Live and deceased donor uterus transplantation as a treatment option for women with absolute uterine factor infertility

Phase 1: Live donor and recipient transplantation Study setting This is a multi-site clinical research study which will be conducted across 5 tertiary hospitals within NSW Australia. The recruitment and pre-clinical screening (including imaging) of patients will be across the Royal Hospital for Women and Prince of Wales Hospital campus. Obstetric care will take place across all 4 participating sites depending on geographic proximity for antenatal and postpartum care. The uterus transplantation surgeries will take place within the theatres at the Westmead Adult Hospital. A total of 12 subjects will receive a uterine transplant as phase 1 of this clinical research study. Six subjects will receive a uterus from a living donor, and six from a deceased donor. Living donors will be screened in relation to the study inclusion criteria. Intervention's 1. In-Vitro Fertilisation treatment In-vitro fertilisation will be done 6 to 18 months before uterus transplantation. The patient will not be menstruating due to uterine absence. The recipient and her partner will attend the fertility clinic and undergo an orientation by a fertility nurse, outlining the process of IVF, and teaching the couple how to inject the medications. The IVF protocol will follow a standard antagonist cycle (initially injecting recombinant FSH daily [dose 75-300U] and then the GnRH antagonist [0.25mg] is added as a second daily injection. This will use the standard IVF protocol consent. During the 10-14 days of ovarian stimulation, there will be 4-5 blood tests and ultrasounds to monitor the stimulation of the ovary. Oocyte pick-up will be conducted trans-abdominally by abdominal ultrasound guidance (due to lack of a full vaginal canal in many women with uterine absence) or trans-vaginally if the length of vagina allows access to the ovaries effectively. The eggs will then be fertilised by either invitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI), depending on the semenanalysis (number and motility of sperm). The embryos are then placed through sequential media to mature the embryos to a Day 5 stage (blastocyst) and these blastocysts are subsequently frozen using a vitrification technique. 2. Uterus transplant Uterus transplantation surgery entails isolation of the uterus with bilateral, long venous, and arterial vascular pedicles. The donor surgery is complex and involves extensive vascular dissection that includes the distal parts of the internal iliac veins and arteries. After surgical isolation, the uterus will be flushed bilaterally through the arterial ends with preservation solution. The vascular ends of the graft will be trimmed and the left-sided vein that will have been divided will be anastomosed end-to-end by a continuous suture (8-0 polypropylene). One hour before final graft retrieval from the donor, surgery to prepare the recipient for transplantation will be initiated in an operating theatre. Through a midline incision, the external iliac vessels will be dissected and prepared for anastomosis. The vaginal vault will then be separated from the bladder and rectum. Sutures will be used for uterine fixation, and will be placed bilaterally through the round ligaments, uterosacral ligaments, and the paravaginal connective tissues. The uterus will be brought into the pelvis and end-to-side vascular anastomoses will be conducted to connect the uterine veins to the external iliac veins (with 8-0 polypropylene sutures) and the anterior divisions of the internal iliac arteries to the external iliac arteries (with 7-0 polypropylene sutures) on both sides. The surgeon will then open the blood flow to the uterus to ascertain that good pulses exist distal to the arterial anastomosis sites and that the uterine tissue will change from pale to reddish, with blanching, evidence of pin prick bleeding and tissue turgor, which is considered a sign of peripheral tissue perfusion. The uterus will then be fixed to the ligaments and sutured the extensive bladder peritoneum on the uterine graft on top of the recipient’s bladder to provide extra structural support. A thin wire cable will be inserted into the uterus and bought out through the midline incision to check the blood flow in the uterus. This probe will be removed after a 3-day observation period. We anticipate that the surgeries of the donor and recipient will proceed uneventfully. It has been reported by Brännström et al that the ischaemic time of the uterine graft will be under 3 hours. It is anticipated that both the donor and recipient will be discharged from hospital after 6 days of postoperative care. 3. Immunosuppression and follow-up Immunosuppression will be tailored to each individual circumstance as described by Brännström et al. Induction immunosuppression will start with prednisolone 20mg (2 tablets), starting 3 days before the transplantation, with a slow reduction of 2.5 mg every week until the dose reaches 10mg (1 tablet) per day, which will continue while uterus is insitu. On the day of surgery Intravenous thymoglobulin or Antithymocyte globulin (2.5 mg/kg bodyweight - 5 mg/kg body weight) will be given (received twice on the day of surgery only). The use of induction therapy intravenous drugs will be dependent on the immunological risk of the recipient. Maintenance immunosuppression: once daily oral tacrolimus (9-15ng/mL for first month) will be started on the day of surgery and continue post transplant, this dose will be reduced to 5–10 ng/mL at 2mths after UTx) aiming at trough levels of 9–10 ng/mL during the first month, and then slow titration down to a level of 6-7 ng/ml, depending on immunological risk as well as the risk of rejection. Mycophenolate mofetil of 1 mg twice / day to be administered orally during the first 10 months post-surgery. Azathioprine 2 mg/kg per day (will then be used instead of mycophenolate mofetil after 10 months, to avoid the potentially teratogenic effects of mycophenolate mofetil in the run-up to embryo transfer. The recipient will be followed up by frequent clinical visits and laboratory examinations with the gynaecological surgical and transplant physician teams, initially a 1 hour appointment, twice weekly will be required during the first postoperative month and then every 2 weeks in months 2–6 with length of visit depending on findings. Subsequently, patients will be reviewed monthly. Ultrasound scans with transvaginal and abdominal probes will be conducted with the radiologist and gynaecologist to assess uterine size, and endometrial thickness and echogenicity. Uterine artery flow velocity waveforms on both sides will be assessed by Doppler ultrasound, with an abdominal probe placed just above the inguinal ligament. Biopsies of the uterine cervix will be obtained at predetermined timepoints by the gynaecologist (at 1, 2, and 4 weeks, and monthly thereafter) and in the event of pathological signs (abnormal vaginal discharge, fever, discoloured cervix, or abdominal pain) that could indicate local infection or graft rejection. The team psychologist will also be conducting fortnightly phone calls with the recipients to monitor adherence and psychological aspects. At each visit with any team member, clear documentation of the visit and findings will be kept. The histological examination of biopsies will use a uterine rejection grading system that was initially developed for the non-human primate uterus. Any presence of cervical intraepithelial neoplasia will be followed-up by tests for human papillomavirus. Clinical follow-up will also include monitoring of blood pressure and bodyweight, and laboratory monitoring. 4. Embryo transfer A single embryo transfer will be conducted around 6-12 months after uterus transplantation during the natural menstrual cycle in alignment with local protocols for frozen embryo transfer, with a soft embryo transfer catheter under abdominal ultrasound guidance. If the initial embryo transfer is not successful, subsequent transfers will be scheduled at monthly intervals (or when the recipient feels ready psychologically) using the remaining embryos. If all embryos are used without success, a further IVF cycle could be considered. During pregnancy, the patient will be monitored according to routine programme for pregnant transplant patients, including frequent visits (every 2–3 weeks) to specialists in high-risk obstetrics and transplantation. 5. Uterus/Graft removal After 2 pregnancies or 5 years of the uterus being insitu in the recipient the uterus is removed to minimise the possible harm of long term immunosuppression. This is a surgery including a big cut on the abdomen, removal of this organ and closure of the skin. The recovery is a 5 day stay in hospital, and up to 6 weeks post operative recovery time at home