Giuliano Testa M.D.

Johannesson, L., Wall, A., Warren, A.M., Gregg, A.R. and Testa, G. (2021). “Decisions on second pregnancy after uterus transplantation and timing for removal of the uterus-DUETS (Dallas UtErus Transplant Study).” Bjog Mar 4. [Epub ahead of print].

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Since the first live birth to a woman after uterus transplantation (UTx) was reported in 2014,(1) the number of UTx procedures has increased and births have occurred in multiple centers worldwide.(2) Despite the growth of UTx, it is a novel procedure, with most cases having been done under experimental protocols, and there remains much debate about the ethics of UTx. Centers have allowed recipients one or two pregnancies, limiting recipient-graft time (RGT), the time from UTx to hysterectomy, to 5 years. Few UTx recipients have delivered more than one baby to date.

Agarwal, A., Johannesson, L., Findeis, S.K., Punar, M., Askar, M., Ma, T.W., Pinto, K., Demetris, A.J. and Testa, G. (2021). “Clinicopathologic Analysis of Uterine Allografts Including Proposed Scoring of Ischemia-reperfusion Injury and T Cell-mediated Rejection-Dallas UtErus Transplant Study: A Pilot Study.” Transplantation Jan 20. [Epub ahead of print.].

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BACKGROUND: Uterus transplantation (UTx) enables pregnancy in infertile women. This study describes the histopathological changes of ischemia reperfusion injury and mostly acute T cell-mediated rejection (TCMR) in UTx and proposes modification toward a working formulation grading system with associated treatments. METHODS: Protocol and indication biopsies from 11 living and 2 deceased donor UTx recipients were analyzed. Serving as a control were 49 age-matched nontransplanted uteri. All posttransplant histopathological specimens were evaluated in a blinded fashion by 3 pathologists. Response to treatment was assessed by follow-up biopsies. Serial serum donor-specific antibody (DSA) responses were also recorded. RESULTS: Changes attributed to ischemia reperfusion resolved within 2 weeks of UTx in most of the patients. For TCMR grading, perivascular inflammation, focal capillary disruption, and interstitial hemorrhage were added to interface inflammation, intercellular edema, stromal inflammation, and epithelial apoptotic bodies. Of the 173 protocol biopsies, 98 were classified as negative for TCMR; 34, indeterminate-borderline; 35, mild; 3, moderate; and 3, severe, 1 of which occurred in a DSA-positive recipient and also showed microvascular injury. Corticosteroids successfully treated all moderate to severe TCMR episodes. Mild TCMR was treated by increasing existing baseline immunosuppression. Indeterminate-borderline episodes were not treated. Neither ischemia reperfusion injury nor TCMR with DSA adversely affected embryo transfer. CONCLUSION: Relying on a modified histopathological grading system, we developed a treatment strategy resulting in resolution of TCMR and successful pregnancies.

Johannesson, L., Koon, E.C., Bayer, J., McKenna, G.J., Wall, A., Fernandez, H., Martinez, E.J., Gupta, A., Ruiz, R., Onaca, N. and Testa, G. (2021). “Dallas UtErus Transplant Study: Early Outcomes and Complications of Robot-assisted Hysterectomy for Living Uterus Donors.” Transplantation 105(1): 225-230.

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BACKGROUND: Uterus transplantation is a treatment for absolute uterine infertility and can be performed with living and deceased donors. Given the safety and increased utilization of robotic assistance with other gynecologic and transplant donor operations, we adopted a robot-assisted approach to donor hysterectomy. This study compared early outcomes and morbidity of the robot-assisted approach to donor hysterectomy with the traditionally performed open approach and addressed whether the robot-assisted approach is safe and offers advantages for the donor. METHODS: Our institution has performed 18 living donor hysterectomies for uterus transplantation. This retrospective review compared the last 5 cases utilizing a robot-assisted technique and vaginal extraction of the uterus graft with the first 13 cases performed with an open laparotomy technique. Demographic, intraoperative, and postoperative data were examined. RESULTS: There were no differences between the robot-assisted and the open living donor group with respect to age, body mass index, or gynecological history. Although the median operative time was shorter for the open approach (6.27 versus 10.46 h), the donors’ median estimated blood loss, length of hospital stay, and length of sick leave were less with the robot-assisted approach. There was no conversion to open hysterectomy in the robot-assisted cases, and the incidence of complications was similar between the 2 groups. There was no difference in early graft function. CONCLUSIONS: These preliminary results show that robot-assisted living donor hysterectomy is feasible and safe for the donors; it allows a faster postoperative recovery and the same early graft function.

Testa, G., G. J. McKenna, J. Bayer, A. Wall, H. Fernandez, E. Martinez, A. Gupta, R. Ruiz, N. Onaca, R. T. Gunby, A. R. Gregg, M. Olausson, E. C. Koon and L. Johannesson (2020). “The Evolution of Transplantation From Saving Lives to Fertility Treatment: DUETS (Dallas UtErus Transplant Study).” Ann Surg Jul 9. [Epub ahead of print.].

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OBJECTIVE: We report the results of the first 20 uterus transplants performed in our institution. SUMMARY BACKGROUND DATA: Uterus transplantation (UTx) aims at giving women affected by absolute uterine-factor infertility the possibility of carrying their own pregnancy. UTx has evolved from experimental to an established surgical procedure. METHODS: The Dallas Uterus Transplant Study (DUETS) program started in 2016. The uterus was transplanted in orthotopic position with vascular anastomoses to the external iliac vessels and removed when 1 or 2 live births were achieved. Immunosuppression lasted only for the duration of the uterus graft. RESULTS: Twenty women, median age 29.7 years, enrolled in the study, with 10 in phase 1 and 10 in phase 2. All but 2 recipients had a congenital absence of the uterus. Eighteen recipients received uteri from living donors and 2 from deceased donors. In phase 1, 50% of recipients had a technically successful uterus transplant, compared to 90% in phase 2. Four recipients with a technical success in phase 1 have delivered 1 or 2 babies, and the fifth recipient with a technical success is >30 weeks pregnant. In phase 2, 2 recipients have delivered healthy babies and 5 are pregnant. CONCLUSIONS: UTx is a unique type of transplant; whose only true success is a healthy child birth. Based on results presented here, involving refinement of the surgical technique and donor selection process, UTx is now an established solution for absolute uterine-factor infertility.

Testa, G., L. Johannesson and A. E. Wall (2020). “Considering Uterus Transplantation for a Same-Sex Couple: A Case Study.” J Clin Ethics 31(2): 154-157.

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A woman with congenital absence of a uterus applied for participation in a clinical trial for uterus transplantation. She was married to a woman who had the potential to carry a child without the need for aggressive medical intervention. Thus, the question arose regarding whether the infertile partner should be considered for uterus transplantation. In this article we discuss the ethical issues with uterus transplantation for a member of a same-sex couple, whose partner could carry a pregnancy. We review the medical criteria for uterus transplantation, discuss the additional options for parenthood in same-sex couples, examine how to determine if this meets the criteria of just distribution of uterus grafts, and ultimately argue that the value of gestation is at the level of the individual rather than the couple.