BJOG ExchangeBenjamin P Jones,a,bSrdjan Saso,a,bc
Isabel Quiroga, Joseph Yazbek,a,b &J Richard Smitha,ba

West London Gynecological Cancer Centre,Hammersmith Hospital, Imperial CollegeNHS Trust, London, UK bDepartment ofSurgery and Cancer, Imperial College London,London, UK cThe Oxford Transplant Centre,
The Churchill Hospital, Oxford UniversityHospitals NHS Trust, Oxford, UK
Accepted 18 July 2019.
DOI: 10.1111/1471-0528.15912

Author’s replySir,
I thank you for the opportunity torespond to the letter submitted inresponse to my original article ‘UK
criteria for uterus transplantation: areview’.1 I read with interest the letter,as it is written by the members of theUK-based team that are soon toconduct uterus transplants.2 The information has clarified and supported
many of the points that I raised in
my article.
The response engages with three ofthe five criteria that I considered: theuse of own ovum by recipients, thepreference for a partner, and donors.
The authors have taken the time toclarify and provide the medical justifications for these selection criteria forthe research trials. Overall, the authorsagree with my own recommendations
on these three points; that although
medical justification currently does notsupport the use of donor ovum, thismay be alleviated in the future, that ‘it isinappropriate and unjust to exclude
single women and potential recipientswith appropriate social support shouldbe eligible for UTx’, and that the use ofdeceased donors should be prioritised ‘ifsimilar or superior outcomes aredemonstrated’. As I also acknowledged,
the authors note that the scarcity ofdeceased donors is a major limitation,

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and I welcome the news that the UKteam are pursuing research into bioengineered uteri. Although not yet arealistic option, bioengineered uteri will
overcome the concerns that I, andothers, have raised about living donation.3 The thoughts of the UK team on
the other two selection criteria that I
also raised in my article would bewelcomed.
What becomes apparent from theoriginal article and the response letter,is that there is an ongoing tension
between medical justifications for selection criteria, and legal and ethicaljustifications. In my article, the legal
and ethical justifications for selection
criteria were discussed, and theauthors’ response engages with themedical justifications. This is understandable considering the different
expertise and viewpoints from which
we are writing. It is not disputed that
medical justifications for selection criteria that support the best interests ofthe participants are not appropriate,
rather that as an outside (non-medical)
observer of uterus transplantation,
greater engagement by the medical
community with the legal and ethicalprinciples and other stakeholders
should be embraced. Interdisciplinary
approaches are welcomed and encouraged, particularly in the sphere of
reproductive medicine, where medicine, ethics, law, religion and cultural
perspectives all have a role to play. It is
recognised that the UK team haveengaged with non-medical stakeholders,4 and I hope that this continues,
both within the UK and with otherteams worldwide. &References
1 Hammond-Browning N. UK criteria for uterustransplantation: a review. BJOG 2019;126:1320–6.
2 Jones BP, Srdjan S, Quiroga I, Yazbek J, Smith
JR. Re. UK criteria for uterus transplantation: areview BJOG 2019;126:1507–8.
3 Williams NJ. Should deceased donation be
morally preferred in uterine transplantation
trials? Bioethics 2016;30:415–24.

4 Jones BP, Williams NJ, Saso S, Thum M-Y,Quiroga I, Yazbek J, et al. Uterine transplantation in transgender women. BJOG 2019;
126:152–6.

N Hammond-Browning
University of Gloucestershire, Oxstalls
Campus, Gloucester, UK
Accepted 21 August 2019.
DOI: 10.1111/1471-0528.15909

Re: Rethinking the time interval toembryo transfer after uterustransplantation – DUETS (DallasUtErus Transplant Study)Sir,
We read with great satisfaction andinterest the commentary by Johannesson
et al.1 entitled Rethinking the time interval to embryo transfer after uterus transplantation – DUETS (Dallas UtErus
Transplant Study). In this commentary,
the authors recommended a deceased
recipient graft time after uterus transplantation (UTx) to reduce the risks andlong-term side effects of immunosuppression, especially in the time fromtransplant to embryo transfer (ET).
The first successful live birth afterUTx was achieved in 2014 in Sweden.2 A
waiting period of 12–18 months for ET
after UTx was initially planned in theSwedish protocol, based on other solidorgan transplant recipients.3 However,UTx is a life-enhancing rather than lifesaving procedure, and an ephemeraltransplantation that differs from vitalorgan transplantations requiring longterm graft function for survival. Because
UTx has a different purpose to that ofvital organ transplantation, new criteria
for pregnancy in UTx should be considered based on risks to the recipientand fetus, and the adequacy of graftfunction. Therefore, we fully agree withthe comment of Johannesson et al.1 that‘the transplant-to-ET interval should
differ from recommendations in otherª 2019 Royal College of Obstetricians and Gynaecologists

BJOG Exchangeorgan and vascular allograft transplantations’.
The group in Dallas reported thefirst live birth after UTx in the USA
with a 6-month interval from transplant to ET, and further shortened therecipient graft time by immediate hysterectomy after delivery.4 Based on
their experience, they discussed several
key areas in which to decrease the timeframe, including embryo generation,
endometrial preparation, recovery aftersurgery, graft function, teratogenicity
due to immunosuppressants, risks ofacute rejection, viral infection that may
cause fetal disorder and premalignant
lesions, and a second pregnancy
attempt to minimise the risk of maternal mortality and morbidity. Regarding
the timing of hysterectomy after caesarean section, before the first delivery
in the USA,4 we strongly supported theSwedish view that hysterectomy shouldbe performed at least a few months
after delivery to ensure that the delivered baby is healthy and allow theuterus to return to its normal size.
Although simultaneous hysterectomy
after caesarean section may be more
complicated and may result in more

bleeding compared with regularabdominal hysterectomy, it is not adifficult procedure for a skilled surgeon. Therefore, hysterectomy at delivery appears reasonable to decrease theburden on a recipient by avoiding relaparotomy and longer-term immunosuppressant therapy. Moreover, shorter
intervention and observation periods inclinical trials will reduce the costs ofimmunosuppressants and examinations, which is beneficial for patientsand researchers.
The ‘patient-centered criteria’ todetermine the timing of ET recommended by the authors are not necessarily based on current establishedevidence, but the achievements using
these criteria by the authors and otherteams worldwide have great potential
for yielding novel criteria for the waiting
period between transplantation and ET
that differ from those for conventionalorgan transplantation. Therefore, thiscommentary on the time interval to ET
after UTx and shortening of the recipient graft time is particularly importantfor decreasing the burden on recipients.
This concept requires further discussion
for future UTx. &ª 2019 Royal College of Obstetricians and Gynaecologists

References
1 Johannesson L, Wall A, Putman JM, Zhang L,Testa G, Diaz-Garcia C. Rethinking the timeinterval to embryo transfer after uterustransplantation – DUETS(DallasUtErus
Transplant Study). BJOG 2019;126:1305–9.
€m M, Johannesson L, Bokstro€m H,2 Br€
annstro€m N, Mo€lne J, Dahm-K€
Kvarnstroahler P, et al.
Livebirth after uterus transplantation. Lancet
2015;385:607–16.
€m N, Mo€lne J, Dahm3 Johannesson L, Kvarnstro
K€ahler P, Enskog A, Diaz-Garcia C, et al.
Uterus transplantation trial: 1-year outcome.
Fertil Steril 2015;103:199–204.
4 Testa G, McKenna GJ, Gunby RT Jr, Anthony
T, Koon EC, Warren AM, et al. First live birth
after uterus transplantation in the UnitedStates. Am J Transplant 2018;18:1270–4.

Iori Kisu,
Kouji Banno, &Daisuke Aoki
Department of Obstetrics and Gynaecology,
Keio University School of Medicine, Tokyo,
Japan
Accepted 13 August 2019.
The authors of the original article were invited toreply, but did not feel that a response wasnecessary.
DOI: 10.1111/1471-0528.15921

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