Uterus transplants linked to high live birth rate, longterm safety

Uterus transplants were associated with a high live birth rate among women with absolute uterine-factor infertility after success graft survival, according to findings from a new case series.

An investigation into the effectiveness of uterus transplants in 20 participants between 2016 – 2019 has shown that 14 resulted in a successful allograft; all 14 of those participants subsequently gave birth to ≥1 live-born infant. The findings are highly promising to the approximate 1 in 500 women with absolute uterine infertility—and supportive of further research into the transplant procedure’s applicability with donors either alive or deceased.

Investigators led by Giuliano Testa, MD, MBA, and Liza Johannesson, MD, PhD, of the Baylor Annette C. and Harold C. Simmons Transplant Institute at Baylor University Medical Center, conducted the Dallas Uterus Transplant Study (DUETS) to assess the long-term outcomes of uterus transplant in women with absolute uterus infertility and ≥1 functioning ovary. The procedure and its effect on women’s fertility following successful graft is still lesser-known; the team noted that there had been 48 transplants and 33 corresponding live births in the US as of May 1.

“The development of uterus transplant offers an option for women with absolute uterine infertility to experience pregnancy and childbirth,” Testa, Johannesson and colleagues wrote. “Since the first successful uterus transplant in 2011, more than 100 uterus transplant procedures have been performed worldwide, using grafts from living or deceased donors.”

The team conducted their analysis of patients undergoing uterus transplants who met the criteria of childbearing age (defined as aged 20 – 40 years), an absolute uterine-factor infertility, and ≥1 functioning ovary. Participants were also required to meet medical and psychological protocol criteria and be willing to undergo in vitro fertilization (IVF).

Among the 20 transplant recipients, median age was 30 years old (range, 20 – 36). Patients had a median body mass index (BMI) of 25 (range, 19 – 34). A majority were White (n = 16), followed by Asian (n = 2), Black / African American (n = 1) or an undisclosed race/ethnicity (n = 1). All 20 recipients underwent a laparotomy; median hospital stay for the procedure was 6 days (range, 5 – 16).

Among the 20 transplant donors, median age was 37 (range, 30 – 56). Median BMI was also 25; all donors were White. Most (n = 17) donated nondirected while living; 1 donated as directed while living, and 2 were deceased. Five donors underwent a robotically-assisted donation surgery.

Among the transplant recipient, 6 (30%) experienced graft failure; another 9 (45%) experienced an infection and 10 (71%) experienced a vaginal stricture). Fourteen experienced a rejection from IVF—primarily defined as a nonpregnancy treated with steroid cycling or thymoglobulin (n = 9). Another 14 participants each experienced maternal complications including gestational hypertension or diabetes, or preeclampsia, and obstetrical complications including insufficient cervix or preterm labor.

Median time from uterus transplant to first embryo transfer was 4.1 months; 7 recipients experienced a live birth following the first embryo transfer, 2 experienced it after 2 transfers, and 5 required >2 embryo transfers. Investigators reported a live birth rate per embryo transfer of 43%.

Fourteen (70%) recipients had ≥1 live childbirth and another 2 had a second live birth after the procedure. Births occurred at a median of 14.2 months (range, 11 – 53.9) following transplant. Six participants had their uterus removed at the time of their first or second delivery.

Median gestational age at live birth was 36 weeks and 1 day. No congenital malformations were observed in any of the children, and only 1 child failed to meet communicative milestones at 12 months that which resulted in an autism spectrum disorder diagnosis.

“This case series of 20 women in a single institution demonstrated acceptable graft survival following a multidisciplinary approach to uterus transplant, conception, and subsequent live birth,” investigators wrote. “During the study period, the technical success of graft survival improved with time and experience.”

Testa, Johannesson and colleagues noted that the national US data for infertility treatment in women <35 years old using their own ova suggests a live birth rate of 68.9% following any amount of cycles.

“The live birth success rate in this study suggests that a successfully transplanted uterus is capable of functioning at least on par with a native, in situ uterus,” they wrote.

Indeed, the team concluded the case series shows a “technical feasibility” and associated high live birth rate among women who achieve graft survival from uterus transplants.

References

1. ^{Testa G, McKenna GJ, Wall A, et al. Uterus Transplant in Women With Absolute Uterine-Factor Infertility. JAMA. Published online August 15, 2024. doi:10.1001/jama.2024.11679}
2. ^{SART. Final national summary report for 2020. Accessed February 8, 2024. https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?reportingYear=2020}