Uterus Transplant

Long-term Course of Kidney Function in Uterus Transplant Recipients Under Treatment With Tacrolimus and After Transplantectomy: Results of the First Clinical Cohort

Background

Chronic kidney disease is common after non-renal solid organ transplantation, mainly secondary to calcineurin inhibitors toxicity. Uterus transplantation (UTx) is an innovative treatment for women with absolute uterine factor infertility. UTx is exclusive because it is transient with the absence of lifelong immunosuppression and is performed in young healthy participants. Therefore, UTx provides a unique setting for evaluating the effect of time-limited calcineurin inhibitors treatment on recipients' kidney function.

Methods

In the first UTx cohort worldwide, we studied kidney function using estimated glomerular filtration rate (eGFR) in 7 women over a median follow-up of 121 (119-126) mo.

Results

Median eGFR (mL/min/1.73 m2) of the cohort was 113 at UTx, which declined to 74 during month 3, 71 at months 10-12, 76 at hysterectomy (HE), and 83 at last follow-up. Median duration of tacrolimus exposure was 52 (22-83) mo, and median trough levels (µg/L) were 10 during month 3 and 5.8 at HE. Between UTx and month 3, decline in kidney function was observed in all 7 participants with a median eGFR slope for the whole cohort of -24 mL/min/1.73 m2, which declined further by -4 mL/min/1.73 m2 until months 10-12. Thereafter, eGFR slope improved in 3 participants, remained stable in 3, and worsened in 1 until HE/tacrolimus discontinuation, after which it improved in 2. Eventually, between UTx and last follow-up, 4 of 7 participants had a decline in their eGFR, the median annual eGFR slope being negative at -1.9 mL/min/1.73 m2/y for the whole group.

Conclusions

Kidney function declined in all recipients early after UTx followed by a persistent long-term decrease in majority, despite transplantectomy and discontinuation of immunosuppression. Thus, UTx may incur an increased risk of chronic kidney disease even in this young and healthy population, highlighting the importance of close surveillance of kidney function and minimization of tacrolimus exposure.

Immunosuppression in uterus transplantation: from transplant to delivery

INTRODUCTION

Uterus transplantation introduces unique challenges regarding immunosuppression, including the effects of immunosuppressive drugs on the fetus and graft rejection during pregnancy. Although immunosuppressive regimens are based on protocols used after solid organ transplantation, in recipients of uterus grafts, the physician must consider therapy modifications based on the phase of the transplant, from the intra-operative period through to delivery.

AREAS COVERED

This review discusses the current immunosuppressive rationale in uterus transplantation, focusing on the therapy in each phase of the transplant. The authors present an overview of the already approved immunosuppressive medications for solid organ transplantation, their application in uterus transplant prior to pregnancy, during pregnancy and as rejection treatment.

EXPERT OPINION

Most medications used for uterus transplant are adopted from solid organ transplantation experience, especially kidney transplantation, and rejection is treated in standard fashion. Research is needed to clarify the drugs' effects on fetal and neonatal well-being and to develop new medications to achieve better tolerance. Early markers of uterus graft rejection need to be identified, and prior rejection episodes should no longer be a cause to remove the graft during delivery in a recipient who wants a further pregnancy.

The Ethical Evolution of Uterus Transplantation From Concept to Clinical Procedure

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.

UK criteria for uterus transplantation: a review

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.

Revaluation and lessons learned from the first 9 cases of a Czech uterus transplantation trial: Four deceased donor and 5 living donor uterus transplantations

Although uterus transplantation is still in the experimental stage, it has promising potential as a treatment for women with absolute uterine factor infertility based on the childbirths from living donor trials conducted in Sweden and the United States. We report the main characteristics and perioperative and postoperative courses of both recipients and donors following 4 deceased donor and 5 living donor uterus transplantations. Three main priorities differentiate this study from the previously reported uterus transplantations. First, clinical experience with the largest worldwide group of deceased donor uterine transplants is described. Second, in the majority of living donor uterine recipients, only 2 ovarian veins were used for venous blood outflow. All of these recipient procedures were surgically successful, and follow-up posttransplant ultrasound examinations revealed normal uterine blood supply and outflow. Third, in only one living and one deceased donor recipient, the transplanted uterus relied on only 2 uterine veins for venous outflow with a 50% surgical success rate. In all other recipients, 2 uterine and 2 ovarian veins were utilized. Although a successful pregnancy has not yet been achieved, the presented surgical and functional results of our trial are promising.

Uterine Autotransplantation in the Nonhuman Primate With Preservation of the Uterine and Ovarian Vascular Pedicles

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.

Uterus transplantation: Toward clinical application in Japan

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.

Psychological Issues Associated With Absolute Uterine Factor Infertility and Attitudes of Patients Toward Uterine Transplantation

CONTEXT

Uterine transplantation (UTx).

OBJECTIVE

To explore patients' knowledge of and attitudes toward UTx before and after a short educational intervention via a video and question and answer (Q&A) session.

DESIGN

Large, in-depth survey investigating patients' motivations, aims, and beliefs on UTx.

SETTING

Imperial College London.

PARTICIPANTS

Women diagnosed with absolute uterine factor infertility (AUFI) who were seeking information on UTx and had already volunteered to participate in the study.

INTERVENTION

A semistructured interview involving a brief baseline questionnaire before a Q&A session and a 20-minute video exploring the main risks and benefits for UTx.

MAIN OUTCOME MEASURES

Attitudes of self-referred patients with AUFI toward UTx before and after education focusing on UTx. Rank order of importance of key UTx-related issues.

RESULTS

Forty women were interviewed. Following the video presentation and Q&A session, 97.5% (n = 39) would undergo UTx ahead of surrogacy and adoption in full knowledge that the latter 2 options would be ultimately safer for their own well-being and the fact that the graft could fail even prior to conception. All felt that UTx should take place, and 92.5% saw UTx as achievable.

CONCLUSION

The study demonstrates a keen interest in UTx, partly because other options seem difficult to access. It is worth noting that people appear to be distancing themselves from the risk. This requires careful assessment in any clinical program. This study is the first to demonstrate a qualitative relationship between patients with AUFI and their curiosity and desire for UTx. It paves the way for forming the introduction into the psychological assessment of a potential patient.

Fertility Risk Assessment and Preservation in Male and Female Prepubertal and Adolescent Cancer Patients

Cancer represents the second cause of death in prepubertal children and adolescents, although it is currently associated with an overall survival rate of 80%–85%. The annual incidence rate is 186.6 per 1 million children and adolescents aged up to 19 years. Both disease and treatment options are associated with life-altering, long-term effects that require monitoring. Infertility is a common issue, and as such, fertility preservation represents an essential part in the management of young patients with cancer who are at risk of premature gonadal failure. This review deals with the up-to-date available data on fertility risk assessment and preservation strategies that should be addressed prior to antineoplastic therapy in this vulnerable subgroup of cancer patients.

The Ethics of Allocating Uterine Transplants

In September 2014, a healthy male child was born in Sweden following a successful uterine transplantation (UTx). The event brought hope to many women without functional uteruses around the world. Having a child with a transplanted uterus is now possible, and as knowledge of the procedure proliferates and interest in UTx grows, it is important to begin thinking about how a scarce supply of uteruses will be allocated. This article represents a first discussion of the range of factors that must be considered in answering the allocation question. The primary issues addressed are (1) the motivation to seek treatment, (2) allocation by age, (3) child-rearing capacity, and (4) the amount of infertility treatment required. A set of eligibility and ranking criteria are presented. These criteria are not exhaustive but are intended to spark discussion about how uteruses can be allocated in a just manner.

Regenerative medicine for the treatment of reproductive system disorders: current and potential options

Regenerative medicine has opened new avenues for treating patients with severe reproductive system disorders, such as congenital abnormalities, cancer, trauma, infection, inflammation and iatrogenic injuries. Over the past two decades, scientists have advanced the field of reproductive tissue engineering to restore normal sexual function and preserve fertility in both female and male patients. In this review, we summarize recent advances in the use of cell, tissue, and organ-based regenerative medicine strategies for clinical application in reproductive system disorders.

Survey of Perceptions of Health Care Professionals in the United Kingdom toward Uterine Transplant

Context

Currently, the only 2 options that women with absolute uterine factor infertility have for managing their infertility are surragocy or adoption. These women may also benefit from a possible future third option: uterine transplant

Objective

To investigate the opinions and views of UK health care professionals toward uterine transplant and rank issues related to uterine transplant by importance in order to make uterine transplant transparent and understandable to colleagues.

Design

Large, in-depth survey investigating health care professionals' opinions on uterine transplant.

Setting

Analysis done at Imperial College London.

Participants

UK transplant professionals (surgeons, nurses, operating room staff, and donor coordinators) and obstetricians and gynecologists (trainees, members, and fellows of the Royal College of Obstetricians and Gynaecologists).

Intervention

Questionnaires were given out at hospital grand rounds, trainee teaching days, and conferences (national and international).

Main Outcome Measures

Should uterine transplant take place? Is uterine transplant achievable? What is the rank order of importance of key issues related to uterine transplant?

Results

The study had 528 participants. With respect to overall support for uterine transplant and as a possible future therapeutic option for absolute uterine factor infertility, 93.8% (n=495) thought that uterine transplant should take place if considered appropriate medically, surgically, and ethically and 57.2% (n= 302) thought it was an achievable objective. Issues related to immunology of uterine transplant and pregnancy after uterine transplant were unanimously thought of as most important. More effort is required to educate health care professionals about all aspects of uterine transplant.

Experimental uterus transplantation

Today, most causes of infertility are successfully treated. Yet there is still a subgroup of female infertility affecting around 4%, which so far is untreatable because of an absolute uterine factor. To acquire motherhood, these women are today referred to either adoption or surrogacy. Research in the field of uterus transplantation has been evaluated in different animal models for decades and has presently reached a human clinical application as a possible treatment for absolute uterine factor infertility. Organ transplantation is no longer reserved to those with a life-threatening disease and neither is organ transplantation together with concurrent immunosuppression prohibiting pregnancy. Uterus transplantation involves four parties - recipient, donor, partner of recipient and future child - and is a subject of ethical controversies.

Uterus transplantation: ethical and regulatory challenges

Moving forward rapidly in the clinical research phase, uterus transplantation may be a future treatment option for women with uterine factor infertility, which accounts for three per cent of all infertility in women. This new method of treatment would allow women, who currently rely on gestational surrogacy or adoption, to gestate and birth their own genetic offspring. Since uterus transplantation carries significant risk when compared with surrogacy and adoption as well as when compared with other organ transplants, it requires greater justification because its goals are quality of life, not life-saving, in their scope. It is important to address questions regarding the physical, psychosocial and ethical risks and benefits of uterus transplantation for all three parties involved--the patient, the donor and the potential child--as well as discuss the regulatory implications as research on uterus transplantations moves forward.

Uterine transplantation: a step too far?

The options currently available to women with uterine infertility are adoption or surrogacy. Recently the option of uterine transplantation has been explored which would allow a woman to carry her own genetically related child. Although this type of transplant raises similar ethical considerations to other types of non-life-saving organ transplantation, such as facial tissue and limb, it also raises its own very unique considerations. In this paper, some of the considerations surrounding uterine transplantation, such as informed consent and an individual's rights, and potential limit to reproductive autonomy are explored.

[Uterus transplantation. Current situation]

Except adoption, absolute uterine factor infertility lacks solution in case of motherhood desire. Gestational surrogacy is still not approved in France. Over the last decade, uterus transplantation experimentation made advances. Data from animal research, progress in immunosuppressive treatment and knowledge about pregnancy after transplantation provide a scenario in which a human allotransplantation project can become reality.

Immunology of uterine transplantation: a review

The idea of using organ transplantation to solve quality-of-life issues was first introduced a century ago, with cornea transplants and thrusted before the world again in 1998, following a controversial hand transplant. Uterus transplantation (UTn) has been proposed as another quality-of-life transplant for the cure of permanent uterine factor infertility. In order to proceed in humans, a greater appreciation of the immunological mechanisms that underlie UTn is desirable. Allogeneic UTn (animal model) was first described by 2 studies in 1969. The first and only human UTn, performed in 2000, was an early attempt with limited use of animal model experiments prior to moving onto the human setting. Since then, work using rat, mouse, ovine, goat, and nonhuman primate models has demonstrated that the uterus is a very different but manageable organ immunologically compared to other transplanted organs. Therefore, specifically exploring immunological issues relating to UTn is a valuable and necessary part of the inevitable scientific process leading to successful human UTn.

Use of cyclosporine in uterine transplantation

Uterine transplantation has been proposed as a possible solution to absolute uterine factor infertility untreatable by any other option. Since the first human attempt in 2000, various teams have tried to clarify which immunosuppressant would be most suitable for protecting the allogeneic uterine graft while posing a minimal risk to the fetus. Cyclosporine A (CsA) is an immunosuppressant widely used by transplant recipients. It is currently being tested as a potential immunosuppressant to be used during UTn. Its effect on the mother and fetus and its influence upon the graft during pregnancy have been of major concern. We review the role of CsA in UTn and its effect on pregnant transplant recipients and their offspring.

Rescue radical trachelectomy for preservation of fertility in benign disease

OBJECTIVES

To report a series of patients treated with modified radical abdominal trachelectomy to preserve fertility in benign disease that would normally result in hysterectomy.

DESIGN

We reviewed all cases of radical abdominal trachelectomy performed for nonneoplastic indications.

PATIENT(S)

Of the >160 radical abdominal trachelectomies we performed, four cases were performed for benign indications. One patient had a 10-year history of progressive endometriosis with worsening hydronephrosis, failed medical therapy, and infertility. Two myomectomy patients had intraoperative consultation and a third had preoperative consultation for large lower segment/cervical myomas with conversion to trachelectomy rather than hysterectomy.

INTERVENTION(S)

Modified radical trachelectomy was successfully completed in all patients.

MAIN OUTCOME MEASURE(S)

We measured the successful completion of the surgery without hysterectomy, complications, and follow-up.

RESULT(S)

Hysterectomy was avoided in all patients, and all resumed normal menses. There were no intraoperative or postoperative complications. One required hysterectomy for recurrence 1 year later, and the remainder were symptom free at 1-5 years of follow-up.

CONCLUSION(S)

Although traditionally performed with cervical cancer, radical abdominal trachelectomy can be modified to preserve fertility for benign indications that would otherwise require hysterectomy.

[Uterine transplantation: animal and human studies]

Many cases of not life saving transplanted organs were described with the aim of improving quality of life. Uterus graft could be an alternative solution to adoption or surrogacy for women who have uterine factor infertility. Different animals' studies with mouse, sheep or monkey showed feasibility of the surgical technique with large vessels patch. One case of human uterine transplant has been reported but failed. Cold storage of the uterus in protective solution has been explored with mouse, sheep and human. Only pregnancy after uterus graft by syngenic mouse has been published. Results about pregnancy after allograft with sheep or monkey are necessary before pregnancy after human uterus graft becomes a reality.