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Uterus Transplantation - Evolution Of The Field Of Transplant From Saving Lives To Fertility Treatment
Giuliano Testa, *E. Colin Koon, *Greg J McKenna, *Robert T Gunby, Jr., *Johanna Bayer, *Anji E Wall, *Richard Ruiz, *Nicholas Onaca, *Amar Gupta, *Eric J Martinez, *Anthony R Gregg, *Liza Johannesson
Baylor University Medical Center, Dallas, TX

Objective
Uterus transplantation (UTx) is the newest field in transplantation, and enables women with absolute uterine factor infertility (AUFI) to give birth after carrying their own pregnancies. We present the largest single center UTx experience in the world.
Methods
From Sep 2016 – Aug 2019, both deceased (DD) and living donor (LD) UTx were performed in 20 women of gestational age, having AUFI from either congenital or acquired causes. The uterus was transplanted in orthotopic position with anastomoses to the iliac vessels. Embryo transfer occurred 4 – 6 months post UTx. Immunosuppression was calcineurin inhibitors and antimetabolites. Graft hysterectomy was performed after completing 1 or 2 pregnancies, allowing immunosuppression discontinuation.
Results
14/20 UTx were technically successful. To date, 12/14 women achieved pregnancy and 6 have delivered children. There were no surgical complications in any of the mothers or children of successful UTx. Two LD had ureteral injury (Clavien Grade II) treated conservatively.

Case #	Recipient Age	Recipient BMI	Cause of AUFI	Donor Type	Donor Surgery	Donor Age	Graft Outcome	Failed embryo transfer	Pregnancy	Miscarriage	Delivery
1	31	19	MRKH	NDLD	LAP	42	Loss	N/A	N/A	N/A	N/A
2	33	26	MRKH	NDLD	LAP	56	Loss	N/A	N/A	N/A	N/A
3	34	34	MRKH	NDLD	LAP	45	Loss	N/A	N/A	N/A	N/A
4	29	25	MRKH	NDLD	LAP	34	Removed after delivery	0	1	0	1
5	27	23	MRKH	NDLD	LAP	36	Viable	0	4	2	1, Current pregnancy
6	36	22	MRKH	DD	Multiorgan retrieval	30	Viable	3	1	1	Current pregnancy
7	24	31	MRKH	NDLD	LAP	39	Viable	3	1	0	1
8	29	22	MRKH	DD	Multiorgan retrieval	44	Loss	N/A	N/A	N/A	N/A
9	22	25	MRKH	NDLD	LAP	35	Viable	0	1	0	1
10	29	21	Hysterectomy	NDLD	LAP	48	Loss	N/A	N/A	N/A	N/A
11	20	25	MRKH	NDLD	LAP	32	Viable	0	1	0	1
12	23	30	MRKH	DLD	LAP	33	Viable	0	1	1	0
13	30	30	MRKH	NDLD	LAP	39	Viable	0	1	0	1
14	21	19	MRKH	NDLD	LAP	32	Loss	N/A	N/A	N/A	N/A
15	31	26	Myomectomy /subtotal hysterectomy	NDLD	LAP	43	Viable	1	1	0	Current pregnancy
16	30	28	MRKH	NDLD	RA	30	Viable	1	1	0	Current pregnancy
17	34	25	MRKH	NDLD	RA	30	Viable	0	1	1	0
18	33	21	MRKH	NDLD	RA	37	Viable	0	1	0	Current pregnancy
19	34	23	MRKH	NDLD	RA	32	Viable	Not started	N/A	N/A	N/A
20	29	21	MRKH	NDLD	RA	38	Viable	Not started	N/A	N/A	N/A
MRKH, Mayer-Rokitansky Kuster Hauser; NDLD, Non Directed Living Donor; DD, Deceased Donor, DLD, Directed Living Donor, LAP, Laparotomy; RA, Robotic assisted

Conclusion
UTx is a transplant solution to AUFI. After the initial learning curve, 5 of the 6 graft failures occurred in the first 10 cases, in the last 10 recipients only 1 graft failed, 90% technical success rate, with a pregnancy and delivery rate projected to match other infertility treatments. Transplantation has overcome the final barrier to fertility, once thought impossible, providing the experience of pregnancy and motherhood to women with AUFI.

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