UterusTransplantation

Additional Info

• Audio File:uab/ua174.mp3
• Doctors:Porrett, Paige
• Featured Speaker:Paige Porrett, MD
• CME Series:Medical Innovations
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4236
• Guest Bio:Paige Porrett, MD is an associate professor of surgery and the director of VCA transplantation at UAB. 
  
  Release Date: October 19, 2020
  Expiration Date: October 19, 2023
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Presenters:
  Paige Porrett, MD, PhD
  Assistant Professor in UAB Transplant Surgery
  
  Dr. Porrett has the following financial relationships with commercial interests:
  
  Consulting Fee – Janssen Pharmaceuticals
  
  Dr. Porrett does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.
  
  There is no commercial support for this activity.
• Transcription:UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
  
  Melanie Cole (Host):  Welcome to the UAB Med Cast. I’m Melanie Cole and today, we’re discussing uterine transplants. Joining me for this fascinating segment is Dr. Paige Porrett. She’s an Associate Professor of Surgery and the Director of VCA Transplantation at UAB Medicine. Dr. Porrett, I’m so glad to have you with us. Before we get into this, you’re new to UAB Medicine. Tell us a little bit about yourself.
  
  Paige Porrett, MD (Guest):  Hi, thanks Melanie. Yes, I’m new to UAB Medicine. I come from the University of Pennsylvania where I have been a Surgeon and Faculty Member for the last almost 20 years. and I had the privilege of starting the Uterus Transplant Program while a faculty at Penn with associates from the Obstetrics and Gynecology Department.
  
  Host:  So, then let’s talk about uterine transplantation. Tell us first, about the prevalence of uterine factor infertility and what are some of the causes that we know about?
  
  Dr. Porrett:  So, uterine factor infertility is a disease that affects many women around the globe. It has no specific targeted population, meaning it affects women of all ages, races, ethnicities, et cetera. Uterine factor infertility is a type of infertility that we think affects approximately 200,000 women in the United States but that is an estimate. The type of infertility or specifically uterine factor infertility that we’re treating with uterus transplantation is something called absolute uterine factor infertility. And what that means is that the women seeking transplant or who are affected by this condition do not have a uterus in place. And that is because either she was born without a uterus, which is a congenital abnormality that is certainly seen. Or because the uterus has been surgically removed. For example, for an early stage cervical cancer or because of a problem during delivery of a previous child.
  
  Host:  Well tell us a little bit about this. How did it come about? How many of them have been done? Have they been successful? Tell us a little bit about really what’s going on with uterine transplants.
  
  Dr. Porrett:  Right, thank you. So, uterus transplant and pun very much intended is certainly the new kid on the block in transplantation. So, the first successful live birth from a uterus transplant recipient was about six years ago in Gothenburg, Sweden as part of a clinical research trial. And since that miraculous child was born, uterus transplant has sort of taken the world by storm. But that said, there are still only select centers in the world offering this new treatment for women and couples with uterine factor infertility as a complex medical and surgical procedure which I am happy to discuss the details of further.
  
  But there has been about 100 uterus transplants, we think, in the world performed to date. There are currently three uterus transplant centers in the United States, UAB will be the fourth. And to date, in the last four years or so, there’s been approximately thirty, 3-0, uterus transplants performed in the United States. From those 30 transplants, we’ve had approximately eight live births in the US alone. But we think collectively in the world, that the number of children that have been born from uterus transplant recipients numbers approximately 40.
  
  Host:  That is so cool. So, as we’re talking about the procedure, and I would like to hear you tell other providers some of the technical considerations, but I think one of the most important factors is going to be patient selection. Who is an ideal candidate? Tell us a little bit about what they have to undergo before you will even consider them as a candidate. Tell us a little bit about patient selection.
  
  Dr. Porrett:  Great. So, with patient selection, we have a couple of important considerations in mind and these are – some of these are central to what we do in organ transplant, the transplantation of vital organs. But many of these are unique to uterus and the reason they are unique is because in transplantation, when we transplant vital organs, there is no alternative to death, really, for these patients who come to us for kidney or liver or heart transplants for example.
  
  But uterus transplant is a completely elective and optional procedure. It is intended to improve the quality of life for the recipient, not to improve the length of life for the recipient. So, this colors every aspect of our selection. Because these women have alternatives to a uterus transplant in order to build their family and these are good options that do exist, although they are complex options which is one of the reasons why women are seeking a third option, being uterus transplant
  
  So, these are women who have uterine factor infertility, specifically absolute uterine factor infertility. And they are usually in their reproductive age range which I’ll say averages from 21 to 40 years old. They have to be in good medical condition. And they have to be able to obviously, accept a transplant from another human being which at UAB, we’re going to use transplants from deceased donors. Although, uterus transplant recipients have had a transplant and had live births around the world from both living as well as deceased donors.
  
  The ideal candidate also has to be able to comply with the immunosuppression regimen. And this is the final point that I’ll make about patient selection. Because the transplant requires that the patient take antirejection medicines which are very similar to the same – they are the same medicines that are used for other types of organ transplant. These medicines are largely safe but there are definitely toxicities and side effects of the medications. Which is one of the reasons why when we select candidates, we have to make sure that they are going to be medically suitable and able to take the medications that are required so that they don’t reject the uterus. But after child bearing is done, the uterus is unique from all other vital organ transplants because we will remove it at the end of the childbearing period of time and the immunosuppression medications will be stopped. So, the overall amount of immunosuppression that these women are exposed to will be just for a few short years while they are undergoing their childbearing.
  
  Host:  That really is amazing that you take it out after they’re done. How many children are they allowed to have with it?
  
  Dr. Porrett:  Another great question. So, presently, we’re going to allow upwards of two, or I should say up to two children. And that assumes that the first pregnancy and childbirth went well and we’re not – and we’re without significant complication. We don’t actually know in the world how many children these women might be capable of bearing but the reason we limit the current children – the number of children that are allowed with a uterus transplant to two is because of the medical complexity that arises in women who undergo cesarean section and childbirth essentially over two times. And this is also coupled with the idea that obviously it takes time from pregnancy to get to childbirth and we want to minimize overall, the total number of years these women have immunosuppression.
  
  Host:  And what about the actual live birth? Are there concerns of prenatal medical complications? Are they considered a very high risk pregnancy or high risk for preterm labor, low birth weight? And if so, to what do you attribute those things?
  
  Dr. Porrett:  Yes, so, these are certainly high risk pregnancies when they occur. At this point in time, we have certainly seen in the global experience with uterus transplantation, complications such as preeclampsia, and preterm birth. But the preterm birth is really, I call it for indication which means these children are delivered by a cesarean section, so this is not spontaneous preterm birth we’re talking about. It is because the doctors specifically the maternal fetal medicine specialists who are the high risk obstetricians who are managing these women through their transplant and their pregnancy have decided that it is better to take the baby out than to leave it in and usually that is done primarily because of preeclampsia or severe gestational hypertension.
  
  The overall rate of that occurrence happening we think is probably about one in five uterus transplant recipients but again, this is new and there’s not a lot of data in terms of how many women might suffer from those complications. We don’t really know why biologically, these women are – these uterus transplant recipients are at a higher risk of having preeclampsia and other complications such as that during their pregnancies. But this is not necessarily a risk that is different in the uterus transplant recipient from other organ transplant recipients and there have been thousands of women who’ve had a prior heart or kidney or liver transplant who’ve undergone pregnancy after transplant.
  
  And in short, we think it’s because of the medications that these patients are on.
  
  Host:  Dr. Porrett, are there ethical issues surrounding uterus transplantation in any way?
  
  Dr. Porrett:  Yeah, there are a number of issues, ethical issues specifically around uterus transplant and I would say that most of this gears around the safety profile of uterus transplantation as well as the accessibility of this as a family building modality in the setting of other things. So, what I mean specifically by that is that a woman as I mentioned before, does not have to go through a uterus transplant in order to build a family even if she does not have a uterus because she could either build a family with her partner to adoption of a child or she could use a gestational carrier or a surrogate. When a woman has a uterus transplant, as I mentioned, she is taking immunosuppression medications that increases the risk to both her and her baby of going through the pregnancy. These are not risks that are present when one uses a gestational carrier.
  
  And so, that is one of the primary controversies around uterus transplantation is the wisdom of proceeding with the transplant when there is an alternative that allows you to have a biologic child but doesn’t put the baby or mom at risk for the complications that I mentioned.
  
  Host:  So, tell us a little bit about the psychological issues that might be involved. Is there an aspect as you’re doing your patient selection evaluation, as you’re talking with the patient and other providers; is there a psychosocial, psychological aspect that you’ve seen so far?
  
  Dr. Porrett:  Yes, this is a very important and complex question that you asked and I’m happy to answer it to the best that I can. So, I’ve been very impressed as a transplant surgeon new to the field of reproductive medicine at large about the complex decision making that goes on when women and couples start their families. And the – since there’s so many unique aspects to what I’ll call the informed consent procedure for uterus transplant; we have tackled this by essentially asking candidates who are coming through our program to undergo a pretty significant psychologic as well as a psychosocial screening program.
  
  Obviously, the decision to have a child is one of the biggest if not the biggest decision that any individual faces. And so, the decision in terms of their financial wellbeing, the type of committed relationship one is in; these are all aspects that not only the candidate has to evaluate but we as the transplant program would evaluate. We also want to make sure that we understand the motivation for uterus transplantation from the candidate that’s to come through. So, for example, if they have the option of taking – of using a gestational carrier or adopting a child; what is it about the uterus transplant that’s really motivating their behavior? Why would a candidate decide to take on additional medical risk when these other options are available? And that has given me, personally, a lot of insight into the struggles that these women and couples have undergone when it comes to dealing both with the diagnosis of uterine factor infertility as well as understanding the limitations or the access they have to a gestational carrier.
  
  And while not I’ll call it a specific psychologic dimension that we interrogate to a great extent, it’s very interesting to hear women talk about what they perceive to be the benefit of a uterus transplant and why they would take on the medical risks that I discussed. Some central issues that we hear about a lot, are privacy and control. Which I think are themes quite common within the reproductive medicine community but are not as obvious to someone like me with a transplant surgery background.
  
  Host:  Are these still considered in the experimental stage? And have they been covered by research funding? Tell us a little bit about the program there at UAB and if it becomes part of medical practice; is this going to be something that’s very expensive? Do you see other programs like it showing up around the country? Tell us what you think will happen and if funding is involved.
  
  Dr. Porrett:  Great important question. So, this is part of my mission together in partnership with UAB is actually to make this as accessible to women as possible by hopefully pushing or propelling this field forward to the extent that third party carriers and health insurance companies will actually pay for this. At present, the procedure is not paid for by health insurance companies. And so, up until this point in time, within the United States, and actually around the globe, that this is true everywhere; the uterus transplant programs have been funded exclusively by individual institutions and or research grants that actually are present at those institutions.
  
  So UAB has made a commitment to also supporting us with institutional dollars and resources, however, one of the major pieces of work that we have in front of us is to actually advocate for this patient population who has not really had a seat at the table since the prior – the ways that people build families are not covered, right, by health insurance. We’ve never heard of anyone asking their healthcare insurance company to pay for the adoption costs for example that are associated with adoption, I mean the fees. So, this is new territory for the health insurance companies and it’s important work that UAB and myself in partnership with them are going to want to do to make this accessible to everybody who is in need.
  
  Host:  It is really something and I’m so glad that you’ve joined UAB for this fascinating program. Before we wrap up, I’m sure that you are involved in this multidisciplinary team and that this is a very, very important part of this type of surgery and transplantation. Tell us a little bit about it and why it’s so important and to let referring physicians, people that are interested in your research, other providers that have questions, let them know what you would like the takeaway message to be from this podcast about the program that you started at UAB Medicine.
  
  Dr. Porrett:  Well thank you for that opportunity and to address the prior question actually that you had asked as well. This is still in the early stage phases but at this point in time, there have been enough live births and transplants performed around the world that we think that we can offer this program to select candidates who are highly informed outside of the context of a formal clinical research trial. But that said, there are still many knowledge gaps that we have and I’m hopeful that the candidates who come to UAB and elsewhere will still agree to participate in other elements of research as we learn from these individuals and make uterus transplant in the future safer and better at the end of the day.
  
  But what I’d like to communicate to any individual listening to this be it provider or potential patient is that uterus transplant is about hope and this is something – a new technology, an innovation that has not been previously available for a large community of individuals who frankly, were afraid or unable to really come to their medical provider and tell them that they have this problem that because the medical community did not have a solution, the solution that we have today. So, I would really encourage all both patients and providers to be open minded about this, to be eager to seek additional information to determine whether it’s something that would be right for them. But I’ve been very impressed by how receptive both patients and the larger medical community have been about this despite the controversy because everybody understands very much how important it is for individuals who are starting families to have the choice about how they want to start their family, what the risks are that are involved. So, information is key here.
  
  Host:  It certainly is. And thank you so much Dr. Porrett for joining us today. What an absolutely fascinating topic and a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of the UAB Med Cast. To refer your patients or more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole.
• Hosts:Melanie Cole, MS