Giuliano Testa M.D.

Farrell, R. M., L. Johannesson, R. Flyckt, E. G. Richards, G. Testa, A. Tzakis and T. Falcone (2020). “Evolving Ethical Issues with Advances in Uterus Transplantation.” Am J Obstet Gynecol Jan 22. [Epub ahead of print].

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While uterus transplantation was once considered only a theoretical possibility for patients with uterine factor infertility, researchers have now developed methods of transplantation that have led to successful pregnancies with multiple children born to date. Because of the unique and significant nature of this type of research, it has been undertaken with collaboration not only with scientists and physicians but also with bioethicists, who paved the initial path for research of uterus transplantation to take place. As the science of uterus transplantation continues to advance, so too must the public dialogue among obstetrician/gynecologists, transplant surgeons, bioethicists, and other key stakeholders in defining the continued direction of research in addition to planning for the clinical implementation of uterus transplantation as a therapeutic option. Given the rapid advances in this field, the time has come to revisit the fundamental questions raised at the inception of uterus transplantation and, looking forward, determine the future of this approach given emerging data on the procedure’s impact on individuals, families, and society.

Jones, B. P., S. Saso, A. L’Heveder, T. Bracewell-Milnes, M. Y. Thum, C. Diaz-Garcia, D. A. MacIntyre, I. Quiroga, S. Ghaem-Maghami, G. Testa, L. Johannesson, P. R. Bennett, J. Yazbek and J. R. Smith (2020). “The vaginal microbiome in uterine transplantation.” BJOG 127(2): 230-238.

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Women with congenital absolute uterine factor infertility (AUFI) often need vaginal restoration to optimise sexual function. Given their lack of procreative ability, little consideration has previously been given to the resultant vaginal microbiome (VM). Uterine transplantation (UTx) now offers the opportunity to restore these women’s reproductive potential. The structure of the VM is associated with clinical and reproductive implications that are intricately intertwined with the process of UTx. Consideration of how vaginal restoration methods impact VM is now warranted and assessment of the VM in future UTx procedures is essential to understand the interrelation of the VM and clinical and reproductive outcomes. TWEETABLE ABSTRACT: The vaginal microbiome has numerous implications for clinical and reproductive outcomes in the context of uterine transplantation.

Ramani, A., G. Testa, Y. Ghouri, E. C. Koon, M. Di Salvo, G. J. McKenna, J. Bayer, A. M. Warren, A. Wall and L. Johannesson (2019). “DUETS (Dallas UtErus Transplant Study):Complete report of 6-month and initial 2-year outcomes following open donor hysterectomy.” Clin Transplant Nov 22. [Epub ahead of print].

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INTRODUCTION: Uterus transplantation has shown success in treating women with uterine-factor infertility who want to carry their own pregnancy. METHODS: We report the medical, sexual, and psychological outcomes of our first cohort of 13 living-donor hysterectomies. As we have transitioned from open to robotically assisted hysterectomy, this report represents the complete series of open-donor hysterectomies at our center, all with >/=6-month postoperative outcomes. RESULTS: The open donor hysterectomy had a median of a 6.5-hour surgical time, 0.8 L estimated blood loss, 6-day hospital stay, and 28-day sick leave. Three donors had a grade III or IV complications, one reported new-onset psychological symptoms, and 9 experienced transient sexual discomfort. All complications were addressed and resolved, and all donors returned to their presurgical social and physical activities. CONCLUSION: Since uterus transplantation is not life-saving or life-extending, the risks in living uterus donation must be weighed against the benefit of giving another woman the opportunity to give birth to her own child. This report provides data to support more detailed informed consent regarding the medical, psychological, and sexual complications of open living donor hysterectomy and allows for further evaluation of the ethical acceptability of this procedure.

Kristek, J., L. Johannesson, G. Testa, R. Chmel, M. Olausson, N. Kvarnstrom, N. Karydis and J. Fronek (2019). “Limited Availability of Deceased Uterus Donors: A Transatlantic Perspective.” Transplantation 103(12): 2449-2452.

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Women with absolute uterine-factor infertility (AUFI) had until recently only the opportunity to have children through adoption, foster parenting, or gestational surrogacy. However, for some women with AUFI, none of these options is possible because of religious, societal, personal, or other reasons. Uterus transplantation (UTx) has recently been introduced as a unique opportunity for both genetic and gestational motherhood. To date, most UTx were accomplished with uterus transplants procured from living donors. Although deceased donor (DD) UTx have been performed successfully, the overall experience remains rare. Notably, most (10/13) DD UTx have been performed by the teams in Dallas, TX and Prague, Czech Republic. Recently, the first baby was born to a recipient after DD UTx in São Paulo, demonstrating proof of concept for DD UTx. DD UTx is desirable, as it avoids risks associated with complex live donor hysterectomies and (2) not every patient in need may have a qualifying living donor available. Thus, it appears critical to analyze the potential of DD UTx. Several unknowns and limitations to this pursuit need to be addressed and include (1) the lack of standardized evaluation criteria of uterus DD (both standard and extended criteria), (2) information on the availability of potential uterus DDs, (3) assuring that potential donors will be identified by organ procurement organizations (OPOs), and (4) issues of consent beyond that taken for the procurement of solid organs for transplantation. Here, we address those issues in a transatlantic approach with an analysis in the Czech Republic, Sweden, the United Kingdom, and the United States. We aimed to roughly approximate the volume of potential uterus donors, demand for transplantation linked to geographical region. Moreover, we suggest criteria allowing OPOs to identify uterus DD and introduce the experience at our institutions on getting consent. (Excerpt from text, p. 2449; no abstract available.)

Mahmood, S., L. Johannesson, G. Testa and G. de Prisco (2019). “Duets (Dallas Uterus Transplant Study): The Role of Imaging in Uterus Transplantation.” SAGE Open Med Sep 9: eCollection 2019.

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Objective: Uterus transplantation is rapidly becoming a viable clinical option for women with uterine-factor infertility and a desire for parenthood. Radiological imaging plays a central role in selecting the optimal living donors for uterus transplantation and serves to exclude any pathology and evaluate the uterine vasculature. The latter is the most important variable in the ultimate technical success of the uterus transplant. In this first report of imaging in the setting of uterus transplantation, we report our experience with living-donor selection, and the evolution of the imaging techniques that ultimately allowed a significant improvement in donor selection and transplant outcome. We also suggest a framework for preoperative imaging in uterus transplantation. Methods: Between 2016 and 2018, 27 potential living donors were evaluated by imaging prior to uterine donation for uterus transplantation. Predonation imaging included a screening chest radiograph, dual-phase computed tomography (CT) angiograms of the abdomen and pelvis in the arterial and venous phases and pelvic sonography with Doppler. Seventeen potential donors additionally underwent multiphasic pelvic MR angiograms. The imaging performed was meant to display features of the vascular anatomy relevant for uterus transplantation. Results: Out of the 27 potential live donors who were evaluated by imaging, 9 eventually donated their uterus for transplantation. The most frequent reason for exclusion was suboptimal quality of the vessels (33%), including small uterine arteries, the presence of atherosclerosis or small size/poor quality of the uterine or utero-ovarian veins, or both. The next most common reason was voluntary patient withdrawal or failure to complete the evaluation process (28%). Three potential donors (16.6%) were rejected for uterine factors, fibroids, and/or adenomyosis. Other reasons for donor rejection included ABO incompatibility and unfavorable psychological evaluation. Conclusion: Diagnostic imaging plays a crucial role in selecting appropriate potential donors, screening prospective recipients, planning the graft procedure, and following up on any graft or nongraft-related complications in both the donor and recipient after the transplantation procedure is performed. Contrast-enhanced CT and MR angiographies have complementary roles, especially when evaluating the donor for adequacy of the arterial and venous supply to the uterine graft and the experience gained from our series indicates that the inclusion of both modalities contributed directly to successful uterus transplant graft survival by selecting patients with favorable arterial and venous vasculature.