North America Sees Its First Birth After a Deceased-Donor Uterus Transplant

By Marilynn Larkin

March 23, 2020

NEW YORK (Reuters Health) - A healthy baby was delivered by cesarean hysterectomy to a 33-year-old woman with a deceased-donor uterus, a case study reveals.

"Uterus transplantation is the only known potential treatment for absolute uterine factor infertility," write Dr. Tommaso Falcone of Cleveland Clinic in Ohio and colleagues. "Until recently, all live-births resulting from uterus transplantation involved living donors, with only one prior birth from a deceased donor."

The current case report, published in the American Journal of Obstetrics and Gynecology, is from Cleveland Clinic's clinical trial of uterus transplantation, which opened in 2015 and is ongoing. In 2017, a 33-year-old woman without a uterus was matched to a 24-year-old parous deceased brain-dead donor.

"Obtaining an excellent uterus with a proper blood supply is the most challenging aspect," Dr. Falcone said in an email to Reuters Health. "However, the transplant itself has two important technical challenges - the anastomosis of the blood vessels and anastomosis of the donor to recipient vagina."

The transplant was performed with vaginal anastomosis and vascular anastomoses bilaterally, from the donor's internal iliac vessels to the recipient's external iliac vessels. Induction and maintenance immunosuppression were achieved, then modified in anticipation of pregnancy six months post-transplant.

However, before the planned embryo transfer, an ectocervical biopsy revealed ulceration and a significant diffuse, plasma cell-rich mixed inflammatory cell infiltrate, histologically interpreted as grade 3 rejection, likely with an antibody-mediated component.

The team initiated an aggressive immunosuppressive regimen targeting both cellular and humoral rejection. After three months of treatment, there was no histologic evidence of rejection; three months after the rejection had completely cleared, an uneventful embryo transfer was performed and pregnancy was established.

At 21 weeks, the recipient was diagnosed with central placenta previa with accreta. Nonetheless, a healthy neonate was delivered at 34 weeks gestation.

The authors conclude, "This achievement underscores the capacity of the transplanted uterus to recover from a severe, prolonged rejection and yet produce a viable neonate."

Dr. Michael Thomas, Professor and Chair, Department of Obstetrics and Gynecology at the University of Cincinnati College of Medicine in Ohio, told Reuters Health by phone, "There are definitely people who would want a procedure such as this. There are no guidelines as yet, but a report from a 2016 Uterus Transplantation Intersociety Roundtable, sponsored by the American Society for Reproductive Medicine in collaboration with the American Society of Reconstructive Transplantation, goes into requirements for the procedure in more detail." (https://bit.ly/2J4X1Du)

"Recommendations include the need for an interdisciplinary team consisting of a transplant surgeon, gynecologist, high-risk obstetrician, fertility specialist, anesthesiologist, transplant psychiatrist, infectious disease specialist, social worker, patient advocate, and research nurse," he said.

"For now, it's a matter of making sure you have the right institution and the right patient population for the medical and surgical issues that come up," he noted. "It's important that the procedure be done at an institution with a proven track record of transplantation and collaboration among all stakeholders. As we move forward, all institutions that perform the procedure need to come together to create guidelines."

SOURCE: https://bit.ly/3a98s94 American Journal of Obstetrics and Gynecology, online March 6, 2020.

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