1
|
Walter JR, Johannesson L, Falcone T, Putnam JM, Testa G, Richards EG, O'Neill KE. In vitro fertilization practice in patients with absolute uterine factor undergoing uterus transplant in the United States. Fertil Steril 2024:S0015-0282(24)00245-0. [PMID: 38631504 DOI: 10.1016/j.fertnstert.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/06/2024] [Accepted: 04/09/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To report detailed, pooled multicenter experiences and outcomes after in vitro fertilization (IVF) treatment among patients undergoing uterus transplantation (UTx) in the US. DESIGN Cohort study. SETTING Hospital. PATIENTS Patients undergoing UTxsfrom the three longest-running UTx clinical trials in the US. INTERVENTION In vitro fertilization treatment among patients undergoing UTx.. MAIN OUTCOME MEASURES Reproductive outcomes pretransplant and posttransplant ovarian stimulation. RESULTS Thirty-one uterus transplant recipients were included in this cohort (mean [±SD] age at transplant was 31 ± 4.7 years). Before transplant, recipients completed a mean of two oocyte retrievals (range 1-4), banking a mean of eight untested embryos (range 3-24) or six euploid embryos (range 2-10). Posttransplant retrieval cycles were required in 19% (n = 6/31) of recipients, for a total of 16 cycles (range 2-4 cycles per recipient). All posttransplant retrievals were performed vaginally without complications. Preimplantation genetic testing was used by 74% (n = 23/31) of subjects. Seventy-two autologous single embryo transfers (ETs) occurred in 23 patients who completed at least one ET. Two ETs followed a fresh IVF treatment cycle, and the remainder (n = 70) were frozen ETs. Endometrial preparation was more commonly performed with programmed protocols (n = 61) (exogenous administration of estrogen and progesterone) compared with natural cycle protocols (n = 9). The overall live birth rate (LBR) for this cohort was 35% (n = 25/72) per ET. Among those patients (n = 21) who had an ET leading to a live birth, a mean of 2.2 ETs were performed. The overall LBR after the first ET was 57% (n = 13/23) and rose to 74% (n = 17/23) after a second ET. There was no difference in rate of preeclampsia, live birth, neonatal birth, or placental weights among programmed vs. natural cycle frozen ETs. There were no differences in the LBR between living or deceased donor uteri (37% vs. 32%). CONCLUSIONS Posttransplant ovarian stimulation was required in 26% (n = 6/23) of recipients undergoing at least one ET, despite high rates of preimplantation genetic testing and pretransplant embryo cryopreservation. Posttransplant retrievals were performed transvaginally, without complications. Future reporting of IVF treatment experiences will be essential to optimizing reproductive outcomes after a uterus transplant. CLINICAL TRIAL REGISTRATION NUMBERS NCT02656550 (Baylor University Medical Center); NCT03307356 (University of Pennsylvania); and NCT02573415 (Cleveland Clinic).
Collapse
Affiliation(s)
- Jessica R Walter
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Liza Johannesson
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Tommaso Falcone
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio
| | - J Michael Putnam
- Fertility Center of Dallas, Baylor University Medical Center, Dallas, Texas
| | - Giuliano Testa
- Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Elliott G Richards
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio
| | - Kathleen E O'Neill
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Penn Fertility Care, University of Pennsylvania, Philadelphia, Pennsylvania.
| |
Collapse
|
2
|
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
|
3
|
Escandón JM, Bustos VP, Santamaría E, Langstein HN, Ciudad P, Hernandez-Alejandro R, Moore RG, Leckenby JI, Manrique OJ. Evolution and Transformation of Uterine Transplantation: A Systematic Review of Surgical Techniques and Outcomes. J Reconstr Microsurg 2021; 38:429-440. [PMID: 34535036 DOI: 10.1055/s-0041-1735261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Uterine transplantation (UTx) is acknowledged to be on the second (2A) of five steps of development in accordance with the staging system for the evaluation of surgical innovations. Accordingly, we aimed to systematically review the available evidence of the surgical techniques and outcomes of UTx in terms of graft survival. METHODS A comprehensive search was conducted across PubMed Medline, Cochrane-EBMR, Scopus, Web of Science, and CENTRAL through November 2020. RESULTS Forty studies, reporting 64 recipients and 64 donors, satisfied inclusion criteria. The surgical time and the estimated blood loss were 515 minutes and 679 mL for graft procurement via laparotomy, 210 minutes and 100 mL for laparoscopic-assisted graft harvest, and 660 minutes and 173 mL for robotic-assisted procedures, respectively. Urinary tract infections (n = 8) and injury to the urinary system (n = 6) were the most common donor complications. Using the donor's internal iliac system, two arterial anastomoses were performed in all cases. Venous outflow was accomplished through the uterine veins (UVs) in 13 cases, a combination of the UVs and the ovarian/uteroovarian veins (OVs/UOVs) in 36 cases, and solely through the OVs/UOVs in 13 cases. Ischemia time was 161 and 258 minutes when using living donors (LD) and deceased donors (DD), respectively. Forty-eight uteri were successfully transplanted or fulfilled the purpose of transplantation, 41 from LDs and 7 from DDs. Twenty-five and four live childbirths from LDs and DDs have been reported, respectively. CONCLUSION UTx is still experimental. Further series are required to recommend specific surgical techniques that best yield a successful transplant and reduce complications for donors and recipients.
Collapse
Affiliation(s)
- Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Eric Santamaría
- Department of Plastic and Reconstructive Surgery, Hospital General Dr. Manuel Gea Gonzalez, National Cancer Institute, Mexico City, Mexico
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Roberto Hernandez-Alejandro
- Department of Surgery and Division of Abdominal Transplantation and Hepatobiliary Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Richard G Moore
- Department of Obstetrics and Gynecology, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Jonathan I Leckenby
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| |
Collapse
|
4
|
Abstract
Uterus transplantation (UTx) offers women with absolute uterine factor infertility the option to gestate and birth their own biologically related child. The first birth following living donation UTx happened in 2014. The first birth following deceased donation happened in December 2017, with further successes since. Interest in deceased donation UTx is increasing. The authors established a database to track UTx clinical trials and outcomes. Utilising this database and existing literature, this article reviews the first reported cases of deceased donation UTx and outcomes, and drawing upon comparisons with living donor UTx, comments upon the future for this area of reproductive transplantation research. This is the first article to bring together the literature on deceased donation UTx procedures and outcomes.
Collapse
|
5
|
The Evolution of Transplantation From Saving Lives to Fertility Treatment: DUETS (Dallas UtErus Transplant Study). Ann Surg 2021; 272:411-417. [PMID: 32657928 DOI: 10.1097/sla.0000000000004199] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE We report the results of the first 20 uterus transplants performed in our institution. SUMMARY BACKGROUND DATA Uterus transplantation (UTx) aims at giving women affected by absolute uterine-factor infertility the possibility of carrying their own pregnancy. UTx has evolved from experimental to an established surgical procedure. METHODS The Dallas Uterus Transplant Study (DUETS) program started in 2016. The uterus was transplanted in orthotopic position with vascular anastomoses to the external iliac vessels and removed when 1 or 2 live births were achieved. Immunosuppression lasted only for the duration of the uterus graft. RESULTS Twenty women, median age 29.7 years, enrolled in the study, with 10 in phase 1 and 10 in phase 2. All but 2 recipients had a congenital absence of the uterus. Eighteen recipients received uteri from living donors and 2 from deceased donors. In phase 1, 50% of recipients had a technically successful uterus transplant, compared to 90% in phase 2. Four recipients with a technical success in phase 1 have delivered 1 or 2 babies, and the fifth recipient with a technical success is >30 weeks pregnant. In phase 2, 2 recipients have delivered healthy babies and 5 are pregnant. CONCLUSIONS UTx is a unique type of transplant; whose only true success is a healthy child birth. Based on results presented here, involving refinement of the surgical technique and donor selection process, UTx is now an established solution for absolute uterine-factor infertility.
Collapse
|
6
|
Liu Y, Ding Y, Zhang X, Zhang Y, Hua K. Morphologic assessment of hypertonic citrate adenine, histidine-tryptophan-ketoglutarate, and university of Wisconsin solutions for hypothermic uterus preservation in rats. J Obstet Gynaecol Res 2021; 47:1097-1109. [PMID: 33410204 DOI: 10.1111/jog.14645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/06/2020] [Accepted: 12/17/2020] [Indexed: 12/11/2022]
Abstract
AIM Optimizing perfusate for static cold storage is one of the key ways of reducing organ dysfunction and rejection in organ transplantation. Here, we tested the effectiveness of the three different solutions for hypothermic uterus preservation. METHODS Twenty rats were divided into four groups, five in each group. Uterine grafts were retrieved and perfused in situ. The uteri were preserved at 4°C in normal saline as control group (group NS), hypertonic citrate adenine (group HCA), histidine-tryptophan-ketoglutarate (group HTK), or university of Wisconsin solutions (group UW) for 0, 12, 24, and 48 h, respectively. HE, electron microscopy, TUNEL staining, and Cleaved Caspase3 immunohistochemical staining were assessed at each time point. RESULTS There was no significant difference in the uterine retrieval time, perfusion time, and the amount of perfusion solution in NS, HCA, HTK, and UW groups (p > 0.05). HCA and HTK can well preserve the pathological morphology of rat uterine tissues for up to 24 h, and the apoptosis rates of the two groups are 7.2% and 7.1%, respectively, with no statistical difference (p > 0.05). Still, the protective effect of HTK on the ultrastructure of cells was much better than HCA. There was a significant difference in the apoptosis rate of UW (6.5%), HTK (8.8%), and HCA (9.4%) at 48 h, with mitochondrial and endoplasmic reticulum structure well preserved only in UW. CONCLUSION At 4°C, normal saline is not suitable to preserve rat uterus for more than 12 h. The morphologic results would favor the use of HTK rather than HCA for short-term hypothermic uterus preservation (≤24 h). UW is better than HTK and HCA for 48 h hypothermic uterus preservation.
Collapse
Affiliation(s)
- Yu Liu
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Yan Ding
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xuyin Zhang
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Ying Zhang
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Keqin Hua
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| |
Collapse
|
7
|
D'Amico G, Quintini C, Eghtesad B, Hashimoto K, Ricci S, Flyckt R, Del Prete L, Miller C, Falcone T, Tzakis A. Uterus Recovery from Deceased Donor: Simple Technique Securing Safety of Vital Organs and Uterus Graft. J Am Coll Surg 2020; 232:e1-e6. [PMID: 33217551 DOI: 10.1016/j.jamcollsurg.2020.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Giuseppe D'Amico
- Departments of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH.
| | - Cristiano Quintini
- Departments of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Bijan Eghtesad
- Departments of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Koji Hashimoto
- Departments of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Stephanie Ricci
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Rebecca Flyckt
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Luca Del Prete
- Departments of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Charles Miller
- Departments of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Tommaso Falcone
- Obstetrics and Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Andreas Tzakis
- Departments of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| |
Collapse
|