Stina Järvholm

Uterus transplantation: current progress and future prospects

Even if reproductive medicine has been remarkably successful during the past few decades, with the introduction of in vitro fertilization in the late 1970s and intracytoplasmic sperm injection in the early 1990s, it has been repeatedly mocked by infertility due to an absolute uterine factor. No treatment has been available for the women suffering from an absent or dysfunctional uterus, in terms of carrying a pregnancy. Approximately one in 500 women suffer from absolute uterine infertility, and the option so far to become a mother has been to either adopt or utilize gestational surrogacy. As of today, a total of eleven cases of human uterus transplantations have been reported worldwide, conducted in three different countries. The results of these initial experimental cases far exceed what might be expected of a novel surgical method. Many more uterus transplantations are to be expected in the near future, as other research teams’ preparations are being ready to be put into clinical practice. In this review, we summarize the current worldwide experience of uterus transplantation as a treatment of absolute uterine factor infertility and the future prospects of human uterus transplantation.

Uterus transplantation trial: Psychological evaluation of recipients and partners during the post-transplantation year

OBJECTIVE To explore the psychology and well-being of the nine patients undergoing uterus transplantation (UTx) as part of the first clinical trial, during the first 12 months of which seven patients experienced graft survival with occasional mild rejection episodes and two patients experienced graft failure, with hysterectomy. DESIGN Prospective observational study. SETTING University hospital. PATIENT(S) Nine female uterine recipients and their partners. INTERVENTION(S) Psychological evaluations by questionnaires focusing on quality of life, mood, relationship, and fertility quality of life were conducted at inclusion and at 3, 6, and 12 months after UTx. MAIN OUTCOME MEASURE(S) Scores of four different questionnaires regarding mood, quality of life, fertility quality of life, and relationship. RESULT(S) In all questionnaire domains, the recipients and their partners showed a similar pattern at baseline, and the UTx group, including both recipients and partners, scored similarly or better when compared with relevant norm groups. Among the recipients there was a reversible decline in score of physical activity and increased bodily pain at 3 months past surgery. CONCLUSION(S) The results show that participants of this first UTx trial were psychologically stable both at baseline and during the first year, despite rejection episodes and possible worries about viability of graft. CLINICAL TRIAL REGISTRATION NUMBER ClinicalTrials.govNCT01844362.

Psychological aspects in pre‐transplantation assessments of patients prior to entering the first uterus transplantation trial

Uterus transplantation is a treatment of uterine factor infertility. It raises questions of psychological aspects and well‐being among the participants, which is of great importance as this is a new type of a major surgical procedure. This commentary focuses on the psychology surrounding this novel type of transplantation and the importance of patient selection. In addition, psychological aspects of events during the first postoperative year and the follow‐up are discussed.

Live Donors of the Initial Observational Study of Uterus Transplantation—Psychological and Medical Follow-Up Until 1 Year After Surgery in the 9 Cases

Background The first prospective observational study of uterus transplantation was initiated in 2013 with live donation to 9 women with absolute uterine factor infertility. We explored the medical complications and psychosocial wellbeing of the donors during the first postoperative year. Methods Complications were registered and graded according to the Clavien-Dindo (C-D) classification. Symptoms related to the surgery were registered. Data on length of hospital stay, sick leave, socioeconomic parameters, and life events were obtained. Psychological evaluations (Psychological General Well-Being, Dyadic Adjustment Scale, Hospital Anxiety and Depression Scale [HADS], SF-36) questionnaires focusing on quality of life, mood, and relationship, were conducted at inclusion and at 3, 6, and 12 months after uterus donation. Results One major surgical complication (C-D IIIb) occurred. A ureteric-vaginal fistula developed 2 weeks after uterus procurement. The fistula was surgically repaired. Two self-reported and transient complications (C-D I) were noted (nocturia, meralgia paresthetica). Hospital stays of all donors were 6 days and median sick leave was 56 days (range, 14-132). At inclusion, median scores exceeded the normative values of the Swedish population in Psychological General Well-Being and Dyadic Adjustment Scale. HADS-Anxiety was detected preoperatively in 1 donor. Two donors exceeded 10-point declines in SF-36 summary scores and increased their HADS scores by 6 points during the observation period. All donors returned to their predonation levels of physical health. Conclusions The results support that it is feasible to retrieve a uterus safely from a live donor. Further studies are needed to better evaluate the method.

The choice of Pre-implantation Genetic Diagnosis (PGD), a qualitative study among men and women

Background: Previous qualitative studies have shown that the decision to undergo Pre-implantation Genetic Diagnosis (PGD) is a demanding situation that increases psychological burden and activates moral beliefs and cognitive assessments. Most studies are based on women’s experiences. Studies about the choice are mostly done in a hypothetical setting. Objective: The aim of this study was to investigate psychological aspects, the influence of the healthcare system and ethical considerations in relation to men and women’s decision to undergo PGD. Method: Nineteen couples (19 women and 17 men) all planning and eligible for PGD in Sweden were interviewed. Data were analysed with a thematic approach. Results: The analysis lead to the formation of a master theme, labelled Choosing. In addition, three subthemes emerged – In relation to myself, In relation to the child, and In relation to the society – and nine underlying categories. No differences were found between men and women concerning emotional depth or cognitive recognition of the decision. Conclusion: The men and women in this study were a heterogeneous group with great variations in reproductive history. However, they expressed common themes about what affected them in their deciding to undergo PGD. The themes are complex and activate ethical reasoning. The results of the present study are relevant for pre-PGD counselling, and indicate that support should be provided to men as well as to women.

Experiences of Pre-Implantation Genetic Diagnosis (PGD) in Sweden: a Three-Year Follow-Up of Men and Women

Men and women with a hereditary genetic disease are faced with different options when they wish to become parents. One is pre-implantation genetic diagnosis (PGD) which is a combination of in vitro fertilization (IVF) and genetic analysis of the embryo before implantation. The present study focused on men and women’s psychological experiences of PGD three years after applying for PGD. Nineteen women and seventeen men (i.e. seventeen couples and two women) participated. The interviews were analysed by thematic method. It is better to have tried was identified as a master theme, under which came three underlying sub-themes, which had the following headings: Practical experience of PGD, Psychological experience of PGD and Goals of PGD. The results show that men and women three years after PGD are still psychologically affected by their experience. The men and women raised concerns that their relationship had been affected, both positively and negatively, and feelings of anxiety and depression still remained. Healthcare services should recognize the heterogeneous nature of the group being studied and therefore the need for counselling can arise at different times and in relation to different areas, regardless of the outcome of the PGD.

Risk factors for depression and anxiety among men and women planning for pre-implantation genetic diagnosis

Abstract Background: Previous studies have shown that women planning for in vitro fertilisation (IVF) show more distress than do men. Most studies about distress and pre-implantation genetic diagnosis (PGD) are based on women’s experiences. Little is known about what are the risk factors for men and women to experience anxiety or depression when planning for PGD. Objective: The first aim was to investigate presence of symptoms of depression and anxiety in men (n = 17) and women (n = 19) planning for PGD and compare this to men (n = 23) and women (n = 24) who were planning their first IVF. The second aim was to investigate if specified risk factors could predict the presence of anxiety and depression in the PGD group. Method: Anxiety and depression were measured with the questionnaire, the Hospital Anxiety and Depressions Scale (HADS). The Swedish version of the short Sense of Coherence scale was used to measure individuals’ sense of coherence. An index was created for six risk factors tested in the PGD group. Results: Low Sense of Coherence and history of miscarriage or termination were predictors of symptoms of depression among women in the PGD group. Socioeconomic risk and having a child with the genetic disease were predictors for anxiety in men. Conclusion: Women planning for PGD and IVF reported similar levels of anxiety or depression while men in the PGD group reported significantly more anxiety than men planning for IVF. Risk factors indicating depression or anxiety were found in the PGD group. The results of the present study are relevant for pre PGD counselling.

Preoperative psychological evaluation of uterus transplant recipients, partners, and living donors: Suggested framework

Uterus transplant has become a real option for women with uterine‐factor infertility to become pregnant and give birth. The screening before uterus transplant consists of a multidisciplinary evaluation and includes the potential recipient, living donor, and, to some extent, the recipients partner and future co‐parent. The psychological evaluation has evolved from broad‐based screening in the first uterus transplant trial, where the aim was to find suitable candidates for a novel experimental procedure with an unknown outcome, to a more directed screening with specific psychological domains for a complex infertility treatment with promising results. This report outlines a consensus by investigators with pioneering experience in the field of the key factors and suggests a framework for psychological evaluation of recipients and their partners as well as for live uterus donors before uterus transplant. We identify the main areas of particular value to the recipient screening (general psychological health, factors associated with infertility, and medication adherence), the partner (general psychological health and factors associated with infertility), and the living donor (psychological health and motivation to donate, especially in the case of the nondirected donor).

Is pre-implantation genetic diagnosis (PGD) more of a strain regarding satisfaction with marital quality for male or female partners? A three-year follow-up study

Abstract Introduction: Men and women with a hereditary genetic disease are faced with different options when they plan to become parents. One is pre-implantation genetic diagnosis (PGD) which is a combination of in vitro fertilization (IVF) and genetic analysis of the embryo before implantation. The present study focuses on how men and women planning for PGD experience the quality of marital satisfaction when they apply for treatment and again, three years later. Methods: The study was a prospective cohort study where all couples (n = 22) applying for PGD during 2010 and 2011 were eligible. Nineteen women and 17 men (i.e. 17 couples and two women) participated. Participants answered several questionnaires (Dyadic Adjustment Scale, Hospital Anxiety and Depression Scale and Parental Stress Questionnaire) before PGD treatment, and again three years later. Results: Women who underwent PGD rated the quality of their marital relationship similarly to that of first-time parents and IVF couples, whereas men rated the marital quality somewhat lower than the contrasts groups. Satisfaction with marital quality was stable over the three-year period although men were less satisfied than women on both occasions. At year three, there was a significant correlation between martial satisfaction and parental stress in men, and between martial satisfaction and anxiety and depression in women. Discussion: Men are equally, or more, affected by their situation than their female partners, with consequences for satisfaction with marital quality. For this reason they should be included in any counselling offered.