Corneas, kidneys, lungs, hearts…now uteri (and yes, I checked it- that is the correct plural) can join the list of organs transplanted successfully and functionally into other humans. That's as reported in the Lancet and as Rick and I discuss on PodMed this week. What's the story?
Sometime in 2013 a 35 year old woman who lacked a uterus since birth, a condition known as Rokitansky syndrome, underwent transplantation of a uterus from her 61 year old, obviously postmenopausal friend, who had given birth to two children during her reproductive years. Lack of a functional uterus is not uncommon; so-called 'absolute uterine factor infertility' can occur as a result of congenital absence of a uterus, hysterectomy, or a number of adhesions within the organ, and affects some 12,000 women in the UK alone.
As stated, the uterus was harvested from a live donor, who first took oral contraceptives for three months prior to organ retrieval to assure that bleeding would occur as predicted. The surgery spanned just over 10 hours due to extensive dissection relative to isolation and preservation of the vasculature supplying the organ. From my perspective, this is a mighty generous undertaking on the part of the donor!
In contrast, the recipient's operation took just less than five hours but that, of course, is where the easy part ended. Immunosuppression was initiated and many and frequent examinations of the transplanted uterus ensued. Menses appeared spontaneously 43 days after the transplant, and continued at regular intervals thereafter. Two minor rejection episodes were managed successfully and one year after uterine transplantation, the patient underwent embryo transfer with she and her partner's embryos, previously conceived via IVF. Pregnancy commenced and continued normally for 31 weeks, when the patient developed pre-eclampsia. The baby, a girl, was delivered by Cesarean section at 31 weeks and 5 days gestation, and had normal Apgar scores and other measures of health. Thus far, both mother and baby seem to be doing well.
The authors coin a term, "ephemeral transplant," to describe the fact that after one or two pregnancies, the transplanted uterus can and likely should be removed to allow the recipient to cease immunosuppression. Such removal should not take place immediately following birth as both the health of the infant and a period of recovery for the mother should be assured, but they say this successful management of infertility provides proof of concept that such a strategy is possible for women with absolute uterine factor infertility. Hmmm. Rick and I are both in awe of so many aspects of this report, perhaps mostly because who knew that recycled uteri could still be so clearly functional? As those bumper stickers extolling the virtues of organ donation state, "Don't take your organs with you to heaven, we need them right here," I wonder how much pressure potential donors might be under if such a practice becomes widespread? Somehow that harvesting operation doesn't appeal; I think there would have to be some pretty persuasive reasons to participate. For now, yet one more miraculous medical intervention to ponder.
Other topics this week include a pan on transfusions for yet another group of people: those with septic shock, in NEJM, another in the Lancet on quality of life for teenagers with cerebral palsy, and in JAMA Internal Medicine, a look at decision fatigue and the prescription of antibiotics among physicians. Until next week, y'all live well.