Uterine transplant

from Wikipedia, the free encyclopedia

A uterine transplant is a surgical procedure in which a healthy uterus ( uterus in Latin ) is transferred ( transplanted ) into an organism in which the uterus is missing, such as in Mayer-Rokitansky-Küster-Hauser syndrome , or is ill. As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation , effectively rendering the female sterile. This phenomenon is known as absolute uterine factor infertility (AUFI). Uterine transplant is a possible treatment for this form of infertility .

history

Studies

In 1896, Emil Knauer , as a 29-year-old assistant to Rudolf Chrobak at the Vienna University Women's Clinic, published the first study on ovarian autotransplantation that documented normal function in rabbits . In 1918 studies of uterine transplants in guinea pigs were published. In the years 1964 and 1966 Eraslan, Hamernik and Hardy were at the Medical Center of the University of Mississippi in Jackson (Mississippi) , the first to an auto transplant the uterus at the dog conducted and then achieved a pregnancy with this uterus. In 2010, Diaz-Garcia and staff from the Department of Obstetrics and Gynecology at the University of Gothenburg in Sweden demonstrated the world's first successful allogeneic uterine transplant in a rat with healthy offspring.

Case reports

Transplants

In 1931, Lili Elbe , a Danish intersex woman , died in Germany , presumably of a rejection reaction, three months after she received possibly the world's first uterine transplant from Kurt Warnekros in Dresden as the fourth part of sex reassignment surgery. However, the procedure was never published scientifically.

In 2000, in Saudi Arabia , a uterus transplant from a 46-year-old patient to a 26-year-old recipient of Wafa Fagee made after at birth due to severe bleeding, a hysterectomy be performed had. The transplanted uterus worked for 99 days. The patient had two spontaneous mentoring cycles until amenorrhea occurred. An exploratory laparotomy confirmed uterine necrosis and the uterus had to be removed.
The medical community then discussed whether the transplant could actually be described as successful. The practice has also raised some moral and ethical concerns that have been discussed in the literature.

In Turkey , on August 9, 2011, the world's first uterine transplant with the organ from a brain-dead 22-year-old donor was carried out by a team of doctors from the Akdeniz University Hospital in Antalya . 21-year-old Turkish woman Derya Sert, who was born without a uterus, was the first woman in history to receive a uterus from a deceased donor. The operation, carried out by Ömer Özkan, Munire Erman Akar and their team, was the world's first uterine transplant after which long-term function of the uterus could be achieved. The patient developed a regular menstrual cycle 20 days after the procedure and became pregnant twice after embryo transfer. However, both pregnancies ended in miscarriage in early pregnancy. The reason for this remained unclear. However, the ability of the uterus to carry a pregnancy to term was not known prior to the transplant as the donor had not given birth.

In Sweden , the first mother-to-daughter transplant was performed in 2012 by doctors at the Sahlgrenska University Hospital of Gothenburg University under the direction of Mats Brännström

The first uterus transplant in the United States took place on 24 February 2016 in the Cleveland Clinic of Case Western Reserve University in Cleveland ( Ohio ) instead. Due to complications, however, the uterus had to be removed on March 8, 2016. In April 2016, it was announced that an infection with Candida albicans had damaged the local artery, affecting the blood supply to the uterus and requiring it to be removed.

The first uterine transplant performed in India was held on May 18, 2017 at the Galaxy Care Hospital in Pune , Maharashtra . The 26-year-old patient was born without a uterus and received her mother's uterus during the transplant. On October 18, 2018, after IVF in April 2018, the first baby was born by caesarean section.

In Germany, the first uterine transplant was performed on October 14, 2016 at the University Hospital Tübingen . A 23-year-old patient with Mayer-Rokitansky-Küster-Hauser syndrome received the transplant from her mother. The operation was performed by a multidisciplinary team of doctors from the clinic under the direction of Sara Brucker , Diethelm Wallwiener and Alfred Königsrainer in cooperation with the Swedish transplant team under the direction of Mats Brännström. A second attempt at transplantation at the University Hospital Tübingen failed intraoperatively. Another center is planned at the University Hospital Erlangen .

Further transplants have so far been carried out in China , the Czech Republic and Brazil .

In October 2017, the Swedish team succeeded in laparoscopically removing the donor's uterus with the aid of a robot .

First pregnancies

In October 2014 it was announced that the first healthy baby had been born to a uterine transplant recipient in Sweden . The British medical journal The Lancet reported that the 1,800 g boy was born in September. The baby was born prematurely by caesarean section at around 32 weeks after the mother developed preeclampsia . The 36-year-old mother received a uterus from a 61-year-old living donor in 2013 in an operation led by Mats Brännström, professor of obstetrics and gynecology at the University of Gothenburg. The woman had healthy ovaries but was born without a uterus, a condition that affects about one in 4,500 women. An embryo was transferred into the transplanted uterus, which was generated by in vitro fertilization from an egg cell of the woman and the sperm of her husband. Triple immunosuppression with tacrolimus , azathioprine and corticosteroids was performed. There were three mild episodes of rejection, one during pregnancy, but all of which were successfully suppressed with medication.

In November 2017, the first baby after a uterine transplant was born in the United States . She was born at Baylor University Medical Center in Dallas , Texas after a uterine donation from a non-targeted living donor .

In December 2018, The Lancet reported on the first birth after a uterus transplantation of a deceased person at the Universidade de São Paulo in Brazil .

In Germany, the first children after uterine transplantation were born in March and May 2019 at the University Hospital Tübingen.

By April 2019, 15 children were born worldwide after a uterine transplant, and one month later 17 children.

Procedures

Uterine transplant begins with the operation to remove the uterus on the donor . Techniques for doing this exist for animals, including primates and, more recently, for humans. The removed uterus may need to be stored, for example for transport to the recipient's location. Studies of cold ischemia / reperfusion suggest ischemic tolerance greater than 24 hours.

The recipient is facing three major operations. First of all, the transplant surgery takes place. When pregnancy occurs and fetal viability is reached, a cesarean section is performed. Since the recipient has to be treated with immunosuppressive therapy , a hysterectomy is performed after the family planning is completed in order to be able to end the immunosuppressive therapy. The uterus is therefore only intended as a temporary transplant.

ethics

A uterine transplant is expensive and the costs are not covered by health insurance . Unlike other methods of reproductive medicine , it is a relatively new and somewhat experimental procedure, performed only by a few specialized surgeons in selected centers, and with the associated risks of relatively invasive organ transplantation, including infection and organ rejection. Some ethicists consider the risks for a living donor as opposed to a post-mortem donor to be too great, others consider the entire procedure to be ethically questionable, especially since the transplant is not a life-saving procedure.

Montreal criteria

In addition to cost considerations, uterine transplants also involve complex ethical issues. The principle of autonomy supports the procedure, while the principle of primum non nocere speaks against it. To counter this dilemma, the Montreal criteria for the ethical justification of uterine transplantation were developed at McGill University and published in Transplant International in 2012 and presented at the 20th World Congress of the International Federation of Gynecology and Obstetrics in Rome in October 2012 . In 2013 an update on the Montreal Criteria was published in the journal Fertility and Sterility and proposed as an international standard for the ethical conduct of the procedure.

The criteria set out conditions for the recipient, donor, and health team:

  1. The recipient is a genetic woman with no medical contraindications to the transplant, has a missing uterus for which no other treatment option exists, has "personal or legal contraindications" to other options such as surrogacy or adoption . She must confirm that she wants a child, is fit for maternity, is mentally healthy, is likely to be treatable from the procedure and understands the risks of the procedure.
  2. The donor is a woman of childbearing age without contraindications to the procedure, who no longer wishes to have children or who has agreed to a donation of her uterus after her death. It is required that there are no constraints and that the donor be aware of the importance and be able to make informed decisions.
  3. The health team belongs to an institution that fulfills Moore's third criterion regarding institutional stability and that both parties, donor and recipient, have given informed consent. It is required that there is no conflict of interest . The anonymity can be protected unless the recipient or donor waives this right.

literature

  • MW Beckmann, L. Lotz, SP Renner, T. Hildebrandt, RE Horch, A. Weigand, AM Boos, W. Lang, I. Hoffmann, R. Dittrich: Uterus transplantation - perspectives and risks. Gynäkologe 50 (2017), pp. 389-396, doi: 10.1007 / s00129-017-4080-9

Web links

Individual evidence

  1. ^ Emil Knauer: Some experiments on ovarian transplantation in rabbits . In: Zentralblatt für Gynäkologie . 20, 1896, pp. 524-8.
  2. ↑ David Nugent, Dror Meirow, Philip F. Brook, Yves Aubard, Roger Gordon Gosden: Transplantation in reproductive medicine: Previous experience, present knowledge and future prospects . In: Human Reproduction Update . 3, No. 3, 1997, pp. 267-80. doi : 10.1093 / humupd / 3.3.267 . PMID 9322102 .
  3. ^ Cora Hesselberg, Leo Loeb: Auto and homoiotransplantation of the uterus in the guinea-pig . In: J Med Res . 38, No. 1, 1918, pp. 11-31. PMID 19972414 .
  4. ↑ Sadan Eraslan, Robert J. Hamernik, James D. Hardy: Replantation of uterus and ovaries in dogs, with successful pregnancy . In: Archives of Surgery . 92, No. 1, 1966, pp. 9-12. doi : 10.1001 / archsurg.1966.01320190011002 . PMID 5948103 .
  5. ↑ César Díaz-García, Shamima N. Akhi, Ann Wallin, Antonio Pellicer, Mats Brännström: First report on fertility after allogeneic uterus transplantation . In: Acta Obstetricia et Gynecologica Scandinavica . 89, No. 11, September, pp. 1491-1494. doi : 10.3109 / 00016349.2010.520688 .
  6. ^ Biography of Lili Elbe
  7. ↑ Susanne Kailitz: The experiment. In: The time . January 12, 2012, accessed December 25, 2019.
  8. ↑ Anjana Nair, Jeanetta Stega, J. Richard Smith, Giuseppe Del Priore: Uterus Transplant . In: Annals of the New York Academy of Sciences . 1127, 2008, pp. 83-91. doi : 10.1196 / annals.1434.003 . PMID 18443334 .
  9. ↑ Wafa Fageeh, H. Raffa, H. Jabbad, A. Marzouki: transplantation of the human uterus. Int J Gynaecol Obstet 76 (2002), pp. 245-51, PMID 11880127 , doi: 10.1016 / S0020-7292 (01) 00597-5 .
  10. ↑ Denise Grady: Medical First: A Transplant Of a Uterus . In: The New York Times , March 7, 2002. 
  11. ^ A b c Ariel Lefkowitz, Marcel Edwards, Jacques Balayla: The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation . In: Transplant International . 25, No. 4, 2012, pp. 439-47. doi : 10.1111 / j.1432-2277.2012.01438.x . PMID 22356169 .
  12. ↑ Omer Ozkan, Munire Erman Akar, Okan Erdogan, Necmiye Hadimioglu, Murat Yilmaz, Filiz Gunseren, Mehmet Cincik, Elif Pestereli, Huseyin Kocak, Derya Mutlu, Ayhan Dinckan, Omer Gecici, Gamze Bektas, Gultekin Suleymanlar results of the first human : Preliminary Uterus transplant from a multiorgan donor. Fertil sterile. 99 (2013), pp. 470-6, PMID 23084266 , doi: 10.1016 / j.fertnstert.2012.09.035
  13. ↑ World's first successful uterus transplant performed in Turkey - RT . Rt.com. Retrieved December 25, 2019.
  14. ^ Doctors hopeful for uterus transplant . Hurriyetdailynews.com. September 13, 2011. Accessed December 25, 2019.
  15. ↑ a b c d MW Beckmann, L. Lotz, SP Renner, T. Hildebrandt, RE Horch, A. Weigand, AM Boos, W. Lang, I. Hoffmann, R. Dittrich: Uterus transplantation - perspectives and risks. Gynäkologe 50 (2017), pp. 389-396, doi: 10.1007 / s00129-017-4080-9
  16. ↑ Mats Brännström, Liza Johannesson, Pernilla Dahm-Kähler, Anders Enskog, Johan Mölne, Niclas Kvarnström, Cesar Diaz-Garcia, Ash Hanafy, Cecilia Lundmark, Janusz Marcickiewicz, Markus Gäbel, Klaus Groth, Randa Akouri, Saskia Eklind, Jan Holgersson, Andreas Tzakis, Michael Olausson: First clinical uterus transplantation trial: a six-month report . In: Fertility and Sterility . 101, No. 5, September, pp. 1228-1236. doi : 10.1016 / j.fertnstert.2014.02.024 . PMID 24582522 .
  17. ↑ Mats Brännström, Cesar Diaz-Garcia, Ash Hanafy, Michael Olausson, Andreas Tzakis: Uterus transplantation: animal research and human possibilities . In: Fertility and Sterility . 97, No. 6, September, pp. 1269-1276. doi : 10.1016 / j.fertnstert.2012.04.001 .
  18. ↑ M. Brännström, CA Wranning, A. Altchek: Experimental uterus transplantation . In: Human Reproduction Update . 16, No. 3, November 7, 2009, pp. 329-345. doi : 10.1093 / humupd / dmp049 . PMID 19897849 .
  19. ^ Brie Zeltner: Cleveland Clinic introduces nation's first uterus transplant recipient . In: The Plain Dealer , March 7, 2016. Retrieved December 25, 2019. 
  20. ^ Brie Zeltner: Nation's first uterus transplant, performed at the Cleveland Clinic, fails . In: The Plain Dealer , March 9, 2016. Retrieved December 25, 2019. 
  21. ↑ Denise Grady: Yeast Infection Led to Removal of Transplanted Uterus , The New York Times. April 8, 2016. Retrieved December 25, 2019. 
  22. ↑ Pune: Woman to get her mother's womb in India's first uterine transplant . May 12, 2017. Retrieved December 25, 2019.
  23. ↑ India's first uterine transplant to take place on May 18: Baroda woman to receive womb from mother . May 12, 2017. Retrieved December 25, 2019.
  24. ↑ India's first uterine transplant baby born: What is a womb transplant? TimesNowNews.com of October 19, 2018
  25. ↑ Ellen Katz: First uterine transplant performed in Germany. Press release of the University Hospital Tübingen from November 10, 2016
  26. ↑ Further uterine transplants planned. , Doctors newspaper online from 10 November 2016
  27. ↑ Uterus transplants - Center planned at the University of Erlangen. Doctors newspaper online from November 16, 2017
  28. ↑ Margareta Gustafsson Kubista: First birth after robot-assisted uterus transplant. Press release from the University of Gothenburg on April 9, 2019
  29. ^ A b Mary Corcoran: First birth after a robot-assisted uterine transplant Univadis Medical News of April 11, 2019
  30. ↑ Woman has healthy baby boy after womb transplant in Sweden . In: ABC News .
  31. ↑ M. Brännström, L. Johannesson, H. Bokström, N. Kvarnström, J. Mölne, P. Dahm-Kähler, A. Enskog, M. Milenkovic, J. Ekberg, C. Diaz-Garcia, M. Gäbel, A Hanafy, H. Hagberg, M. Olausson, L. Nilsson: Livebirth after uterus transplantation . In: The Lancet . 385, 2014, pp. 607-616. doi : 10.1016 / S0140-6736 (14) 61728-1 .
  32. ↑ The first baby in the US born via uterus transplant is here . Retrieved December 25, 2019.
  33. ↑ Dani Ejzenberg, Wellington Andraus, Luana Regina Baratelli Carelli Mendes, Liliana Ducatti, Alice Song, Ryan Tanigawa et al .: Livebirth after uterus transplantation from a deceased donor in a recipient with uterine infertility. Lancet, 392 (2018), pp. 2697-2704, DOI: 10.1016 / S0140-6736 (18) 31766-5
  34. ↑ a b Healthy children after uterine transplantation. , Press release of the University Hospital Tübingen from May 23, 2019
  35. ↑ Liza Johannesson, Cesar Diaz-Garcia, Henrik Leonhardt, Pernilla Dahm-Kähler, Janusz Marcickiewicz, Michael Olausson, Mats Brännström: Vascular Pedicle Lengths After Hysterectomy . In: Obstetrics & Gynecology . 119, No. 6, September, pp. 1219-1225. doi : 10.1097 / AOG.0b013e318255006f .
  36. ↑ a b M. Brännström, CA Wranning, A. Altchek: Experimental uterus transplantation . In: Human Reproduction Update . 16, No. 3, 2009, pp. 329-45. doi : 10.1093 / humupd / dmp049 . PMID 19897849 .
  37. ↑ CA Wranning, SN Akhi, C. Diaz-Garcia, M. Brännström: Pregnancy after syngeneic uterus transplantation and spontaneous mating in the rat . In: Human Reproduction . 26, No. 3, December 15, 2010, pp. 553-558. doi : 10.1093 / humrep / deq358 . PMID 21159686 .
  38. ^ A. Enskog, L. Johannesson, DC Chai, P. Dahm-Kahler, J. Marcickiewicz, A. Nyachieo, JM Mwenda, M. Brännström: Uterus transplantation in the baboon: methodology and long-term function after auto-transplantation . In: Human Reproduction . 25, No. 8, June 2, 2010, pp. 1980-1987. doi : 10.1093 / humrep / deq109 . PMID 20519250 .
  39. ↑ Pernilla Dahm-Kähler, Caiza Wranning, Cecilia Lundmark, Anders Enskog, Johan Mölne, Janusz Marcickiewicz, Randa Racho El-Akouri, John McCracken, Mats Brännström: Transplantation of the uterus in sheep: Methodology and early reperfusion events . In: Journal of Obstetrics and Gynecology Research . 34, No. 5, September, pp. 784-793. doi : 10.1111 / j.1447-0756.2008.00854.x .
  40. ↑ Caiza Almen Wranning, Randa Racho El-Akouri, Cecilia Lundmark, Pernilla Dahm-Kahler, Johan Molne, Anders Enskog, Mats Brännström: Auto-transplantation of the uterus in the domestic pig (Sus scrofa): Surgical technique and early reperfusion events . In: Journal of Obstetrics and Gynecology Research . 32, No. 4, September, pp. 358-367. doi : 10.1111 / j.1447-0756.2006.00426.x .
  41. ↑ Ossola, Alexandra: Everything You Need To Know About Uterus Transplants . In: Popular Science . February 18, 2014. Retrieved October 10, 2014.
  42. ^ BBC News . In: BBC News . Retrieved December 25, 2019.
  43. ^ The Daily Telegraph . In: Telegraph.co.uk . October 3, 2014. Retrieved December 25, 2019.
  44. ↑ The Uterine Transplant Procedure - Ethical Considerations. , Opinion No. 29/2018 of the National Ethics Commission in the field of human medicine NEK of Switzerland of 23 March 2018
  45. ↑ Claudia Bozzaro, Franziska Krause, Melanie Weismann: uterus transplant. Ethically Justified? Ethik Med 31 (2019), pp. 113–129, DOI: 10.1007 / s00481-019-00519-4
  46. ↑ C. Petrini, S. Gainotti, A. Morresi, A. Nanni Costa ' Ethical Issues in Uterine Transplantation: Psychological Implications and Informed Consent. Transplant Proc 49 (2017), pp. 707-710, DOI: 10.1016 / j.transproceed.2017.02.013 , PMID 28457377 .
  47. ↑ Hartmut Kress : Uterine Transplantation - Ethically Justifiable and Legally Regulated? Guest lecture as part of the lecture series "Ethics in Medicine" at the University of Freiburg / Br. (Studium generale) on November 7, 2017.
  48. ^ A Lefkowitz, M Edwards, J Balayla: Ethical considerations in the era of the uterine transplant: an update of the Montreal Criteria for the Ethical Feasibility of Uterine Transplantation. Fertility and Sterility, 2013, doi : 10.1016 / j.fertnstert.2013.05.026
  49. ^ Moore FD: Ethical problems special to surgery: surgical teaching, surgical innovation, and the surgeon in managed care . In: Arch Surg . 135, 2000, pp. 14-16. doi : 10.1001 / archsurg.135.1.14 .