Journal of

Clinical Medicine
Review

Current Progress in Uterus Transplantation Researchin Asia
Iori Kisu 1, *,† , Yu Liu 2,† , Gaowen Chen 3,† , Min Jong Song 4 , Cherry Yin-Yi Chang 5,6 ,Tan Hak Koon 7 , Kouji Banno 1 and Daisuke Aoki 1
1
2
3
4
5
6
7

*
†

Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo 1608582, Japan;
kbanno@keio.jp (K.B.); aoki@z7.keio.jp (D.A.)
Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University,
Shanghai 200011, China; liuyu160046@126.com
Department of Obstetrics and Gynecology, Zhujiang Hospital, Southern Medical University,
Guangzhou 510282, China; cgw2012@163.com
Department of Obstetrics and Gynecology, Daejeon St. Mary’s hospital, Daejeon 34943, Korea;
bitsugar@catholic.ac.kr
Department of Obstetrics and Gynecology, China Medical University Hospital, Taichung 40447, Taiwan;
d4754@mail.cmuh.org.tw
Department of Obstetrics and Gynecology, School of Medicine, China Medical University,
Taichung 40447, Taiwan
Department of Obstetrics and Gynecology, Singapore General Hospital, Singapore 169608, Singapore;tan.hak.koon@singhealth.com.sg
Correspondence: iori71march@hotmail.co.jp; Tel.: +81-3-3353-1211; Fax: +81-3-3353-0249
Equal contribution.

Received: 15 January 2019; Accepted: 12 February 2019; Published: 14 February 2019


Abstract: Uterus transplantation (UTx) is now a possible approach for women with absolute uterine
factor infertility to deliver a child, following the first successful delivery by Brännström et al. in
Sweden in September 2014. This remarkable achievement attracted major attention worldwide andcaused many countries to prepare for UTx, including countries in Asia. To date, three groups have
performed UTx in humans in Asia, and many others are aiming for the clinical application of UTx
with accumulation of basic experimental data. Therefore, it is likely that UTx will expand rapidly in
Asia in the near future, although this will depend on ethical, social and religious views in each country.
With this background, herein we summarize the current progress of UTx in East, Southeast and SouthAsia, with the purpose of increasing understanding of the current status of basic and clinical UTx
research in each country and sharing progress and knowledge to ensure future development of UTx
research in Asia.
Keywords: uterus transplantation; uterine factor infertility; Mayer-Rokitansky-Küster-Hauser syndrome

1. Introduction
Uterus transplantation (UTx) is now an alternative to gestational surrogacy and adoption for
women with absolute uterine factor infertility (AUFI) to have a child. Brännström et al. achieved thefirst human delivery after UTx in 2014 in Sweden [1] and this great achievement attracted attention
worldwide and led many countries to prepare for UTx. As of October 2018, more than 50 UTx
procedures had been performed in Saudi Arabia, Turkey, Sweden, China, USA, Czech, Brazil, Germany,
Serbia, India and Lebanon, and a total of 13 babies were born after these procedures in Sweden, USA,
Brazil, Serbia and India. Many other countries are now aiming for clinical application of UTx, includingFrance, UK, Belgium, Spain, Italy, Japan, South Korea, Singapore, Taiwan, Australia, Russia, Egypt,

J. Clin. Med. 2019, 8, 245; doi:10.3390/jcm8020245

www.mdpi.com/journal/jcm

Clin. Med.
8, x FOR PEER REVIEW
J. Clin.J. Med.
2019,2019,8, 2452 of 215of 13

Australia, Russia, Egypt, Mexico, Colombia and Argentina. Thus, UTx is rapidly spreadingworldwide
and andis starting
to be recognized
new assisted
reproductive
technology(ART) and
Mexico,Colombia
Argentina.
Thus, UTxas
is arapidly
spreadingworldwide
and is starting
to betransplantation
although it isstill at the(ART)experimental
stage and has
many medical,
recognized
as a newtechnique,assisted reproductive
technology
and transplantation
technique,althoughtechnical
ethical issues
to beresolved[2]. medical, technical and ethical issues to be resolved [2].
it is stillat theandexperimental
stage
and
has many
UTx
hasmainlybeen
performed
inEuropean countries,
countries, insurrogacy
is notUTx has mainly been performed in European
in many
manyofofwhich
which
surrogacy
is notpermitted, but research and clinical application of UTx has recently also spread in Asia. Therefore, it
permitted, but research and clinical application of UTx has recently also spread in Asia. Therefore, it is
is important to understand the current status of basic and clinical UTx research and share knowledge
important to understand the current status of basic and clinical UTx research and share knowledge toto ensure future progress of UTx research in Asia. With this background, we herein summarize theensurefuture progress of UTx research in Asia. With this background, we herein summarize the current
current progress of UTx in East, Southeast and South Asia based on international and domestic
progressof UTx in
East,Southeastand South
Asia based on international and domestic publications,publications,press
releasesand personalcommunications.
press releases and personal communications.
2. Uterus Transplantation (UTx) Research Groups in Asia

2. Uterus Transplantation (UTx) Research Groups in Asia

To the best of our knowledge, there are 13 groups currently working on UTx research in Asia:
To thein
bestof ourknowledge,
thereoneareeach
13 groups
currently
onand
UTxTaiwan
research
in Asia:
seven
China,
twoin Japan, andin India,
Korea,working
Singapore(Figure1). sevenA
in China,
two inJapan, andone eachin research
India, Korea,
Singapore
and Taiwan (Figure 1). A summary ofsummaryof groups
performing
UTx
is givenin Table 1.

groups performing UTx research is given in Table 1.

Figure 1. Current groups for UTx (uterus transplantation) research in Asia.
Table 1. Groups performing UTx (uterus transplantation) research in Asia.
Figure 1. Current groups for UTx (uterus transplantation) research in Asia.

CountryCountry
China
China

India

City

Team Leader

University/Hospitaltransplantation)
in Asia.Hospital
Xi0 an Table 1. Groups
Wei L performing UTx (uterus
FourthMilitary Medicalresearch
University/Xijing
Guangzhou
Wang YF/Chen GWSouthern Medical University/Zhujiang Hospital
City
Team
LeaderY
University/Hospital
Shanghai
Hua KQ/Liu
Fudan University/Obstetrics
and Gynecology Hospital of Fudan University
Wan LXP
TongjiFourth
University/Shanghai
First
Maternity and Infant
Hospital
Xi′an
WeiMilitary Medical
University/Xijing
Hospital
Jinan
Chen ZJ GW
Shandong University/Reproductive
Hospital Affiliated with
Shandong University
Guangzhou
Wang YF/Chen
Southern Medical University/Zhujiang
Hospital
Beijing
Yao YQ
Chinese People's Liberation Army General Hospital
Shanghai
Hua KQ/Liu Y
Fudan University/Obstetrics and Gynecology Hospital of Fudan University
Jilin
Zhang WY
Jilin University/The Jilin University Second Hospital
Wan XP
Chen ZJ
Kisu
Yao
YQI
Yamamuro
Zhang
WYO
Song MJ S
Puntambekar

Korea
India
Singapore

SingaporeTan HK

Singapore General Hospital

TaiwanTaichung

Lin WC

China Medical University/China Medical University Hospital

Japan

Puntambekar S

Tongji University/Shanghai First Maternity and Infant Hospital
Galaxy CARE Laparoscopy InstituteShandong University/Reproductive
Hospital Affiliated with Shandong University
Keio
University/Keio
University
Hospital
ChinesePeople's
Liberation
Army General
Hospital
Nagoya Daini
Cross Hospital
Jilin University/The
JilinRed
University
Second Hospital
Catholic
University/Daejeon
St. Mary's
Hospital
GalaxyCARE Laparoscopy
Institute

Pune
Jinan
Tokyo
Beijing
Nagoya
Jilin
Seoul
Pune

J. Clin. Med. 2019, 8, 245

3 of 13

3. Basic UTx Research
A relatively large number of basic UTx studies in large animals, including non-human primates,
have been performed in Asia, compared to other areas of the world (Table 2). Among them, Kisu’sgroup from Keio University Hospital in Tokyo, Japan has accumulated a large UTx data archive inlarge animal basic studies. There are an estimated 50,000–60,000 women of reproductive age with AUFIin Japan [3] and gestational surrogacy is forbidden in Japan [4]. Basic research on UTx in animals has
been performed for approximately 10 years based on the view that extensive training and preparation
through preclinical experiments, as also done by the Swedish group for over a decade, are likely to benecessary for successful human UTx.
UTx research in a non-human primate (cynomolgus macaque) was launched in 2009 because
the guidelines of the International Federation of Gynecology and Obstetrics (FIGO) indicate that
adequate studies in large animals, including primates, should be conducted before clinical applicationof UTx in humans [5]. Experiments in more than 80 cynomolgus macaques have now been performed,
since these animals are anatomically and physiologically similar to humans, but are about the same
size as human newborns (approx. 3 kg); therefore, a delicate surgical technique is required. A large
amount of data has been accumulated, as described in a previous review [6], including examinationof uterine blood flow [7–9], surgical procedures for autologous and allogeneic UTx [9–14], methods
for organ perfusion in a deceased donor model [15], immunological response and rejection [16], andischemia/reperfusion injury [17,18]. The major achievements include the first natural pregnancy anddelivery after autologous UTx in primates and the first pregnancy after allogeneic UTx in a non-humanprimate experimental model in 2012 [11] and 2018 (unpublished data), respectively. Another Japanesegroup, led by Yamamuro at Nagoya Daini Red Cross Hospital, is currently preparing for launch of
UTx animal experiments, but none have been performed to date.
Most UTx groups in Asia are based in China, the reason for which might be under the backgroundthat domestic animal studies of UTx began earlier in Asia. At the start of the century, three Chinesegroups began to explore animal models of UTx at almost the same time, and also at about the time
UTx research began in Sweden. However, results of the studies in China were published in domestic
journals, and thus failed to achieve international attention until Wei’s group (Xijing Hospital, X’ian)performed the first human UTx in China [19]. UTx studies in rat, rabbit, dog, pig, cynomolgus monkey
and rhesus monkey have produced important information on vascular harvesting, uterine perfusion,ischemia injury, uterus preservation, and characteristics of graft rejection after allogeneic UTx. Livebirths have been achieved after syngeneic UTx in rat [20] and autologous UTx in dog [21] models.
Research findings from the seven Chinese groups (Table 1) are summarized below.
Wei’s group at Xijing Hospital (Fourth Military Medical University, Xi0 an) performed allogeneic
UTx in 10 sheep as a pilot study prior to human application [22]. The advantage of using sheep is thatthe body size and pelvic vascular anatomy are similar to those in young women, although the uterus
is bicornuate. Techniques for orthotopic and allogeneic UTx and subsequent immunosuppressive
protocols were developed and evaluated in sheep. Two of the 10 transplanted uteri showed signs of
estrus after transplantation.
Based on the FIGO recommendations [5], since 2010 Wang and Yu’s group at Zhujiang Hospital(Southern Medical University, Guangzhou) have prepared for UTx in non-human primates throughexperiments in the cynomolgus macaque model. In four initial autologous UTx procedures, one animal
died intraoperatively due to venous hemorrhage. At 30–45 days after UTx, second-look laparotomy
was performed in the surviving animals, but no signs of cyclicity and menstruation were found. Theinternal genitalia and pelvic cavity had severe adhesions and the utero-tubo-ovarian system wasatrophic. This team subsequently attempted two allogeneic UTxs, but with poor postoperative results.
It is regrettable that this initial outcome has yet to be published (Table 2).

J. Clin. Med. 2019, 8, 245

4 of 13

Table 2. Basic UTx research in Asia.
Country

Team Leader
Wei L

Wang YF/Yu P

Animals

Study

Number

Evaluation

Sheep

Allogeneic UTx

10

UPT

Showing signs of estrus after allogeneic UTx in 2 of 10 transplanted uteri

Cynomolgus
macaque

Autologous UTx

4

UPT

Out of four animals, one died intraoperatively due to venous hemorrhage.
Surviving animals underwent second-look laparotomy within 30–45 days

Allogeneic UTx

2

UPT

One animal died on postoperative day 2 because of abdominal infection. One
survived without cyclicity or menstruation

Cynomolgus
macaque

Autologous UTx

6

UPT

Recovery of menstruation (2 of 6) but no pregnancy

Allogeneic UTx

4

UPTNo menstruation after alloUTx

Rhesus macaque

Allogeneic UTx

2

UPTNo menstruation after alloUTx but cyclicity resumed in one animal

RabbitAllogeneic UTx

2

UPT

Successful allo UTx with short-term survival

Perfusion

4

Uterine harvesting andperfusion

Successful uterine harvesting and perfusion (3/4)

N/A (ongoing)

N/A

Wang YF/Chen GW

Hua KQ/Liu Y

China

Cynomolgus
macaque

Allogeneic UTx

Rat

Syngeneic UTx

10

UPT

Restored fertility (50%) with live birth to 20 rats

Syngeneic UTx

30

UPT

Recipient survival 60% (18/30), graft survival 83.3% (15/18)

Syngeneic UTx

60

UPT

Recipient survival 88.3% (53/60), graft survival 88.7% (47/53) Establishing UTxmodels in rats

Allogeneic UTx

30

Rejection patterns of uterine
transplant

Recipient survival 100%, acute rejection of allogeneic UTx in rats involves IFN-γ

Allogeneic UTx

36

Immunosuppressive therapy

Recipient survival 100%, Cyclosporine A has significant therapeutic effect on
allograft rejection after UTx in rats

Dog

Autologous UTx

10

UPT

Recipient survival rate 60% (6/10), graft survival 66.7% (4/6) with 2 long-term
survival, one hormone-induced estrus and vaginal delivery of 3 live puppies

Pig

Autologous UTx

5

UPTThree survived from surgery, one long-term survival (>6 mo)
Surgical success 100%, long-term survival 80%, one had temporary
estrus resumed

Wan XP

Chen ZJ

Allogeneic UTx

5

UPT

Rhesus macaque

Allogeneic UTx

1

UPTDeath due to chronic failure 28 days after surgery

Dog

Allogeneic UTx

8

UPTFive survived from surgery, none survived more than 96 h

Ischemia

10

Allowable warm ischemic time

Acceptable warm ischemia time for UTx in dogs is up to 60 min

Unknown

Unknown

Unknown

Unknown

Yao YQ

Zhang WY
India

Puntambekar S

Main Outcome

J. Clin. Med. 2019, 8, 245

5 of 13

Table 2. Cont.
Country

Japan

Team Leader

Study

Number

Evaluation

Main Outcome

Cynomolgus
macaque

Autologous UTx

9UPT

Pregnancy and delivery after auto-UTx

Allogeneic UTx

14

UPT

Pregnancy after allo-UTx

Uterine blood flow

1

Uterine blood flow using ICG
fluorescence

ICG fluorescence imaging is useful for evaluation of uterine blood flows

Procurement

22

Minimally invasive donor
surgery

Using ovarian veins reduce risks for donors

Ischemia

18

Warm ischemia/reperfusion
injuryAllowable warm ischemic time >4 h

Perfusion

3

Organ perfusion in brain deaddonor models

Perfusion via femoral artery and/or external iliac artery could be useful

Uterine rejection

3

Clinical features associatedwith irreversible rejection

Increases in WBC, LDH and CRP and uterine shrinkage after transient swellingin irreversible rejection

N/A

N/A

10

UPT

Successful perfusion after autologous UTx

Bioengineering

60

Bioengineered uterus using abioscaffold

Establishment of protocol for decellularization of rat uterus

Pig

Autologous UTx

3

UPT

Successful perfusion after autologous UTx

Sheep

Autologous UTx

1

UPT

Successful UPT

Allogeneic UTx

1

UPT

Successful UPT

Autologous UTx

1

UPT

Successful UPT

Allogeneic UTx

2

UPT

Any evidence of hyperacute rejection for up to 6 h postoperatively

Allogeneic UTx

3

UPTFunctional uterus after allogeneic UTx

Kisu I

Yamamuro O

Korea

Animals

N/A

N/A

Rat

Autologous UTxSong MJ

SingaporeTan HK

Cynomolgus
macaqueTaiwanLin WCSheep* UPT: uterine procurement and transplantation, ICG: indocyanine green, WBC: white blood cell, LDH: lactate dehydrogenase, CRP: C-reactive protein.

J. Clin. Med. 2019, 8, 245

6 of 13After accumulating knowledge and skills in previous work, Wang and Chen’s group (Zhujiang
Hospital, Guangzhou) further optimized surgical strategies in 6 autologous [23] and 4 allogeneic
UTxs in cynomolgus macaques and two allogeneic UTxs in rhesus macaques (unpublished data).
Menstruation recovered following two of the autologous UTxs, but with no subsequent pregnancy.
In the allogeneic UTx models, no menstruation was established, but cyclicity resumed in one
rhesus macaque postoperatively. In these studies, different surgical protocols were used for venous
anastomosis in the primate models, and finally anastomosis of utero-ovarian veins, rather thanuterine veins, was chosen to reestablish drainage of the transplanted uterus. All animals, including
those resuming menstruation, underwent second-look laparotomy or autopsy, in which moderate
to severe pelvic adhesion over the internal genitalia was found in all cases. Therefore, IVF-ET(in-vitro fertilization-embryo transfer) was abandoned in two menstruating cynomolgus macaques
after autologous UTx. Despite the poor results of allogeneic UTx, performance of UTx in a primate
model provides ideal training for surgeons in vascular dissection and anastomosis. This then permits
effective procurement of the uterus in brain-dead human donors.
There are two UTx groups in Shanghai. Hua and Liu’s group at the Obstetrics and Gynecology
Hospital (Fudan University) has done extensive research on preservation of female fertility [24,25].
This group has treated a significant number of patients with genital malformation who wanted to havetheir own child, and are committed to extending UTx to the clinical stage [26,27]. The New Zealandwhite rabbit was chosen as the primary animal model for UTx because the use of primates as animalmodels for development of surgical methods raises ethical and economic concerns. In addition, UTx
using rabbits had not been performed in China. Two allogeneic UTxs were performed in rabbits andshort-term survival occurred in both cases. The surgical protocol and immunosuppressive therapy
were learned from a British group [28,29]. Due to the small complicated branch of the rabbit uterus
blood vessels, a modified perfusate containing nitroglycerin had to be used to achieve adequate
uterine perfusion. The two allogeneic UTx procedures were completed, but long-term survival was
not achieved and histopathology showed severe uterus rejection, with immunosuppression withtacrolimus and hydrocortisone seemingly insufficient (unpublished data). Further exploration of theseresults is required. Thereafter, this group observed UTx in a cynomolgus macaque conducted by
Kisu’s group in July 2018, and studied the allogeneic UTx cynomolgus macaque model with regard to
aortic-caval macrovascular patch harvesting, MHC gene typing, and the immunosuppression protocol,
which are all important for the success of the procedure. Studies using the cynomolgus macaque are
currently being established in Hua and Liu’s group.
Wan’s group from Shanghai First Maternity and Infant Hospital (Tongji University) has done a lotof work in establishing UTx models in rats, and examining rejection patterns and immunosuppressive
therapy for allogeneic UTx in rats [30–33]. The most important study used 20 female Wistar rats aged
8–10 weeks as donors and recipients, and the recipients then mated spontaneously with male Wistar
rats for 12 weeks. Ten UTx procedures in syngeneic rats succeeded in restoring fertility in 50% of theanimals, with live birth of 20 rats (20). No recent results have been reported by this group.
In 2001, when the first UTx research started in China, Chen’s group from the Reproductive
Hospital (Shandong University, Jinan) explored orthotopic uterus autologous UTx models in 10 beagle
bitches, of which 6 survived surgery with a 66.7% (4/6) graft survival rate, and 2 achieved long term
survival, including one with hormone-induced estrus that delivered 3 live puppies vaginally [21].
Thereafter, another group led by Zhang from The Jilin University Second Hospital in Jilin performed
allogeneic UTx on mongrel dogs. This study revealed that the acceptable warm ischemia time for UTx
in dogs is up to 60 min, and 5 dogs (62.5%) survived the surgery, but none survived for >96 h [34].
The main reasons for the poor survival were anastomotic bleeding and infection. Nowadays, dogs are
seldom used as a UTx model.

J. Clin. Med. 2019, 8, 245

7 of 13

Ten years later, Yao’s group from the Chinese People’s Liberation Army General Hospital in
Beijing performed autologous UTx in 5 pigs, of which 3 survived surgery, including one with long-term
survival of >6 months. This group then performed allogeneic UTx in a rhesus macaque that survived
for 28 days after surgery, with a probable cause of death of organ failure due to anorexia and chronic
anemia, without pathological evidence of rejection [35]. Recently, Yao’s group reported allogeneic UTx
in 5 pigs, with 100% surgical success and 80% long-term survival. One pig resumed temporary estrus,
but gestation was not achieved after artificial embryo transfer [36].
In Korea, Song’s group from the Catholic University Medical Center (Catholic University, Seoul)
has accumulated experimental and clinical data in collaboration with Brännström et al. in Sweden.
This group conducted autologous UTx in 10 rats and 3 domestic pigs, and achieved successfulorgan perfusion after autologous UTx in these animals. The Korean group has also developed abioengineered uterus in rats for future UTx. The Korean and Swedish groups have established a
protocol for decellularization of the rat uterus and are now examining bioscaffold rejection. Song’s
group also observed UTx in cynomolgus macaques conducted by Kisu’s group in Japan in July 2018
and is ready to perform preclinical studies such as fresh cadeveric uterine dissection.
In Singapore, initial interest in exploring the feasibility of UTx led to informal discussions in 2012
between the Departments of Obstetrics and Gynaecology and Plastic and Reconstructive Surgery at
Singapore General Hospital, the largest tertiary teaching hospital in Singapore. In 2013, a Uterine
Transplantation Group (Tan’s group from Singapore General Hospital) was formed, comprisinggynaecologists, vascular surgeons, plastic surgeons, transplant physicians, high-risk obstetricians,and psychologists. One autologous UTx, followed by two allogeneic UTxs, in cynomolgus macaques
were performed (one autologous and one allogeneic UTx under the supervision of Dr. Kisu) anduterine procurement and reimplantation were achieved. The allogeneic UTx did not show evidence ofhyperacute rejection for up to 6 h postoperatively with the immunosuppression regime used. One
autologous and one allogeneic UTx in sheep were then conducted in Gothenburg, Sweden, under
the supervision of Dr. Brännström and his group, and these resulted in two successful sheep uterine
procurements and transplantation.
In Taiwan, Lin’s group from China Medical University Hospital in Taichung have set up the teamfor the uterine transplantation and performed three autologus UTx in sheep models. In these three
sheep, two were confirmed functional uteri after surgery. Gestational surrogacy is forbidden in Taiwan,
and researchers need to provide an animal model report to prove sufficient training and preparation
based on preclinical experiments prior to clinical application.
4. Preclinical ResearchPreclinical studies using human cadavers or deceased multi-organ donors are likely to beparticularly important before clinical application, especially for surgical training (Table 3). Kisu’sgroup in Tokyo has performed four fresh cadaveric uterus dissections and transplantations to simulate
UTx in humans, two of which were conducted in collaboration with the Singaporean group at the endof 2015. These procedures resulted in two completely dissected uterus specimens, and led to technicaladvancements in the surgical procedure for dissection of vessels surrounding the uterus and retrieval
and reimplantation of the uterus. Kisu’s group and Song’s group in Seoul also observed two human
UTx procedures with robot-assisted donor surgery performed in Sweden in April 2018 to learn surgicalskills and details of postoperative management.

J. Clin. Med. 2019, 8, 245

8 of 13

Table 3. Preclinical studies and human UTx research in Asia.
Country

Team Leader

Performance of UTx

Pre-Clinical Study or Human UTxMain Outcome

Approval of EthicalCommittee

Wei L

Yes

First human robot-assisted UTx

Successful uterine procurement and recovery ofuterine function

Done

Cold ischemic preservation of uterine tissue, uteri retrieval(8 cases), organ perfusion and ischemic study (4 cases)* All studies performed from brain-dead donors

Show that uterine tissues are nearly normal in
2.5 h after perfusion
Confirm different perfusion methods via
external iliac artery or abdominal aorta.

UTx with living donor by laparoscopic donor surgery

Removal of transplanted uterus 30 days after
surgery (acute left uterine vein thrombosis)

No-

OngoingWang YF/
Chen GW
China

India

Yes

Hua KQ/Liu Y

No

Wan XP

No

No

-

No

Chen ZJNo

Allowable cold ischemic time in human uterus with HTK(histidine-tryptophan-ketoglutarate) as perfusate (4cases)

Human uterine myometrial tissue tolerates
cold ischemia for at least 6 h in HTK solution

Done

Yao YQ

No

No

-

No

Zhang WY

No

No

-

No

Puntambekar S

Yes

UTx with living donor by laparoscopic donor surgery

First successful delivery in Asia

Done

Kisu INo

Cadeveric uterine dissection (4 cases)* 2 cases performed with Singaporean teamSuccessful dissection of vessels surrounding
the uterus and retrieval of the uterus

No

Yamamuro O

No

No

-

No

Song MJ

No

No

-

No

Successful dissection of vessels surrounding
the uterus and retrieval of the uterus

Done

-

No

Japan
Korea

Done

SingaporeTan HK

No

Cadeveric uterine dissection (3 cases)* 2 cases performed with Japanese team

TaiwanLin WCNoNo

J. Clin. Med. 2019, 8, 245

9 of 13Since 2015, Wang and Chen’s group in Guangzhou, which has conducted most preclinical studies
in Asia, performed uterine retrieval from a brain-dead donor (URBD) in 8 cases (partial data publishedin a Chinese journal) [37], with the aim of exploring standard procurement techniques and assessing
the feasibility of perfusion methods with different protocols. Using different surgical strategies ofradical hysterectomy and trachelectomy, it was found that radical en-bloc resection of parametrial
tissue should be performed, instead of exposure of the uterine artery, vein and ureter, in URBD to
avoid vascular rupture. Procurement of the uterus synchronized with liver retrieval was also achievedin the third and fourth case. Interestingly, this group plans to evaluate the outcome of various organ
perfusion solutions at 4 ◦ C using heparinized physiological saline, histidine-tryptophan-ketoglutarate(HTK), UW and Celsior. The group has also screened more than 280 women with AUFI and ultimately
selected 11 for human UTx, including one who has already undergone UTx (unpublished data).
In another study, Chen’s group investigated the safety of cold extracorporeal perfusion with HTK
and ischemic storage of the human uterus, and found that human uterine myometrial tissue cantolerate cold ischemia for at least 6 h when stored in HTK solution after a short time of extracorporeal
perfusion [38]. Updates on clinical registration for human UTx are awaited from this group.
5. UTx in Humans
Clinical applications of UTx in Asia have only been achieved in China and India, although there aremany groups in Asia that have examined animal models of UTx in preparation for clinical application(Table 3). Of the 3 UTx procedures in humans in China to date, two were carried out by this group,and the other by Wang and Chen’s group. Wei’s group in Xi’an performed the first robot-assisted UTx
worldwide in November 2015, in which a woman with Mayer-Rokitansky-Küster-Hauser (MRKH)
syndrome received a uterus from her mother, and had recovered periodic menstruation without
rejection at one year after surgery under the standard maintenance immunosuppression (tacrolimus,
steroids, and mycophenolate mofetil (MMF)) [22]. Donor surgery is regarded as highly invasive, andless invasive donor procedures are needed. Therefore, this first trial of robot-assisted donor surgeryemphasized the benefits of minimally invasive methods for procurement of the uterus. Also, a new
operative procedure was developed for using the ovarian vein as a drainage vein instead of the uterinevein, leading to a reduced operative time and bleeding volume. Consequently, use of robotic surgery
and the ovarian vein are likely to reduce risks in living donor surgery for UTx.
Wang and Chen’s group in Guangzhou performed human UTx from mother to daughter with
MRKH syndrome using laparoscopic donor surgery in February 2017 (unpublished data). Vasculargrafts harvested with the uterus included the hypogastric arteries, uterine vein and ovarian veins.
Uterine veins were anastomosed to external iliac veins after lengthening using the great saphenous
veins of the donor. Standard maintenance immunosuppressants were used after surgery. Unfortunately,
the transplanted uterus had to be removed on postoperative day 30 due to acute left uterine veinthrombosis caused by the long vascular graft.
Puntambekar’s group from the Galaxy CARE Laparoscopy Institute (Pune, India) performed
two UTxs with laparoscopic live-donor uterus retrieval on two successive days in May 2017 [39,40].
The recipients were patients with MRKH syndrome and Asherman syndrome, respectively, and theirmothers were the donors. Vessels were harvested laparoscopically in both donors, and the uterus
with vascular pedicles was retrieved via a small abdominal incision to prevent injury to the harvested
vessels. The operative time for the donor surgery was 4 h and blood loss was approximately 100 mL
in both donors, indicating a reduced operative time and bleeding volume. Both recipients started
regular menstruation after UTx under the standard maintenance immunosuppressants. In a press
release [41], it was announced that one patient had delivered a baby in October 2018, as the first baby
born after UTx in Asia and after laparoscopic donor surgery. This outcome shows that laparoscopic
donor surgery is feasible and has the advantages of a minimally invasive technique, which is likely tomotivate the performance of minimally invasive UTx.

J. Clin. Med. 2019, 8, 245

10 of 13

6. Future Directions in Asia
UTx in humans has been conducted worldwide, but more studies are required before UTx can beconsidered to be a part of general clinical practice. There are many medical, ethical, social and religious
issues to be resolved, and the backgrounds to these issues vary among countries in Asia. The ethicalaspects of UTx require a thorough discussion in the context of each background.
In Japan, UTx has yet to reach the point of clinical application despite accumulation of a lot ofdata in animal models. Clinical practice requires not only technology and knowledge acquisition inbasic experiments, but also discussion in institutions and academic societies, and consensus-buildingin the public. To address ethical and social problems, since 2012 more than 10 meetings with academics
and specialists in obstetrics and gynecology, surgery, ethics, philosophy, clinical psychology andnursing, and with a representative group of patients with infertility, have been held to discuss clinicalapplication of UTx. In 2014, the Japan Society for Uterus Transplantation (JSUT) was establishedbecause discussions beyond the internal debate and conveyance of information to the public wereneeded for further progress [42]. The JSUT informs the public about UTx technology; addresses
medical, social and ethical perspectives on UTx; and discusses clinical application of UTx in Japan.
In 2018, Kisu’s group from Keio University Hospital in Tokyo requested that the Japan Society of
Obstetrics and Gynecology and the Japan Society for Transplantation establish a consensus on clinicalapplication of UTx in Japan. The Japanese Association of Medical Science plans to set up a jointcommittee of multidisciplinary experts. Due to concern regarding the burden of the donor in thesurgical procedure and the Japanese conservative view of innovative techniques with limited evidence,
discussion on clinical application in Japan is unlikely to proceed smoothly.
Gestational surrogacy is forbidden in China, and although adoption can lead to legal motherhood,
only UTx gives the mother legal, biological and gestational motherhood. Clinical application of UTx in
China had been attempted since 2015, with three UTxs performed from living donors (one at Zhujiang
Hospital and two at Xijing Hospital). No pregnancy has been reported and detailed data will be publishedin the near future. Progress on the ethics of human UTx in China seems slow (unpublished data), despite
development of various UTx models in different animals and preclinical studies, as discussed above.
A national internet-based survey is suggested regarding the attitudes of the public and gynecologists
towards UTx. It is recognized that recipients should be adequately informed of the surgical qualificationsof the group, the risks of transplantation surgery and immunosuppressive treatment; possible pregnancy
complications under immunosuppression; and the potential need for a subsequent hysterectomy.
From social and legal perspectives, UTx seems to have gained more acceptance in China comparedwith Japan and other countries in Asia. Thus, a few Chinese researchers have received government
grants to conduct basic and clinical studies of UTx. However, since the senior researchers prefer topublish their outcomes in Chinese journals in the parent language, most of the results are unknown
outside China. It would be positive for the Chinese groups to establish an academic society for UTx, as
done by Kisu’s group, but based on Chinese cultural traditions and socioeconomic conditions. Regularacademic meetings will promote mutual learning, raise public awareness of UTx, and allow exchangeof the latest developments on UTx at the international level. The first case worldwide of live birthfollowing UTx from a deceased donor in Brazil is inspiring [43], and recent conference data shows that
more than 600,000 people have registered to become volunteer organ donors in China, with nearly
20,000 having donated organs [44]. Thus, the UTx groups can work with the China Organ Transplant
Response System (COTRS) and Red Cross office to address the ethics of uterine transplants.
In Korea, it is estimated that there are more than 10,000 women of reproductive age with AUFI
based on the prevalence (there are no published statistical data) and gestational surrogacy is forbidden.
The team at Catholic University Medical Center set up a UTx task force in 2014 to conduct preclinicaland animal studies, as preparation for human UTx. This task force plans to establish a multidisciplinary
expert meeting, including gynecologists, transplant surgeons, ethical scholars, priests and clinicalpsychologists, to address medical, ethical and social problems; and is also ready to launch the Korean

J. Clin. Med. 2019, 8, 245

11 of 13Society of Uterus Transplantation to inform the public about UTx and promote collaboration among
academic groups.
In Singapore, the UTx group has successfully obtained approval from the Bioethics andCentralized IRB (Institutional Review Board). However, Singapore recently enacted a Human
Biomedical Research Act, and the group has submitted their UTx research project to the Ministry of
Health through the Tissue and Research Application System. Permission from the Ministry is likely. In
Taiwan, completion of practice in animals and sharing the data with the Ministry of Health and Welfare
is required for approval of a new technique. The Taiwan Association of Obstetrics and Gynecology has
welcomed progress in UTx but the institution or hospital which plans to perform the procedure need
to obtain approval of the practice from the government. Regarding Puntambekar’s group in India,
which is the only one in Asia to succeed in delivery after UTx, further procedures and deliveries arelikely, along with sharing of accumulated experience and techniques, especially in laparoscopic donor
surgery, in Asia and worldwide.
7. Conclusions
Despite still being in the experimental stage, UTx is now a possible approach for women with
AUFI to deliver a child. Clinical application of UTx has spread rapidly to many countries, including in
Asia, following the first successful delivery after UTx in Sweden. This has led several groups to conduct
UTx and many to prepare for clinical trials. However, we notice that several medical centers aroundthe globe are declaring a potential schedule for human UTx without adequate preparatory studies.
Establishment of UTx as a new therapy requires accumulation of clinical study data, thorough training
and testing in animal models, and international collaboration and information sharing. Moreover,differences in social, ethical and religious backgrounds among countries make it important to examine
whether the clinical use of UTx is desirable in each society. It is likely that UTx will expand rapidly
in Asia in countries with differences in these backgrounds. Therefore, we believe that it is beneficial
to understand the current situation of UTx in each country, to share progress and knowledge, and tocollaborate with each other internationally to ensure the future development of UTx in Asia.
Author Contributions: Each author wrote part of this paper. I.K. was responsible for final editing. I.K., Y.L. and
G.C. contributed equally to the paper. All authors read and approved the final manuscript.
Conflicts of Interest: The authors declare no conflict of interest.

References
1.

2.
3.

4.
5.
6.
7.

Brännström, M.; Johannesson, L.; Bokstrom, H.; Kvarnstrom, N.; Molne, J.; Dahm-Kahler, P.; Enskog, A.;
Milenkovic, M.; Ekberg, J.; Diaz-Garcia, C.; et al. Livebirth after uterus transplantation. The Lancet 2015, 385,
607–616. [CrossRef]
Kisu, I.; Banno, K.; Mihara, M.; Suganuma, N.; Aoki, D. Current status of uterus transplantation in primatesand issues for clinical application. Fertil. Steril. 2013, 100, 280e94. [CrossRef] [PubMed]
Kisu, I.; Banno, K.; Soeda, E.; Kurihara, Y.; Okushima, M.; Yamaguchi, A.; Nakagawa, E.; Umene, K.;
Aoki, D. Survey of attitudes toward uterus transplantation among Japanese women of reproductive age:
A cross-sectional study. PLoS ONE 2016, 11, e0156179. [CrossRef] [PubMed]
Kisu, I.; Banno, K.; Mihara, M.; Iida, T.; Yoshimura, Y. Current status of surrogacy in Japan and uterine
transplantation research. Eur. J. Obstet. Gynecol. Reprod. Biol. 2011, 158, 135–140. [CrossRef] [PubMed]
Milliez, J. Uterine transplantation FIGO Committee for the Ethical Aspects of Human Reproduction and
Women’s Health. Int. J. Gynaecol. Obstet. 2009, 106, 270. [CrossRef] [PubMed]
Kisu, I.; Banno, K.; Matoba, Y.; Adachi, M.; Aoki, D. Basic research on uterus transplantation in nonhumanprimates in Japan. J. Obstet. Gynaecol. Res. 2018, 44, 1871–1881. [CrossRef] [PubMed]
Kisu, I.; Banno, K.; Mihara, M.; Lin, L.Y.; Tsuji, K.; Yanokura, M.; Hara, H.; Araki, J.; Iida, T.; Abe, T.; et al.
Indocyanine green fluorescence imaging for evaluation of uterine blood flow in cynomolgus macaque.
PLoS ONE 2012, 7, e35124. [CrossRef] [PubMed]

J. Clin. Med. 2019, 8, 245

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.
21.
22.

23.

24.

12 of 13

Kisu, I.; Banno, K.; Yanokura, M.; Nogami, Y.; Umene, K.; Tsuji, K.; Masuda, K.; Ueki, A.; Kobayashi, Y.;
Aoki, D. Indocyanine green fluorescence imaging in the pregnant cynomolgus macaque: Childbearing
is supported by a unilateral uterine artery and vein alone? Arch. Gynecol. Obstet. 2013, 288, 1309–1315.
[CrossRef] [PubMed]
Mihara, M.; Kisu, I.; Hara, H.; Iida, T.; Yamamoto, T.; Araki, J.; Hayashi, Y.; Moriguchi, H.; Narushima, M.;
Banno, K.; et al. Uterus autotransplantation in cynomolgus macaques: Intraoperative evaluation of uterine
blood flow using indocyanine green. Human Reprod. 2011, 26, 3019–3027. [CrossRef] [PubMed]
Kisu, I.; Mihara, M.; Banno, K.; Hara, H.; Yamamoto, T.; Araki, J.; Iida, T.; Hayashi, Y.; Moriguchi, H.; Aoki, D.
A new surgical technique of uterine auto-transplantation in cynomolgus monkey: Preliminary report about
two cases. Arch. Gynecol. Obstet. 2012, 285, 129–137. [CrossRef]
Mihara, M.; Kisu, I.; Hara, H.; Iida, T.; Araki, J.; Shim, T.; Narushima, M.; Yamamoto, T.; Moriguchi, H.;
Kato, Y.; et al. Uterine autotransplantation in cynomolgus macaques: The first case of pregnancy and delivery.
Human Reprod. 2012, 27, 2332–2340. [CrossRef] [PubMed]
Kisu, I.; Mihara, M.; Banno, K.; Hara, H.; Masugi, Y.; Araki, J.; Iida, T.; Yamada, Y.; Kato, Y.; Shiina, T.; et al.
Uterus allotransplantation in cynomolgus macaque: A preliminary experience with non-human primate
models. J. Obstet. Gynaecol. Res. 2014, 40, 907–918. [CrossRef] [PubMed]
Kisu, I.; Banno, K.; Mihara, M.; Hara, H.; Umene, K.; Adachi, M.; Nogami, Y.; Aoki, D. A surgical
technique using the ovarian vein in non-human primate models of potential living-donor surgery of uterustransplantation. Acta Obstet. Gynecol. Scand. 2015, 94, 942–948. [CrossRef] [PubMed]
Obara, H.; Kisu, I.; Kato, Y.; Yamada, Y.; Matsubara, K.; Emoto, K.; Adachi, M.; Matoba, Y.; Umene, K.;
Nogami, Y.; et al. Surgical technique for allogeneic uterus transplantation in macaques. Sci. Rep. 2016, 27,
35989. [CrossRef] [PubMed]
Kisu, I.; Kato, Y.; Yamada, Y.; Matsubara, K.; Obara, H.; Emoto, K.; Adachi, M.; Umene, K.; Nogami, Y.;
Banno, K.; et al. Organ perfusion for uterus transplantation in non-human primates with assumed
procurement of a uterus from a brain-dead donor. Transplant. Proc. 2016, 48, 1266–1269. [CrossRef] [PubMed]
Kisu, I.; Kato, Y.; Yamada, Y.; Matsubara, K.; Obara, H.; Emoto, K.; Adachi, M.; Umene, K.; Nogami, Y.;
Banno, K.; et al. Clinical features indicating irreversible rejection after uterus allotransplantation incynomolgus monkey. Transplantation 2016, 100, S457–S458.
Adachi, M.; Kisu, I.; Nagai, T.; Emoto, K.; Banno, K.; Umene, K.; Nogami, Y.; Tsuchiya, H.; Itagaki, I.;
Kawamoto, I.; et al. Evaluation of allowable time and histopathological changes in warm ischemia of theuterus in cynomolgus monkey as a model for uterus transplantation. Acta Obstet. Gynecol. Scand. 2016, 95,
991–998. [CrossRef]
Kisu, I.; Umene, K.; Adachi, M.; Emoto, K.; Nogami, Y.; Banno, K.; Itagaki, I.; Kawamoto, I.; Nakagawa, T.;
Narita, H.; et al. Allowable warm ischemic time and morphological and biochemical changes in uterine
ischemia/reperfusion injury in cynomolgus macaque: A basic study for uterus transplantation. Human
Reprod. 2017, 32, 2026–2035. [CrossRef]
Wei, L.; Xue, T.; Tao, K.S.; Zhang, G.; Zhao, G.Y.; Yu, S.Q.; Cheng, L.; Yang, Z.X.; Zheng, M.J.; Li, F.;et al. Modified human uterus transplantation using ovarian veins for venous drainage: The first report ofsurgically successful robotic-assisted uterus procurement and follow-up for 12 months. Fertil. Steril. 2017,
108, 346–356. [CrossRef]
Yan, Q.; Wan, X.P.; He, X.Y.; Wu, X.M.; Yang, Y.X.; Xi, X.W. Establishing of the model of orthotopic uterine
transplantation in syngeneic rats. Chin. J. Organ. Trasplant. 2006, 27, 562–563.
Shen, Y.; Wang, Z.T.; Chen, Z.J.; Liu, X.M.; Sun, W.H.; Wang, L.H. Orthotopic uterus and ovary
autotransplantation in Beagle dogs. Chin. J. Microsurg. 2006, 29, 450–452.
Wei, L.; Xue, T.; Yang, H.; Zhao, G.Y.; Zhang, G.; Lu, Z.H.; Huang, Y.H.; Ma, X.D.; Liu, H.X.; Liang, S.R.; et al.
Modified uterine allotransplantation and immunosuppression procedure in the sheep model. PLoS ONE
2013, 8, e81300. [CrossRef]
Wang, Y.; Zhu, Y.; Yu, P.; Chen, G.; Cai, B.; Zhang, Z.; Liu, N.; Lu, X.; Xiong, J.; Zhong, L.; et al. Uterine
autologous transplantation in cynomolgus monkeys: A preliminary report of 6 case. Zhonghua Yi Xue Za Zhi
2014, 94, 3774–3777.
Ding, Y.; Shao, J.L.; Li, J.W.; Zhang, Y.; Hong, K.H.; Hua, K.Q.; Wang, X. Successful fertility following
optimized perfusion and cryopreservation of whole ovary and allotransplantation in a premature ovarian
insufficiency rat model. J. Ovarian Res. 2018, 11, 35. [CrossRef]

J. Clin. Med. 2019, 8, 245

25.

26.
27.

28.

29.

30.
31.
32.
33.
34.
35.
36.
37.

38.
39.

40.

41.
42.
43.

44.

13 of 13Xu, H.Y.; Tang, X.; Ding, J.; Qiu, J.; Zhang, X.; Hua, K. Ovarian conservation is associated with better survival
in young patients with T1N0M0 cervical adenocarcinoma: A population-based study. Arch. Gynecol. Obstet.
2018, 297, 775–784. [CrossRef]
Zhang, Y.; Chen, Y.; Hua, K. Outcomes in patients undergoing robotic reconstructive uterovaginal
anastomosis of congenital cervical and vaginal atresia. Int. J. Med. Robot 2017, 13, 1–6. [CrossRef]
Shen, F.; Zhang, X.Y.; Yin, C.Y.; Ding, J.X.; Hua, K.Q. Comparison of small intestinal submucosa graft withsplit-thickness skin graft for cervicovaginal reconstruction of congenital vaginal and cervical aplasia. Human
Reprod. 2016, 31, 2499–2505. [CrossRef]
Saso, S.; Hurst, S.; Chatterjee, J.; Kuzmin, E.; Thum, Y.; David, A.L.; Hakim, N.; Corless, D.J.; Boyd, M.;
Noakes, D.E.; et al. Test of long-term uterine survival after allogeneic transplantation in rabbits. J. Obstet.
Gynaecol. Res. 2014, 40, 754–762. [CrossRef]
Saso, S.; Petts, G.; Chatterjee, J.; Thum, M.Y.; David, A.L.; Corless, D.; Boyd, M.; Noakes, D.; Lindsay, I.;
Del Priore, G.; et al. Uterine Allotransplantation in a Rabbit Model Using Aorto-Caval Anastomosis:
A Long-Term Viability Study. Eur. J. Obstet. Gynecol. Reprod. Biol. 2014, 182, 185–193. [CrossRef]
Yan, Q.; Wan, X.P.; He, X.Y.; Xi, X.W.; Yang, Y.X. Establishment of the model of hetertopic uterine
transplantation in syngeneic rats. Chin. J. Obstet. Gynecol. 2005, 40, 291–294.
Yan, Q.; Wu, X.M.; He, X.Y.; Xi, X.W.; Yang, Y.X.; Wan, X.P. Study on orthotopic uterine transplantation insyngeneic rat. Shandong Med. J. 2009, 49, 10–11.
He, X.Y.; Yan, Q.; Wan, X.P.; Wu, X.M.; Qi, L.; Yang, Y.X.; Liu, L. Expression of cytokines in allogeneic uterustransplantation in rats. J. Shanghai Jiaotong Univ. (Med. Sci.) 2006, 26, 1339–1342.
He, X.Y.; Yan, Q.; Wan, X.P.; Xi, X.W.; Wu, X.M.; Tang, X.D. Observation of acute rejection after allogeneic
uterus transplantation in rats. Chin. J. Organ Transplant. 2006, 27, 181–183.
Hui, Y.C.; Zhang, W.Y. Exploratory study on orthotopic uterus allotransplantation in dogs. J. Math Med. 2015,
28, 658–659.
Zhang, X.L.; Yao, Y.Q.; Xiang, L. Application research on the technology of uterus allotransplantation in
rhesus monkey. J. Reprod. Med. 2017, 26, 927–931.
Zhang, X.; Liu, J.; Wu, Q.; Liu, Z.; Yan, Z. Uterus Allo-Transplantation in a Swine Model: Long-Term Graft
Survival and Reproductive Function. Med. Sci. Monit. 2018, 24, 8422–8429. [CrossRef]
Chen, G.W.; Liu, X.Y.; Cui, Z.Y.; Zheng, Y.H.; Jiang, H.W.; Yang, H.Y.; Lin, Y.Z.; Zhu, Y.; Wang, Y.; Li, X.X.;
et al. Surgical technique and outcomes of uteri retrieval from brain-dead multi-organ donors: A preclinicalresearch of human uterine transplantation. Zhonghua Yi Xue Za Zhi 2018, 98, 3178–3182.
Xu, X.X.; Liu, W.; Wan, J.P.; Li, T.; Wang, F.; Wang, X.; Yan, L.; Li, C.Z.; Chen, Z.J. Safety limit of cold
extracorporeal perfusion and ischaemic storage of human uterus. J. Shandong Univ. (Health Sci.) 2017, 55, 85–91.
Puntambekar, S.; Telang, M.; Kulkarni, P.; Jadhav, S.; Sathe, R.; Warty, N.; Puntambekar, S.; Kade, S.;
Panse, M.; Agarkhedkar, N.; et al. Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for
Uterine Transplant. J. Minim. Invasive Gynecol. 2018, 25, 571–572. [CrossRef]
Puntambekar, S.; Telang, M.; Kulkarni, P.; Puntambekar, S.; Jadhav, S.; Panse, M.; Sathe, R.; Agarkhedkar, N.;
Warty, N.; Kade, S.; et al. Laparoscopic-Assisted Uterus Retrieval From Live Organ Donors for Uterine
Transplant: Our Experience of Two Patients. J. Minim. Invasive Gynecol. 2018, 25, 622–631. [CrossRef]
India’s First Uterine Transplant Baby Is a Girl. Available online: https://www.thehindu.com/news/cities/
mumbai/indias-first-uterine-transplant-baby-is-a-girl/article25275240.ece (accessed on 20 December 2018).
Suganuma, N.; Hayashi, A.; Kisu, I.; Banno, K.; Hara, H.; Mihara, M. Uterus transplantation: Toward clinicalapplication in Japan. Reprod. Med. Biol. 2017, 16, 305–313. [CrossRef]
Ejzenberg, D.; Andraus, W.; Mendes, L.R.B.C.; Ducatti, L.; Song, A.; Tanigawa, R.; Rocha-Santos, V.;
Arantes, R.M.; Soares, J.M., Jr.; Serafini, P.C.; et al. Livebirth after uterus transplantation from a deceased
donor in a recipient with uterine infertility. The Lancet 2018, 392, 2697–2704. [CrossRef]
Guo, Y. The “Chinese Mode” of Organ Donation and Transplantation: Moving Towards the Center Stage ofthe World. Hepatobiliary Surg. Nutr. 2018, 7, 615–662. [CrossRef]© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open accessarticle distributed under the terms and conditions of the Creative Commons Attribution(CC BY) license (http://creativecommons.org/licenses/by/4.0/).