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Selecting living donors for uterus transplantation: lessons learned from two transplantations resulting in menstrual functionality and another attempt, aborted after organ retrieval

  • General Gynecology
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Archives of Gynecology and Obstetrics Aims and scope Submit manuscript

Abstract

Purpose

To contribute to establishing donor selection criteria based on our experience with two successful living-donor human uterus transplantations (UTx) and an aborted attempt.

Methods

This interventional study included three patients with uterine agenesis, aged 23, 34, and 23 years, scheduled for UTx, and their uterus-donating mothers, aged 46, 61, and 46 years, respectively. Interventions included preoperative investigations, donor surgery, back-table preparation, and recipient surgery. Preoperative imaging, surgical data, histopathology, menstrual pattern, and uterine blood flow were the main outcome measures.

Results

In the first case (46-year-old mother/23-year-old daughter), donor/recipient surgery took 12.12/5.95 h. Regular spontaneous menstruations started 6-week post-transplantation, continuing at 24–28-day intervals throughout the 6-month observation period. Repeated follow-up cervical biopsies showed no signs of rejection. In the second case (61-year-old donor), surgery lasted 13.10 h; attempts to flush the retrieved uterus failed due to extreme resistance of the left uterine artery (UA) and inability to perfuse the right UA. Transplantation was aborted to avoid graft vessel thrombosis or insufficient blood flow during potential pregnancy. Histopathology revealed intimal fibrosis and initial sclerosis (right UA), extensive intimal fibrosis (parametric arterial segments), and subtotal arterial stenosis (myometrial vascular network). In the third case (46-year-old mother/23-year-old daughter), donor/recipient surgery took 9.05/4.52 h. Menstruations started 6-week post-transplantation. Repeated cervical biopsies showed no signs of rejection during the initial 12-week follow-up period.

Conclusions

Meticulous preoperative evaluation of potential living uterus donors is essential. This may include selective contrast-enhanced UA angiograms and limitation of donor age, at least in donors with risk factors for atherosclerosis.

Clinical trial registration

ClinicalTrials.gov Identifier: NCT03048396.

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Abbreviations

ACE:

Angiotensin-converting enzyme

AUFI:

Absolute uterine factor infertility

BMI:

Body mass index

CMV:

Cytomegalovirus

CT:

Computed tomography

EBV:

Epstein Barr virus

HbA1c:

Glycated hemoglobin

HC2:

Hybrid Capture 2

HDL:

High-density lipoprotein

HLA:

Human leukocyte antigen

HPV:

Human papilloma virus

HRT:

Hormone replacement therapy

HTK:

Histidine-tryptophan-ketoglutarate (solution)

IFCC:

International Federation for Clinical Chemistry

IVF:

In vitro fertilization

LDL:

Low-density lipoprotein

MRA:

Magnetic resonance angiography

MRKHS:

Mayer–Rokitansky–Küster–Hauser syndrome

Pap:

Papanicolaou (smear)

UA:

Uterine artery

UTx:

Uterus transplantation

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, University of Tübingen, Calwerstrasse 7, 72076, Tübingen, Germany

    Sara Y. Brucker, Florin-Andrei Taran, Katharina Rall, Dorit Schöller, Melanie Henes, Bernhard Krämer, Christl Reisenauer, Markus Hoopmann, Karl-Oliver Kagan & Diethelm Wallwiener

  2. Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden

    Mats Brännström & Pernilla Dahm-Kähler

  3. Stockholm IVF, Stockholm, Sweden

    Mats Brännström

  4. Department of General, Visceral, and Transplant Surgery, University of Tübingen, Tübingen, Germany

    Silvio Nadalin & Alfred Königsrainer

  5. Department of Pathology, University of Tübingen, Tübingen, Germany

    Hans Bösmüller & Falko Fend

  6. Department of Diagnostic and Interventional Radiology, University of Tübingen, Tübingen, Germany

    Konstatin Nikolaou & Mike Notohamiprodjo

  7. Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany

    Peter Rosenberger, Christian Grasshoff & Eckhard Heim

  8. Department of Transplantation, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden

    Niclas Kvarnström

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  1. Sara Y. Brucker
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Contributions

SYB: protocol/project development, data collection or management, data analysis, and manuscript writing/editing. MB: protocol/project development, data collection or management, data analysis, and manuscript writing/editing. FAT: data collection or management, data analysis, and manuscript writing/editing. KR: data collection or management, data analysis, and manuscript writing/editing. KN: data collection or management, and manuscript writing/editing. MN: data collection or management, and manuscript writing/editing. NK: data collection or management, and manuscript writing/editing. PD-K: protocol/project development, data collection or management, data analysis, and manuscript writing/editing. DW: protocol/project development, data collection or management, data analysis, and manuscript writing/editing. All other authors: performance of the research and critical revision of the draft manuscript. All authors: final approval of the manuscript version to be published.

Corresponding author

Correspondence to Sara Y. Brucker.

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There was no funding for the present work.

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The authors declare that they have no conflict of interest.

Research involving human participants and/or animals

Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study. All patients gave their written informed consent for publication.

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Brucker, S.Y., Brännström, M., Taran, FA. et al. Selecting living donors for uterus transplantation: lessons learned from two transplantations resulting in menstrual functionality and another attempt, aborted after organ retrieval. Arch Gynecol Obstet 297, 675–684 (2018). https://doi.org/10.1007/s00404-017-4626-z

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