Uterus transplantation in the human: a complex surgical, medical and ethical challenge

Abstract

As discussed in the current issue of this journal, uterine transplantation in the human is becoming a real possibility, and a range of research and ethical criteria have been proposed to regulate its introduction (Del Priore et al., 2012). However, the need to ensure a normal pregnancy outcome will become a major clinical challenge for several reasons. First, the vascular anastomoses of the transplanted uterus will be severely tested during pregnancy. The uterus is indeed not a steady-state organ, such as the liver or kidney, but an organ requiring exceptional vascular plasticity to accommodate a growing fetus. During gestation, blood supply to the uterus increases from 45 to 750 ml/min, representing ∼25% of the cardiac output at term. Furthermore, deep placentation in humans involves transformation of a relative small number of spiral arteries into large vessels that provide 90% of uterine blood flow to the intervillous space of the placenta by midpregnancy. Without high-quality vascular anastomoses that can accommodate such a dramatic increase in blood flow in a short space of time, fatal placental ischemia during pregnancy may be unavoidable.