Updates in Gynaecology

Edited by Dr Roman

First Uterine Transplant in USA

by Jose Roman

From John Murphy, MDLinx, 03/07/2016

 

Surgeons performed the nation’s first uterus transplant on February 24, 2016 at the Cleveland Clinic, in Cleveland, OH. The 26-year-old patient underwent a 9-hour surgery that, if all goes well, will eventually allow her to become pregnant and give birth.

Cleveland Clinic performs nation’s first uterus transplant

 

A team of transplant surgeons and gynecological surgeons performed the nation’s first uterus transplant during a 9-hour surgery. (Video: Cleveland Clinic)

She’s recovering well, and she’s looking forward to moving on to the next phase of this study,” said transplant surgeon John Fung, MD, PhD, Director of the Cleveland Clinic’s Transplantation Center, at a press conference held March 7, 2016 to discuss the groundbreaking procedure.

“Despite the name uterine transplant, the focus of this procedure is not on the uterus—it’s on women and children and families,” said bioethicist Ruth M. Farrell, MD, a member of the 70-person surgery and support team involved in making the transplant a success. The surgical team consisted of two transplant surgeons, two gynecological surgeons, multiple nurses, and anesthesiologists, as well as other support staff.

The patient in this surgery is the first participant in a uterine transplant study. The study will enroll a total of 10 women who are infertile due to absence or malfunction of the uterus. “Women born without a uterus have a medical condition that affects every aspect of their lives, from the time they’re diagnosed from young adolescence, to when they’re adults looking for relationships and trying to decide if and how to have a family. These women face the real possibility of never having children,” Dr. Farrell said.

Uterine factor infertility (UFI) affects 3% to 5% of reproductive-aged women—an estimated 50,000 women in the United States.

As in this patient’s procedure, each subject will undergo transplantation using a deceased donor uterus. In this case, the donor was a healthy woman of reproductive age who had given birth previously to healthy children.

The Transplant Surgery

The surgery took 9 hours due in large part to the challenging location of the uterus in the body, according principal investigator and transplant surgeon Andreas Tzakis, MD, PhD, Program Director of the Transplantation Center.

“The procedure involves an area deep in the pelvis, dissection near vital structures, and suturing of small vessels. So while it’s not a massive operation, it is quite tedious and demands a great deal of attention,” he said.

The most important part of the procedure involves making the vascular connections—suturing the uterine artery and vein to the recipient’s external iliac artery and vein. “This part is crucial,” said gynecologic surgeon Rebecca Flyckt, MD, Director of the Fertility Preservation Program in the Ob/Gyn & Women’s Health Institute at Cleveland Clinic.

After these vascular connections are made, and “once a good blood supply is established, the uterus ‘pinks up’ and we’re able to reconnect the vaginas of the donor and the recipient, and also give the uterus support by suspending it to some of the connective tissues of the pelvis,” Dr. Flyckt explained.

One Year of Monitoring

“After a successful transplant is performed, let’s keep in mind we have to wait one full year before even thinking about pregnancy,” Dr. Flyckt said.

During this time, the patient will continue antirejection medications and return to the clinic for monthly evaluations for any rejection of the transplant. “To monitor rejection of the uterus, unlike kidney or liver [transplant] patients, we unfortunately don’t have a blot test to do, so we have to monitor them through direct visualization of the organ [through the cervix],” said transplant surgeon Bijan Eghtesad, MD.

Prior to the transplant surgery, the patient had received in vitro fertilization to produce 6 to 10 mature embryos, which were preserved by freezing. Once the team approves that the patient’s uterus is healthy and viable, “we’ll begin to transfer those embryos one by one until we get to the goal of a healthy pregnancy,” Dr. Flyckt said.

The team expects the patient to be able to give birth to one to two babies by C-section, and then the uterus will either be surgically removed or assimilated by the body. The reason for this short-term—or “ephemeral”—transplant is to prevent the patient from having to take a lifetime’s worth of anti-rejection medications, Dr. Eghtesad explained.

For now, the patient is in stable condition and the transplant team has deemed the procedure a success—with reservations. “While we view this first US uterine transplant as a significant step forward, we won’t be celebrating until a transplant results in the birth of a healthy baby to a healthy mother,” Dr. Tzakis said.

 

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