Pregnancy after CMV infection following uterus transplantation: A case report from the Dallas Uterus Transplant Study

Maternal and perinatal outcomes of live births after uterus transplantation: A systematic review

INTRODUCTION

Uterus transplantation (UTx) is a treatment for absolute uterine factor infertility. The results of pregnancies of this complex infertility treatment should be established. The aim of the study was to systematically review maternal and neonatal outcomes in the pregnancies of women who have undergone UTx.

MATERIAL AND METHODS

The population of this review were women that have undergone UTx and delivered child(ren). Cesarean delivery after UTx were planned to be compared with studies reporting maternal mortality/morbidity and perinatal mortality/morbidity after delivery by elective cesarean section without UTx. Systematic literature searches were performed utilizing Medline, Embase, the Cochrane Library, Cinahl, PsycInfo, Web of Science, and clinicaltrials.gov for studies written in English language and published between January 1, 2010, and November 08, 2023. No study design limitation was applied. If no comparative studies were identified, we planned to report the outcomes from the case reports and case series. Included studies were assessed for risk of bias using a checklist for case series. The study protocol was registered with the International Platform of Registered Systematic Review and Meta-analysis Protocols (registration number: INPLASY202310052).

RESULTS

Twenty-four articles were identified, containing data on 40 unique live births. Multiple publications including same cases were identified and clearly indicated. No comparative studies were identified. The certainty of evidence was very low, as all studies were either case reports (n = 15) or case series (n = 9). All deliveries were by cesarean section and 47.5% of them resulted in emergency cesarean sections. Out of the 21 elective cesarean sections, 52.4% were performed before 37 weeks' gestation. Historical comparison to population data on pregnancies delivered by cesarean section found a markedly increased risk for both the mother and child following cesarean section for UTx. Risks for placenta previa and preterm birth were notably high after UTx; however, some of the later may reflect the results of provider-initiated births.

CONCLUSIONS

The maternal and perinatal outcomes of 40 live births post-UTx indicate that these pregnancies may be at high risk of maternal and perinatal complications. Aiming to delay elective cesarean section beyond 37 weeks' gestation could potentially reduce some of these risks. Registration of maternal and perinatal outcomes after UTx through quality registries are essential and obstetrical care guidelines for these women should be established.

Immune surveillance of cytomegalovirus in tissues

Cytomegalovirus (CMV), a representative member of the Betaherpesvirinae subfamily of herpesviruses, is common in the human population, but immunocompetent individuals are generally asymptomatic when infected with this virus. However, in immunocompromised individuals and immunologically immature fetuses and newborns, CMV can cause a wide range of often long-lasting morbidities and even death. CMV is not only widespread throughout the population but it is also widespread in its hosts, infecting and establishing latency in nearly all tissues and organs. Thus, understanding the pathogenesis of and immune responses to this virus is a prerequisite for developing effective prevention and treatment strategies. Multiple arms of the immune system are engaged to contain the infection, and general concepts of immune control of CMV are now reasonably well understood. Nonetheless, in recent years, tissue-specific immune responses have emerged as an essential factor for resolving CMV infection. As tissues differ in biology and function, so do immune responses to CMV and pathological processes during infection. This review discusses state-of-the-art knowledge of the immune response to CMV infection in tissues, with particular emphasis on several well-studied and most commonly affected organs.

Acute Rejection Rates in Vascularized Composite Allografts: A Systematic Review of Case Reports

INTRODUCTION

Vascularized Composite Allografts (VCA) are usually performed in a full major histocompatibility complex mismatch setting, with a risk of acute rejection depending on factors such as the type of immunosuppression therapy and the quality of graft preservation. In this systematic review, we present the different immunosuppression protocols used in VCA and point out relationships between acute rejection rates and possible factors that might influence it.

METHODS

This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We systematically searched Medline (PubMed), Embase, and The Cochrane Library between November 2022 and February 2023, using following Mesh Terms: Transplant, Transplantation, Hand, Face, Uterus, Penis, Abdominal Wall, Larynx, and Composite Tissue Allografts. All VCA case reports and reviews describing multiple case reports were included.

RESULTS

We discovered 211 VCA cases reported. The preferred treatment was a combination of antithymocyte globulins, mycophenolate mofetil (MMF), tacrolimus, and steroids; and a combination of MMF, tacrolimus, and steroids for induction and maintenance treatment, respectively. Burn patients showed a higher acute rejection rate (P = 0.073) and were administered higher MMF doses (P = 0.020).

CONCLUSIONS

In contrast to previous statements, the field of VCA is not rapidly evolving, as it has encountered challenges in addressing immune-related concerns. This is highlighted by the absence of a standardized immunosuppression regimen. Consequently, more substantial data are required to draw more conclusive results regarding the immunogenicity of VCAs and the potential superiority of one immunosuppressive treatment over another. Future efforts should be made to report the VCA surgeries comprehensively, and muti-institutional long-term prospective follow-up studies should be performed to compare the number of acute rejections with influencing factors.

Miracles of science: Birth after uterus transplantation

AIM

The concept of regaining childbearing ability via uterus transplantation (UTx) motivates many infertile women to pursue giving birth to their own children. This article provides insight into maternal and neonatal outcomes of the procedure globally and facilitates quality of care in related medical fields.

METHODS

The authors searched ISI Web of Science, MEDLINE, non-PubMed-indexed journals, and common search engines to identify peer-review publications and unpublished sources in scientific reference databases.

RESULTS

The feasibility of the procedure has been proven with 46 healthy children in 88 procedures so far. Success relies upon dedicated teamwork involving transplantation surgery, obstetrics and reproductive medicine, neonatology, pediatrics, psychology, and bioethics. However, challenges exist owing to donor, recipient, and fetus. Fetal growth in genetically foreign uterine allograft with altered feto-maternal interface and vascular anatomy, immunosuppressive exposure, lack of graft innervation leading to "unable-to-feel" uterine contractions and conception via assisted reproductive technology create notable risks during pregnancy. Significant portion of women are complicated by at least one or more obstetric problems. Preeclampsia, gestational hypertension and diabetes mellitus, elevated kidney indices, and preterm delivery are common complications.

CONCLUSIONS

UTx has short- and long-term satisfying outcome. Advancements in the post-transplant management would undoubtedly lead this experimental procedure into mainstream clinical practice in the near future. However, both women and children of UTx need special consideration due to prematurity-related neonatal problems and the long-term effects of transplant pregnancy. Notable health risks for the recipient and fetus should be discussed with potential candidates for UTx.

Pregnancy management and outcome after uterus transplantation

Uterus transplantation is a novel approach in women whose uterus is absent or severely abnormal. However, it is still an experimental procedure that poses risks to both mother and baby. To date, 32 live births after uterus transplantation have been reported in peer-reviewed journals, with several maternal, fetal and neonatal complications. The most common complications were preterm delivery, hypertensive disorders and placenta previa. Four patients experienced episodes of transplant rejection during pregnancy. The appropriate management of complicated and non-complicated pregnancies following uterus transplantation is still unresolved. In this review, obstetric outcomes after uterus transplantation and optimal management during pregnancy are discussed in light of the available data. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Graft Failure after Uterus Transplantation in 16 Recipients: A Review

Uterus transplantation (UTx) is now an alternative to surrogacy and adoption for women with uterine factor infertility to have children; however, there are still unresolved clinical and technical issues. One of these is that the graft failure rate after transplantation is somewhat higher than that of other life-saving organ transplants, which is a critical concern. Herein, we summarize the details of 16 graft failures after UTx with living or deceased donors using the published literature in order to learn from these negative outcomes. To date, the main causes of graft failure are vascular factors (arterial and/or venous thrombosis, atherosclerosis, and poor perfusion). Many recipients with thrombosis develop graft failure within one month of surgery. Therefore, it is necessary to devise a safe and stable surgical technique with higher success rates for further development in the UTx field.

Immunosuppression in Uterus Transplantation: Experience From the Dallas Uterus Transplant Study

BACKGROUND

Uterus transplantation is a temporary transplant allowing women with absolute uterine factor infertility to experience pregnancy and childbirth. The degree of immunosuppression (IS) required to prevent rejection while minimizing toxicity to the recipient and fetus remains an area of investigation.

METHODS

In this article, we describe immunosuppressive therapy, rejection episodes, infections, and adverse events in 14 uterus transplant recipients. Induction consisted of antithymocyte globulin and methylprednisolone. Ten recipients (71%) received no steroids postoperatively, and 4 (29%) had steroids tapered off at 42 d. All received oral tacrolimus, either immediate release (n = 2, 14%) or extended release (n = 12, 86%). Mycophenolate was used in 4 cases (29%), de novo azathioprine in 9 (64%), and de novo everolimus in 1 (7%).

RESULTS

Sixteen clinically silent, treatment-responsive rejection episodes occurred in 10 recipients. Five recipients (36%) experienced acute kidney injury. In 3 recipients, IS was discontinued due to renal dysfunction. Eleven infection episodes were noted in 7 recipients. No babies had congenital abnormalities.

CONCLUSIONS

Our experience demonstrates that safe IS regimens can be used for uterus transplant recipients before and during pregnancy.

Meeting Report: Third International Congress of the International Society of Uterus Transplantation, Tübingen

Uterus transplantation (UTx) is currently the only available treatment for absolute uterine factor infertility. The International Society of Uterus Transplantation (ISUTx) was formally founded in 2017 and joined the Transplantation Society as a formal section in 2021. The Third International Congress of the ISUTx was held in Tübingen, Germany, in October 2021, as a hybrid meeting, attended virtually by about 450 delegates and in person by 35 delegates. This report summarizes the Tübingen meeting and complementary topics of relevance presented at the Second ISUTx state-of-the-art webinar meeting, held in Prague, in October 2020. Main topics covered included surgical considerations, including dissection of veins in living donors and the pros and cons of minimally invasive surgery; managing immune risks; UTx during the COVID-19 pandemic; lessons learnt in the areas of imaging and cytomegalovirus infection; long-term psychological outcomes; opportunities to increase organ availability; and new horizons in UTx, including potential reuse of transplants and the utilization of robotic approaches. Implementation of an International UTx Registry was discussed and considered crucial to assure quality, safety, and further progress in UTx. Attempts made thus far have been promising.

Immunologic and Infectious Concerns in Uterus Transplantation

Pharmacologic immunosuppression is required for the success of uterus transplantation but can provoke several complications for the transplant recipient. In this review, we discuss the immunologic complications that can occur in the uterus transplant recipient. First, we provide the latest update on immunosuppression regimens used by programs throughout the world. Next, we discuss the prevalence, mechanisms, treatment, and outcome of rejection in uterus transplant recipients. Finally, we discuss infectious complications of varying severity alongside their treatment and impact.

Genetic Screening and Teratogenic Exposures: Considerations in Caring for the Uterus Transplant Patient

Counseling the uterus transplant patient requires an enhanced knowledge of unique genetic challenges that include an understanding of the spectrum of Mayer-Rokitansky-Küster-Hauser syndrome. Patients should understand their options for genetic screening and testing including preimplantation genetic testing for aneuploidy, genetic screening, and diagnostic testing. This patient population is potentially at risk for fetal anomalies due to the increased susceptibility to infections, such as cytomegalovirus. There are management strategies to minimize this risk. The risk of teratogenicity from mycophenolate is eliminated by a washout period before embryo transfer.

Uterus transplantation - donor and recipient work-up

PURPOSE OF REVIEW

Uterus transplantation (UTx) is transitioning from an experimental procedure to a clinical treatment for absolute uterine factor infertility (AUFI). Standardized protocols for the evaluation and selection of donors and recipients that maximize chances of success - a healthy live birth - are needed.

RECENT FINDINGS

To date, recipient eligibility has been limited to otherwise healthy women with AUFI who are of childbearing age and are good candidates for in-vitro fertilization (IVF). For donors (living or deceased), selection criteria vary, apart from basic requirements of blood-type compatibility and freedom from critical infectious diseases, but generally require a term birth and a uterus free from uterine pathologies. The stepwise evaluation process for candidate recipients and living donors moves through health screening (medical and psychosocial); initial selection committee review; IVF (recipients only); and final selection committee review. This eliminates candidates with poor chances of success before exposure to unnecessary risks.

SUMMARY

The currently stringent selection criteria for prospective recipients and donors will likely broaden, as UTx becomes more widely available. Continued research is needed to define the donor, recipient and uterine graft factors associated with successful outcomes, and to support the development of standardized selection criteria.

Risk constellations, viral infections, and prophylaxis in uterine transplantation

PURPOSE OF REVIEW

Uterine transplantation (UTx) is a burgeoning new category of solid organ transplantation (SOT) that is practiced at several centers worldwide (first transplantation in 2013). Although there are still relatively low numbers of transplants (<75 published in literature), they are increasing in frequency and thus we attempt to discuss the current documented infections in this population as well as theoretical infectious risks and summarize prophylaxis and treatment strategies of centers current performing these procedures.

RECENT FINDINGS

The most reported posttransplantation infection is not surprisingly urinary tract infections, with other documented infections including bacterial infections at site of graft (Enterococcus), herpes simplex virus, cytomegalovirus (CMV), human papillomavirus, Candida, and reportedly posttransplant lymphoproliferative disorder. The net state of immunosuppression and host factors (host colonization and serologic status of viral exposures) plays a significant role in infectious risk and with low numbers of infections documented, much of our guidance surrounding prophylaxis is inferred from SOT literature.

SUMMARY

In this review, we give an overview of described infections in UTx and theoretical infectious risks, detailing how to tailor prophylaxis base on host risk, with specific focus that the goal of transplantation is completion of a successful pregnancy as the desired outcome. Special considerations should be given to pregnant recipients when managing infectious complications and further data collection and reporting regarding infectious complications is crucial to advance this field as numbers of transplantation continue to increase.

Immunosuppression after uterus transplantation

PURPOSE OF REVIEW

Clinical uterus transplantation (UTx) is growing rapidly. The procedure represents the only therapy for women with absolute uterine factor infertility to give birth to a biological baby. Immunosuppression after UTx needs to carefully balance effects with the healthy mother and baby. Unique for UTx is the 'temporary' character of the procedure with a transplant hysterectomy being performed after delivery. Most of the practice on immunosuppression in UTx is currently based on the experience in solid organ transplantation (SOT).

RECENT FINDINGS

Clinical UTx-trials have been performed in centers worldwide during the recent years and experience on immunosuppression has accumulated.

SUMMARY

Immunosuppression in UTx has been successfully applied as maintenance treatment in addition to effectively treating acute T- and B-cell mediated rejections. Understanding the biology of UTx in more detail is expected to refine future approaches.