Uterine transplant science has entered ‘a completely new world’

The first modern attempt to transfer a womb from one human to another occurred around the turn of the millennium. But surgeons had to remove the organ, which had become necrotic, 99 days later. The first successful The transplant was performed in 2011, but even then the recipient could not immediately become pregnant and give birth to a baby. It took another three years before the world’s first person with a transplanted uterus gave birth.

More than seventy such babies have been born worldwide in the past ten years. “It’s a completely new world,” said Giuliano Testa, chief of abdominal transplantation at Baylor University Medical Center.

Nearly a third of these babies – 22 and counting – were born in Baylor, Texas. On Thursday, Testa and his team published a large cohort study JAMA analyzing the results of the first 20 patients of the program. All women were of childbearing age and had no uterus (most were born without a uterus), but had at least one functioning ovary. Most of the uteri came from living donors, but two came from deceased donors.

Fourteen women underwent successful transplants, all of whom were able to have at least one child.

“That success rate is extraordinary, and I want that to get out,” said Liza Johannesson, medical director of uterine transplants at Baylor, who collaborates with Testa and co-authored the study. “We want this to be an option for all women who need it.”

Six patients had transplant failures, all within two weeks of the procedure. Part of the problem may have been a learning curve: The study initially included only ten patients, and five of the six with failed transplants were in that first group. These were “technical” failures, Testa said, involving aspects of the surgery such as how surgeons connected the organ’s blood vessels, what material was used for sutures and selecting a uterus that would work well in a transplant.

The team saw only one transplant failure in the second group of 10 people, the researchers said. All twenty transplants took place between September 2016 and August 2019.

Only one other cohort study has been previously published on uterus transplants, in 2022. A Swedish team, which included Johannesson before she moved to Baylor, performed seven successful transplants out of nine attempts. Six women, including the first ever transplant recipient to have a baby in 2014, have given birth.

“It’s hard to get data from that because they were the first to do this,” Johannesson said. “This is the first time we can actually see the safety and efficacy of this procedure.”

So far, the signs are good: high success rates for transplants and live births, safe and healthy children so far, and early signs that immunosuppressants — typically given to transplant recipients so their bodies don’t reject the new organ — won’t last long. long-term damage, the researchers said. (The uterus transplants are removed after recipients no longer need them to bear children.) And the Baylor team has figured out how to identify the right uterus for transfer: It must come from a donor who has previously had a baby has had, is pre-menopausal, and, of course, who matches the recipient’s blood type, Testa said.

People who donated a uterus did have some complications, but these were similar to other gynecological hysterectomies, and none had long-term complications, the researchers noted. Over the course of the study, the team changed the way they remove the uterus from a traditional midline incision to a minimally invasive technique.

“They’ve really embraced the idea of ​​putting improvement into practice over time, to understand how you can make this safer or more effective. And that’s reflected in the results,” says Jessica Walter, assistant professor of reproductive endocrinology and infertility at Northwestern University Feinberg School of Medicine, who co-authored an editorial on the study in JAMA.

But while the field has made progress, some people question the idea of ​​uterus transplantation. “Even in medicine there is a lot of skepticism,” says Walter.

Absolute infertility due to uterine factors (when a woman has no uterus, either because she was born without a uterus or because it had to be removed) affects approximately one in 500 women worldwide.

Bioethicists have raised concerns about uterus transplants in the past, saying there are other options, such as surrogacy and adoption, that could pose fewer risks to the patient and fetus. But Walter and Johannesson both said separately that infertility is a disease and people deserve treatment.

Walters herself was a skeptic when she first heard about uterus transplants. The procedure seemed invasive and complicated. But she did her fellowship training at Penn Medicine, home to one of only four programs in the U.S. that performs uterine transplants.

“The firsts – the first time the patient had a transplant, the first time she had her period after the transplant, the positive pregnancy test,” Walter said. “Immersing myself in the science, the patients, the practitioners and researchers really changed my view that this is science, and this is an innovation like anything else.”

The field has developed rapidly, but challenges await us that go beyond science. Like in vitro fertilization and surrogacy, the two main treatments for infertility, a uterus transplant is expensive.

Many transgender women are hopeful that uterus transplants will one day be available to them, but that is likely a distant possibility. Scientists need to rewind and do animal studies on how a uterus might fare in a different “hormonal environment” before clinically testing the procedure with transgender people, Wagner said.

Among cisgender women, more long-term research is still needed on the donors, recipients and the children they have, experts said.

“We want other centers to start up,” Johannesson said. “Our main goal is to publish all our data as much as possible.”