Absolute Uterine Factor Infertility (AUFI), has, until now been the only remaining untreatable subtype of female infertility. Members of our staff have been key researchers globally in the Uterus Transplantation Project that was started and lead by Professor Mats Brannstrom. The team performed the first truly successful uterus transplant after the first child carried by a transplanted uterus was born in Gothenburg in early September of 2014. This pioneering team has to date performed nine of the 11 reported human uterus transplantations in the world. This is the first available treatment for AUFI and has essentially eliminated AUFI as a diagnosis. Prof. Brännström and the pioneering IVF doctors L. Nilsson and M. Milenkovic are active at Stockholm IVF. We are in a globally unique position to offer expert consultation and information on uterus transplantation for women, couples and doctors.
Uterus Transplantation - Step-by-step
The investigation prior to uterus transplantation is an important process for the recipient, the recipient´s partner and the donor. They will all meet expert doctors and psychologists that have unique experience of uterus transplantation. The doctors are specialists in gynaecology, reproductive medicine or transplantation surgery. The purpose of this long and fairly complex investigation process is to ascertain that all individuals (recipient, partner of recipient and donor) are suitable for the procedure and to ensure that the chance for success is high. It is important to examine that the uterus is fully normal and that the potential to carry a pregnancy is high. Another essential factor to examine is the size of the recipient´s ovarian reserve and the quality of her oocytes. This is done by IVF treatment, well in advance of the transplantation. The embryos that are achieved through IVF are then cryopreserved and stored until embryo transfer a year after transplantation. The donor, who may be a close relative or friend, should be under 55 years of age and have had at least one uneventful pregnancy. She must be of good general health and not obese.
Embryos achieved by IVF are cryopreserved in liquid nitrogen
2. The operations
If the preoperative investigation finds all three individuals (donor, recipient and recipient’s partner) to be suitable for uterus transplantation we can set a date for surgery. Usual preoperative routines are applied, where both the recipient and the donor arrive at the hospital in the morning of surgery. At the same time our team of four gynaecologists, two transplantation surgeons, one anaesthesiologist and the head nurse have their last preoperative planning meeting before the two operations.
This is the first operation to be started in the morning of the day of transplantation. It is primarily performed by our team of highly skilled and experienced gynaecological surgeons. During the operation, which takes several hours, the uterus and its blood vessels are gently removed from surrounding organs and tissue. After removal of the uterus the surgery of the donor is complete, she is woken by our anaesthesiologist and is later taken care of by the postoperative care team.
The donor uterus is removed from surrounding organs and tissue
Preparation for transplantation
After removal the uterus is brought to a so-called “back-table” to be chilled by flushing a cold preservation solution through the blood vessels. This is done to avoid damage to the organ when it is out of the body without blood flow (so-called “ischaemic time”).
The uterus is flushed with a cold preservation solution on the iced back-table.
When about one hour remains of the donor operation, the surgery of the recipient starts in the adjacent operating room. The blood vessels, pelvic ligaments and the top of the vagina are prepared for transplantation. After the uterus has been brought from the back-table into the recipient op. room, the blood vessels of the uterus are firstly attached to initiate blood flow through the organ. The surgery of the recipient is completed by attaching the uterus to its pelvic ligaments and to the top of the vagina. Before the abdomen is closed we ensure that we have established a good blood flow to the uterus and that it is held in place by the ligaments strongly enough to carry a pregnancy.
The donor blood vessels are attached to the recipient blood vessels and the organ is sutured into place.
3. The week following uterus transplantation
After the day of transplantation, both the donor and the recipient stay at the postoperative care unit overnight. Later both the donor and recipient are transferred to the surgical ward, where they will stay and be taken care of for approximately a week. At this time the recipient has started her immunosuppressive medication in order to avoid rejection of the uterine graft. Non-invasive ultrasound is used to monitor the blood flow to the uterus closely during the first 3 days and later intermittently. Gynaecological investigations are performed at regular intervals to ascertain that the uterine cervix looks normal. Already the day after surgery, physiotherapists help both the recipient and donor with mobilization from bed-rest. This is important to avoid development deep vein thrombi (DVT) in the legs. After around a week in the ward both the recipient and the donors are discharged to their home with recommendations on activities. Sick-leaves are based on the nature of the patient’s occupation and her normal activities.
4. The year following transplantation
Menstruations will usually start 1-2 months after transplantation and later continue with regular intervals. During the initial 12 months after transplantation it is important to examine the transplanted organ frequently to ensure that the blood flow to the uterus is normal and that there are no signs of rejection. It is well known in organ transplantation that most rejection episodes occur during the first 6 months after transplantation. During this time, the doses of immunosuppression medication will be somewhat higher to prevent episodes of rejection. If there are any episodes of partial rejection this is detected very early at the frequent visits to your gynaecologist. These visit includes an ultrasound examination and a routine gynaecologic examination, where a small biopsy is taken from the cervix. All possible rejection episodes will be detected early as small but typical changes of the biopsy seen in the microscope. At this early stage of rejection, the patient does not experience any symptoms nor will the rejection have caused any permanent damage to the organ. Rejection episodes can easily be treated with a 5-day cortisone regime. During the first post-transplantation year blood samples are taken at regularly to make sure the blood levels of the immunosuppressive medications are at optimal levels.
5. Embryo transfer and pregnancy
If the preceding 3-4 months have been uneventful without episodes of rejection we try to achieve pregnancy by embryo transfer one year after transplantation.
The embryo transfer (ET) is performed as a transfer of frozen embryos (Freeze-ET) which is a step in a normal IVF procedure. We recommend transferring a single embryo, to avoid a twin or triplet pregnancy, which would cause unnecessary physiological stress to the transplanted uterus. The embryos are transferred 2-3 days after ovulation in the natural menstrual cycle, which is monitored by urine test and ultrasound. During the ET procedure, the embryo is inserted into the cavity of the uterus using a thin plastic catheter. If there is an absence of menstruation within the first 3 weeks after ET there is a great possibility that you have become pregnant. If pregnancy has been established we will provide follow up monitoring 5 weeks after ET to make sure the foetus is growing in the normal location and developing normally. During the rest of the pregnancy you will be monitored by the antenatal care unit by a specialist in feto-maternal medicine who will work in close collaboration with your transplantation doctor to keep the optimal doses of immunosuppressive medication during pregnancy.
6. Birth and continuation
To minimize the possible risks connected to natural birth after uterus transplantation we deliver the children with caesarean section a few weeks before full term. If the parents want a second child the transplanted uterus may be kept after delivery. IVF treatment to achieve a second successful pregnancy can start 6 months after delivery.
After more than 10 years of groundbreaking research we launched the world´s first clinical trial of human uterus transplantation in early 2013. Nearly two years later, we are happy to announce the first childbirth after uterus transplantation in Gothenburg in early September of 2014. The results and outcomes the first live birth was published in The Lancet, which is regarded as one of the most prestigious and respected scientific journals. Furthermore the story was covered by most international press including BBC, Bloomberg, CBC and many well known international newspapers across the globe.
Latest update: 2016-02-15