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Clinical pregnancy after uterus transplantation

      Objective

      To present the first clinical pregnancy after uterus transplantation.

      Design

      Case study.

      Setting

      Tertiary center.

      Patient(s)

      A 23-year-old Mayer-Rokitansky-Kuster-Hauser syndrome patient with previous vaginal reconstruction and uterus transplantation.

      Intervention(s)

      Eighteen months after the transplant, the endometrium was prepared for transfer of the thawed embryos.

      Main Outcome Measure(s)

      Implantation of embryo in an allografted human uterus.

      Result(s)

      The first ET cycle with one day 3 thawed embryo resulted in a biochemical pregnancy. The second ET cycle resulted in a clinical pregnancy confirmed with transvaginal ultrasound visualization of an intrauterine gestational sac with decidualization.

      Conclusion(s)

      We have presented the first clinical pregnancy in a patient with absolute uterine infertility after uterus allotransplantation. Although the real success is the delivery of a healthy near-term baby, this clinical pregnancy is a great step forward and a proof of concept that the implantation phase works.

      Key Words

      Discuss: You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/akarme-clinical-pregnancy-uterus-transplantation/
      Absolute uterine factor infertility (UFI) is one of the devastating causes of infertility (
      • Milliez J.
      Uterine transplantation FIGO Committee for the ethical aspects of human reproduction and women's health.
      ). Currently, gestational surrogacy is the sole option for having a genetic offspring in these patients (
      • Beski S.
      • Gorgy A.
      • Venkat G.
      • Craft I.L.
      • Edmonds K.
      Gestational surrogacy: a feasible option for patients with Rokitansky syndrome.
      ). Despite the progress in assisted reproductive technologies in the last decades, no current approach has been able to treat the problem of UFI. UFI may result from congenital (complete Müllerian agenesis, uterine hypoplasia) or acquired causes such as hysterectomy due to malignant and benign reasons (myoma, adenomyosis, postpartum hemorrhage) or due to intrauterine adhesions, which affect approximately 3%–5% of the general population (
      • Milliez J.
      Uterine transplantation FIGO Committee for the ethical aspects of human reproduction and women's health.
      ,
      • Saravelos Saravelos S.H.
      • Cocksedge K.A.
      • Li T.C.
      Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: a critical appraisal.
      ,
      • Kwee A.
      • Bots M.L.
      • Visser G.H.
      • Bruinse H.W.
      Emergency peripartum hysterectomy: a prospective study in The Netherlands.
      ,
      • Erman Akar M.
      • Saygili Yilmaz E.
      • Yuksel B.
      • Yilmaz Z.
      Emergency peripartum hysterectomy.
      ,
      • Farquhar C.M.
      • Steiner C.A.
      Hysterectomy rates in the United States 1990–1997.
      ,
      • Quinn M.A.
      • Benedet J.L.
      • Odicino F.
      • Maisonneuve P.
      • Beller U.
      • Creasman W.T.
      • et al.
      Carcinoma of the cervix uteri. FIGO 26th annual report on the results of treatment in gynecological cancer.
      ,
      • Del Priore G.
      • Saso S.
      • Meslin E.M.
      • Tzakis A.
      • Brännström M.
      • Clarke A.
      • et al.
      Uterine transplantation—a real possibility? The Indianapolis consensus.
      ). Uterus transplantation research has been carried out in different animal models including nonhuman primates to define the optimum surgical technique and clarify the immunological and technical aspects (
      • Del Priore G.
      • Saso S.
      • Meslin E.M.
      • Tzakis A.
      • Brännström M.
      • Clarke A.
      • et al.
      Uterine transplantation—a real possibility? The Indianapolis consensus.
      ,
      • Eraslan S.
      • Hamernik R.J.
      • Hardy J.D.
      Replantation of uterus and ovaries in dogs, with successful pregnancy.
      ,
      • Racho El-Akouri R.
      • Kurlberg G.
      • Brannstrom M.
      Successful uterine transplantation in the mouse: pregnancy and postnatal development of offspring.
      ,
      • Wranning C.A.
      • Akhi S.N.
      • Kurlberg G.
      • Brannstrom M.
      Uterus transplantation in the rat: model development, surgical learning and morphological evaluation of healing.
      ,
      • Wranning C.A.
      • El-Akouri R.R.
      • Lundmark C.
      • Dahm-Kahler P.
      • Molne J.
      • Enskog A.
      • et al.
      Auto-transplantation of the uterus in the domestic pig: surgical technique and early reperfusion events.
      ,
      • Enskog A.
      • Johannesson L.
      • Chai D.C.
      • Dahm-Kahler P.
      • Marcickiewicz J.
      • Nyachieo A.
      • et al.
      Uterus transplantation in the baboon: methodology and long term function after auto transplantation.
      ). As a result of the tremendous work of these researchers, pregnancy after allo- and auto- uterus transplantation has been documented in some animal species including nonhuman primates (
      • Wranning C.A.
      • Akhi S.N.
      • Diaz- Garcia C.
      • Brannstrom M.
      Pregnancy after syngenic uterus transplantation and spontaneous mating in the rat.
      ,
      • Diaz-Garcia C.
      • Akhi S.N.
      • Wallin A.
      • Pellicer A.
      • Brannstrom M.
      First report on fertility after allogenic uterus transplantation.
      ,
      • Ramirez E.R.
      • Ramirez Nessetti D.K.
      • Nessetti M.B.
      • Khatamee M.
      • Wolfson M.R.
      • Shaffer T.H.
      • et al.
      Pregnancy and outcome of uterine allotransplantation and assisted reproduction in sheep.
      ,
      • Mihara M.
      • Kisu I.
      • Hara H.
      • Lida T.
      • Araki J.
      • Shim T.
      • et al.
      Uterine allotransplantation in cynomolgus macaques the first case of pregnancy and delivery.
      ).
      Here we report the first clinical pregnancy in a human after uterus allotransplantation.

      Materials and methods

       Patient Information

      The patient was a 23-year-old woman with complete Müllerian agenesis previously operated for vaginal reconstruction with jejunum. She was selected as one of the candidates for uterus transplantation after 6 months of counseling and discussion of the surgical, immunosuppression treatment and pregnancy-related risks. Local transplantation committee and Institutional Review Board approval was obtained for this study. She and her husband were examined for infertility by measurement of basal hormone levels and antral follicle reserve, ovarian reserve tests (anti-Müllerian hormone, 1.95 ng/mL; thyroid-stimulating hormone, 5.9 μIU/mL; PRL, 44.3 ng/mL), and sperm analysis. Sperm analysis was evaluated with World Health Organization 2010 criteria (total progressive sperm count, 64 million/mL) (
      • Gottardo F.
      • Kliesch S.
      World Health Organization. Semen analysis: spermiogram according to WHO 2010 criteria.
      ).
      Testing for lupus anticoagulant and anticardiolipin antibodies, factor V Leiden deficiency, activated protein C resistance, prothrombin G20210A, polymorphism at position 677 for methyl tetrahydrofolate reductase (MTHFR) gene, and protein S were performed to rule out thrombophilia and hyperhomocysteinemia. The patient was homozygoous for polymorphism at position 677 for the MTHFR gene. Low molecular weight (LMW) heparin (4000 IU, Clexane, Enoxaparine Na, Sanofi Pasteur As.) and levothyroxine (50 mg Euthyrox, Merck Ilac) were administered daily. Cabergoline (0.5 mg, Dostinex, Pfizer Pharmacia Saglik Urunleri) was administered weekly.

       IVF Procedure

      Multiple-dose flexible GnRH antagonist protocol (0.25 mg daily when leading follicle is 14–15 mm) was used in the first IVF cycle (
      • Albuquerque L.E.
      • Tso L.O.
      • Saconato H.
      • Albuquerque M.C.
      • Macedo C.R.
      Depot versus daily administration of gonadotrophin releasing hormone agonist protocols for pituitary down regulation in assisted reproduction cycles.
      ). E2 and P levels were 2,421 pg/mL and 0.7 ng/mL on the day of hCG administration. Ten oocytes were picked up yielding six metaphase II (MII) oocytes and three grade 1 embryos. Pituitary down-regulation with daily GnRH agonist (long protocol) was commenced in the second IVF cycle (
      • Al-Inany H.G.
      • Youssef M.A.
      • Aboulghar M.
      • Broekmans F.
      • Sterrenburg M.
      • Smit J.
      • et al.
      Gonadotrophin-releasing hormone antagonists for assisted reproductive technology.
      ). E2 and P levels were 3,700 pg/mL and 1.1 ng/mL at hCG day. Twelve oocytes were collected yielding nine MII oocytes and five grade 1 embryos. Both oocyte pick-up procedures were performed transvaginally 36 hours after 250 hCG injection (Ovitrelle, Merck Serono).

       Embryo Vitrification

      Irvine Scientific brand was used in the first, and Vitrolife brand was used in the second IVF cycle. Retrieved oocytes were prepared for intracytoplasmic sperm injection (ICSI) (
      • Palermo G.D.
      • Neri Q.V.
      • Monahan D.
      • Kocent J.
      • Rosenwaks Z.
      Development and current applications of assisted fertilization.
      ). Polyvinylpyrrolidon was used for sperm selection and immobilization. ICSI was performed in HEPES-buffered medium (
      • Palermo G.D.
      • Schlegel P.N.
      • Colombero L.T.
      • Zaninovic N.
      • Moy F.
      • Rosenwaks Z.
      Aggressive sperm immobilization prior to intracytoplasmic sperm injection with immature spermatozoa improves fertilization and pregnancy rates.
      ). Injected oocytes were transferred to a fertilization medium (P-1 Irvine Scientific; G-IVF, Vitrolife) supplemented with 10% human serum albumin. After pronuclear evaluation on the next day after ICSI, zygotes bearing both two pronuclei and a second polar body were transferred to the fresh cleavage medium (Early Cleavage Medium with gentamicin, Irvine Scientific; G1, Vitrolife), supplemented by 10% human serum albumin for culture until day 3.
      On day 3, embryos were evaluated according to the Istanbul Consensus Workshop of the Alpha Scientists (
      • Alpha Scientists in Reproductive Medicine and ESHRE Special Interest Group of Embryology
      The Istanbul consensus workshop on embryo assessment: proceedings of an expert meeting.
      ). A day 3 embryo with <10% fragmentation, without multinucleation, and a stage-specific cell size was rated as good and scored as a grade 1 embryo. The number of blastomeres and the percentage of fragmentation were also counted and recorded.
      All day 3 embryos were vitrified one by one, using cryotop (Kitazato Biopharma) and cryotip (Irvine Scientific) in the first IVF procedure and the cryoloop device (Vitroloop, Vitrolife) in the second IVF procedure (
      • Alpha Scientists in Reproductive Medicine
      The alpha consensus meeting on cryopreservation key performance indicators and benchmarks: proceedings of an expert meeting.
      ,
      • Kuwayama M.
      Highly efficient vitrification method for cryopreservation of human oocytes.
      ,
      • Bonetti A.
      • Cervi M.
      • Tomei F.
      • Marchini M.
      • Ortolani F.
      • Manno M.
      Ultrastructural evaluation of metaphase II oocytes after vitrification: closed versus open devices.
      ,
      • Desai N.
      • Blackmon H.
      • Szeptycki J.
      • Goldfarb J.
      Cryoloop vitrification of human day 3 cleavage-stage embryos: post-vitrification development, pregnancy outcomes and live births.
      ).

       Uterus Transplantation

      Uterus allotransplantation has been performed from a 22-year-old deceased donor after pretests of HLA matching and screening for TORCH (
      • Ozkan O.
      • Erman-Akar M.
      • Ozkan O.
      • Erdogan O.
      • Hadimioglu N.
      • Yilmaz M.
      • et al.
      Preliminary results of the first human uterus transplantation from multiorgan donor.
      ). Vascular anastomoses were performed between the recipient's external iliac vessels and the donor's internal iliac vessels.

       Immunosuppression Protocol and Infection Prophylaxis

      Induction immunosuppression with a 2.0 mg/dL daily dose of antithymocyte globulin and 1,000 mg of prednisolone was started initially. Maintanence immunosuppression was with 0.2 mg/kg tacrolimus, mycophenolate mofetil (MMF; 2 g/day), and 20 mg prednisolone for the first 12 months. After studying the data on the teratogenic effects of MMF, we discontinued it and replaced it with azathioprine starting from postoperative month 12 (
      • EBPG Expert Group on Renal Transplantation
      European best practice guidelines for renal transplantation. Section IV. Long-term management of the transplant recipient. Pregnancy in renal transplant recipients.
      ).
      Immunosuppressant doses with respect to future pregnancy were prednisone <15 mg/day, azathioprine <2 mg/kg, and tacrolimus at therapeutic levels (5–15 ng/mL) monitored biweekly (
      • EBPG Expert Group on Renal Transplantation
      European best practice guidelines for renal transplantation. Section IV. Long-term management of the transplant recipient. Pregnancy in renal transplant recipients.
      ). The dose for prednisone and azathioprine was adjusted based on clinical or laboratory findings of infection, rejection, or leukopenia (
      • Habas E.
      • Khammaj A.
      • Rayani A.
      Hematologic side effects of azathioprine and mycophenolate in kidney transplantation.
      ). Complete blood cell count, liver, and kidney function tests were also performed weekly to monitor the safety of treatment. Fluconazole, piperacillin/tazobactam, cotrimoxazole, oral nystatin drops, and oral valacyclovir tablets were administered for prophylaxis. SC heparin was performed for antithrombotic prophylaxis (MTHFR C677T homozygote mutant and protein S, 28.3%).

       Follow-up Examinations

      During follow-up, bilateral uterine artery Doppler ultrasound was performed twice a day for the first 10 days, every day for the next 20 days, and then biweekly. Vaginal biopsies were taken every 2 weeks in the first 3 months. Cervical biopsies were taken every month, and endometrial biopsies were performed every 3 months to monitor findings of thromboses or rejection. Uterine blood flow was assessed using color Doppler ultrasound (Voluson E8, General Electric) with a 9.0 MHz transvaginal transducer (RIC5-9-D endocavity probe, General Electric). Three-dimensional ultrasound demonstrated normal uterine cavity (Fig. 1). We performed color Doppler ultrasound of the uterine arteries at the cervicocorporeal level lateral to the cervix as suggested by Kupesic-Plavsik et al. (
      • Kupesic-Plavsik S.
      • Kurjak A.
      • Baston K.
      Normal pelvic anatomy assessed by 2D, 3D and color doppler ultrasound. In color Doppler 3D and 4D ultrasound in gynecology, infertility and obstetrics.
      ). We defined the cutoff point for the Doppler resistance index as 0.80 on the basis of the present data for renal transplantation evaluation (
      • Adibi A.
      • Ramezani M.
      • Mortazavi M.
      • Taheri S.
      Color Doppler indexes in early phase after kidney transplantation and their association with kidney function on six month follow up.
      ). Speculum examination of the cervix was performed once a week.
      Figure thumbnail gr1
      Figure 1Three-dimensional ultrasound appearance of the transplanted uterus.

       Endometrial Preparation

      Eighteen months after uterus allotransplantation and confirmation of the graft stability, the endometrium was prepared with a standard artificial E2 replacement protocol and down-regulation of gonadotropins with leuprolide acetate and treatment with E2 hemihydrate 6 mg (Novo Nordisk Limited) in the first ET cycle. In the second ET, endometrium was prepared with E2 replacement (Novo Nordisk Limited) without gonadotropin down-regulation. Hormone stimulation was begun starting from menstruation day 2 for 15 days in the first and for 11 days in the second ET cycle, at which time the endometrium had reached 9 mm in endometrial thickness and was trilaminar in shape and progesterone (Progynex 50 mg, Farmako Eczacilik) stimulation was started. Hormone stimulation was maintained with E2 hemihydrate 6 mg and P 50 mg. LMW heparin (Clexane, enoxaparine 4,000 IU/day, Aventis Pharma Sanayi ve Ticaret), pentoxiphiline (trentilin retard 800 mg/day, Berksam ilac), and vitamin E (Evicap Fort, 800 IU/day, Kocak Eczacilik) were administered to increase endometrial perfusion.

       Embryo Thawing and Transfer

      For warming of the vitrified embryos, the cryo device tip was quickly plunged into a cryoprotectant solution including sucrose, and after several steps of washing in decreasing concentrations of sucrose, embryos were equilibrated in an equilibration solution for 5 minutes on the heated stage at 37°C (
      • Alpha Scientists in Reproductive Medicine
      The alpha consensus meeting on cryopreservation key performance indicators and benchmarks: proceedings of an expert meeting.
      ,
      • Kuwayama M.
      Highly efficient vitrification method for cryopreservation of human oocytes.
      ,
      • Bonetti A.
      • Cervi M.
      • Tomei F.
      • Marchini M.
      • Ortolani F.
      • Manno M.
      Ultrastructural evaluation of metaphase II oocytes after vitrification: closed versus open devices.
      ,
      • Desai N.
      • Blackmon H.
      • Szeptycki J.
      • Goldfarb J.
      Cryoloop vitrification of human day 3 cleavage-stage embryos: post-vitrification development, pregnancy outcomes and live births.
      ). Finally, warmed embryos were transferred into the ET medium supplemented by 10% human serum albumin checked for viability, and an unselective quarter laser assisted hatching was performed before ET as described (
      • Mantoudis E.
      • Podsiadly B.T.
      • Gorgy A.
      • Venkat G.
      • Craft L.L.
      A comparison between quarter, partial and total laser assisted hatching in selected infertility patients.
      ). When the rate of cell loss was found to be 50% in the first thawed vial, the second vial was thawed.
      The patient was placed in the lithotomy position, and the cervix was exposed using a bivalve speculum. The exocervix was flushed with 1–2 mL of IVF flushing media connected to a syringe. Trial ET was performed in both ET cycles. The place of the tip of the catheter was measured by transabdominal ultrasound with full bladder approximately 15 mm from the fundal surface of the endometrium to the external cervical os (
      • Sallam H.
      • Sadek S.
      Ultrasound-guided embryo transfer: a metaanalysis of randomized controlled trials.
      ,
      • Derks R.S.
      • Farquhar C.
      • Mol B.W.
      • Buckingham K.
      • Heineman M.J.
      Techniques for preparation prior to embryo transfer.
      ). The catheter was first loaded with transfer medium, and then the embryos were loaded in the catheter. One day 3 thawed embryo was transferred under real time ultrasound guidance, 3 days after the initial P application in both ET cycles.
      A SureView catheter (the Wallace Sure View Embryo Replacement Catheter) was used in the first ET cycle, and a Cook Soft-Trans Embryo Transfer Catheter (Cook Ob/Gyn) was used in the second ET cycle.
      We thawed five embryos. We have three embryos left.

      Results

      Starting from the first month after transplantation, the patient had menstrual bleeding with almost every cycle. The patient had her first menstruation 20 days after the procedure. Since the transplant procedure she has had 18 menstrual cycles. Basal hormone levels revealed no accompanying problems. The time interval between the transplantation procedure and the pregnancy trial was chosen based on the present data (
      • Cruz Lemini M.C.
      • Ibargüengoitia Ochoa I.
      • Villanueva Gonzalez M.A.
      Perinatal outcome following renal transplantation.
      ,
      • Kuvacic I.
      • Sprem M.
      • Skrablin S.
      • Kalafatić D.
      • Bubić-Filipi L.
      • Milici D.
      • et al.
      Pregnancy outcome in renal transplant recipients.
      ,
      • McKay D.B.
      • Josephson M.A.
      • Armenti V.T.
      • August P.
      • Coscia L.A.
      • Davis C.L.
      Reproduction and transplantation: report on the AST consensus conference on reproductive issues and transplantation.
      ,
      • Pezeshki M.
      • Taherian A.A.
      • Gharavy M.
      • Ledger W.L.
      Menstrual characteristics and pregnancy in women after renal transplantation.
      ,
      • Armanti V.T.
      • Constantinescu S.
      • Moritz M.J.
      • Davison J.M.
      Pregnancy after transplantation.
      ). At least a 12-month interval is suggested by the transplant teams, after stable graft function was ensured. Menstruations generally lasted 3 days, and no dysmenorrhea was observed.The patient has been sexually active starting from postoperative 3 months. The patient had three urinary tract infections controlled with amoxicillin clavulonate and sulfamethoxazole and trimethoprim at postoperative 4, 6, and 12 months. During the follow-up, it was observed that endometrial thickness reached 12 mm and that the endometrium was trilaminar in shape.
      The immunosuppressive therapy during ETs was prednisolone 10 mg/day, azathiopurine 50 mg/day, and tacrolimus 3 mg/day as intended (tacrolimus level, 6.29 ng/mL) (
      • EBPG Expert Group on Renal Transplantation
      European best practice guidelines for renal transplantation. Section IV. Long-term management of the transplant recipient. Pregnancy in renal transplant recipients.
      ). Eleven days after the first ET, serum hCG levels were consistent with a confirmed biochemical pregnancy (hCG, 35.7 IU/L). However, a drop in hCG levels was observed 4 days after the first hCG measurement.
      Doubling of hCG levels over time and transvaginal ultrasound confirmed an intrauterine pregnancy of five gestational weeks after the second ET (Fig. 2). However, the gestational sac failed to develop on follow-up 7 days after the initial examination, and she had vaginal bleeding in the following days. The pregnancy was considered nonviable despite adequate luteal phase support confirmed with high serum P levels (60 ng/mL).
      Figure thumbnail gr2
      Figure 2Ultrasound appearance of the intrauterine gestational sac and the embryo.
      Unviable pregnancy was terminated by aspiration and curettage (inhibin A, 31.24pg/mL). Histopathological examination showed endometrial decidua and chorion villus with no signs of infection (Fig. 3). Nucleated erythrocytes were not observed in the miscarriage specimen (
      • Jauniaux E.
      • Burton G.
      Pathophysiology of histological changes in early pregnancy loss.
      ,
      • Hempstock J.
      • Jauniaux E.
      • Greenwold N.
      • Burton G.
      The contribution of placental oxidative stress to early pregnancy failure.
      ). Cytogenetic analysis of the abortus material confirmed normal karyotype (46,XX).
      Figure thumbnail gr3
      Figure 3Pathologic aspect of the miscarriage specimen showing chorion villi.

      Discussion

      Patients with UFI either congenital or acquired have no fertility options other than gestational surrogacy, which is approved in only a few countries (
      • Chambers G.M.
      • Sullivan E.A.
      • Ishihara O.
      • Chapman M.G.
      • Adamson G.D.
      The economic impact of assisted reproductive technology: a review of selected developed countries.
      ,
      International Federation of Fertility Societies International Conference.
      ,
      • Brinsden P.R.
      Gestational surrogacy.
      ). Pregnancy and delivery have already been reported after allograft in animals such as rat and sheep (
      • Wranning C.A.
      • Akhi S.N.
      • Diaz- Garcia C.
      • Brannstrom M.
      Pregnancy after syngenic uterus transplantation and spontaneous mating in the rat.
      ,
      • Diaz-Garcia C.
      • Akhi S.N.
      • Wallin A.
      • Pellicer A.
      • Brannstrom M.
      First report on fertility after allogenic uterus transplantation.
      ). Natural pregnancy could not be achieved in other allograft experimental models such as baboons, possibly owing to severe adhesion and tubal obstruction after surgery and the limitation of maintaining ideal immunosuppressive levels in animal models (
      • Wranning C.A.
      • El-Akouri R.R.
      • Lundmark C.
      • Dahm-Kahler P.
      • Molne J.
      • Enskog A.
      • et al.
      Auto-transplantation of the uterus in the domestic pig: surgical technique and early reperfusion events.
      ).
      Gestational surrogacy studies have confirmed that there has been no genetic trait transmission to offsprings in Mayer-Rokitansky-Kuster-Hauser patients. No optimal ovulation induction protocol has been defined for ovulation induction in complete Müllerian agenesis patients (
      • Wood E.G.
      • Batzer F.R.
      • Corson S.L.
      Ovarian response to gonadotrophins, optimal method for oocyte retrieval and pregnancy outcome in patients with vaginal agenesis.
      ,
      • Bosch E.
      • Ezcurra D.
      Individualised controlled ovarian stimulation (iCOS): maximizing success rates for assisted reproductive technology patients.
      ).
      Certain technical difficulties during oocyte pick-up have been reported owing to short, inelastic neovagina, pelvic kidney, and high lateral placement of ovaries in patients with complete Müllerian agenesis (
      • Damario M.A.
      Transabdominal-transperitoneal ultrasound-guided oocyte retrieval in a patient with Müllerian agenesis.
      ,
      • Petrozza J.C.
      • Gray M.R.
      • Davis A.J.
      • Reindollar R.H.
      Congenital absence of the uterus and vagina is not commonly transmitted as a dominant genetic trait: outcomes of surrogate pregnancies.
      ). Thrombophilia screening was also evaluated in our patient. Thrombophilia screening is important in the evaluation of the potential thrombophilia-related risks of the transplant candidate and to identify potential patients with implantation failures (
      • Jauniaux E.
      • Farquharion R.
      • Christiansen O.
      • Exalto N.
      Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage.
      ,
      • Rey E.
      • Kahn S.R.
      • David M.
      • Shrier I.
      Thrombophilic disorders and fetal loss: a meta-analysis.
      ). To date, approximately 14,000 pregnancies after solid organ transplantation have been documented (
      • EBPG Expert Group on Renal Transplantation
      European best practice guidelines for renal transplantation. Section IV. Long-term management of the transplant recipient. Pregnancy in renal transplant recipients.
      ,
      • Kuvacic I.
      • Sprem M.
      • Skrablin S.
      • Kalafatić D.
      • Bubić-Filipi L.
      • Milici D.
      • et al.
      Pregnancy outcome in renal transplant recipients.
      ,
      • McKay D.B.
      • Josephson M.A.
      • Armenti V.T.
      • August P.
      • Coscia L.A.
      • Davis C.L.
      Reproduction and transplantation: report on the AST consensus conference on reproductive issues and transplantation.
      ,
      • Pezeshki M.
      • Taherian A.A.
      • Gharavy M.
      • Ledger W.L.
      Menstrual characteristics and pregnancy in women after renal transplantation.
      ,
      • Armanti V.T.
      • Constantinescu S.
      • Moritz M.J.
      • Davison J.M.
      Pregnancy after transplantation.
      ). The need for the use of immunosuppressive agents and their teratogenic potential is still a major problem in transplant patients. Considering the transplantation community's opinions, we discontinued MMF and switched to azathioprine starting from postoperative month 12 (
      • Kim M.
      • Rostas S.
      • Gabardi S.
      Mycophenolate fetal toxicity and risk evaluation and mitigation strategies.
      ). We have used a triple regimen of tacrolimus, azathioprine, and corticosteroids for maintenance therapy before and during pregnancy. The American Society of Transplantation has noted that pregnancy timing should be individualized based on graft stability, risk of acute rejection, and risk of infection. Although some researchers reported that pregnancies sooner than 2 years after transplantation had higher abortion and preterm rates, the difference was not confirmed statistically (
      • Kuvacic I.
      • Sprem M.
      • Skrablin S.
      • Kalafatić D.
      • Bubić-Filipi L.
      • Milici D.
      • et al.
      Pregnancy outcome in renal transplant recipients.
      ,
      • McKay D.B.
      • Josephson M.A.
      • Armenti V.T.
      • August P.
      • Coscia L.A.
      • Davis C.L.
      Reproduction and transplantation: report on the AST consensus conference on reproductive issues and transplantation.
      ,
      • Pezeshki M.
      • Taherian A.A.
      • Gharavy M.
      • Ledger W.L.
      Menstrual characteristics and pregnancy in women after renal transplantation.
      ,
      • Armanti V.T.
      • Constantinescu S.
      • Moritz M.J.
      • Davison J.M.
      Pregnancy after transplantation.
      ).
      The ideal endometrial preparation method for vitrified thawed ET cycles is unclear (
      • Glujovsky D.
      • Pesce R.
      • Fiszbajn G.
      • Sueldo C.
      • Hart R.J.
      • Ciapponi A.
      Endometrial preparation for women undergoing embryo transfer with frozen embryos or embryos derived from donor oocytes.
      ,
      • Dal Prato L.
      • Borini A.
      • Cattoli M.
      • Bonu M.A.
      • Sciajno R.
      • Flamigni C.
      Endometrial preparation for frozen-thawed embryo transfer with or without pretreatment with gonadotropin-releasing hormone agonist.
      ,
      • Wright K.P.
      • Guibert J.
      • Weitzen S.
      • Davy S.
      • Fauque P.
      • Olivennes F.
      Artificial versus stimulated cycles for endometrial preparation prior to frozen-thawed embryo transfer.
      ). We have prepared the endometrium with and without GnRH agonist in the first and second ET cycles.
      The cytogenetic result was 46,XX, which may also be contamination from maternal tissue. Hysteroembryoscopy is an optimal tool to obtain embryonic tissue without contamination. However due to potential morbidity in a transplanted uterus, it was not justified. Comparative genomic hybridization of the hysteroembryoscopic biopsy material could give more insight into the genetic causes of early and recurrent spontaneous abortion (
      • Robberecht C.
      • Pexsters A.
      • Deprest J.
      • Fryns J.P.
      • D'Hooghe T.
      • Vermeesch J.R.
      Cytogenetic and morphologic analysis of early products of conception following hysteroembryoscopy from couples with recurrent pregnancy loss.
      ). Nucleated erythrocytes which would probably be an important evidence of fetal tissue were not observed in the pathological evaluation of the specimen (
      • Jauniaux E.
      • Burton G.
      Pathophysiology of histological changes in early pregnancy loss.
      ,
      • Hempstock J.
      • Jauniaux E.
      • Greenwold N.
      • Burton G.
      The contribution of placental oxidative stress to early pregnancy failure.
      ).
      Expectant management was not an appropriate choice because of infection risk and detectable inhibin A levels. Undetectable serum inhibin A levels might be correlated with successful expectant management in miscarriages, with low sensitivity (
      • Elson J.
      • Tailor A.
      • Salim R.
      • Hillaby K.
      • Dew T.
      • Jurkovic D.
      Expectant management of miscarriage prediction of outcome using ultrasound and novel biochemical markers.
      ). Inhibin A might reflect persistent functioning trophoblasts.
      Analyzing the etiology in this miscarriage is quite important to limit the immunosuppression-related risks in this important case. We have already investigated the evidence-based guidelines for recurrent miscarriages (RM) including endocrinologic, anatomic, coagulation, and cytogenetic factors (
      • Jauniaux E.
      • Farquharion R.
      • Christiansen O.
      • Exalto N.
      Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage.
      ). Researchers have also shown that RM patients who have a higher number of uterine natural killer cells could be treated with prednisolone (
      • Quenby S.
      • Kalumbi C.
      • Bates M.
      • Farquharson R.
      • Vince G.
      Prednisolone reduces preconceptual endometrial natural killer cells in women with recurrent miscarriage.
      ,
      • Quenby S.
      • Farquharson R.
      • Young M.
      • Vince G.
      Successful pregnancy outcome following 19 consecutive pregnancies.
      ,
      • Ogasawara M.
      • Aoki K.
      Successful uterine steroid therapy in a case with a history of ten miscarriages.
      ). Further research and data are needed to have a consensus regarding the use of IV immunoglobulin, anti-tumor necrosis factor, sildenafil, glucocorticoids, or cellular therapies in women with RM (
      • Carp H.J.
      • Sapir T.
      • Shoenfeld Y.
      Intravenous immunoglobulin and recurrent pregnancy loss.
      ,
      • Christiansen O.B.
      • Nielsen H.S.
      • Pedersen B.
      Active or passive immunization in unexplained recurrent miscarriage.
      ,
      • Jerzak M.
      • Kniotek M.
      • Mrozek J.
      • Gorski A.
      • Baranowski W.
      Sildenafil citrate decreased natural killer cell activity and enhanced chance of successful pregnancy in women with a history of recurrent miscarriage.
      ).
      We have presented the first clinical pregnancy after uterus allotransplantation in a patient with absolute uterine infertility. Although the real success is the delivery of a healthy, near-term baby, this clinical pregnancy is a great step forward and proof of concept that the implantation phase was successful.

      References

        • Milliez J.
        Uterine transplantation FIGO Committee for the ethical aspects of human reproduction and women's health.
        Int J Gynaecol Obstet. 2009; 106: 270
        • Beski S.
        • Gorgy A.
        • Venkat G.
        • Craft I.L.
        • Edmonds K.
        Gestational surrogacy: a feasible option for patients with Rokitansky syndrome.
        Hum Reprod. 2000; 15: 2326-2328
        • Saravelos Saravelos S.H.
        • Cocksedge K.A.
        • Li T.C.
        Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: a critical appraisal.
        Hum Reprod Update. 2008; 14: 415-429
        • Kwee A.
        • Bots M.L.
        • Visser G.H.
        • Bruinse H.W.
        Emergency peripartum hysterectomy: a prospective study in The Netherlands.
        Eur J Obstet Gynecol Reprod Biol. 2006; 124: 187-192
        • Erman Akar M.
        • Saygili Yilmaz E.
        • Yuksel B.
        • Yilmaz Z.
        Emergency peripartum hysterectomy.
        Eur J Obstet Gynecol Reprod Biol. 2004; 113: 178-181
        • Farquhar C.M.
        • Steiner C.A.
        Hysterectomy rates in the United States 1990–1997.
        Obstet Gynecol. 2002; 99: 229-234
        • Quinn M.A.
        • Benedet J.L.
        • Odicino F.
        • Maisonneuve P.
        • Beller U.
        • Creasman W.T.
        • et al.
        Carcinoma of the cervix uteri. FIGO 26th annual report on the results of treatment in gynecological cancer.
        Int J Gynaecol Obstet. 2006; 95: S43-103
        • Del Priore G.
        • Saso S.
        • Meslin E.M.
        • Tzakis A.
        • Brännström M.
        • Clarke A.
        • et al.
        Uterine transplantation—a real possibility? The Indianapolis consensus.
        Hum Reprod. 2013; 28: 288-291
        • Eraslan S.
        • Hamernik R.J.
        • Hardy J.D.
        Replantation of uterus and ovaries in dogs, with successful pregnancy.
        Arch Surg. 1966; 92: 9-12
        • Racho El-Akouri R.
        • Kurlberg G.
        • Brannstrom M.
        Successful uterine transplantation in the mouse: pregnancy and postnatal development of offspring.
        Hum Reprod. 2003; 18: 2024-2030
        • Wranning C.A.
        • Akhi S.N.
        • Kurlberg G.
        • Brannstrom M.
        Uterus transplantation in the rat: model development, surgical learning and morphological evaluation of healing.
        Acta Obstet Gynecol Scand. 2008; 87: 1239-1247
        • Wranning C.A.
        • El-Akouri R.R.
        • Lundmark C.
        • Dahm-Kahler P.
        • Molne J.
        • Enskog A.
        • et al.
        Auto-transplantation of the uterus in the domestic pig: surgical technique and early reperfusion events.
        J Obstet Gynaecol Res. 2006; 32: 358-367
        • Enskog A.
        • Johannesson L.
        • Chai D.C.
        • Dahm-Kahler P.
        • Marcickiewicz J.
        • Nyachieo A.
        • et al.
        Uterus transplantation in the baboon: methodology and long term function after auto transplantation.
        Hum Reprod. 2010; 25: 1980-1987
        • Wranning C.A.
        • Akhi S.N.
        • Diaz- Garcia C.
        • Brannstrom M.
        Pregnancy after syngenic uterus transplantation and spontaneous mating in the rat.
        Hum Reprod. 2011; 26: 553-558
        • Diaz-Garcia C.
        • Akhi S.N.
        • Wallin A.
        • Pellicer A.
        • Brannstrom M.
        First report on fertility after allogenic uterus transplantation.
        Acta Obstet Gynecol Scand. 2010; 89: 1491-1494
        • Ramirez E.R.
        • Ramirez Nessetti D.K.
        • Nessetti M.B.
        • Khatamee M.
        • Wolfson M.R.
        • Shaffer T.H.
        • et al.
        Pregnancy and outcome of uterine allotransplantation and assisted reproduction in sheep.
        J Minim Invasive Gynecol. 2011; 18: 238-245
        • Mihara M.
        • Kisu I.
        • Hara H.
        • Lida T.
        • Araki J.
        • Shim T.
        • et al.
        Uterine allotransplantation in cynomolgus macaques the first case of pregnancy and delivery.
        Hum Reprod. 2012; 27: 2332-2340
        • Gottardo F.
        • Kliesch S.
        World Health Organization. Semen analysis: spermiogram according to WHO 2010 criteria.
        Urologe A. 2011; 50: 101-108
        • Albuquerque L.E.
        • Tso L.O.
        • Saconato H.
        • Albuquerque M.C.
        • Macedo C.R.
        Depot versus daily administration of gonadotrophin releasing hormone agonist protocols for pituitary down regulation in assisted reproduction cycles.
        Cochrane Database Syst Rev. 2013; : CD002808
        • Al-Inany H.G.
        • Youssef M.A.
        • Aboulghar M.
        • Broekmans F.
        • Sterrenburg M.
        • Smit J.
        • et al.
        Gonadotrophin-releasing hormone antagonists for assisted reproductive technology.
        Cochrane Database Syst Rev. 2011; : CD001750
        • Palermo G.D.
        • Neri Q.V.
        • Monahan D.
        • Kocent J.
        • Rosenwaks Z.
        Development and current applications of assisted fertilization.
        Fertil Steril. 2012; 97: 248-259
        • Palermo G.D.
        • Schlegel P.N.
        • Colombero L.T.
        • Zaninovic N.
        • Moy F.
        • Rosenwaks Z.
        Aggressive sperm immobilization prior to intracytoplasmic sperm injection with immature spermatozoa improves fertilization and pregnancy rates.
        Hum Reprod. 1996; 11: 1023-1029
        • Alpha Scientists in Reproductive Medicine and ESHRE Special Interest Group of Embryology
        The Istanbul consensus workshop on embryo assessment: proceedings of an expert meeting.
        Hum Reprod. 2011; 26: 1270-1283
        • Alpha Scientists in Reproductive Medicine
        The alpha consensus meeting on cryopreservation key performance indicators and benchmarks: proceedings of an expert meeting.
        Reprod Biomed Online. 2012; 25: 146-167
        • Kuwayama M.
        Highly efficient vitrification method for cryopreservation of human oocytes.
        Reprod Biomed Online. 2005; 11: 300-308
        • Bonetti A.
        • Cervi M.
        • Tomei F.
        • Marchini M.
        • Ortolani F.
        • Manno M.
        Ultrastructural evaluation of metaphase II oocytes after vitrification: closed versus open devices.
        Fertil Steril. 2011; 95: 928-935
        • Desai N.
        • Blackmon H.
        • Szeptycki J.
        • Goldfarb J.
        Cryoloop vitrification of human day 3 cleavage-stage embryos: post-vitrification development, pregnancy outcomes and live births.
        Reprod Biomed Online. 2007; 14: 208-213
        • Ozkan O.
        • Erman-Akar M.
        • Ozkan O.
        • Erdogan O.
        • Hadimioglu N.
        • Yilmaz M.
        • et al.
        Preliminary results of the first human uterus transplantation from multiorgan donor.
        Fertil Steril. 2013; 99: 470-476
        • EBPG Expert Group on Renal Transplantation
        European best practice guidelines for renal transplantation. Section IV. Long-term management of the transplant recipient. Pregnancy in renal transplant recipients.
        Nephrol Dial Transplant. 2002; 17: 50-55
        • Habas E.
        • Khammaj A.
        • Rayani A.
        Hematologic side effects of azathioprine and mycophenolate in kidney transplantation.
        Transplant Proc. 2011; 43: 504-506
        • Kupesic-Plavsik S.
        • Kurjak A.
        • Baston K.
        Normal pelvic anatomy assessed by 2D, 3D and color doppler ultrasound. In color Doppler 3D and 4D ultrasound in gynecology, infertility and obstetrics.
        Jaypee Brothers, New Delhi2011 (12–21)
        • Adibi A.
        • Ramezani M.
        • Mortazavi M.
        • Taheri S.
        Color Doppler indexes in early phase after kidney transplantation and their association with kidney function on six month follow up.
        Adv Biomed Res. 2012; 1: 62
        • Mantoudis E.
        • Podsiadly B.T.
        • Gorgy A.
        • Venkat G.
        • Craft L.L.
        A comparison between quarter, partial and total laser assisted hatching in selected infertility patients.
        Hum Reprod. 2001; 16: 2182-2186
        • Sallam H.
        • Sadek S.
        Ultrasound-guided embryo transfer: a metaanalysis of randomized controlled trials.
        Fertil Steril. 2003; 80: 1042-1046
        • Derks R.S.
        • Farquhar C.
        • Mol B.W.
        • Buckingham K.
        • Heineman M.J.
        Techniques for preparation prior to embryo transfer.
        Cochrane Database Syst Rev. 2009; : CD007682
        • Cruz Lemini M.C.
        • Ibargüengoitia Ochoa I.
        • Villanueva Gonzalez M.A.
        Perinatal outcome following renal transplantation.
        Int J Gynaecol Obstet. 2007; 96: 76-79
        • Kuvacic I.
        • Sprem M.
        • Skrablin S.
        • Kalafatić D.
        • Bubić-Filipi L.
        • Milici D.
        • et al.
        Pregnancy outcome in renal transplant recipients.
        Int J Gynaecol Obstet. 2000; 70: 313-317
        • McKay D.B.
        • Josephson M.A.
        • Armenti V.T.
        • August P.
        • Coscia L.A.
        • Davis C.L.
        Reproduction and transplantation: report on the AST consensus conference on reproductive issues and transplantation.
        Am J Transplant. 2005; 5: 1592-1599
        • Pezeshki M.
        • Taherian A.A.
        • Gharavy M.
        • Ledger W.L.
        Menstrual characteristics and pregnancy in women after renal transplantation.
        Int J Gynaecol Obstet. 2004; 85: 119-125
        • Armanti V.T.
        • Constantinescu S.
        • Moritz M.J.
        • Davison J.M.
        Pregnancy after transplantation.
        Transplant Rev (Orlando). 2008; 22: 223-240
        • Jauniaux E.
        • Burton G.
        Pathophysiology of histological changes in early pregnancy loss.
        Placenta. 2005; 26: 114-123
        • Hempstock J.
        • Jauniaux E.
        • Greenwold N.
        • Burton G.
        The contribution of placental oxidative stress to early pregnancy failure.
        Hum Pathol. 2003; 34: 1265-1275
        • Chambers G.M.
        • Sullivan E.A.
        • Ishihara O.
        • Chapman M.G.
        • Adamson G.D.
        The economic impact of assisted reproductive technology: a review of selected developed countries.
        Fertil Steril. 2009; 91: 2281-2294
      1. International Federation of Fertility Societies International Conference.
        IFFS Surveillance Fertil Steril. 2004; 71: 1S-54S
        • Brinsden P.R.
        Gestational surrogacy.
        Hum Reprod Update. 2003; 9: 483-491
        • Wood E.G.
        • Batzer F.R.
        • Corson S.L.
        Ovarian response to gonadotrophins, optimal method for oocyte retrieval and pregnancy outcome in patients with vaginal agenesis.
        Hum Reprod. 1999; 14: 1178-1181
        • Bosch E.
        • Ezcurra D.
        Individualised controlled ovarian stimulation (iCOS): maximizing success rates for assisted reproductive technology patients.
        Reprod Biol Endocrinol. 2011; 9: 82
        • Damario M.A.
        Transabdominal-transperitoneal ultrasound-guided oocyte retrieval in a patient with Müllerian agenesis.
        Fertil Steril. 2002; 78: 189-191
        • Petrozza J.C.
        • Gray M.R.
        • Davis A.J.
        • Reindollar R.H.
        Congenital absence of the uterus and vagina is not commonly transmitted as a dominant genetic trait: outcomes of surrogate pregnancies.
        Fertil Steril. 1997; 2: 387-389
        • Jauniaux E.
        • Farquharion R.
        • Christiansen O.
        • Exalto N.
        Evidence-based guidelines for the investigation and medical treatment of recurrent miscarriage.
        Hum Reprod. 2006; 21: 2216-2222
        • Rey E.
        • Kahn S.R.
        • David M.
        • Shrier I.
        Thrombophilic disorders and fetal loss: a meta-analysis.
        Lancet. 2003; 361: 901-908
        • Kim M.
        • Rostas S.
        • Gabardi S.
        Mycophenolate fetal toxicity and risk evaluation and mitigation strategies.
        Am J Transplant. 2013; 13: 1383-1389
        • Glujovsky D.
        • Pesce R.
        • Fiszbajn G.
        • Sueldo C.
        • Hart R.J.
        • Ciapponi A.
        Endometrial preparation for women undergoing embryo transfer with frozen embryos or embryos derived from donor oocytes.
        Cochrane Database Syst Rev. 2010; 20: CD006359
        • Dal Prato L.
        • Borini A.
        • Cattoli M.
        • Bonu M.A.
        • Sciajno R.
        • Flamigni C.
        Endometrial preparation for frozen-thawed embryo transfer with or without pretreatment with gonadotropin-releasing hormone agonist.
        Fertil Steril. 2002; 77: 956-960
        • Wright K.P.
        • Guibert J.
        • Weitzen S.
        • Davy S.
        • Fauque P.
        • Olivennes F.
        Artificial versus stimulated cycles for endometrial preparation prior to frozen-thawed embryo transfer.
        Reprod Biomed Online. 2006; 13: 321-325
        • Robberecht C.
        • Pexsters A.
        • Deprest J.
        • Fryns J.P.
        • D'Hooghe T.
        • Vermeesch J.R.
        Cytogenetic and morphologic analysis of early products of conception following hysteroembryoscopy from couples with recurrent pregnancy loss.
        Prenat Diagn. 2012; 32: 933-942
        • Elson J.
        • Tailor A.
        • Salim R.
        • Hillaby K.
        • Dew T.
        • Jurkovic D.
        Expectant management of miscarriage prediction of outcome using ultrasound and novel biochemical markers.
        Hum Reprod. 2005; 20: 2330-2333
        • Quenby S.
        • Kalumbi C.
        • Bates M.
        • Farquharson R.
        • Vince G.
        Prednisolone reduces preconceptual endometrial natural killer cells in women with recurrent miscarriage.
        Fertil Steril. 2005; 84: 980-984
        • Quenby S.
        • Farquharson R.
        • Young M.
        • Vince G.
        Successful pregnancy outcome following 19 consecutive pregnancies.
        Hum Reprod. 2003; 18: 2562-2564
        • Ogasawara M.
        • Aoki K.
        Successful uterine steroid therapy in a case with a history of ten miscarriages.
        Am J Reprod Immunol. 2000; 44: 253-255
        • Carp H.J.
        • Sapir T.
        • Shoenfeld Y.
        Intravenous immunoglobulin and recurrent pregnancy loss.
        Clin Rev Allergy Immunol. 2005; 29: 327-332
        • Christiansen O.B.
        • Nielsen H.S.
        • Pedersen B.
        Active or passive immunization in unexplained recurrent miscarriage.
        J Reprod Immunol. 2004; 62: 41-52
        • Jerzak M.
        • Kniotek M.
        • Mrozek J.
        • Gorski A.
        • Baranowski W.
        Sildenafil citrate decreased natural killer cell activity and enhanced chance of successful pregnancy in women with a history of recurrent miscarriage.
        Fertil Steril. 2008; 90: 1848-1853