**4.3 Uterus transplant**

Uterus transplantation has emerged as an alternative solution for female infertility. The first success in uterine transplantation was to ensure pregnancy by replantation of the uterus and ovaries in dogs [19].

The first example of human application was a live uterine transplant in Saudi Arabia on April 2000, to a 26-year old woman who lost her uterus six years ago due to postpartum hemorrhage. The donor was 46-year old lady. The patient had acute vascular thrombosis 99 days after transplant and had a hysterectomy. Although acute thrombosis and infarction were detected in the vessels in macroscopic and microscopic examination of the excised uterus, no findings suggesting rejection were found [20]. An important milestone in uterine transplantation is the allograft uterine transplant performed to a 23-year-old woman diagnosed with Mayer-Rokitansky-Kuster-Hauser syndrome in 2011 at Akdeniz University, Turkey. Embryo transfer was provided 18 months after transplantation and live birth was not possible although clinical pregnancy was detected by transvaginal ultrasound [21].

The first clinical applications in Sweeden were made with nine living donors. In 2013, uterus transplantation was performed on a 23-year-old woman with congenital absence of uterus [Rokitansky syndrome] at Sahlgrenska University Hospital in Gothenburg, Sweeden. The donor was a living 61-year old lady. The patient, who had a menstruation on the 43rd day after the transplant, continued to have regular menstruation. One year after the transplant, a single embryo transfer resulted in pregnancy. Therefore, the triple immunosuppression was started. The patient, pregnant for 31 weeks and five days, was admitted to the hospital with complaints of preeclampsia and was taken to cesarean section due to abnormal cardiotocography findings. A healthy male baby, with APGAR scores of 9,9,10 and with a weight

compatible [1775 gr] with gestational age, was born. Thus, the first live birth was achieved with the uterine transplantation method in the medical literature [22].

Uterine transplantation does not carry a vital indication. Medical, surgical, legal, ethical, psychological, and social aspects of the process are discussed in medical and related communities. Common requirements for recipient and donor are good general health, no history of infection and cancer in the last five years. The upper age limit for the recipient is 35–40 and 55–65 for the donor. In elderly women, it is believed that the vessels be affected by arteriosclerosis, probably due to the atrophic nature of the uterus. The effect of age on graft success is unknown. Among the peroperative problems is the long duration of surgical intervention, especially in the donor.

A characteristic of uterine transplantation is the removal of the transplanted uterus after one or two births to prevent the patient from immunosuppressive therapy for a longer period. This period is foreseen as an average of five years. Therefore, it is not particularly superior to prefer live donors. Besides, psychological problems that the recipient may feel against the donor are eliminated by the use of cadaver uterus. Ethical foundations of uterine transplantation are gathered under the name of Montreal criteria. Accordingly, six conditions should be fulfilled for the recipient, four conditions for the donor, and four conditions for the healthcare team performing the treatment [23].
