic and Reconstructive SurgerySaiseikai Kawaguchi General HospitalKawaguchiJapan
| | - Makoto Mihara
- Project Team for Uterus TransplantationJapan
- Department of Lymphatic and Reconstructive SurgerySaiseikai Kawaguchi General HospitalKawaguchiJapan
| |
Collapse
|
46
|
|
47
|
Zaidi D. Re-Evaluating the Ethics of Uterine Transplantation. THE JOURNAL OF CLINICAL ETHICS 2017. [DOI: 10.1086/jce2017283212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
48
|
Uterus tolerance to extended cold ischemic storage after auto-transplantation in ewes. Eur J Obstet Gynecol Reprod Biol 2017; 214:162-167. [DOI: 10.1016/j.ejogrb.2017.05.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 05/05/2017] [Accepted: 05/14/2017] [Indexed: 01/27/2023]
|
49
|
|
50
|
Flyckt RL, Farrell RM, Perni UC, Tzakis AG, Falcone T. Deceased Donor Uterine Transplantation: Innovation and Adaptation. Obstet Gynecol 2017; 128:837-842. [PMID: 27607877 DOI: 10.1097/aog.0000000000001617] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This commentary endeavors to share our practical experience in developing and implementing the first uterine transplant clinical trial in the United States. Uterine transplant is a promising novel treatment for uterine factor infertility. After reported successful live births after uterine transplant in Sweden, research teams around the world are either embarking on or are considering the development of uterine transplant protocols. Our observations on the applied rather than theoretical aspects of uterine transplantation research in human subjects are detailed in this article. Important among these considerations are composing a broad and experienced multidisciplinary team as well as performing adequate preclinical preparations, including ideally animal studies and practice organ procurements. Ethical preparation is tantamount to clinical preparation for the complexities inherent in uterine transplant, and our suggestions for updating the current ethical criteria for uterine transplant are outlined here. We also describe our perspectives on the strengths and weaknesses of living compared with deceased donor models. Finally, we describe how a strong program can recover and adapt in the face of setbacks to continue a path toward innovation.
Collapse
|