Infertility can be emotionally challenging for anyone. For women born without a uterus or who lose theirs' to illness and surgery, it can be devastating, with a finality that until now has ended their hope of ever bearing a child.
However, since the first successful uterine transplant and birth in Sweden a few years ago, a new hope has begun to glimmer.
"The first three uterine transplant programs in the United States at the Cleveland Clinic, Baylor, and the University of Pennsylvania are all clinical trials that have only been able to accept a limited number of patients. The program we're establishing at the University of Alabama at Birmingham through UAB Medicine is the first free standing program in this country. We're the only transplant center in the region and one of the few in the world now accepting referrals for applications," Paige Porrett, MD, PhD, said.
Porrett, an associate professor in UAB's Division of Transplantation and Comprehensive Transplant Institute, is leading the program. She is an abdominal organ transplant surgeon and immunologist who performed all the transplants to date at the University of Pennsylvania. She is also a national and international leader in the field and an NIH-funded specialist in transplant and reproductive immunology.
"Since uterine transplants aren't covered by insurance, most of the funding has to come from the institution. Although the pandemic is making all budgeting difficult to predict, we are hopeful that we will be able to help around 25 patients as the program becomes established," Porrett said.
To qualify for a transplant referral, patients who want to apply should be women of child bearing age who are in generally good health.
"Undergoing a transplant, taking immunosuppressants, and then pregnancy followed by caesarean delivery and removal of the uterus are a physically demanding process," Porrett said. "The patient needs to be healthy and have a strong motivation. When we interview a potential patient, we want to understand why she has decided to choose this option rather than growing her family through adoption or a gestational carrier before we approve the procedure."
If the pregnancy has gone well and the couple wishes to have another child, the uterus can be left in place for a second pregnancy beginning about six months later. Then the uterus is removed and immunosuppressive medications are ended.
"We choose medications that are as gentle as possible to the mother and that have a good track record of being used by patients with other types of transplants who become pregnant and carry their babies to term without any known negative effects on the child," Porrett said.
To improve the odds of achieving pregnancy quickly, in vitro fertilization is used, with one embryo implanted at a time. Donor eggs can be employed if the patient doesn't have eggs that can be used.
"Patients usually become pregnant on the first or second attempt," Porrett said. "This is the same approach used by the original Swedish program and it avoids risks from surgical adhesions and other uncertainties.
"Unlike the Swedish program, the UAB program will not use a uterus from a living donor. Programs are split about half and half on the issue of living donors. At present, we have decided to work only with organs from deceased donors. The procedure for removing a uterus for transplant is more complex than most hysterectomies. We want to avoid potential complications that might compromise the health of living donors. Like kidney transplants, uterine transplants can be physically demanding on the donor. Unlike kidney transplants, which may be necessary to save a life, there is usually time to wait for a donor, and adoption and gestational carriers are still two other options for building a family."
Just as with other types of transplants, there are likely to be many more people who need a transplant than there will be available donor organs. Uterine factor infertility may affect as many as five percent of reproductive-age women. UAB expects to see patients from across the southeast and the United States, and then eventually from other parts of the world.
"We match donors and patients by blood type. Ideally we prefer a donor who has successfully carried a child and given birth so we have evidence that the organ is functional. We also examine it closely to be sure there are no conditions such as fibroids that might cause difficulties," Porrett said.
As of now, uterine transplants are only available to women who were born as XX chromosome females, but that could change at some point in the future.
"More research would need to be done in managing the hormonal demands of pregnancy, but within a few years, we could see uterine transplant becoming part of the discussion in gender reassignment cases," Porrett said.
For physicians considering referrals or individuals who would like to know more about whether they might be a candidate, Porrett said. "Our doors are open to both providers and patients anywhere who want to learn more about this exciting new therapy."
To contact the program, call 833-UAB-CTI1.
