Uterus transplantation Fact sheet.

Abstract

In uterus transplantation, a uterus from a live or a deceased donor is transplanted temporarily to a woman who lacks a functional womb so that she can become pregnant and have one or more babies. Before uterus transplantation, the recipient carries out in vitro fertilization with cryopreservation of embryos until embryo transfer a year after transplantation. To avoid uterine graft rejection, immunosuppressant drugs are given until the uterus is removed after childbirth(s). To date (2019), more than 60 uterus transplantations have been performed worldwide that have resulted in more than 15 babies being born:2 The uterus, whether from a deceased donor or a live donor, needs to be assessed for its potential to carry a pregnancy. Live donors should be given a detailed gynecological examination, preoperative uterine imaging and angiography by CT and MRI, and uterine cancer screening including human papillomavirus testing, Papanicolaou smear and endometrial biopsy. Hormonal priming for several months can be performed in postmenopausal live donors. In the case of the donor, the uterus extraction requires a precise surgical procedure but advances in operative procedures5, 6 and successful use of robotic-assisted laparoscopy2 have made operating on the donors considerably less invasive (Figure 1). The potential side effects of immunosuppression include nephrotoxicity, bone marrow toxicity, diabetes, and an increased risk of malignancies. Comorbidity and complications during gestation are more frequent in organ transplanted women. Recipient follow up should continue even after the hysterectomy of the transplanted uterus (for at least 10 years and ideally for a lifetime) and should include psychological assessments and medical examinations focusing on potential long-term side effects of immunosuppressants. As in the case of pregnancies in other organ transplanted women, there is increased risk of low birthweight, preterm birth, preeclampsia, rejection episodes, spontaneous abortion and intrauterine death.7 The children of uterus transplant recipients should have long-term follow up. Criteria defining minimum quality standards for uterus transplant programs and the long-term follow up of living donors, recipients, and children need to be determined. There is a strong clinical interest and demand by patients for uterus transplantation. The acceptance of the procedure as an infertility treatment for women with absolute uterine factor infertility is high, and even in countries that permit surrogacy, such as the UK, it is preferred by patients over gestational surrogacy and adoption. In the past 3 years, several uterus transplant programs have been initiated throughout the world including China, USA, Brazil, Czech Republic, Germany, Serbia, France, Mexico, and India. Nonetheless, bioethical concerns have also been raised regarding risk-benefit analysis for the live donor, recipient, and child, live and deceased donor strategies, informed consent, equitable access, and fair selection of participants. It is largely considered an ethically acceptable solution to absolute uterine infertility.