Original Research ajog.

org

OBSTETRICS
Living uterus donation and transplantation: experience of
interest and screening in a single center in the United States
Liza Johannesson, MD, PhD; Kristin Wallis, BSN; E. Colin Koon, MD, PhD; Greg J. McKenna, MD; Tiffany Anthony, MD;
Sara G. Leffingwell, BS; Goran B. Klintmalm, MD, PhD; Robert T. Gunby Jr, MD; Giuliano Testa, MD

BACKGROUND: Little is known about attitudes toward uterus donation
and transplantation in society and the interest of the women the treatment
is aimed to assist.
OBJECTIVE: This study examined the interest of recipients and living
donors in our uterus transplantation program; it describes the screening
protocol we developed and the results of the screening and reports de-
mographic data and characteristics of screened candidates.
STUDY DESIGN: Initial screening and evaluation included physical
examinations by a gynecologist and a transplant surgeon; psychological
evaluation; imaging (x-ray, computed tomography, ultrasound); blood
tests; immunological testing; viral, bacterial, and fungal testing; drug
screen; hormonal testing; Papanicolau smear; urinalysis; and electro-
cardiogram. For selected recipients, the process also included in vitro
fertilization.
RESULTS: A total of 351 women contacted our department with in-
terest in participating in uterus transplantation; 272 were potential re-
cipients and 79 were potential donors. Among these women, 179
potential recipients and 62 potential donors continued the evaluation after
the initial telephone screening. The mean age of the donor candidates
was 40 years; all had completed their own family, and 80% were
nondirected. Most recipient candidates (92%) had an anatomical lack of
the uterus, and of these, 36% had a congenital malformation. The women
with a congenital uterine absence were in general younger than the
women in the group whose uterus had been removed (mean of 28 and 33
years, respectively). In every step of the initial screening and evaluation
process, there were donor and recipient candidates that chose not to
continue the process. The reasons for self-withdrawal after expressing
interest were not returning phone calls or e-mails (17 donors and 76
recipients); after initial phone screening, no longer interested (1 donor
and 9 recipients); in step 1, health history questionnaire not returned after
1 reminder (10 donors and 9 recipients); step 2, not right in their current
life situation (2 donors and 2 recipients), and in step 3, chose another way
to achieve motherhood (1 recipient). Most donor and recipient candidates
(52% and 78%, respectively) could be screened out (because of self-
withdrawal or transplant team’s decision) during the noninvasive and
cost-efficient initial screening.
CONCLUSION: Our initial experience shows a great interest in
participating in a trial of uterus transplantation by both potential recipients
and donors. It is the first study to show interest in nondirected donation. A
sufficient but thoughtful screening process of living donors and recipients
is essential and should aim both to assure donor/recipient safety and to
provide good quality grafts.
Key words: donor, infertility, interest, recipient, uterus transplantation

I n 2014, the first baby was delivered by

a mother born without a uterus.1 The
birth was facilitated by a uterus trans-
plantation almost 2 years prior to the
delivery. While uterus transplantation is
still in an experimental stage, it is a
promising potential treatment for
women with absolute uterine-factor
infertility. Approximately 1 in 500
women are affected by absolute uterine-
factor infertility2; based on the popula-
tion, we estimate that there are about
80,000 reproductive-age women with
absolute uterine-factor infertility in the
United States. The many women who
Cite this article as: Johannesson L, Wallis K, Koon EC,
et al. Living uterus donation and transplantation: expe-
rience of interest and screening in a single center in the
United States. Am J Obstet Gynecol 2017;xxx:xx-xx.
0002-9378/$36.00
ª 2017 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2017.11.594
have no functional uterus but want to
have a child are currently given only
adoption or surrogacy as options.
Uterus transplantation is unique in
several ways. Rather than being life
saving, it enhances quality of life and is
potentially life giving. It is the first tem-
porary organ transplantation, with
planned removal after childbirth. It can
be performed with both living and
deceased donors, although to date the
birth of a child has occurred only after
living-donor transplants.
The first attempt at uterus trans-
plantation in the United States in
2016 was unfortunately unsuccessful.3
The transplant was conducted with a
deceased-donor uterus, and the graft
had to be removed less than 2 weeks
after the transplant. Six months after
this initial uterus transplantation, we
performed the first living-donor
uterus transplantation in the United
States.
While public attitudes toward tradi-
tional organ donation are favorable and
uterus transplantation is considered a
promising treatment option among
health care professionals, little is known
about attitudes toward uterus donation
and transplantation in society and the
interest of the women the treatment is
aimed to assist. In this paper, we present
our initial experience with the interest of
potential recipients and donors for
uterus transplantation, the development
of a screening protocol, and the de-
mographic data and characteristics of
our screened candidates.
Materials and Methods
Our clinical uterus transplantation trial
(Project 015-158) was performed at
Baylor University Medical Center
(Dallas, TX) and was approved by the
institutional review board. The policy
of the program is to present all poten-
tial uterus recipients with the possibility

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Original Research OBSTETRICS ajog.org

of both living and deceased donor

TABLE 1
transplants at the time of evaluation for
Evaluation of candidates for in vitro fertilization
transplantation.
Type Test The candidates (both potential donors
Health care professional Physical examination and recipients) independently contacted
evaluation our institution. There was no advertising
or recruiting for the clinical trial aside
Pelvic examination
from information on the hospital web
Psychological evaluation (including in-depth interview site and a local press conference to
and standardized questionnairesa)
announce the start of the trial, during
Imaging Chest x-ray which contact information was provided
Computed tomography, abdomen and pelvis (e-mail and phone number) as well as
Vaginal ultrasound
the listing on clinicaltrials.gov (clinical
number NCT02656550).
Doppler ultrasound The first contact with the potential
Transabdominal ultrasound recipient or donor was through a nurse
Blood tests Complete blood count with differential coordinator (with >10 years of experi-
ence in women’s health) assigned to
Comprehensive metabolic panel
the program. The candidates were
Gamma-glutamyl transferase informed at the initial contact about
Lipid panel the experimental nature of the program,
Prothrombin time/international normalized ratio the worldwide experience/outcome of
uterus transplantation, details of the
Partial thromboplastin time
surgery, postoperative care, and poten-
Hemoglobin A1c tial complications. They were also
Immunological testing ABO blood groups Rh antigens informed that participation in the uterus
Human leukocyte antigens transplantation trial possibly could
render costs for them.
Viral, bacterial, and fungal Syphilis The trial would cover investigations,
testing
surgery, hospital stay, medications, and
Chlamydia and gonorrhea (Neisseria gonorrhoeae follow-up visits but would not cover
culture)
in vitro fertilization (IVF), travels, ac-
Herpes simplex virus 1 and 2 commodation, or loss of income. No
Hepatitis C virus RNA by polymerase chain reaction compensation for participating in the
Surface antigen of the hepatitis B virus
trial would be handed out. A basic initial
screening also took place during this first
Cytomegalovirus IgM and IgG contact, with exclusion criteria being age
Epstein-Barr virus IgM and IgG (limit of 65 years for donors and 35 years
HIV for recipients), body mass index (BMI)
limit of 30 kg/m2, medical comorbid-
Fungal screening
ities, and obstetric history. The candi-
Urine culture dates considered to be initially suitable
Rubella and interested in participation pro-
Tuberculosis (T-SPOT) ceeded to the first step of evaluation.
Drug screen Serum alcohol test
Step 1: subjective health screening
Urine drug test
The candidates received an informed
Other tests Papanicolau smear with cotesting for human consent form for screening and a health
papillomavirus
history questionnaire. Candidates were
Urinalysis also encouraged to send any related
Electrocardiogram medical records, if present. Based on the
health history questionnaires, the pri-
Johannesson et al. Uterus transplantation interest. Am J Obstet Gynecol 2017. (continued)
mary investigator (transplant surgeon)

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ajog.org OBSTETRICS Original Research

the IVF process. During the IVF, intra-

TABLE 1 cytoplasmic sperm injection was used,
Evaluation of candidates for in vitro fertilization (continued) and on day 5e6 the blastocysts were
Type Test biopsied for PGS testing. Once the po-
Hormonal testingb Follicle-stimulating hormone
tential recipient had obtained at least 2
day 5e6 blastocysts of satisfactory
Luteinizing hormone quality (may require 1 or more stimu-
Estradiol lations), she was listed for trans-
Prolactin plantation and donor matching.
Anti-Müllerian hormone
Step 5: final selection committee
Thyroid-stimulating hormone meeting
Ig, immunoglobulin. If the potential recipient had a named
a
For recipients only: Fertility Quality of Life Questionnaire. For both recipients and donors: Millon Behavioral Medicine Diag- donor, the donor would have to go
nostic; Hospital Anxiety and Depression Scale; Posttraumatic Strerss Disorder Checklist for Diagnostic and Statistical Manual
of Mental Disorders, fifth edition; 36-Item Short Form Survey; Brief Coping Orientation to Problems Experienced Question- through evaluation steps 1e3 before
naire; Connor-Davidson Resilience Scale 10; Drug Use Questionnaire, and Dyadic Adjustment Scale; b Hormonal testing being approved. If the potential recipient
occurred in step 4; all other testing occurred in step 2.
Johannesson et al. Uterus transplantation interest. Am J Obstet Gynecol 2017.
did not have a donor, she was put on a
list for altruistic donor matching. The
matched donor-recipient pair was pre-
sented at a second selection committee
decided which candidates were eligible psychological evaluation included an in- meeting during which final approval to
for step 2. The decision on eligibility was depth interview and standardized psy- go through with donation/trans-
based on the inclusion and exclusion chological questionnaires (Fertility plantation was given and scheduled. In
criteria of the uterus transplantation trial Quality of Life Questionnaire for re- the event the potential recipient did not
and excluded, for example, vaginal cipients only; Millon Behavioral Medi- have a named donor or could not be
grafts, hormonal replacement therapy, cine Diagnostic, Hospital Anxiety and matched with an existing altruistic
kidney malformations, and severe Depression Scale, Posttraumatic Strerss donor, she was put on a list for deceased
endometriosis. The candidates were Disorder Checklist for Diagnostic and donor matching.
notified and an evaluation schedule Statistical Manual of Mental Disorders,
arranged. fifth edition, 36-Item Short Form Sur- Results
vey, Brief Coping Orientation to Prob- Within a year, 351 women (272 potential
Step 2: objective health screening lems Experienced Questionnaire, recipients and 79 potential donors)
The second step of the evaluation pro- Connor-Davidson Resilience Scale 10, contacted our department with interest
cess consisted of a medical workup. A Drug Use Questionnaire, and Dyadic in participating in the uterus trans-
second informed consent form was given Adjustment Scale for both recipients and plantation trial (>85% contacted the
to the candidates before the process donors). The medical workup took place department during the first 2 months
started. The candidates were informed of over a 2 day period and is detailed in after the trial was announced in a press
the procedure by both transplant sur- Table 1. conference). The characteristics of the
geons and gynecological oncologists 179 potential recipients and 62 potential
separately. They were informed of the Step 3: initial selection committee donors who passed the initial screening
known complications of previously meeting are summarized in Table 2. Of this
performed cases of living donor uterus The 8 potential donors and 11 potential group, 48% of the donor candidates and
donation and transplantation world- recipients screened through step 2 were 22% of the recipient candidates
wide. They were also informed about presented at a selection committee continued to the first step of evaluation
postoperative hospital stay, post- meeting made up of transplant surgeons, (Figure).
operative restrictions, and readjustment gynecologists, obstetricians, a repro- Among the 62 donor candidates who
to normal life. They were thoroughly ductive endocrinologist, a psychologist, went through the initial screening, 74%
informed about the experimental nature and a nurse coordinator. The candidates were altruistic/nondirected. The 16
of the uterus transplantation trial and considered suitable for donation or for directed donor candidates were referred
that there is an unknown outcome for the next step in recipient evaluation were by 5 recipient candidates. The mean age
both recipients and donors. They had the notified. of the donor candidates was 40 years
opportunity to see a psychologist after (range, 21e64 years), and 90% had
receiving the information. Step 4: in vitro fertilization for delivered at least 1 child. All donors had
Clinical evaluations were performed potential recipients completed their own family, and 19
by a transplant surgeon, a gynecological Potential recipients were referred to the (31%) had gone through permanent
oncologist, and a psychologist. The reproductive endocrinologist to begin pregnancy prevention, either female

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Original Research OBSTETRICS ajog.org

had an anatomical lack of the uterus

TABLE 2
(Table 3). Of these women, 36% had
Characteristics of candidates for uterus donation and transplantation
a congenital malformation (Mayer-
Characteristics Recipients Donors Rokitansky-Küster-Hauser syndrome
Candidates included in initial phone screening, n 179 62 [MRKH]). The women with MRKH
were in general younger than the women
Age, y, mean (range) 32 (19e59) 40 (21e64)
in the group whose uterus had been
2
Body mass index, kg/m , mean (range) 27 (18e60) 26 (18e41) removed (mean of 28 and 33 years,
Smoking, n 9 0 respectively). In the group of women
Previous children, n, % 89 (50%) 56 (90%) with a previous hysterectomy, 73% had
their uterus removed because of benign
Biological, n 85 73
causes, 16% because of obstetric com-
Gestational surrogacy (biological), n 3 0 plications, and 11% because of gyneco-
Adopted, n 1 0 logical malignancies (Table 3).
Selected candidates for donation and transplantation, n 10 6
In addition, 47% of the interested
recipient candidates had at least 1 child
Age, y, mean (range) 30 (22e34) 42 (34e55) prior to expressing interest in the clinical
2
Body mass index, kg/m , mean (range) 25 (19e30) 24 (19e28) trial. The selected recipient candidates
Smoking, n 0 0 (n ¼ 10) had a mean age of 30 years and a
Marital status BMI of 25 kg/m2. All selected recipients
were either married or in a committed
Married 9 3
relationship. The majority (70%) were
Divorced 0 2 white/non-Hispanic and had at least a
Committed relationship 1 1 high school education. Detailed charac-
Race/ethnicity teristics of the selected recipients are
shown in Table 2.
White/not Hispanic 7 5
In every step of the initial screening
Hispanic 1 1 and evaluation process, there were donor
Black 1 0 and recipient candidates who chose not
American Indian 1 0 to continue the process. The reasons for
self-withdrawal were, after expressing
Religion
interest, not returning phone calls or
No preference 2 2 e-mails (17 donors and 76 recipients);
Christian 5 4 after initial phone screening, no longer
Muslim 1 0 interested (1 donor and 9 recipients); in
step 1, health history questionnaire not
Unknown 2 0
returned after 1 reminder (10 donors
Geographic origin and 9 recipients); step 2, not right in
United States/Texas 3 6 their current life situation (2 donors and
United States/other state 7 0 2 recipients); and in step 3, chose
another way to achieve motherhood (1
Education level
recipient). None of the donors or re-
High school 2 0 cipients were excluded based on the
Technical school 1 0 psychological evaluation (in-depth
Associate’s degree 1 0 interview and standardized psychologi-
cal questionnaires).
Bachelor’s degree 5 4
Master’s degree 1 2 Comment
Johannesson et al. Uterus transplantation interest. Am J Obstet Gynecol 2017. (continued) Uterus transplantation as a treatment for
certain kinds of infertility is a new,
rapidly growing area of transplantation,
(tubal ligation, 63%) or male (partner/ were nondirected. Detailed characteris- augmented by the first successful de-
husband vasectomy, 37%). The selected tics of the selected donors are shown in livery after a uterus transplant in 2014.1
donor candidates (n ¼ 6) had a mean age Table 2. This is the first study that describes not
of 42 years and a BMI of 24 kg/m2. All of Of the recipient candidates who went only the interest of potential recipients in
the donors had previous children, and all through the initial screening, 164 (92%) uterus transplantation but also the

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TABLE 2
Characteristics of candidates for uterus donation and transplantation
(continued)
Characteristics
Employment
Student
Not employed
Part time
Full time
Number of previous children, mean (range)
Nondirected donor
Johannesson et al. Uterus transplantation interest. Am J Obstet Gynecol 2017.
interest of potential donors at a single
center at the launch of a new transplant
program.
The screening and evaluation pro-
cesses (steps 1e5) were based on a suc-
cession from least to most invasive
examinations. We also aimed to identify
key examinations that would help detect
unsuitable candidates as early as possible
in the process, thus saving time and ex-
penses both for the candidates and the
program.
In our study, 52% of potential donors
and 78% of potential recipients were
rejected on initial screening, and a
further 29% and 12%, respectively, were
rejected during the first step of the
evaluation. The main reason for elimi-
nation during the initial phone screening
was that the potential donors and re-
cipients did not meet the basic inclusion
criteria of the trial (50% and 86%,
respectively). Of the potential donors
and recipients who continued to step 1,
the main reason for not proceeding to
step 2 was self-withdrawal (56% and
41%, respectively) and comorbidities for
potential recipients (27%). Because no
medical examinations are included in
the initial screening or step 1, the ex-
penses are minimal.
After registration of our clinical trial,
we hoped to receive interest from po-
tential recipients, but as the trial became
common knowledge, we were also con-
tacted by interested potential altruistic
OBSTETRICS
Recipients Donors
1 0
2 1
1 0
6 5
0 3 (2e4)
NA 6 tions, who together represented 42% of
donors (23% of 351). It is difficult to
judge whether the interest shown from
potential donors and recipients corre-
lates to that of the general population,
but a few studies have been published
that support the fact that there is a strong
and positive interest in the general pop-
ulation toward uterus transplantation.4-6
A study of public attitudes in the
United States toward vascularized com-
posite allograft donation and trans-
plantation had 1485 participants, of
whom 736 were women (median age, 32
years).4 The survey showed that as many
as 74% of women were willing to donate
their uterus. Among those who were not
willing to donate their uterus, the main
reasons were vague psychological
discomfort, nonspecific, or body part is
not viable (41%, 32%, and 23%, respec-
tively). Only 1% stated identity loss as a
cause for not being willing to donate.
Support for uterus transplantation has
been reported previously. In the United
Kingdom, a survey of 528 health care
professionals showed great support
(94%) for uterus transplantation as a
possible therapeutic option for absolute
uterine-factor infertility.5 Another study
of 3098 women (mean age, 32 years)
explored the attitudes of Japanese
women of reproductive age toward
uterus transplantation.6 The survey
showed 44% in favor of uterus trans-
plantation; 47% had no opinion, and 8%
were against. Uterus transplantation was
MONTH 2017 American Journal of Obstetrics & Gynecology
Original Research
favored more than gestational surrogacy
but less than adoption (35%, 18%, and
62%, respectively).
Kisu et al6 also showed that for
candidate donors and recipients,
deceased donors and congenital uterine
agenesis were favored. In our study, at
this initial state of uterus trans-
plantation, we chose to continue the
evaluation process (step 1) with women
who had MRKH (congenital agenesis)
and women who had a previous hyster-
ectomy because of obstetric complica-
the potential recipients interested in
participating. It was also required that
the women with MRKH have 2 func-
tioning kidneys and nongrafted vaginas.
A recent publication from the team
behind the first uterus transplantation in
the United States showed great interest
in uterus transplantation, with >250
potential recipients of reproductive age
who contacted that center prior to the
first transplant.7 The study showed a
high percentage (64%) of acquired
uterine-factor infertility within the study
population, with a high proportion of
hysterectomies for a benign cause
(50%).7
In our study, the corresponding
numbers were similar or higher (58%
and 78%, respectively). The mean age of
the women who had a hysterectomy of
benign cause was 34 years, and the main
reasons for the hysterectomy were
endometriosis, fibroids, and heavy
bleeding. The relatively high proportion
of young women of child-bearing age
who underwent a hysterectomy for
benign causes was noted by Arian et al,7
who commented on the US culture of
hysterectomy, which results in infertility.
It is interesting to note that most po-
tential donors and recipients who con-
tacted our program did so after it was
publicly known that the first uterus
transplantation in the United States
failed.3 Despite the news of the failed first
attempt, interest in the clinical trial
remained strong.
Arian et al7 also pointed to the fact
that 17% of potential recipients in their
study had at least 1 biological child to
1.e5
Original Research OBSTETRICS ajog.org

FIGURE
Results of initial screening and evaluation process for candidates

Results of the initial screening and evaluation process for candidates of uterus donation and transplantation, showing causes for not continuing evaluation
for both donors and recipients. Administrative reasons included insurance/financial issues or the candidate or spouse being unable to relocate.
BMI, body mass index; HPV, human papillomavirus; HSV, herpes simplex virus; STD, sexually transmitted disease.
Johannesson et al. Uterus transplantation interest. Am J Obstet Gynecol 2017.

dispute the argument that uterus trans-

TABLE 3 plantation would exploit a vulnerable
Causes of infertility among the 179 recipient candidates screened for uterus population unable to have children
transplantation another way. In our study, almost half of
the interested potential recipients had at
Cause N
least 1 child prior to showing interest in
Absent uterus 164 (92%) the clinical trial (biological, n ¼ 85;
Congenital uterine-factor infertility/MRKH 59 adopted, n ¼ 3; biological through sur-
Acquired uterine-factor infertility 104 rogacy, n ¼ 1).
In conclusion, this study shows a great
Hysterectomy for obstetric complications 17
interest in participation in uterus trans-
Hysterectomy for malignancy 11 plantation, both by potential recipients
Hysterectomy for benign conditions 76 and donors. This study is the first to
Transgender female 1 show that interest in donating a uterus is
great, even for nondirected donors. A
Present uterus 15 (8%)
sufficient but thoughtful screening pro-
Undiagnosed infertility 11 cess of living donors and recipients is
Ovarian-factor infertility 2 essential. The process should aim both to
Fallopian tubeefactor infertility 2 assure donor/recipient safety and to
MRKH, Mayer-Rokitansky-Küster-Hauser syndrome.
provide good-quality grafts for the re-
Johannesson et al. Uterus transplantation interest. Am J Obstet Gynecol 2017. cipients. The screening and evaluation
process is time consuming and

1.e6 American Journal of Obstetrics & Gynecology MONTH 2017

ajog.org
expensive. Hence, one of the greatest
challenges is to recognize patient char-
acteristics and examinations that would
identify unsuitable candidates as early in
the process as possible. n Glazier AK. Vascularized composite allograft
Acknowledgment
This observational study had a trial registration
number of NCT02656550.
References
1. Brannstrom M, Johannesson L, Bokstrom H,
et al. Livebirth after uterus transplantation. Lan-
cet 2015;385:607-16.
2. Sieunarine K, Zakaria FB, Boyle DC, et al.
Possibilities for fertility restoration: a new surgical
technique. Int Surg 2005;90:249-56.
OBSTETRICS
3. Flyckt RL, Farrell RM, Perni UC, Tzakis AG,
Falcone T. Deceased donor uterine trans-
plantation: innovation and adaptation. Obstet
Gynecol 2016;128:837-42.
4. Rodrigue JR, Tomich D, Fleishman A,
(VCA) donation and transplantation: a survey of
public attitudes in the United States. Am J
Transplant 2017;17:2687-95.
5. Saso S, Clarke A, Bracewell-Milnes T, et al.
Survey of perceptions of health care pro-
fessionals in the United Kingdom toward
uterine transplant. Prog Transplant 2015;25:
56-63.
6. Kisu I, Banno K, Soeda E, et al. Survey of
attitudes toward uterus transplantation
among Japanese women of reproductive
age: a cross-sectional study. PLoS One
2016;11:e0156179.
MONTH 2017 American Journal of Obstetrics & Gynecology
Original Research
7. Arian SE, Flyckt RL, Farrell RM, Falcone T,
Tzakis AG. Characterizing women with interest
in uterine transplant clinical trials in the United
States: who seeks information on this experi-
mental treatment? Am J Obstet Gynecol
2017;216:190-1.
Author and article information
From the Annette C. and Harold C. Simmons Transplant
Institute (Drs Johannesson, McKenna, Anthony, Klint-
malm, and Testa), Baylor Research Institute (Ms Wallis
and Ms Leffingwell), and Department of Obstetrics and
Gynecology (Drs Koon and Gunby), Baylor University
Medical Center, Dallas, TX.
Received Aug. 22, 2017; revised Nov. 7, 2017;
accepted Nov. 29, 2017.
The authors report no conflict of interest.
Corresponding author: Liza Johannesson, MD, PhD.
liza.johannesson@BSWHealth.org
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