Q&A: UAB launches uterus transplant program

In October, the University of Alabama at Birmingham announced that it had established the United States’ fourth — and the Southeast’s first — uterus transplant program.

The program, led by Paige Porrett, MD, PhD, associate professor of surgery in UAB’s division of transplantation and Comprehensive Transplant Institute, will be the first in the U.S. to offer uterus transplants outside of clinical trials and is one of the few centers in the world that is accepting new patients, according to a press release.

Healio Primary Care spoke with Porrett to learn about the program, how uterus transplantation works and which patients are eligible to receive a uterus transplant.

Q: Why is this program needed?

A: There are a lot of women with a disease called uterine factor infertility (UFI). UFI is a particular type of infertility that results when the uterus is either absent or doesn’t work correctly. We’re using uterus transplantation to correct a specific type of UFI known as “absolute UFI.” This is the situation that arises when the uterus is absent. Absolute UFI occurs when a woman is born without a uterus (which affects about one in 5,000 women) or when a woman has had her uterus surgically removed with a hysterectomy.

Women with either of these types of UFI have other options available to them for family building; these include adoption and the use of a gestational carrier or surrogate if the couple wants a biologic child. However, these options are not easily accessible or preferred for all couples impacted by UFI. For example, compensated gestational surrogacy is not legally protected in quite a few states in the United States. At the end of the day, uterus transplant provides a third option for family building for couples affected by UFI.

Q: What has UAB’s program learned from other uterus transplant centers in the United States?

A: We’ve learned a great deal. Although there are not a lot of other uterus transplant programs in the world, the community is very generous with education and sharing of experience. In short, we’ve learned from each other about how to perform this surgery safely, how to select patients for the procedure, how to immunosuppress the patients and how to manage complications that can occur from uterus transplantation. It’s really important for all of us to continue to collaborate the way we have in the past, to share knowledge so that we can advance the field and make this safer and even more effective than it already is.

Q: When should OB-GYNs consider a patient for a uterus transplant?

A: They should consider referring any woman in her reproductive-aged years who is affected by absolute UFI and is ready to start a family. This includes any patient who was born without a uterus or had the uterus removed.

As there’s a lot of nuance in our selection criteria, I would not necessarily expect a medical provider or physician to learn them all... it’s our responsibility at the transplant center to provide extensive education about risks and benefits of uterus transplantation, as well as education about other options. I would simply encourage providers to be open minded and appreciate that this field is transitioning quickly from the realm of research to available clinical care. So if a woman is affected by UFI, we definitely recommend giving her our phone number at the program so we can educate her about uterus transplantation. That’s the most important message I have for providers who might be considering their patients for a uterus transplant.

Q: How common are uterus transplants? How successful are they?

A: The international uterus transplant community estimates that there’s been approximately 100 uterus transplants performed in the world.

In the U.S., we have performed, to date, 31 uterus transplants. Overall, the outcomes are pretty good. The biggest challenge in our field is that there is a pretty high rate of graft loss due to a blood clot known as a thrombosis, which occurs roughly in one in three patients who get uterus transplants. This is a very serious complication that results in graft loss and we don’t fully understand yet why that complication occurs. But for the two-thirds of patients who are able to keep their grafts longer than a month, the pregnancy and delivery success rates are quite good — over 60% of the women who are in that category in the U.S. have gone on to deliver a live-born child, and the remainder of these women are currently pregnant or undergoing embryo transfer to achieve pregnancy. My expectation as we get longer-term follow-up on these candidates is that we’ll see the live birth rate over 80% and maybe higher.

A common question people ask me is about the safety of uterus transplantation in terms of achieving the goal of healthy mom as well as healthy baby — this is obviously our most important goal. There’s no question that this is a high-risk pregnancy, and we do see an increased rate of pregnancy complications such as preeclampsia and preterm birth. But these have, I would say, largely been managed quite well by the maternal-fetal medicine doctors who care for these patients during their high-risk pregnancies, and we’ve been able to have normal babies, to date. All the babies have been born early, around 35 weeks of age, but they have been born without birth defects and are achieving their developmental milestones as they grow. There’s an important caveat I want to reiterate: this is new technology and there have not been a lot of babies born in the world, we think over 20 births to date. Of the babies who were born, the oldest is only 6 years old, so it’s not like we have thousands of babies born to make the data very robust. But I will tell you that of the babies who have been born, the outcomes have been good.

Q: How long can uterus transplants remain viable?

A: This is a really interesting type of transplant because this is the only temporary transplant — every other type of transplant, whether it’s a heart transplant or a kidney transplant, are all meant to be permanent for the life of the patient. Our uterus transplant is a temporary transplant put in place for the express purpose of childbearing. After we put the transplant in, embryo transfers are started after the waiting period and pregnancy is achieved. If the pregnancy has gone well after delivery and if the couple wants to go for a second child, we facilitate this as long as it’s medically safe to do so. Once child-bearing is done, we’ll actually take the uterus out and stop the immunosuppressive medications that are required for this transplant’s success. That whole process can take years, when you think about the timeline of pregnancy. The average candidate, depending on her goals, will have a uterus transplant in place anywhere from 2 to 4 years. For some women, it might be a little but longer, and others less so. Our community is eager to keep the transplant in place for less than 5 years, as we don’t want her to be on the immunosuppression mediation any longer than is necessary. It is important to keep in mind that the anti-rejection medications, do have side effects and toxicity that we are trying to limit. In other words, we try to limit the total amount of exposure that these women have to these drugs, and we try to do that by getting her to her goals and get the uterus out in less than 5 years.

References:

UAB Medicine. Uterus Transplant. https://www.uabmedicine.org/patient-care/treatments/uterus-transplant. Accessed November 10, 2020.

UAB. UAB establishes uterus transplant program. https://www.uab.edu/news/health/item/11630-uab-establishes-uterus-transplant-program. Accessed November 10, 2020.