Uterine transplants allowed 14 women to successfully give birth—but the process is complicated

Over a dozen live births in Texas have resulted among people with uterine-factor infertility after getting a uterus transplant. But there are still many risks and unanswered questions around the procedure—for both recipients and donors.In a case series published in JAMA, researchers reported on the outcomes of 20 women who received a uterus transplant. Of the recipients, 14 (70%) had both a successful uterus transplant and gave birth.“It is the first time that we can offer women with this previously untreatable infertility the chance of becoming pregnant and deliver their own child. It is groundbreaking. It is also exciting that the children born are completely healthy and develop normally,” said study coauthor Dr. Liza Johannesson, associate professor at the Baylor University Medical Center in Dallas.Absolute uterine infertility occurs in about one in every 500 women, traditionally leaving those who wish to start a family to either adopt, or where its legal and available, choose surrogate pregnancies. Absolute uterine infertility can be acquired or congenital due to either a dysfunctional or absent uterus, the paper said.The year 2011 saw the first successful uterus transplant, and since then there have been just over 100 procedures conducted globally resulting in an estimated 70 live births. A total of 48 occurred in the U.S. since May 2024. Donated uteri can come from either living or deceased donors.The Dallas Uterus Transplant Study (DUETS) began enrollment in 2016. Transplants were conducted between September 2016 and August 2019. The selection for donors and recipients was modeled after existing processes for kidney and liver transplants.“When the trial was initiated, there were no specific guidelines or regulations related to uterus transplant. All aspects of the evaluation process, perioperative management, follow-up, and data recording in the trial were directly derived from the existing framework used in the institution’s solid organ transplant program,” the paper said.Donors and recipients underwent an approval process via a multidisciplinary committee which included transplant physicians, obstetricians and gynecologists, psychologists, donor advocates and nurse transplant coordinators. A total of 701 women applied for the study, but after exclusions only 20 were enrolled.Recipients in the study were aged 20 to 36 years with a median age of 30, had absolute uterine-factor infertility, had at least one functioning ovary and had to be willing to undergo in-vitro fertilization (IVF). They also underwent a transplant immunosuppression protocol. Dr. Johannesson noted there were “No concerns for the pregnancies. Women with kidney and liver transplants have been giving birth on immunosuppression for more than 50 years so we know well which medication are safe during pregnancy.”A total of 18 of the women had congenital absence of the uterus with no surgical reconstruction of the vagina and two had undergone a hysterectomy for benign disease in the past.The donors were aged between 25 and 56 years of age with a median age of 37 years, and had histories of having had at least one term live birth. A total of 17 uteri were from living donors and two were from deceased donors.There was “no monetary compensation for the donor. The donation is altruistic,” Dr. Johannesson told the Medical Post.All the embryos were created with the recipients’ own oocytes using IVF technology and prenatal visits occurred every two to three weeks from gestational week 20, the study said. The babies were delivered by cesarean section which was planned at 37 weeks of gestation or more.The primary outcome for the study was efficacy of the procedure leading to at least one live birth. Secondary outcomes were safety for all participants including the recipients, living donors and babies.Of the recipients, six experienced graft loss, five of which were from living donors. The researchers reported that none of the remaining 14 participants who had a successful uterus transplant had any severe complications, though some did have rejection episodes that were treated and resolved.The study noted that 16 of the 24 clinical pregnancies resulted in live births. There were early pregnancy losses in four recipients in which two recipients had two losses.“Gestational hypertension was the most common maternal complication (14.3%), and preterm labor and cervical insufficiency were the most common obstetrical complication (14.3% each),” the paper said. Of the babies born, seven were male and nine were female, were generally healthy and there were no congenital malformations.The transplanted uteri were removed after birth a median of 22 months after the transplant was done. “The uterus is removed after completion of childbirth which was usually one or two deliveries. This is done so that the recipient can stop taking the immunosuppressive medication,” said Dr. Johannesson.She also stated that the donors returned to their normal status after donation, and that no long-term adverse effect was seen.“Uterus transplant was technically feasible and was associated with a high live birth rate following successful graft survival. Adverse events were common, with medical and surgical risks affecting recipients as well as donors,” the authors concluded.However, an accompanying editorial in JAMA stated that the study “reads like science fiction,” still describing it as “a ‘seminal study’ that represents a major step forward for patients with uterine-factor infertility . . .. Recognition of the profound technical and cross disciplinary medical achievement is certainly deserved.”At the same time, the complexity involved in the whole process raises various questions around “how we should define value and acceptable risk in the context of a life generating rather than life-saving organ transplant.”It noted that the procedure is facing skepticism similar to what was seen in the 1970s when IVF was first attempted. For example, back then, the British magazine Nova described IVF as “the biggest threat to humankind since the atom bomb.” The editorial also stated that “Concerns of excessive cost, morality, and medical necessity once levied against IVF are common critiques repeated against uterus transplant.” And because of the high cost and complexity of uterus transplants, the procedure likely would face accessibility issues.But beyond the successes in the study, there were also significant rates of morbidity among both donors and recipients. A total of 22% of the living donors experienced postoperative complications that needed surgical intervention, and 55% of the recipients experienced at least one complication.

Uterine transplants allowed 14 women to successfully give birth—but the process is complicated

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