Livebirth After Uterus Transplantation From a Deceased Donor in a Recipient With Uterine Infertility

Abstract

Infertility is common and affects about 10% to 15% of couples. In such couples, 1 in 500 women has infertility due to uterine causes, with uterine agenesis (Mayer-Rokitansky-Kuster-Hauser [MRKH] syndrome), or due to hysterectomy, malformation, or the sequelae of infection or surgery. Prior hysterectomy is the most common uterine cause of infertility, whereas MRKH syndrome is relatively uncommon and affects 1 in 4500 women. In the past, the only available option for these women to have a child was adoption or surrogacy, until the first uterine transplantation and successful livebirth was reported in Gothenburg, Sweden, in 2013. To date, only 1 Swedish center and 1 US center have published on livebirths from transplanted uteri, and these previous successful livebirths have been all involved live donors. The use of deceased donors would greatly broaden access to this treatment, but uncertainty regarding the feasible of uterine transplantation from a deceased donor arose after report of an unsuccessful pregnancy and subsequent miscarriage 2 years with use of a uterus from a deceased donor. The authors describe a case of uterine transplantation using a donated uterus from a deceased donor. In September 2016, a 32-year-old woman with congenital uterine absence (MRKH syndrome) underwent uterine transplantation in Hospital das Clinicas, University of Sao Paulo, Brazil, from a donor who died of subarachnoid hemorrhage. The 45-year-old donor had had 3 previous vaginal deliveries. The recipient underwent 1 in vitro fertilization cycle 4 months before transplant, which yielded 8 cryopreserved blastocysts. Based on their literature review, the authors believe this to be the first such successful livebirth following transplant from a deceased donor. The recipient showed satisfactory postoperative recovery and was discharged after 8 days' observation in hospital. Immunosuppression was induced with prednisolone and thymoglobulin and continued via tacrolimus and mycophenalate mofetil, until 5 months posttransplantation, at which time azathioprine replaced mycophenalate mofetil. First menstruation occurred 37 days posttransplantation and regularly (every 26-32 days) thereafter. Pregnancy occurred after the first single embryo transfer 7 months posttransplantation. No blood flow velocity waveform abnormalities were detected by Doppler ultrasound of uterine arteries, fetal umbilical, or middle cerebral arteries, nor any fetal growth impairments during pregnancy. No rejection episodes occurred after transplantation or during gestation. Cesarean delivery occurred onDecember 15, 2017, near gestational week 36. The female newborn weighed 2550 g at birth, appropriate for gestational age, with Apgar scores of 9 at 1 minute, 10 at 5 minutes, and 10 at 10 minutes, and along with the mother remains healthy and developing normally 7 months postpartum. The uterus was removed in the same surgical procedure as the livebirth and immunosuppressive therapy were suspended. The researchers concluded that the results establish proof-of-concept for treating uterine infertility by transplantation froma deceased donor, opening a path to healthy pregnancy for all women with uterine factor infertility, without need of living donors or live donor surgery.