Uterus transplantation: revision 1 to 2

Revision 1

Revision 2

categories: ["reproduction", "bodies"]

tags: ["transplantation", "reproduction", "infertility", "pregnancy", "immunosuppression", "ivf", "surgery"]

summary: "A temporary transplant of a donated uterus that lets a woman without a working one carry a pregnancy, then is removed so that immunosuppression can stop."

summary: "A temporary transplant of a donated uterus that lets a woman without a working one carry a pregnancy, then is removed so that immunosuppression can stop."

updated: "2026-07-27"

updated: "2026-10-29"

humanEvidence: "Dozens of live births have been reported since the first in Sweden in 2014, from both living and deceased donors; graft loss and preterm delivery are common."

humanEvidence: "Dozens of live births have been reported since the first in Sweden in 2014, from both living and deceased donors; graft loss and preterm delivery are common."

access: "Performed at a small number of specialist centres, largely under research protocols, rarely reimbursed, and only after the recipient has completed IVF."

access: "Performed at a small number of specialist centres, largely under research protocols, rarely reimbursed, and only after the recipient has completed IVF."

reversibility: "difficult"

own cannot carry a pregnancy, so that she can gestate and deliver a child. Almost alone among

transplants, it is intended from the outset to be temporary: the graft is removed after one or two

births so that lifelong immunosuppression is never required. Since the first live birth in Sweden in

2014, dozens of children have been born this way — a record no engineered substitute for the uterus,

2014, dozens of children have been born this way, a record that no engineered substitute for the

the [[artificial-womb]] included, can claim.

uterus, the [[artificial-womb]] included, can claim.

```keyfacts

[

## Who it is for

The indication is absolute uterine factor infertility: the uterus is absent, or present but incapable

The indication is absolute uterine factor infertility, in which the uterus is absent or is present

of sustaining a pregnancy. The largest congenital cause is Mayer–Rokitansky–Küster–Hauser

but incapable of sustaining a pregnancy. The largest congenital cause is

syndrome, a form of Müllerian agenesis in which the uterus and upper vagina fail to develop while the

Mayer-Rokitansky-Küster-Hauser syndrome, a form of Müllerian agenesis in which the uterus and upper

ovaries, hormones, and karyotype are typically normal; it occurs in something on the order of one in

vagina fail to develop while the ovaries, hormones and karyotype are typically normal. It occurs in

4,000 to 5,000 female births. The acquired causes are more varied: hysterectomy for postpartum

something on the order of one in 4,000 to 5,000 female births. The acquired causes are more varied:

haemorrhage, cervical cancer, or fibroids; severe intrauterine adhesions; radiation injury.

hysterectomy for postpartum haemorrhage, cervical cancer or fibroids; severe intrauterine adhesions;

and radiation injury.

The detail that makes the procedure attractive to candidates is that the ovaries usually work. A woman

The procedure appeals to candidates because their ovaries usually work. A woman with Müllerian

with Müllerian agenesis produces her own oocytes, so a child gestated in a transplanted uterus is

agenesis produces her own oocytes, so a child gestated in a transplanted uterus is genetically hers.

genetically hers. The alternatives — adoption and gestational surrogacy — either sever that link or

Of the alternatives, adoption severs that genetic link and gestational surrogacy places the

place the pregnancy in another woman's body, and surrogacy is prohibited or legally unenforceable in

pregnancy in another woman's body. Surrogacy is also prohibited or legally unenforceable in much of

much of Europe, including Sweden, where the first sustained programme was built.

Europe, including Sweden, where the first sustained programme was built.

## How it works

Conception cannot happen the ordinary way. The graft is anastomosed to blood vessels but not to the

recipient's fallopian tubes, so sperm and egg never meet inside her. Every candidate therefore

completes in vitro fertilisation, and most programmes bank frozen embryos before the transplant is

attempted; this is the same laboratory pipeline that supports [[embryo-selection]], used here simply

attempted. This is the same laboratory pipeline that supports [[embryo-selection]], used here simply

to produce embryos before there is a uterus to carry them.

The donor operation removes the uterus with long vascular pedicles, usually including segments of the

The donor operation removes the uterus with long vascular pedicles, usually including segments of

internal iliac vessels. Venous drainage is the technical crux: uterine veins are thin-walled,

the internal iliac vessels. Venous drainage is the hardest technical step. Uterine veins are

variable, and awkward to sew, and some teams take utero-ovarian veins instead. In the recipient, the

thin-walled, variable and awkward to sew, and some teams take utero-ovarian veins instead. In the

graft is joined to the external iliac vessels, suspended from the pelvic ligaments, and connected to

recipient, the graft is joined to the external iliac vessels, suspended from the pelvic ligaments,

a vaginal cuff. Menstruation returning within weeks to months is the first sign that the graft is

and connected to a vaginal cuff. The return of menstruation, within weeks to months, is the first

alive.

sign that the graft is alive.

Nothing reconnects the nerves. A transplanted uterus is denervated, which means the recipient does

Nothing reconnects the nerves. A transplanted uterus is denervated, so the recipient does not feel

not feel contractions and cannot labour normally; every reported delivery has been by caesarean

contractions and cannot labour normally, and every reported delivery has been by caesarean section.

section. Immunosuppression is typically tacrolimus-based and adjusted for pregnancy — mycophenolate

Immunosuppression is typically based on tacrolimus and adjusted for pregnancy; mycophenolate is

is teratogenic and is exchanged for an alternative before any embryo transfer. Rejection is monitored

teratogenic and is exchanged for an alternative before any embryo transfer. Rejection is monitored

by cervical biopsy rather than by symptoms, because episodes are common and frequently silent, and

by cervical biopsy rather than by symptoms, because episodes are common and frequently silent. Most

most are reversed with corticosteroids.

are reversed with corticosteroids.

Embryo transfer is generally deferred for several months to a year after transplantation. After one

or two live births, the graft is removed in a second major operation and the drugs stop.

> [!key] The transplant meant to end

> A solid-organ transplant is normally kept for as long as it lasts, and the recipient accepts

> immunosuppression, infection risk, and raised cancer risk for the rest of their life as the price of

> immunosuppression, infection risk and raised cancer risk for the rest of their life as the price

> staying alive. A uterus is not life-sustaining, so the calculation inverts: the graft is worth

> of staying alive. A uterus is not life-sustaining, so the calculation is reversed. The graft is

> keeping only while it is being used, and the standard of success includes taking it out. That is why

> worth keeping only while it is being used, and the standard of success includes taking it out. Its

> its reversibility differs from the implanted devices and edited cells covered elsewhere on this wiki

> reversibility therefore differs from that of the implanted devices and edited cells covered

> — undoing it requires surgery, but the undoing is part of the plan.

> elsewhere on this wiki: undoing it requires surgery, but the undoing is part of the plan.

## Development history

  { "year": "2000", "title": "First human attempt", "text": "A team in Saudi Arabia transplants a uterus from a living donor. The graft is removed after about three months when its blood supply thromboses." },

  { "year": "2000", "title": "First human attempt", "text": "A team in Saudi Arabia transplants a uterus from a living donor. The graft is removed after about three months when its blood supply thromboses." },

  { "year": "2011", "title": "First deceased-donor transplant", "text": "A team at Akdeniz University in Turkey transplants a uterus from a multi-organ donor. The first pregnancies are lost; a live birth from the same graft is reported only years afterwards." },

  { "year": "2011", "title": "First deceased-donor transplant", "text": "A team at Akdeniz University in Turkey transplants a uterus from a multi-organ donor. The first pregnancies are lost; a live birth from the same graft is reported only years afterwards." },

  { "year": "2012", "title": "The Montreal Criteria", "text": "Lefkowitz, Edwards and Balayla publish conditions for ethically permissible uterine transplantation, covering recipient, donor and institutional requirements." },

  { "year": "2012", "title": "The Montreal Criteria", "text": "Lefkowitz, Edwards and Balayla publish conditions for ethically permissible uterine transplantation, covering recipient, donor and institutional requirements." },

  { "year": "2012–2013", "title": "The Gothenburg trial", "text": "Mats Brännström's group at the University of Gothenburg performs nine living-donor transplants, most from mothers and other close relatives, after more than a decade of animal work." },

  { "year": "2012-2013", "title": "The Gothenburg trial", "text": "Mats Brännström's group at the University of Gothenburg performs nine living-donor transplants, most from mothers and other close relatives, after more than a decade of animal work." },

  { "year": "2014", "title": "First live birth", "text": "A boy is born in Sweden to a recipient with Müllerian agenesis, delivered preterm by caesarean after she develops pre-eclampsia." },

  { "year": "2014", "title": "First live birth", "text": "A boy is born in Sweden to a recipient with Müllerian agenesis, delivered preterm by caesarean after she develops pre-eclampsia." },

  { "year": "2017", "title": "United States and deceased-donor births", "text": "Baylor University Medical Center in Dallas reports the first birth in the United States; a team in São Paulo reports the first anywhere from a deceased donor." },

  { "year": "2017", "title": "United States and deceased-donor births", "text": "Baylor University Medical Center in Dallas reports the first birth in the United States; a team in São Paulo reports the first anywhere from a deceased donor." },

  { "year": "2016–2025", "title": "Diffusion", "text": "Programmes open in more than a dozen countries, robotic donor hysterectomy is introduced to shorten the donor operation, and the United Kingdom reports its first birth in 2025." }

  { "year": "2016-2025", "title": "Diffusion", "text": "Programmes open in more than a dozen countries, robotic donor hysterectomy is introduced to shorten the donor operation, and the United Kingdom reports its first birth in 2025." }

]

```

The first attempt, in Saudi Arabia in 2000, established that the graft could survive at all and that

vascular thrombosis was the thing most likely to kill it.[^fageeh2002] The Turkish case a decade later

vascular thrombosis was the thing most likely to kill it.[^fageeh2002] The Turkish case a decade

showed that a uterus from a deceased donor could be transplanted and could conceive.[^ozkan2013] The

later showed that a uterus from a deceased donor could be transplanted and could

first pregnancies there were lost, and a live birth from that graft came only years afterwards. What

conceive.[^ozkan2013] The first pregnancies there were lost, and a live birth from that graft came

separated the Swedish programme from both was preparation: more than a decade of work in rodents,

only years afterwards. The Swedish programme differed from both in its preparation. It drew on more

sheep, and non-human primates on vascular technique and on whether a transplanted

than a decade of work in rodents, sheep and non-human primates on vascular technique, and on whether

uterus could support gestation in any species before it was tried in a person. The 2014 birth was

a transplanted uterus could support gestation in any species, before the procedure was tried in a

reported with the recipient, the donor, the immunosuppressive regimen, and the pregnancy course

person. The 2014 birth was reported with the recipient, the donor, the immunosuppressive regimen and

described in full.[^brannstrom2015] The United States programme at Baylor followed a similar

the course of the pregnancy described in full.[^brannstrom2015] The United States programme at

structured-trial model,[^testa2018] and the Brazilian case removed the assumption that a living donor

Baylor followed a similar structured-trial model,[^testa2018] and the Brazilian case removed the

was necessary.[^ejzenberg2019]

assumption that a living donor was necessary.[^ejzenberg2019]

## Outcomes so far

Fewer than a hundred births have been reported worldwide, from programmes on several continents,

Fewer than a hundred births have been reported worldwide, from programmes on several continents. The

and the count is compiled through an international registry maintained by the transplant societies

count is compiled through an international registry maintained by the transplant societies, not by

rather than through any regulator. On the [[technology-readiness-level|standard readiness scale]] the

any regulator. On the [[technology-readiness-level|standard readiness scale]] the procedure sits

procedure sits near the top — a complete system, qualified through repeated use — while remaining

near the top, as a complete system qualified through repeated use, yet it remains concentrated in a

concentrated in a small number of centres with the surgical, reproductive-medicine, and transplant

small number of centres that have the necessary surgical, reproductive-medicine and transplant

expertise it requires in one building.

expertise in one building.

The failures are as informative as the births. A substantial minority of grafts have been lost, most

of them in the first weeks and most to thrombosis at the vascular anastomoses, which forces an

of them in the first weeks and most to thrombosis at the vascular anastomoses; the loss forces an

unplanned hysterectomy and ends the attempt. Among pregnancies that continue, preterm delivery and

hypertensive disorders including pre-eclampsia are considerably more frequent than in the general

obstetric population, and caesarean delivery is universal by design. The children have generally been

obstetric population, and caesarean delivery is universal by design. The children have generally

of appropriate size for their gestational age, and no consistent pattern of malformation has been

been of appropriate size for their gestational age, and no consistent pattern of malformation has

reported, but the oldest of them are barely into their second decade and systematic long-term

been reported. The oldest of them, however, are barely into their second decade, and systematic

follow-up is thin.

long-term follow-up is thin.

> [!caution] What the birth count does not show

> Announcements report births; they report graft losses, failed embryo transfers, and recipients who

> Announcements report births, and they report graft losses, failed embryo transfers and recipients

> never became pregnant far less consistently. The published denominator — how many women were

> who never became pregnant far less consistently. The published denominator (how many women were

> screened, transplanted, and left without a child — is incomplete, and no randomised or matched

> screened, transplanted, and left without a child) is incomplete. No randomised or matched

> comparison against surrogacy or adoption exists or is likely to. A live birth demonstrates that the

> comparison against surrogacy or adoption exists, and none is likely. A live birth demonstrates

> procedure can work. It does not establish how often it does.

> that the procedure can work; it does not establish how often it does.

## Donors, risk, and consent

Living donors have most often been the recipient's mother or sister, and postmenopausal uteri have

proved usable — the donor in the Swedish case that produced the first birth was a family friend who

proved usable. The donor in the Swedish case that produced the first birth was a family friend who

had been through menopause years earlier. The donation is not a small thing. Removing a uterus with vascular pedicles long enough

had been through menopause years earlier. The donation is a substantial undertaking. Removing a

to graft is a longer and more dissection-heavy operation than a standard hysterectomy, with ureteral

uterus with vascular pedicles long enough to graft is a longer operation, with more dissection, than

injury as the characteristic complication; robotic assistance was introduced partly to reduce that

a standard hysterectomy, and its characteristic complication is ureteral injury; robotic assistance

burden. For the donor the procedure is permanent in a way it is not for the recipient.

was introduced partly to reduce that burden. For the donor the procedure is permanent in a way it is

not for the recipient.

Deceased donation removes that objection entirely and expands the pool, at the cost of less workup,

Deceased donation removes that objection entirely and expands the pool. The cost is less workup,

less scheduling control, and a graft whose history is known only from records. Which source is

less control over scheduling, and a graft whose history is known only from records. Which source is

preferable is an open practical question rather than a settled one, and programmes have split.

preferable remains an open practical question, and programmes have split on it.

> [!debate] A non-lifesaving transplant with three parties at risk

> Critics argue that subjecting a healthy woman to a long operation, a second woman to

> Critics argue that the procedure subjects a healthy woman to a long operation, a second woman to

> immunosuppression, and a fetus to exposure to those drugs — for an outcome that is not survival but

> immunosuppression, and a fetus to exposure to those drugs, for an outcome that is gestation and

> gestation — sits outside what transplantation has previously justified, and that surrogacy or

> not survival. In their view this sits outside what transplantation has previously justified, and

> adoption achieves parenthood without any of it. Supporters answer that the same reasoning would

> surrogacy or adoption achieves parenthood without any of it. Supporters answer that the same

> forbid living kidney donation to a patient who could dialyse, that surrogacy is unavailable or

> reasoning would forbid living kidney donation to a patient who could dialyse, that surrogacy is

> illegal for many candidates, and that carrying a pregnancy is what these women are asking for and

> unavailable or illegal for many candidates, and that carrying a pregnancy is what these women are

> is not interchangeable with obtaining a child. The Montreal Criteria were an early attempt to fix

> asking for and is not interchangeable with obtaining a child. The Montreal Criteria were an early

> the boundary,[^montreal2012] and professional bodies have generally held that the procedure is

> attempt to fix the boundary,[^montreal2012] and professional bodies have generally held that the

> defensible under research protocols with independent donor advocacy.[^asrm2018]

> procedure is defensible under research protocols with independent donor advocacy.[^asrm2018]

## Limitations and open questions

Cost and concentration are the immediate limits. The procedure requires a transplant team, a

reproductive endocrinology unit, a high-risk obstetric service, and years of follow-up; it is rarely

reproductive endocrinology unit, a high-risk obstetric service, and years of follow-up. It is rarely

reimbursed, and the pattern described in [[access-and-inequality]] applies with unusual force to an

intervention that is expensive, elective, and available in a handful of cities.

Whether transgender women could be recipients is discussed in the literature; no such transplant has

been reported. The obstacles are anatomical and endocrine rather than ideological — a male pelvis has

been reported. The obstacles are anatomical and endocrine rather than ideological. A male pelvis has

different vascular geometry and no vaginal canal to attach the graft

different vascular geometry and no vaginal canal to attach the graft to without prior surgery, and

to without prior surgery, and the hormonal support of a pregnancy would have to be supplied entirely

the hormonal support of a pregnancy would have to be supplied entirely by drugs. The question is a

by drugs — and the question is a recurring test case for arguments about

recurring test case for arguments about [[morphological-freedom]] and for the framing of medical

[[morphological-freedom]] and for the framing of medical need set out in

need set out in [[disability-rights-and-enhancement]]. It is also the version of the procedure most

[[disability-rights-and-enhancement]]. It is also the version of the procedure most likely to be

likely to be argued about long before it is attempted, a pattern that

argued about long before it is attempted, which is the pattern [[precautionary-principle|precautionary

[[precautionary-principle|precautionary reasoning]] tends to produce.

reasoning]] tends to produce.

## Alternatives and outlook

The engineered alternative would be a uterus that is not donated at all. Groups including Brännström's

The engineered alternative would be a uterus that is not donated at all. Groups including

have recellularized [[decellularized-scaffolds|decellularized uterine scaffolds]] and reported

Brännström's have recellularized [[decellularized-scaffolds|decellularized uterine scaffolds]] and

pregnancies in rats, and endometrial [[organoids]] reproduce part of the tissue's cyclical behaviour

reported pregnancies in rats, and endometrial [[organoids]] reproduce part of the tissue's cyclical

in culture. Neither approaches a transplantable human organ, and the difficulty is the one that limits

behaviour in culture. Neither approaches a transplantable human organ. The difficulty is the one

[[lab-grown-organs]] and [[organ-bioprinting]] generally: building a vascular tree that can be plumbed

that limits [[lab-grown-organs]] and [[organ-bioprinting]] generally: building a vascular tree that

into a circulation. A uterus built from a patient's own [[induced-pluripotent-stem-cells]] would remove

can be plumbed into a circulation. A uterus built from a patient's own

both the donor and the immunosuppression, which is why it appears in the field's own roadmaps as a

[[induced-pluripotent-stem-cells]] would remove both the donor and the immunosuppression, and for

long-term goal rather than a near-term prospect.

that reason it appears in the field's own roadmaps as a long-term goal rather than a near-term

prospect.

The instructive comparison is with the technologies that have not produced a

The instructive comparison is with the technologies that have not produced a child. [[ectogenesis]]

child. [[ectogenesis]] in its complete form — gestation from fertilisation to term outside a body — has no

in its complete form, gestation from fertilisation to term outside a body, has no demonstration in

demonstration in any mammal, and the devices built so far take over a pregnancy already underway, in

any mammal, and the devices built so far take over a pregnancy already underway, in sheep.

sheep. [[in-vitro-gametogenesis]] has made functional gametes in mice and not in humans. Uterus

[[in-vitro-gametogenesis]] has made functional gametes in mice and not in humans. Uterus

transplantation reached live births by using an organ that already works, transplanted by methods

adapted from other transplants, and accepting the costs of doing so. It is a reminder that

adapted from other transplants, and by accepting the costs of doing so. It is a reminder that

biological problems are more often solved by moving working tissue than by manufacturing it, and that

biological problems are more often solved by moving working tissue than by manufacturing it, and

the reproductive technology furthest from the futurist imagination is the one with children to show

that the reproductive technology furthest from the futurist imagination is the one with children to

for itself. Whether it becomes standard care for absolute uterine factor infertility or remains the

show for itself. Whether it becomes standard care for absolute uterine factor infertility or remains

speciality of a few centres depends less on surgery than on whether health systems decide that

the speciality of a few centres depends less on surgery than on whether health systems decide that

carrying a pregnancy, as distinct from having a child, is a medical need they are obliged to meet.

## See also