In a single-center observational series of women with absolute uterine factor infertility, 31 live births occurred in 27 uterus transplant recipients following assisted reproduction, with maternal medical complications reported in 30% of women and obstetric complications in 45% of live-birth pregnancies.
The JAMA research letter described maternal, obstetric, and neonatal outcomes from the Baylor University Medical Center uterus transplant program. Uterus transplant offers a reproductive option for patients with uterine-factor infertility, including Mayer-Rokitansky-Küster-Hauser syndrome or prior hysterectomy.
Prior to transplant, recipients underwent in vitro fertilization, with single-embryo transfer scheduled at least 3 months following transplant. Maintenance immunosuppression consisted primarily of tacrolimus and azathioprine, and low-dose aspirin was continued throughout pregnancy. Rejection surveillance included scheduled cervical biopsies before and during pregnancy. Cesarean delivery was performed because of concern for dehiscence at the transplanted uterovaginal anastomosis during labor.
Between 2016 and March 2026, 44 women underwent uterus transplant. At 1 month following transplant, 37 had viable transplanted uteri. By April 2026, 33 women had undergone at least one embryo transfer, totaling 90 single-embryo transfers.
Clinical pregnancy — defined as rising human chorionic gonadotropin levels with ultrasonographic detection of a gestational sac — occurred in 31 women and resulted in 47 pregnancies overall. Of those pregnancies, 39 progressed to at least 14 weeks’ gestation and 34 reached 20 weeks.
The 31 live births occurred in 27 women; 23 women delivered one neonate, and four women delivered two neonates each. All live births were by cesarean delivery. Four pregnancies remained ongoing at the time of reporting, including one in the first trimester and three in the second or third trimester.
Pregnancy loss occurred in seven first-trimester pregnancies among six women and in four second-trimester pregnancies among three women. One recipient experienced two consecutive second-trimester miscarriages attributed to cervical insufficiency, subsequently underwent abdominal cerclage placement, and later delivered at full term. Another recipient experienced intrauterine fetal demise at 17 weeks following two prior live births.
Maternal medical complications occurred in eight of 27 women. Gestational diabetes and gestational hypertension each occurred in 11%, while preeclampsia without severe features and tacrolimus-associated mild kidney insufficiency each occurred in 3%. No graft loss, thromboembolic events, or severe infectious morbidity occurred during pregnancy or postpartum.
Among the 31 live-birth pregnancies, obstetric complications occurred in 14 cases. Reported complications included preterm premature rupture of membranes in 16%, spontaneous preterm labor in 13%, and cervical insufficiency requiring cerclage in 10%. Five patients experienced postpartum hemorrhage; two underwent planned cesarean hysterectomy, whereas three retained the transplanted uterus.
Median birth weight was 2,900 g, corresponding to approximately the 47th percentile. Gestational age at delivery ranged from 30 weeks 6 days to up to 38 weeks’ gestation. All newborns had 5-minute Apgar scores of at least 7.
Eleven of 31 newborns (37%) required admission to the neonatal intensive care unit, likely reflecting the frequency of preterm delivery within the cohort. Congenital anomalies were reported in four newborns (13%), including hypospadias, macrocephaly, anteriorly displaced urethra, and familial congenital ptosis. The researchers did not address whether the observed rate exceeded background population risk.
In the Discussion, the researchers noted that uterus transplant recipients differ from recipients of life-saving solid organ transplants because they are typically otherwise healthy and have more limited exposure to immunosuppression. The researchers suggested this distinction may contribute to the absence of fetal growth restriction and the generally favorable neonatal profiles observed in the cohort.
The investigators emphasized that generalizability remains limited because the findings reflect a single-center experience and because access to uterus transplant requires substantial time and resources. They also noted that the observational, iterative development of the program prevents comparisons with alternative techniques or approaches.
“These data support the feasibility of uterus transplant in specialized, multidisciplinary centers capable of integrating transplant surgery, reproductive medicine, and maternal-fetal care,” wrote Liza Johannesson, MD, of Baylor University Medical Center, and colleagues. The researchers added that ongoing reporting and data sharing will be important to refine risk estimates and optimize patient counseling as the field evolves.
Zachary S. Rubeo, MD, disclosed receiving personal fees from Natera outside the submitted work. No other disclosures were reported.
Source: JAMA
