COMMENTARY

Uterine Transplantation: Success and Failure

Peter Kovacs, MD, PhD

Disclosures

December 03, 2019

Until recently, adoption and surrogacy were the only means for women with absolute uterine factor infertility (AUFI) to have a family. The concept of uterine transplantation is not new , but the first such surgery resulting in a live birth was reported only 5 years ago from Sweden. Since then, uterine transplant programs have been established in multiple countries. A recent report summarizes the first 45 cases of uterine transplantation with known outcomes.

AUFI is rare, and the uterine problems that cause it can be congenital or acquired. The most common congenital anomaly is Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. Acquired uterine infertility can be caused by conditions that interfere with implantation (eg, Asherman syndrome, fibroids, adenomyosis, damage due to ischemia/radiation).

MRKH was the cause of AUFI in 89% of the 45 uterine transplant recipients, whose mean age was 27.8 years. Live donors were used in 36 (80%) of the transplants, whereas the organs came from deceased donors in the remaining nine cases. About half of the donors were relatives of the uterine recipients.

Eleven percent of the live donors suffered severe complications (eg, ureteric injury, fistula formation, vaginal cuff dehiscence), and 28% were affected by minor complications (eg, infection, hypotonic bladder, constipation, leg pain, anemia).

Graft failure following transplantation occurred in 13 women (28.8%), leading to emergency hysterectomies for thrombosis, ischemia, or infection. In another seven cases (15.5%), planned hysterectomy was performed after successful delivery. The remaining 25 women (55.5%) still have functioning grafts.

So far, 18 live births have been reported (17 from live donors and one from a deceased donor). All were born by cesarean section. The mean gestational age of the infants at delivery was 34+6 weeks and the mean birth weight was 2500 g. All neonates did well and no congenital anomalies were seen. One third of the women developed preeclampsia and 22% developed cholestasis.

In summary, uterine transplant offers an alternative method to establish a family in women with AUFI. The procedure is associated with significant risks, however, as almost half of the patients experienced minor or more severe complications.

Viewpoint

Uterine transplantation offers women with AUFI another option for starting a family. The procedure is complex, however, and not without risk. Before transplantation, a recipient must undergo in vitro fertilization to cryopreserve embryos for later transfer. Therefore, the ideal candidate would be a young woman with good ovarian reserve, who is either in a stable relationship or open to using donated sperm. Many transplant programs have age restrictions and require the availability of a certain number of embryos before considering a uterine transplant.

The use of a live donor, preferably a close relative, is ideal. This would allow advanced planning and coordination of the hysterectomy and transplant procedures to minimize the risk for ischemic damage of the organ. Donation by a relative allows the use of lower-dose immunosuppression. Live donors are usually older women who have reached their own desired family size. The older uterus may be less elastic and the blood vessels are more likely to be sclerotic, potentially increasing the risk for graft rejection and compromising perinatal outcomes. On the other hand, the use of a brain-dead donor precludes advanced planning, so the risk for ischemic injury is higher.

Most children in this series were born after live-donor uterine transplantation. Prenatal medical complications and the risk for preterm delivery and low birth weight are increased after uterine transplant, possibly as a result of underlying maternal medical problems, suboptimal function of the transplanted uterus, or the need for immunosuppressant therapy. All newborns in this series did well and no congenital anomalies were detected.

Finally, one has to consider the ethical issues surrounding uterus transplantation because the uterus is not a vital organ, and two or three people are exposed to risks (donor, recipient, and newborn) as a result of the procedure. Some of these concerns may be addressed in the future if bioengineered uteri become available. Until then, the surgical technique and the preparation of the recipient should be improved further.

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