Good outcomes from first 5 years of uterus transplants, but concerns remain

For women who can't get pregnant because they don't have a uterus or the one they have no longer works properly, uterine transplants can indeed help these women become mothers, new research shows.

Of 33 women who received a uterus transplant in the United States between 2016 and 2021, 19 delivered a total of 21 babies, the researchers reported.

"Based on the experience of the first five years of uterus transplantation in the U.S., this procedure should be considered a clinical reality in the U.S. and presented as an option for the many women with infertility due to a uterine factor [who are] interested in parenthood," said study first author Dr. Liza Johannesson. She is medical director of uterus transplant at the Annette C. and Harold C. Simmons Transplant Institute at Baylor University Medical Center in Dallas.

But at least two transplant surgeons caution that the risks and expense of this procedure may still outweigh its benefits for some women.

So far, there have been more than 100 uterus transplants performed worldwide, and more than a third have been done in the United States.

Still, the procedure is not a simple one.

Before a uterine transplant, the recipient must take anti-rejection drugs so her body accepts the new organ. All women must also undergo in vitro fertilization to retrieve and then fertilize their eggs. The donor's uterus and blood supply are removed and transplanted into the recipient's pelvis to establish blood flow. A transplanted uterus can come from a deceased donor or a living donor.

About six months after a successful transplant, a single embryo can be implanted in the uterus. After a woman is through having kids, the implanted uterus is removed and immunosuppressive medications can be stopped.

In the study, 74% of recipients still had a working uterus one year after the transplant. In this group, 83% had babies. Blood supply didn't take in the first week or so for the transplants that weren't successful, the researchers noted.

The transplants took place at three centers in the United States: Baylor University Medical Center, the Cleveland Clinic, and Penn Transplant Institute/University of Pennsylvania.

"We also show that success is reproducible and not limited to single centers and that successful outcomes are comparable when the uterus is donated from a living or a deceased donor," Johannesson said.

Most women in the study were born without a uterus, a condition that affects around 1 in 4,500 women. Other options for these women if they wish to have children may include surrogacy or adoption.

"This group is only a small part of a much larger cohort of women with uterine factor infertility who may benefit from a uterus transplantation," Johannesson said. Other candidates may include women who have had their uterus removed due to diseases or conditions such as cancer.

"The women [who] may benefit from this procedure are more than a million in the U.S. alone," Johannesson said.

Transgender women are also increasingly interested in this procedure, she noted.

"There has so far not been any research done to see if a successful uterus transplant would be possible in a transgender female," Johannesson said. That said, there are centers around the world that have a specific interest in this group of women.

The findings are published in the July 6 issue of JAMA Surgery.

In an editorial accompanying the new study, Drs. Rachel Forbes and Seth Karp, from Vanderbilt University Medical Center in Nashville, Tenn., dialed back some of the enthusiasm for widespread adoption of these procedures.

These transplants continue to be done in select centers and should continue to be done only in centers with expertise, said Karp, director of the Vanderbilt Transplant Center.

"Long-term outcomes from immunosuppression and complication rates are not well understood," he said. Anti-rejection drugs can also increase your risk for infections and have other side effects.

About 1 in 4 living donors experienced a complication from the surgery in the new study, Karp noted. These procedures are also costly, ranging between $100,000 and $300,000.

"Speak candidly with your physician about the risks and benefits, and understand that risks are not well understood at this time," Karp said.

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