Pregnancy and Delivery Feasible After Uterus Transplant, but Risks Exist

Recipients of a successful uterus transplant were able to carry a pregnancy to term and have children without abnormalities, a small case series found.

Uterus allograft was successful for 14 of 20 participants (70%) and everyone who had a successful transplant gave birth to at least one live-born infant, reported Liza Johannesson, MD, PhD, of Baylor University Medical Center in Dallas, and colleagues.

However, 11 of the 20 recipients had at least one complication, and there were maternal and/or obstetrical complications in half of the successful pregnancies — most commonly gestational hypertension, cervical insufficiency, and preterm labor (14% each), they wrote in JAMA.

Also, four of the 18 living donors had grade 3 complications. But thus far, congenital abnormalities and developmental delays have not occurred in the 16 live-born children.

This research is “the first clinical study of uterus transplantation that has been published that was able to follow from the actual transplants through the whole journey with deliveries and then eventually to hysterectomies,” Johannesson told MedPage Today in an interview at which a Baylor University press person was also present.

Researchers wanted to know if uterus transplant was both feasible and safe for all parties involved — the recipient, the donor, and the child. This treatment is relatively new; the first successful uterus transplant occurred in 2011.

“Finally, we can see from a study how efficient and how safe this procedure is,” Johannesson said.

One in 500 women have absolute uterine infertility due to a dysfunctional or absent uterus. Traditionally, affected women must choose between adoption or surrogacy if they want to have children, but uterine transplant offers an option where they can experience pregnancy and childbirth.

The uterus was removed via open laparotomy for the first 13 living donors, and then with a minimally invasive robotic-assisted approach with transvaginal allograft extraction for the last five living donors. Then the uterus was surgically placed in “an orthotopic position with vascular anastomoses to the external iliac vessels” in recipients, who were then given immunosuppressive drugs until the transplanted uterus was removed after giving birth or after the graft failed. The technical success of the graft survival improved across the study period.

Prior to the uterus transplants, recipients underwent in vitro fertilization (IVF) to create embryos with the recipients’ own oocytes. The first eight recipients had a single embryo transfer after 6 months and the rest had a single embryo transfer after 3 months. Cesarean delivery was planned at 37 weeks or more gestation depending on the baby’s development. After first or second delivery, a uterine graft hysterectomy was performed at the time of cesarean delivery or postpartum.

Johannesson noted that after a participant completed their family, the transplanted uterus had to be removed so they wouldn’t have to be on immunosuppressive drugs longer than necessary.

Ultimately, “uterus transplantation is on par and even compares favorably to other infertility treatments,” Johannesson said, noting that the research team has continued transplantation for self-funded patients.

In an accompanying editorial, Jessica R. Walter, MD, MSCE, of the Feinberg School of Medicine at Northwestern Medicine, and Emily S. Jungheim, MD, MSCI, of Northwestern University, both in Chicago, compared this novel fertility treatment to the ethical and research questions IVF inspired when it was new.

“The same complexities of care that make this study so remarkable simultaneously raise questions about how we should define value and acceptable risk in the context of a life-generating rather than life-saving organ transplant,” the editorialists wrote.

Walter and Jungheim also noted that the learning and adaptation demonstrated throughout the study contributed to its success.

“For a new, complex procedure, these success rates for a previously untreatable condition should be interpreted as encouraging because they are comparable with the probability of live birth after one IVF treatment in the most favorable of IVF candidates,” they wrote.

The study involved 20 participants with uterine-factor infertility and at least one functioning ovary. Participants underwent a uterus transplant between September 14, 2016 and August 23, 2019. Most donors were living (18) and two were deceased. Donors had to be between ages 25 and 65, have at least one prior term live birth, and have no relevant medical or psychological comorbidities.

Median age of recipients was 30; median age of donors was 37. All donors and most recipients were white; two recipients were Asian, and one was Black.

There were six unsuccessful uterus transplant grafts, and they all occurred within 2 weeks of the transplant and for most, failure was attributed to problems with the vascular anastomosis or graft or donor selection.

The study was limited by its small sample size and the single-center design, which impacts generalizability. While Baylor covered the treatment costs for participants, the cost would be prohibitive for most people.

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