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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.
Uterus transplantation is the transfer of a donated uterus into a woman who has none, or whose 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 that no engineered substitute for the uterus, the Artificial womb included, can claim.
The indication is absolute uterine factor infertility, in which the uterus is absent or is present but incapable of sustaining a pregnancy. The largest congenital cause is Mayer-Rokitansky-Küster-Hauser syndrome, a form of Müllerian agenesis in which the uterus and upper vagina fail to develop while the ovaries, hormones and karyotype are typically normal. It occurs in something on the order of one in 4,000 to 5,000 female births. The acquired causes are more varied: hysterectomy for postpartum haemorrhage, cervical cancer or fibroids; severe intrauterine adhesions; and radiation injury.
The procedure appeals to candidates because their ovaries usually work. A woman with Müllerian agenesis produces her own oocytes, so a child gestated in a transplanted uterus is genetically hers. Of the alternatives, adoption severs that genetic link and gestational surrogacy places the pregnancy in another woman's body. Surrogacy is also prohibited or legally unenforceable in much of Europe, including Sweden, where the first sustained programme was built.
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 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 internal iliac vessels. Venous drainage is the hardest technical step. Uterine veins are thin-walled, variable and awkward to sew, and some teams take utero-ovarian veins instead. In the recipient, the graft is joined to the external iliac vessels, suspended from the pelvic ligaments, and connected to a vaginal cuff. The return of menstruation, within weeks to months, is the first sign that the graft is alive.
Nothing reconnects the nerves. A transplanted uterus is denervated, so the recipient does not feel contractions and cannot labour normally, and every reported delivery has been by caesarean section. Immunosuppression is typically based on tacrolimus and adjusted for pregnancy; mycophenolate is 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. Most 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.
The transplant meant to endA 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 staying alive. A uterus is not life-sustaining, so the calculation is reversed. The graft is worth keeping only while it is being used, and the standard of success includes taking it out. Its reversibility therefore differs from that of the implanted devices and edited cells covered elsewhere on this wiki: undoing it requires surgery, but the undoing is part of the plan.
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.1 The Turkish case a decade later showed that a uterus from a deceased donor could be transplanted and could conceive.2 The first pregnancies there were lost, and a live birth from that graft came only years afterwards. The Swedish programme differed from both in its preparation. It drew on more than a decade of work in rodents, sheep and non-human primates on vascular technique, and on whether a transplanted uterus could support gestation in any species, before the procedure was tried in a person. The 2014 birth was reported with the recipient, the donor, the immunosuppressive regimen and the course of the pregnancy described in full.3 The United States programme at Baylor followed a similar structured-trial model,4 and the Brazilian case removed the assumption that a living donor was necessary.5
Fewer than a hundred births have been reported worldwide, from programmes on several continents. The count is compiled through an international registry maintained by the transplant societies, not by any regulator. On the standard readiness scale the procedure sits near the top, as a complete system qualified through repeated use, yet it remains concentrated in a small number of centres that have the necessary surgical, reproductive-medicine and transplant 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; 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 of appropriate size for their gestational age, and no consistent pattern of malformation has been reported. The oldest of them, however, are barely into their second decade, and systematic long-term follow-up is thin.
What the birth count does not showAnnouncements report births, and they report graft losses, failed embryo transfers and recipients who never became pregnant far less consistently. The published denominator (how many women were screened, transplanted, and left without a child) is incomplete. No randomised or matched comparison against surrogacy or adoption exists, and none is likely. A live birth demonstrates that the procedure can work; it does not establish how often it does.
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 had been through menopause years earlier. The donation is a substantial undertaking. Removing a uterus with vascular pedicles long enough to graft is a longer operation, with more dissection, than a standard hysterectomy, and its characteristic complication is ureteral injury; robotic assistance 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. The cost is less workup, less control over scheduling, and a graft whose history is known only from records. Which source is preferable remains an open practical question, and programmes have split on it.
A non-lifesaving transplant with three parties at riskCritics 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 gestation and not survival. In their view this sits outside what transplantation has previously justified, and surrogacy or adoption achieves parenthood without any of it. Supporters answer that the same reasoning would forbid living kidney donation to a patient who could dialyse, that surrogacy is unavailable or illegal for many candidates, and that carrying a pregnancy is what these women are asking for and is not interchangeable with obtaining a child. The Montreal Criteria were an early attempt to fix the boundary,6 and professional bodies have generally held that the procedure is defensible under research protocols with independent donor advocacy.7
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 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 different vascular geometry and no vaginal canal to attach the graft to without prior surgery, and the hormonal support of a pregnancy would have to be supplied entirely by drugs. The question is a recurring test case for arguments about Morphological freedom and for the framing of medical need set out in Disability rights and enhancement. It is also the version of the procedure most likely to be argued about long before it is attempted, a pattern that precautionary reasoning tends to produce.
The engineered alternative would be a uterus that is not donated at all. Groups including Brännström's have recellularized decellularized uterine scaffolds and reported pregnancies in rats, and endometrial Organoids reproduce part of the tissue's cyclical behaviour in culture. Neither approaches a transplantable human organ. The difficulty is the one that limits Lab-grown organs and Organ bioprinting generally: building a vascular tree that can be plumbed into a circulation. A uterus built from a patient's own Induced pluripotent stem cells would remove both the donor and the immunosuppression, and for 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 child. Ectogenesis in its complete form, gestation from fertilisation to term outside a body, has no demonstration in any mammal, and the devices built so far take over a pregnancy already underway, in sheep. 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 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 the reproductive technology furthest from the futurist imagination is the one with children to show for itself. Whether it becomes standard care for absolute uterine factor infertility or remains 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.
paperFageeh, W. et al. "Transplantation of the human uterus." International Journal of Gynecology & Obstetrics, 2002.↩The first reported human attempt; the graft was removed after about three months when its vessels thrombosed.
paperOzkan, O. et al. "Preliminary results of the first human uterus transplantation from a multiorgan donor." Fertility and Sterility, 2013. ↩
paperBrännström, M. et al. "Livebirth after uterus transplantation." The Lancet, 2015.↩The recipient had Müllerian agenesis; the uterus came from a living donor who had passed menopause years before.
paperTesta, G. et al. "First live birth after uterus transplantation in the United States." American Journal of Transplantation, 2018. ↩
paperEjzenberg, D. et al. "Livebirth after uterus transplantation from a deceased donor in a recipient with uterine infertility." The Lancet, 2019.↩The birth occurred in December 2017 in São Paulo; the report established that a living donor is not required.
paperLefkowitz, A., Edwards, M. and Balayla, J. "The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation." Transplant International, 2012. ↩
statementAmerican Society for Reproductive Medicine, Ethics Committee. "American Society for Reproductive Medicine position statement on uterus transplantation: a committee opinion." Fertility and Sterility, 2018. ↩