Uterus transplantation and beyond

Mats Brännström, Mats Brännström

Abstract

Uterus transplantation is today the only available treatment for absolute uterine factor infertility which is caused by either congenital/surgical uterine absence or that a present uterus is non-functioning. Structured animal-based research, from rodents to nonhuman primates, was the scientific basis for a successful introduction of uterus transplantation as a clinical procedure. The patient groups for uterus transplantation, the preclinical research and data from the published human cases will be covered herein. During recent years the concept of bioengineering of organs and tissues has emerged. Creation of a bioengineered uterus is in the initial research state, with experiments performed in rodents. The research that has been performed to create a bioengineered uterus will be summarized. In conclusion, uterus transplantation is now a clinical experimental procedure for treatment of uterine factor infertility. In parallel to the establishment of this combined assisted reproduction technique and transplantation procedure as a routine clinical procedure, we predict that uterus bioengineering will develop further towards introduction within the human setting, but that this process will take several years.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Schematic drawing of the rat uterus transplantation model. The graft is with the left uterine horn excised to enable only unilateral vascular anastomoses, which are end-to-end on the common iliac artery and vein on the right side. The uterus is anastomosed to the vagina and to a minor, cranial segment of the native uterus, to allow for spontaneous conception with uninterrupted tubal-uterine junction
Fig. 2
Fig. 2
Schematic drawing of the autologous uterus transplantation model in the baboon. The ovaries and oviducts are included in the graft. At back-table preparation ovarian veins are fused side-to-side and the internal iliacs of the graft are reconstructed to allow for one arterial inlet. Anastomoses are then end-to-side on the external iliacs
Fig. 3
Fig. 3
Schematic drawing of vascular connections in human uterus transplantation from live donors. The anterior branches of the internal iliac arteries and segments of the internal iliac veins of the donor are anastomosed end-to-side to the external iliac vessels. On the left side the upper uterine vein, which anatomically converges with the ovarian vein, has been anastomosed to the internal iliac vein of the graft to increase the venous outflow. On the right side one of the ovarian veins were transected before organ retrieval to enable removal of the graft with an intact ureter. The transected vein was reanastomosed end-to-end at back-table preparation
Fig. 4
Fig. 4
General principle for construction of a bioengineered uterus. Stem cells of the future recipient are expanded in vitro. A uterine scaffold (synthetic scaffold or a biologically derived scaffold) is then cellularized by stem cells in vitro in a bioreactor. The bioengineered organ is then transplanted into the recipient, who will not need any immunosuppressive medication and can keep the organ for many years with no side-effects

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