What to Expect From a Uterus Transplant

A uterus transplant is a replacement of the uterus in women who have absolute uterine factor infertility (AUFI). Women with AUFI—a term used to describe any reason why a woman is unable to get pregnant—can have congenital conditions and malformations related to the uterus or conditions which develop over time such as adhesions and fibroids. This type of infertility can also be the result of an altogether absent uterus.

A woman who receives a transplanted uterus often receives the uterus with the intention of conceiving a child. There are certain instances, such as being born without a uterus, where a woman will receive a transplanted uterus for the purposes of balance in reproductive health.

There has been controversy surrounding uterus transplants for some time due to the outcome of the first clinical trial. The first uterus transplant was initially successful, but the uterus was removed shortly after transplant due to tissue death. Despite the failure of the initial trial, there have been successful uterus transplants completed, some of which yielded full-term pregnancies.

Reasons for Uterus Transplant

One of the main reasons a woman would undergo a uterus transplant is for the purpose of AUFI, which affects 1–5% of women who are of child-bearing age. This can include congenital conditions such as having an absent uterus, duplication of uterine structures, lack of fully formed structures, a single uterus divided into two parts, or two uteri sharing a single cervix.

Women living with certain developmental conditions, like Mayer-Rokitansky-Kuster-Hauser syndrome, may have been born without a uterus or with an underdeveloped uterus—another one of the main reasons to receive a uterus transplant.

Other reasons for AUFI are acquired conditions that often result from chronic reproductive diagnoses such as endometriosis or polycystic ovary syndrome (PCOS). These diagnoses may cause issues including uterine adhesions, ovarian and/or uterine cysts, or uterine fibroids. The presence of each of these within the uterus can impact a woman’s ability to conceive a child.

The best candidate for a uterus transplant is a woman who is of child-bearing age, wishes to continue having children, and has AUFI. The woman receiving a uterus transplant should also be in otherwise good health in order to support the immune system and the body’s ability to accept a transplanted uterus.

A uterus transplant is certainly not a first-line treatment for reproductive conditions such as endometriosis. Conservative management is explored in the form of pain medications and lifestyle changes to assist with managing reproductive diagnoses. Surgery may be indicated to assist in removing fibroids or adhesions and improve pain levels and balance hormones.

Who Is Not a Good Candidate?

Women who are simply looking to manage their chronic reproductive issues are not good candidates for uterus transplants. This transplant is more appropriate for women who wish to conceive and carry their own child, understanding the heavy risk associated with this procedure.

Donor Recipient Selection Process

Due to the scarcity of deceased donors, live donors have become necessary to meet the increasing demand for donor uteri. A donor uterus is first screened for systemic illness, infertility, thickness, polyps, fibroids, working blood vessels and arteries, adhesions, and infections.

The donor, whether alive or deceased, will ideally be premenopausal with proven fertility and no previous uterine surgeries which may impact the transplant process. As with all transplants, important factors to consider when selecting a donor include blood type, size of organ needed, time on the waiting list, and how well the donor and recipient’s immune systems match. The severity of the recipient’s condition is typically a factor in the donor selection process for essential organs, but that does not apply in the case of the uterus as it is considered non-essential.

Around 50 people worldwide had received transplanted uteri as of 2019, which has led to 16 successful live births. That said, some of the women who received transplanted uteri needed to have the organ surgically removed due to bodily rejection and tissue death.

Before receiving a uterus transplant, it's important that a woman seeks care from a facility that follows an Institutional Review Board-approved research protocol. This will place appropriate emphasis on their safety during the procedure.

Types of Donors

A uterus transplant can come from either a living or deceased donor. The risk of infection and transplant rejection is much higher when a recipient receives the uterus of a deceased donor. This is thought to be due to the anatomical and vascular changes which occur in the body after death. The ideal candidate is someone who has a similar blood type as the recipient and someone who is in relatively good health, especially reproductive health.

Before Surgery

Before surgery, it's necessary to perform exploratory procedures on both the donor and the recipient to determine pelvic anatomy and the state of the current vasculature.

The recipient is given fertility drugs to assist in harvesting her eggs. These eggs are then fertilized and the embryos are frozen for the purpose of preservation. This is typically a necessary step, as one of the driving reasons for uterus transplant is to allow the recipient to carry a child who is biologically her own.

Surgical Process

The womb and cervix are removed from the donor and implanted into the recipient. Once the uterus is in the recipient, surgeons work diligently to connect muscles, cartilage, tendons, arteries, veins, and other blood vessels in order to allow the uterus to function. The transplant takes several hours and a large team. This is due to the likelihood of a live donor who also needs to be operated on, monitored, and rehabilitated after the surgery.

Complications

Potential risks during the transplant include massive blood loss requiring a transfusion as a life-saving effort, infection, organ rejection, or poor reactions to immunosuppressive medications or anesthesia.

After Surgery

It's important the recipient and donor both remain in the intensive care unit for several days immediately following the transplant. This will allow for pain management along with medical monitoring of how the recipient responds to the immunosuppressive medications. The donor should also be observed for a time to prevent infection and manage pain levels.

Physical therapy will likely be indicated to increase strength in both the donor and the recipient, as any major surgical procedure can cause generalized weakness from deconditioning.

Prognosis

It's important to note uterus transplants are not intended to be permanent options in response to infertility or uterine conditions. The risk of taking immunosuppressive drugs long-term, especially during and before pregnancy, is harmful and not advised. The transplanted uterus is intended to be temporary while attempting pregnancy, and a hysterectomy will be indicated in order to ensure optimal health of the recipient.

Due to the occurrence of this transplant in different countries and the variable long-term results of the transplant, there are no definite numbers regarding the survival rate for women who undergo uterus transplants. Much of the literature discourages women from receiving uterus transplants due to the high risk involved in treating a non-life threatening condition (infertility).

Support and Coping

While studies show that there's a higher prevalence of psychiatric disorders among transplant candidates and recipients, psychological responses to a uterus transplant vary based on the outcome. It's a normal response for a woman to have a negative reaction and potentially enter a short-term depression in response to a failed uterus transplant and/or a subsequently failed pregnancy. Women experiencing depressive symptoms which exceed several months should be evaluated by a healthcare provider for psychiatric recommendations.

A regular stress management routine should be developed to assist with typical feelings following a transplant. This may include support groups, online discussion boards, social gatherings with friends and family, leisure activities of choice, and relaxation activities such as spending time in nature and meditation.

Exercise should be added to a daily schedule after any major surgery or transplant to decrease the risk of infection and improve healthy circulation. Your transplant team will often include a physical therapist who can recommend an appropriate regimen as you heal.

Good nutrition is essential for healing, as well as supporting fertility and successful pregnancy. Your transplant team will often include a dietitian or you can ask for a referral to one.