Medicine:Uterus transplantation

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Short description: Surgical procedure

A uterine transplant is a surgical procedure whereby a healthy uterus is transplanted into an organism of which the uterus is absent or diseased. As part of normal mammalian sexual reproduction, a diseased or absent uterus does not allow normal embryonic implantation, effectively rendering the female infertile. This phenomenon is known as absolute uterine factor infertility (AUFI). Uterine transplant is a potential treatment for this form of infertility.

History

Studies

In 1896, Emil Knauer, a 29-year-old Austrian working in one of Vienna's gynecological clinics, published the first study of ovarian autotransplantation documenting normal function in a rabbit. This led to the investigation of uterine transplantation in 1918.[1][2] In 1964 and 1966, Eraslan, Hamernik and Hardy, at the University of Mississippi Medical Center in Jackson, Mississippi, were the first to perform an animal (dog) autotransplantation of the uterus and subsequently deliver a pregnancy from that uterus.[3] In 2010 Diaz-Garcia and co-workers, at Department of Obstetrics and Gynecology, University of Gothenburg in Sweden, demonstrated the world's first successful allogenic uterus transplantation, in a rat, with healthy offspring.[4]

As of 2023, more than 100 womb transplants have taken place, with around 50 babies having been born worldwide.[5][6]

Notable cases

Germany

Except perhaps in rare cases of intersex individuals, transgender women are born with a male reproductive system. While sex reassignment surgery can create a vagina for these women, the option of a uterus is unavailable to them, meaning they cannot carry a pregnancy and would need to take other routes to parenthood, whether it be a more traditional approach involving coitus or an alternative one such as adoption, egg donation, or a gestational carrier. Nonetheless, at least one uterine transplant for a trans woman occurred, for the Danish artist Lili Elbe (1882–1931).[7] Hoping to have children with her fiancée, she underwent a uterine transplant in 1931, in conjunction with vaginoplasty, in Germany at the age of 48. However, she developed a postsurgical infection and died from cardiac arrest just three months later.[8]

Saudi Arabia

The first modern day attempt at a uterine transplant occurred in 2000, in Saudi Arabia.[9] Wafa Fageeh[9] transplanted a uterus, taken from a 46-year-old patient, into a 26-year-old patient whose uterus had been damaged by hemorrhaging following childbirth.[10] Because the patient ultimately needed for the uterus to be removed after just 99 days, due to necrosis, whether or not the case is considered successful is disputed, but the uterus did function for a time, with the patient experiencing two menstrual cycles.[9] Members of the medical community have expressed concerns over the ethics of the procedure.[11]

Turkey

The first incidence of a uterine transplant involving a deceased donor occurred in Turkey on 9 August 2011; the surgery, performed by Ömer Özkan and Munire Erman Akar, at the Akdeniz University Hospital in Antalya, on Derya Sert, a 21-year-old patient who'd been born without a uterus.[12][13][14][15][16][17] In this case, the patient enjoyed long-term success with the transplanted uterus, experiencing periods and, two years post-surgery, pregnancy.[18][19][20] During that pregnancy, Sert underwent an abortion in her first trimester, after her doctor was unable to detect a fetal heartbeat, but this is a common complication and may not have been related to the transplant.[21] Following another pregnancy that was initiated with in vitro fertilisation and sustained for 28 weeks, the patient finally delivered a baby on June 4, 2020.[22]

Sweden

In Sweden in 2012, the first mother-to-daughter[23] uterine transplant was done by Swedish doctors at Sahlgrenska University Hospital at Gothenburg University led by Mats Brännström.[23][24][25]

In October 2014, it was announced that, for the first time, a healthy baby had been born to a uterine transplant recipient, at an undisclosed location in Sweden. The British medical journal The Lancet reported that the baby boy had been born in September, weighing 1.8 kg (3.9 lb) and that the father had said his son was "amazing". The baby had been delivered prematurely at about 32 weeks, by cesarean section, after the mother had developed pre-eclampsia. The Swedish woman, aged 36, had received a uterus in 2013, from a live 61-year-old donor, in an operation led by Brännström, Professor of Obstetrics and Gynaecology at the University of Gothenburg.[26][27] The woman had healthy ovaries but was born without a uterus, a condition that affects about one in 4,500 women. The procedure used an embryo from a laboratory, created using the woman's ovum and her husband's sperm, which was then implanted into the transplanted uterus. The uterus may have been damaged in the course of the caesarian delivery and it may or may not be suitable for future pregnancies. A regimen of triple immuno-suppression was used with tacrolimus, azathioprine, and corticosteroids. Three mild rejection episodes occurred, one during the pregnancy, but were all successfully suppressed with medication. Some other women were also reported to be pregnant at that time using transplanted uteri.[28]

United States

The first uterine transplant performed in the United States took place on 24 February 2016 at the Cleveland Clinic.[29] The team was led by Dr Andreas Tzakis. The transplant failed due to an undisclosed complication on 8 March, and the uterus was removed.[30] In April, they reported a yeast infection had spread to one of the arteries the surgeons had connected to provide blood flow to the transplanted uterus, which damaged the artery and caused blood clots to form.[31]

In November 2017, the first baby was born after a uterus transplantation in the US.[32] The birth occurred at Baylor University Medical Center in Dallas, Texas, by Drs Liza Johannesson and Giuliano Testa, after a uterus donation from a non-directed living donor.[33] The first baby born after a deceased donor uterus transplant in the US was at the Cleveland Clinic in June 2019.[34]

India

The first uterine transplant performed in India took place on 18 May 2017 at the Galaxy Care Hospital in Pune, Maharashtra. The 26-year-old patient had been born without a uterus, and received her mother's womb in the transplant.[35][36] India's first uterine transplant baby, weighing 1.45 kg, was delivered through a Caesarean section[37] at Galaxy Care Hospital in Pune on Thursday.[38] The surgery was performed by a team of doctors at Pune's Galaxy Care Hospital and led by the hospital's medical director, Shailesh Puntambekar.[39]

Brazil

The first uterine transplant performed in Brazil took place on 2016 at the Hospital das Clínicas da USP in São Paulo. The 32-year-old patient had Mayer-Rokitansky-Küster-Hauser Syndrome, and therefore born without an uterus, and received a deceased donor's womb in the transplant.[35] Brazil's first uterine transplant baby was delivered through a Caesarean section[37] at Hospital das Clínicas da USP in December 2017. The surgery was performed by a team of doctors at Hospital das Clínicas da USP and led by Dani Ejzenberg, the head of the Human Reproductive Center at the hospital. Results of this procedure, the first to be performed in Latin America, were published in the medical journal The Lancet, in December 2018.[39]

United Kingdom

On August 23, 2023, doctors at the Churchill Hospital Oxford in the U.K. conducted the country's first uterus transplant. They removed the uterus from a 40-year-old woman and transplanted it to her 34-year-old sister, who had a rare condition that affected her ability to reproduce.[40] A team of experts performed the surgery for 17 hours in total.[41] Prof Richard Smith, a gynaecological surgeon who led the organ retrieval team, has spent 25 years researching womb transplantation, said that the surgery was a "massive success".[42]

Australia

On 15 December 2023, the first baby (male) was born in Australia to a mother who received a transplanted uterus. Kristy Bryant received the uterus in January 2023 at the Royal Hospital for Women in Sydney, and fell pregnant within three months through embryo implantation. The donor was her mother, Michelle.[43]

Current status

The transplant is intended to be temporary – recipients will have to undergo a hysterectomy after one or two successful pregnancies. This is done to avoid the need to take immunosuppressive drugs for life with a consequent increased risk of infection.[44]

The procedure remains the last resort: it is a relatively new and somewhat experimental procedure, performed only by certain specialist surgeons in select centres, it is expensive and unlikely to be covered by insurance, and it involves risk of infection and organ rejection. Some ethics specialists consider the risks to a live donor too great, and some find the entire procedure ethically questionable, especially since the transplant is not a life-saving procedure.[45][46][47]

Description

Procedures

Uterine transplantation starts with the uterus retrieval surgery on the donor. Working techniques for this exist for animals, including primates and more recently humans.[48][49][50][51][52][53] The recovered uterus may need to be stored, for example for transportation to the location of the recipient. Studies on cold-ischemia reperfusion indicate an ischemic tolerance of more than 24 hours.[49]

The recipient has to look at potentially three major surgeries. First of all, there is the transplantation surgery. If a pregnancy is established and carried to viability a cesarean section is performed. As the recipient is treated with immuno-suppressive therapy, eventually, after completion of childbearing, a hysterectomy needs to be done so that the immuno-suppressive therapy can be terminated.[citation needed]

Ethics

Montreal criteria

Aside from considerations of costs, uterine transplantation involves complex ethical issues. The principle of autonomy supports the procedure, while the principle of non-maleficence argues against it. In regard to the principles of beneficence and justice the procedure appears equivocal.[11] To address this dilemma the "Montreal Criteria for the Ethical Feasibility of Uterine Transplantation" were developed at McGill University and published in Transplant International in 2012.[11] The Montreal Criteria are a set of criteria deemed to be required for the ethical execution of the uterine transplant in humans. These findings were presented at the International Federation of Gynecology and Obstetrics' 20th World Congress in Rome in October 2012.[54] In 2013 an update to "The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation" was published in Fertility and Sterility and has been proposed as the international standard for the ethical execution of the procedure.[55]

The criteria set conditions for the recipient, the donor, and the health care team, specifically:

  1. The recipient is a genetic female, with the ability to consent, with no medical contraindications to transplantation, has uterine disease that has failed other therapy, and has "a personal or legal contraindication" to other options (surrogacy, adoption). The recipient needs to be considered suitable for motherhood, deemed to be psychologically fit on evaluation, is likely to be compliant with treatment and the medical team, and understands the risks of the procedure. In 2021, a revision to the Montreal Criteria was published in Bioethics with an ethical framework for consideration of genetic XY individuals to be eligible for uterine transplants.[56]
  2. The donor is a female of reproductive age with no contraindication to the procedure who has concluded her childbearing or consented donating her uterus after her death. There is no coercion and the donor is responsible and capable of making informed decisions.
  3. The health care team belongs to an institution that meets Moore's third criterion[57] regarding institutional stability and has provided informed consent to both parties. There is no conflict of interests, and anonymity can be protected unless recipient or donor waive this right.

See also

References

  1. ↑ Knauer, Emil (1896). "Einige Versuche über Ovarientransplantation bei Kaninchen" (in de). Zentralblatt für Gynäkologie 20: 524–8. 
  2. ↑ Nugent, D.; Meirow, D.; Brook, P. F.; Aubard, Y.; Gosden, R. G. (1997). "Transplantation in reproductive medicine: Previous experience, present knowledge and future prospects". Human Reproduction Update 3 (3): 267–80. doi:10.1093/humupd/3.3.267. PMID 9322102. 
  3. ↑ Eraslan, S.; Hamernik, R. J.; Hardy, J. D. (1966). "Replantation of uterus and ovaries in dogs, with successful pregnancy". Archives of Surgery 92 (1): 9–12. doi:10.1001/archsurg.1966.01320190011002. PMID 5948103. 
  4. ↑ Díaz-García, César; Akhi, Shamima N.; Wallin, Ann; Pellicer, Antonio; Brännström, Mats (2010). "First report on fertility after allogeneic uterus transplantation". Acta Obstetricia et Gynecologica Scandinavica 89 (11): 1491–1494. doi:10.3109/00016349.2010.520688. PMID 20879912. 
  5. ↑ Brännström, Mats; Racowsky, Catherine; Richards, Elliott G.; Flyckt, Rebecca; Stillman, Robert J.; O’Brien, Jeanne E.; Ryan, Ginny L.; de Ziegler, Dominique (June 2023). "Absolute uterine infertility a cornelian dilemma: uterine transplantation or surrogacy?" (in en). Fertility and Sterility 119 (6): 918–929. doi:10.1016/j.fertnstert.2023.04.005. https://linkinghub.elsevier.com/retrieve/pii/S001502822300290X. 
  6. ↑ "Woman receives sister's womb in first UK transplant" (in en-GB). BBC News. 2023-08-22. https://www.bbc.com/news/health-66514270. 
  7. ↑ Kroløkke, C.; Petersen, T.S.; Herrmann, J.R.; Bach, A.S.; Adrian, S.W.; Klingenberg, R.; Petersen, M.N. (2019). The Cryopolitics of Reproduction on Ice: A New Scandinavian Ice Age. Emerald Studies in Reproduction, Culture and Society. Emerald Publishing Limited. p. 154. ISBN 978-1-83867-044-3. https://books.google.com/books?id=-NC-DwAAQBAJ&pg=PT154. Retrieved 2023-02-22. 
  8. ↑ "Lili Elbe" (in en-us). https://www.biography.com/people/lili-elbe-090815. 
  9. ↑ 9.0 9.1 9.2 Grady, Denise (March 7, 2002). "Medical First: A Transplant Of a Uterus". The New York Times. https://query.nytimes.com/gst/fullpage.html?sec=health&res=9F01EFDC1230F934A35750C0A9649C8B63. 
  10. ↑ Nair, Anjana; Stega, Jeanetta; Smith, J. Richard; Del Priore, Giuseppe (2008). "Uterus Transplant". Annals of the New York Academy of Sciences 1127: 83–91. doi:10.1196/annals.1434.003. PMID 18443334. 
  11. ↑ 11.0 11.1 11.2 Lefkowitz, Ariel; Edwards, Marcel; Balayla, Jacques (2012). "The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation". Transplant International 25 (4): 439–47. doi:10.1111/j.1432-2277.2012.01438.x. PMID 22356169. 
  12. ↑ "Turkish woman has world's first womb transplant". timesofmalta.com. 10 October 2011. http://www.timesofmalta.com/articles/view/20111010/health-fitness/turkish-woman-has-world-s-first-womb-transplant.388596. 
  13. ↑ "Revolutionary 'Womb Transplant' performed in Turkey - World's First". Allvoices.com. http://www.allvoices.com/contributed-news/9926041-revolutionary-womb-transplant-performed-in-turkey-worlds-first. 
  14. ↑ "World's first womb transplant in Turkey promises hope for women". Alarabiya.net. 2011-10-01. http://www.alarabiya.net/articles/2011/10/01/169542.html. 
  15. ↑ "HEALTH - Doctors hopeful for uterus transplant". Hurriyetdailynews.com. 2011-09-13. http://www.hurriyetdailynews.com/doctors-hopeful-for-uterus-transplant.aspx?pageID=238&nID=12614&NewsCatID=373. 
  16. ↑ "World's first uterus transplant performed in Turkey/TRT-English". Trt-world.com. 2012-02-27. http://www.trt-world.com/trtworld/en/newsDetail.aspx?HaberKodu=0222eb41-3a81-41b9-9123-2a256f5f2b31. 
  17. ↑ "Turkish surgeons perform world's first uterus transplant | Family & Health". World Bulletin. http://www.worldbulletin.net/?aType=haber&ArticleID=77268. 
  18. ↑ "Womb transplant recipient Derya Sert pregnant". AAP. 2013-04-13. http://www.news.com.au/technology/sci-tech/womb-transplant-recipient-derya-sert-pregnant/story-fn5fsgyc-1226619553524. 
  19. ↑ "Yahoo Health". 12 April 2013. http://shine.yahoo.com/healthy-living/womb-transplant-patient-derya-sert-is-pregnant--confirms-doctor-210119461.html. 
  20. ↑ "World's first woman with uterus transplant gets pregnant - HEALTH". 14 April 2013. http://www.hurriyetdailynews.com/worlds-first-uterus-transplant-patient-pregnant-say-doctors.aspx?pageID=238&nID=44790&NewsCatID=373. 
  21. ↑ Derya Sert'in gebeliği sonlandırıldı. CNNTurk.com. (in Turkish)
  22. ↑ "Kadavradan rahim nakli yapılan Derya Sert anne oldu" (in tr). Anadolu Agency. 2020-06-26. https://www.aa.com.tr/tr/saglik/kadavradan-rahim-nakli-yapilan-derya-sert-anne-oldu/1890754. 
  23. ↑ 23.0 23.1 Brännström, Mats; Johannesson, Liza; Dahm-Kähler, Pernilla; Enskog, Anders; Mölne, Johan; Kvarnström, Niclas; Diaz-Garcia, Cesar; Hanafy, Ash et al. (2014). "First clinical uterus transplantation trial: a six-month report". Fertility and Sterility 101 (5): 1228–1236. doi:10.1016/j.fertnstert.2014.02.024. PMID 24582522. 
  24. ↑ Brännström, Mats; Diaz-Garcia, Cesar; Hanafy, Ash; Olausson, Michael; Tzakis, Andreas (2012). "Uterus transplantation: animal research and human possibilities". Fertility and Sterility 97 (6): 1269–1276. doi:10.1016/j.fertnstert.2012.04.001. PMID 22542990. 
  25. ↑ Brännström, M.; Wranning, C. A.; Altchek, A. (7 November 2009). "Experimental uterus transplantation". Human Reproduction Update 16 (3): 329–345. doi:10.1093/humupd/dmp049. PMID 19897849. 
  26. ↑ "Woman has healthy baby boy after womb transplant in Sweden". ABC News. 4 October 2014. http://www.abc.net.au/news/2014-10-04/woman-has-baby-after-womb-transplant-in-sweden/5790726. 
  27. ↑ Brännström, M.; Johannesson, L.; Bokström, H.; Kvarnström, N.; Mölne, J.; Dahm-Kähler, P.; Enskog, A.; Milenkovic, M. et al. (2014). "Livebirth after uterus transplantation". The Lancet 385 (9968): 607–616. doi:10.1016/S0140-6736(14)61728-1. PMID 25301505. 
  28. ↑ "BBC News - Womb transplant couple 'had no doubt' of success". BBC News. https://www.bbc.co.uk/news/health-29516910. 
  29. ↑ Zeltner, Brie (2016-03-07). "Cleveland Clinic introduces nation's first uterus transplant recipient". The Plain Dealer. http://www.cleveland.com/healthfit/index.ssf/2016/03/cleveland_clinic_introduces_it.html. 
  30. ↑ Zeltner, Brie (2016-03-09). "Nation's first uterus transplant, performed at the Cleveland Clinic, fails". The Plain Dealer. http://www.cleveland.com/healthfit/index.ssf/2016/03/nations_first_uterus_transplan.html. 
  31. ↑ Denise Grady (April 8, 2016). "Yeast Infection Led to Removal of Transplanted Uterus". The New York Times. https://www.nytimes.com/2016/04/09/health/yeast-infectionled-to-removal-of-transplanted-uterus.html. 
  32. ↑ Sifferlin, Alexandra (2017-12-01). "First U.S. Baby Born After a Uterus Transplant". Time (magazine). http://time.com/5044565/exclusive-first-u-s-baby-born-after-a-uterus-transplant/. 
  33. ↑ "The first baby in the U.S. born via uterus transplant is here". December 2017. http://time.com/5044565/exclusive-first-u-s-baby-born-after-a-uterus-transplant/. 
  34. ↑ Flyckt, R.; Falcone, T.; Quintini, C. et al. (August 2020), "First birth from a deceased donor uterus in the United States: from severe graft rejection to successful cesarean delivery", American Journal of Obstetrics and Gynecology 223 (2): 143–151, doi:10.1016/j.ajog.2020.03.001, PMID 32151611 
  35. ↑ 35.0 35.1 Pinheiro, Lara (5 December 2018). "Caso do primeiro bebê nascido de transplante de útero com doadora falecida é publicado em revista". https://g1.globo.com/ciencia-e-saude/noticia/2018/12/05/caso-do-primeiro-bebe-nascido-de-transplante-de-utero-com-doadora-falecida-e-publicado-em-revista.ghtml. 
  36. ↑ "India's first uterine transplant to take place on 18 May: Baroda woman to receive womb from mother". 12 May 2017. http://www.firstpost.com/india/indias-first-uterine-transplant-to-take-place-on-18-may-baroda-woman-to-receive-womb-from-mother-3439518.html. 
  37. ↑ 37.0 37.1 "Miracle baby: the first uterine transplant baby born in India" (in en-US). Mom And Baby Care (Mom ABC). 2018-11-01. http://www.momabc.net/first-uterine-transplant-india/. 
  38. ↑ Arora, Medhavi. "Mom donates womb to daughter in India's first uterus transplant". CNN. https://edition.cnn.com/2017/05/19/health/india-uterus-womb-transplant/index.html. 
  39. ↑ 39.0 39.1 Ejzenberg, Dani; Andraus, Wellington; Baratelli Carelli Mendes, Luana Regina; Ducatti, Liliana; Song, Alice; Tanigawa, Ryan; Rocha-Santos, Vinicius; MacEdo Arantes, Rubens et al. (2018). "Livebirth after uterus transplantation from a deceased donor in a recipient with uterine infertility" (in en-IN). The Lancet 392 (10165): 2697–2704. doi:10.1016/S0140-6736(18)31766-5. PMID 30527853. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31766-5/fulltext. Retrieved 2022-07-13. 
  40. ↑ Varghese, Rebecca Rose (2023-09-28). "What does it mean to have a uterus transplant? | Explained" (in en-IN). The Hindu. ISSN 0971-751X. https://www.thehindu.com/sci-tech/science/uterus-transplant-process-cost-explained/article67355912.ece. 
  41. ↑ Desk, India TV News; News, India TV (2023-08-24). "Woman donates her womb to younger sister; Britain's first successful uterus transplant" (in en). https://www.indiatvnews.com/health/woman-donates-her-womb-to-younger-sister-britain-s-first-successful-uterus-transplant-2023-08-24-888698. 
  42. ↑ "Woman receives sister's womb in first UK transplant" (in en-GB). BBC News. 2023-08-22. https://www.bbc.com/news/health-66514270. 
  43. ↑ Australia's first uterus transplant recipient Kirsty Bryant gives birth to healthy baby boy, Emma Siossian , ABC News Online, 2023-12-19
  44. ↑ Ossola, Alexandra (18 February 2014). "Everything You Need To Know About Uterus Transplants". Popular Science. http://www.popsci.com/blog-network/ladybits/everything-you-need-know-about-uterus-transplants. 
  45. ↑ "Medical first: Baby born to woman who got new womb". Journal Star (2006-2014 Gatehouse Media, Inc.). 4 October 2014. http://www.pjstar.com/article/20141003/NEWS/141009710/?Start=2. 
  46. ↑ "BBC News". 4 October 2014. https://www.bbc.co.uk/news/health-29485996. 
  47. ↑ "The Daily Telegraph". Telegraph.co.uk. 3 October 2014. https://www.telegraph.co.uk/health/healthnews/11139991/The-first-baby-has-been-born-following-a-womb-transplant.html. 
  48. ↑ Johannesson, Liza; Diaz-Garcia, Cesar; Leonhardt, Henrik; Dahm-Kähler, Pernilla; Marcickiewicz, Janusz; Olausson, Michael; Brännström, Mats (2012). "Vascular Pedicle Lengths After Hysterectomy". Obstetrics & Gynecology 119 (6): 1219–1225. doi:10.1097/AOG.0b013e318255006f. PMID 22617587. 
  49. ↑ 49.0 49.1 Brännström, M.; Wranning, C. A.; Altchek, A. (2009). "Experimental uterus transplantation". Human Reproduction Update 16 (3): 329–45. doi:10.1093/humupd/dmp049. PMID 19897849. 
  50. ↑ Wranning, C. A.; Akhi, S. N.; Diaz-Garcia, C.; Brännström, M. (15 December 2010). "Pregnancy after syngeneic uterus transplantation and spontaneous mating in the rat". Human Reproduction 26 (3): 553–558. doi:10.1093/humrep/deq358. PMID 21159686. 
  51. ↑ Enskog, A.; Johannesson, L.; Chai, D. C.; Dahm-Kahler, P.; Marcickiewicz, J.; Nyachieo, A.; Mwenda, J. M.; Brännström, M. (2 June 2010). "Uterus transplantation in the baboon: methodology and long-term function after auto-transplantation". Human Reproduction 25 (8): 1980–1987. doi:10.1093/humrep/deq109. PMID 20519250. 
  52. ↑ Dahm-Kähler, Pernilla; Wranning, Caiza; Lundmark, Cecilia; Enskog, Anders; Mölne, Johan; Marcickiewicz, Janusz; El-Akouri, Randa Racho; McCracken, John et al. (2008). "Transplantation of the uterus in sheep: Methodology and early reperfusion events". Journal of Obstetrics and Gynaecology Research 34 (5): 784–793. doi:10.1111/j.1447-0756.2008.00854.x. PMID 18834335. 
  53. ↑ Wranning, Caiza Almen; El-Akouri, Randa Racho; Lundmark, Cecilia; Dahm-Kahler, Pernilla; Molne, Johan; Enskog, Anders; Brännström, Mats (2006). "Auto-transplantation of the uterus in the domestic pig (Sus scrofa): Surgical technique and early reperfusion events". Journal of Obstetrics and Gynaecology Research 32 (4): 358–367. doi:10.1111/j.1447-0756.2006.00426.x. PMID 16882260. 
  54. ↑ Lefkowitz A.; Edwards M.; Balayla J. (2012). "O081 the Montreal Criteria for the Ethical Feasibility of Uterine Transplantation". International Journal of Gynecology & Obstetrics 119 (Supplement 3): S289. doi:10.1016/S0020-7292(12)60511-6. 
  55. ↑ Lefkowitz Ariel (2013). "Ethical considerations in the era of the uterine transplant: an update of the Montreal Criteria for the Ethical Feasibility of Uterine Transplantation". Fertility and Sterility 100 (4): 924–926. doi:10.1016/j.fertnstert.2013.05.026. PMID 23768985. 
  56. ↑ Balayla J.; Pounds P.; Lasry A.; Volodarsky-Perel A.; Gil A. (2021). "The Montreal Criteria and uterine transplants in transgender women". Bioethics 35 (4): 326–330. doi:10.1111/bioe.12832. PMID 33550647. 
  57. ↑ Moore FD (2000). "Ethical problems special to surgery: surgical teaching, surgical innovation, and the surgeon in managed care". Arch Surg 135 (1): 14–16. doi:10.1001/archsurg.135.1.14. PMID 10636340. 

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