The First 5 Years of Uterus Transplant in the US—A Report From the United States Uterus Transplant Consortium

Abstract

ABSTRACT Women affected by absolute uterine-factor infertility (AUFI) were previously considered to have an untreatable condition, although uterus transplant has now changed this calculation. Although AUFI is a cause of female infertility (affecting 1 in 500 women), the counseling describing potential family-building options (gestational carrier or adoption) now includes a third choice of uterus transplant. This procedure is meant to restore reproductive ability and to allow gestation and childbirth. Further data regarding uterus transplant are essential to counsel appropriate individuals regarding this potential option. The US Uterus Transplant Consortium was formed in 2019 by centers performing uterus transplant in the United States: Baylor University Medical Center, Dallas, Tex; Cleveland Clinic, Cleveland, Ohio; and the University of Pennsylvania, PA. Accounting for approximately half of worldwide cases and of live births after uterus transplant, these centers have been instrumental in the evolution of the procedure, including the invention of novel surgical techniques for deceased donors, early embryo transfer, using the superior uterine veins for live birth and graft survival, and fully robotic living donor hysterectomies. This study examined data from all uterine transplants performed in the United States between 2016 and 2021, including donor, recipient, and offspring outcomes. Follow-up included the time from uterine transplant until the most recent visit. Evaluation of patients took place via a multidisciplinary transplant team and an independent living advocate. Primary outcomes of the study included patient survival (primary living donor outcome), allograft survival (30 days, 1 year, and 3 years), and live birth. Offspring primary outcomes included weight percentile and gestational age at delivery. During the study years (2016–2021), a total of 33 uterus transplants were performed, with 21 living and 12 deceased donors. No mortality of living donors or recipients was recorded. Overall, 25 of 33 uterus transplants had a viable graft at 30 days, and 19 of the 33 participants (58%) were able to achieve at least 1 live birth. A total of 8 recipients experienced graft loss (26%), and infection occurred in 10 participants (30%). Acute cellular rejection occurred for 10 participants within the 1-year graft survival group, but these patients were successfully treated. Time to the first menstrual cycle after transplant was a mean of 30 days (range, 10–59 days). Pregnancy following the transplant requires in vitro fertilization, as fallopian tubes are not transplanted with the uterus. For those participants who were able to conceive, the most common complications were gestational diabetes (12%), gestational hypertension (24%), and preeclampsia (12%). The mean gestational age at delivery was 36 weeks 6 days (range, 30 weeks 1 day to 38 weeks), with more than half (52%) being born after 36 weeks' gestation. After live birth, patients underwent a graft hysterectomy, the timing of which was determined by the patient (either during delivery or later in the recovery process). Medical indications for hysterectomy were conditions such as preeclampsia, acute kidney injury, abnormal placentation, and gestational diabetes. Overall, the first 5 years of US clinical experience of uterus transplant demonstrate technical feasibility and the ability of patients to have a live birth. High rates of technical success (76%) within US centers performing uterus transplants are promising. Despite the fact that the 1-year survival rate of the uterus transplant (76%) is lower than other organ transplant graft survival rates, the required longevity of the uterus differs from others. Nevertheless, a learning curve is expected to allow for improvements to this success rate over time. Based on the outcomes of uterine transplant described in this report, the authors conclude that the procedure is safe for both mother and child, as success is not limited to single centers, and is reproducible. They note that the success of the procedure is achieved both with living and deceased donors, and the rate of success is comparable to other infertility treatments. They conclude that the procedure ought to be recognized as an option for AUFI-diagnosed individuals desiring parenthood.