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Transplantation DIRECT 2021 www.transplantationdirect.com 1
ISSN: 2373-8731
DOI: 10.1097/TXD.0000000000001124
Received 2 November 2020. Revision received 1 December 2020.
Accepted 2 December 2020.
1 West London Gynaecological Cancer Centre, Hammersmith Hospital, Imperial
College NHS Trust, London, United Kingdom.
2 Department of Surgery and Cancer, Imperial College London, London, United
Kingdom.
3 Department of Politics, Philosophy and Religion, Lancaster University,
Lancaster, United Kingdom.
4 Lister Fertility Clinic, The Lister Hospital, London, United Kingdom.
5 The Oxford Transplant Centre, The Churchill Hospital, Oxford University
Hospitals NHS Trust, Oxford, United Kingdom.
N.J.W.’s research is funded by a Leverhulme Early Career Research Fellowship
in Arts and Humanities (grant ECF-2018-113). S.W.’s research is funded by a
Wellcome Trust Senior Investigator Award (grant 097897/Z/11/Z).
The authors declare no conflicts of interest.
Uterine Transplantation Using Living Donation:
A Cross-sectional Study Assessing Perceptions,
Acceptability, and Suitability
Benjamin P. Jones, MBChB, BSc (Hons), MRCOG,1,2 Abirami Rajamanoharan, BSc,1 Nicola J. Williams, PhD,3
Saaliha Vali, BSc,1,2 Srdjan Saso, PhD, MRCOG, MRCS,1,2 Ifigenia Mantrali, BSc,1,2 Maria Jalmbrant, BSc (Hons),1
Meen-Yau Thum, MD, MRCOG,2,4 Cesar Diaz-Garcia, MD, PhD,5 Sadaf Ghaem-Maghami, PhD,1,2
Stephen Wilkinson, PhD,3 Isabel Quiroga, Dphil, FRCS,5 Peter Friend, MD, FRCS,4 Joseph Yazbek, MD,1,2
and J. Richard Smith, MD, FRCOG1,2
INTRODUCTION
The rst live birth following uterine transplantation (UTx)
was reported in 2014.1 More than 70 cases have now been
performed worldwide, and outcomes have recently been
reported from 45 cases, which have yielded 9 live births
so far.2 UTx has thereby been proven a feasible fertility
restoring intervention for women with absolute uterine
factor infertility, allowing them to conceive and gestate
their future children. UTx is a nonvital, quality-of-life–
enhancing solid organ transplant. The nonessential nature
of a uterus after the completion of one’s family allows the
opportunity to use both living donors (LDs) and deceased
Organ Donation and Procurement
Background. A uterine transplantation is a nonvital, quality-of-life–enhancing solid organ transplant. Given improve-
ments in donor risk profile and the anticipated shortage of suitable deceased donors, nondirected donation could facilitate
sustainability as uterine transplantation moves from research into the clinical realm. The aim of this article is to determine
perceptions and identify motivations of potential nondirected living uterus donors and assess acceptability and suitability.
Methods. A cross-sectional survey using an electronic questionnaire among women who have inquired about donating
their uterus for uterine transplantation. Results. The majority of respondents “strongly agreed” or “agreed” that the most
prevalent motivations to donate their uterus include helping someone carry and give birth to their own baby (n = 150; 99%),
helping others (n = 147; 97%), and because they no longer need their womb (n = 147; 97%). After considering risks of uterus
donation, the majority were still keen to donate their uterus (n = 144; 95%), but following a process of exclusion using donor
selection criteria, less than a third (n = 42; 29%) were found to be suitable to proceed. Conclusions. This study demon-
strates novel insight into the motivations of women who wish to donate their uterus and displays high levels of acceptability
after consideration of the risks involved. Despite the physical risk and transient impact upon ability to undertake activities
of daily living, women who donate their uterus expect to gain psychological and emotional benefits from enabling another
woman to gestate and give birth to their own future children. However, currently used selection criteria reduce the number
of potential donors significantly.
(Transplantation Direct 2021;7: e673; doi: 10.1097/TXD.0000000000001124. Published online 18 February, 2021.)
B.P.J. conceived the study and wrote the article. A.R., N.J.W., and S.V. helped
write the article and reviewed the final draft. S.S., I.M., M.J., M.-Y.T., C.D-.G.,
S.G-.M., S.W., I.Q., P.F., J.Y., and J.R.S. reviewed and contributed to the article.
Supplemental digital content (SDC) is available for this article. Direct URL
citations appear in the printed text, and links to the digital files are provided in the
HTML text of this article on the journal’s Web site (www.transplantationdirect.
com).
Correspondenec: Benjamin P. Jones, MBChB, BSc (Hons), MRCOG,
Department of Surgery and Cancer, Imperial College London, Du Cane Rd,
London W12 0NN, United Kingdom. (benjamin.jones@nhs.net).
Copyright © 2021 The Author(s). Transplantation Direct. Published by Wolters
Kluwer Health, Inc. This is an open access article distributed under the Creative
Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribu-
tion, and reproduction in any medium, provided the original work is properly cited.
2 Transplantation DIRECT ■ 2021 www.transplantationdirect.com
donors (DDs). Each donor type presents ethical, logistical,
physiological, immunological, and anatomical advantages
and disadvantages that continue to stimulate debate.3,4 LD
can either be directed or nondirected in nature. Directed
organ donations include the donation of an organ that is
intended for a specic individual, from someone with an
emotional or biological relationship, such as a friend or
close family member. Conversely, nondirected donations
are from donors with no such preexisting relationships
and are unknown to the recipient.
The greatest advantage of DD is that whereas LD neces-
sitates and risks signicant physical and psychological harms
to donors, DD completely avoids these harms and risks. In
LD UTx cases so far, >1 in 10 donors have suffered a compli-
cation necessitating further surgical intervention,2 including
ureteric injuries,5-7 fecal impaction requiring digital evacua-
tion under anesthesia,8 and vaginal cuff dehiscence.9 Around
a quarter of donors have suffered less serious complications
including wound infection,7 bladder hypotonia,6 urinary tract
infection,2 leg/buttock pain, depression,9 intubation-related
respiratory failure, and anemia.2 The risks associated with LD
are however expected to diminish over time as surgical tech-
niques and selection criteria are nessed. Recent modications
to the vascular dissection process have, for example, reduced
surgical risks and operative times,2 by prioritizing ovarian
venous drainage when possible,6,9-11 as opposed to the uterine
venous complex.7 Similarly, the implementation of minimally
invasive surgical techniques in recent cases offers further risk
reduction and an enhanced recovery process.11-13
The ethics literature on UTx discusses the risks associated
with LD as well as concerns regarding consent and the poten-
tial for donor regret.14-16 This has led many to conclude that
DD is preferable provided that there are sufcient donor uteri,
similar success rates, and that retrieval does not threaten the
viability of lifesaving organs for transplant.17-19 When these
conditions are not met, however, the use of LDs may be justi-
ed provided that the donor provides informed and volun-
tary consent, the risks are proportionate to potential benets
and fall below an acceptable absolute threshold, and risks to
the donor are minimized.17 This is similar to the approach
adopted in other solid organ transplants that use LD such as
kidney and liver lobe transplantation.
Given improvements in donor risk prole and the antici-
pated shortage of suitable DDs,20 a combination of both LD
and DD will likely be needed in short to medium term.21
In the context of LD, reliance solely on directed donations
could exclude potential recipients who do not have a will-
ing and suitable donor among their friends or family mem-
bers. Therefore, as is the case in other solid organ transplants,
allowing nondirected altruistic donation from donors previ-
ously unknown to the recipient could facilitate sustainabil-
ity as UTx progresses from research into the clinical realm.
However, nondirected living organ donation raises ethical
concerns regarding the potential for undue inducement and
defective understanding.22 Despite this, some scholars have
suggested that nondirected donation could be preferable to
directed donation because the use of donors known to recipi-
ents brings with it the risk of undue pressure to donate from
family members or friends.16,23
In light of this, the primary aim of this study was to
identify the perceptions of potential donors toward uterus
donation and evaluate their motivations underpinning
their desire to donate. Second, investigation of their suita-
bility, as well as determination of acceptability and willing-
ness to proceed were also evaluated, after disclosure and
discussion of the risks associated with donation, expected
recovery period and process, and its potential impact upon
their lives.
MATERIALS AND METHODS
Study Design
This study was developed as a direct response to
demand from women who contacted Womb Transplant
UK to inquire about the possibility of uterus donation.
All women who contacted Womb Transplant UK (regis-
tered charity no. 1138559) to enquire about donating their
uterus between November 1, 2014, and November 1, 2019
were invited to participate. An email containing a link to
an electronic questionnaire, as well as 2 information leaf-
lets, was sent to potential participants. One information
leaflet detailed the conduct of the study, whereas the other
explained the proposed process of LD UTx (Appendix S1,
SDC, http://links.lww.com/TXD/A312). The questionnaire
contained an initial 4-question consent process, which
required agreement before proceeding to the 58-question
questionnaire (Appendix S2, SDC, http://links.lww.com/
TXD/A312). The online platform SurveyMonkey was used
to distribute the questionnaire over a 6-mo period between
June 1, 2019 and November 31, 2019. Initial questions
elicited demographic information before determining
background medical, surgical, psychiatric, obstetric,
gynecological, and social history. Further questions ascer-
tained perceptions of adoption, surrogacy, and knowledge
and opinions of UTx. Subsequent questions specifically
assessed acceptability of the necessary preoperative inves-
tigations, the potential need for hormone supplementation
in postmenopausal donors, and willingness to donate after
considering the risks and expected recovery time of uterus
donation. The final questions determined knowledge and
perceptions of potential recipient risk, views on the pro-
vision of updates regarding recipient progress posttrans-
plant, and financial considerations. Most questions were
closed, using tick boxes, with the option to include further
comment in cases when further description was warranted.
Likert scales were used in questions related to perceptions.
A number of women were consulted in the creation of the
information leaflets and questionnaire to help refine ques-
tions, content, and phraseology. The questionnaire was
further piloted among a sample of potential donors to
assess understanding and readability.
Ethics Approval
Ethics approval was received from Imperial College
Research Ethics Committee on May 30, 2019 (reference no:
19IC5202).
Data Analysis
SPSS version 24 software (SPSS, Chicago, IL) was used
for analysis. Descriptive statistical analysis was described
as mean ± SD or median ± range. The Likert scale responses
were quantied using a weighted ranking system to ascer-
tain the most inuential perceived factor (0 = not at all;
4 = denitely).
© 2021 The Author(s). Published by Wolters Kluwer Health, Inc. Jones et al 3
RESULTS
Two hundred eighty-ve women approached the charity
regarding the possibility of donating their uterus. Of them,
152 women subsequently completed the questionnaire, result-
ing in a response rate of 53.3%. The cohort comprised 151
women and 1 female to male transgender man. The demo-
graphics of the respondents are summarized in Table1. The
most prevalent age group was 30–39 y (n = 50; 33%). The
majority of respondents were Caucasian (n = 143; 94%), u-
ent in English (n = 151; 99%), married (n = 76; 50%), and
in either full-time/part-time employment or self-employed
(n = 103; 68%). A minority (n = 24; 16%) were current
smokers, 30% were ex-smokers (n=45), and the remainder
had never smoked (n = 83; 55%).
Medical History
Table 2 summarizes the obstetric background of our
cohort. Over a third were nulliparous (n = 56; 37%). Of those
who had children previously (n = 96), around three-quarters
(n = 70; 73%) delivered their children vaginally, whereas
the remainder had at least 1 child born by cesarean section
(n = 26; 27%). Of those who had previously had cesarean sec-
tions, 13% (n = 12) had 1, 11% (n = 11) had 2, and 3% had ≥3.
More than three-quarters of those with previous pregnancies
had not experienced signicant antenatal or postnatal com-
plications (n = 74; 77%). The most frequently encountered
obstetric complication was preterm delivery, which impacted
11% (n = 11).
Around a quarter of our cohort had previously experienced
miscarriages (n = 37; 24%), and 5% (n = 8) had experienced
≥3. Seventeen percent (n = 26) of respondents were postmeno-
pausal. Of those still menstruating, 84% (n = 106) reported
regular cycles and 16% (n = 20) reported irregular cycles.
Nearly a quarter of participants had previous abnormal cer-
vical cytology (n = 34; 22%). Fifty percent of this number
subsequently underwent surgical treatment (n = 17), and 50%
were monitored conservatively (n = 17) and 97% (n = 33) had
normal cytology since.
The mean body mass index of participants was 28.4 kg/
m2 ± 8.56. Sixty-one percent (n = 93) did not report any sig-
nicant medical history. The previous medical, psychologi-
cal, and abdominopelvic surgical history of participants is
summarized in Table3. Only 1 individual reported a previ-
ous history of malignancy, which affected her breast. None
of the women in this cohort were known to be HIV positive
or to have syphilis or hepatitis. Around half reported other
minor medical conditions, which would not impact suitabil-
ity to donate their uterus (n = 29; 49%). Over three-quarters
of participants did not have any previous psychiatric history
(n = 116; 76%). The majority of the cohort had not previously
undergone abdominopelvic surgery (n = 90; 59%).
TABLE 1.
Basic demographic information of uterine donor cohort
Number (n) %
Age (y) 16–19 2 1
20–29 36 24
30–39 50 33
40–49 43 28
50–59 14 9
60+ 7 5
Body mass index (kg/m2) <18.4 Underweight 5 3
18.5–24.4 Normal 54 36
25–29.9 Overweight 45 30
30–34.9 Obesity I 27 18
35–39.9 Obesity II 11 7
>40 Obesity III 10 7
Ethnicity White 143 94
Asian 4 3
Black 2 1
Mixed 2 1
Other 1 1
Language English 143 94
Non-English but fluent in English 8 5
Non-English but not fluent in English 1 1
Religion Christianity 43 28
Hinduism 2 1
Islam 2 1
Atheism 61 40
Other 31 20
Would rather not say 13 9
Employment status Employed full time 57 38
Employed part time 26 17
Self-employed 20 13
Housewife 26 17
Unemployed 12 8
Student 5 3
Would rather not say 6 4
Relationship status Single 43 28
Living with partner 19 13
Married 76 50
Divorced 9 6
Separated 2 1
Would rather not say 3 2
Smoking status Never smoked 83 55
Ex-smoker 45 30
Current smoker 24 16
Alcohol intake (U/wk) 0 69 45
≤14 79 52
>14 4 3
TABLE 2.
Obstetric history of study cohort
Number (n) %
No. of miscarriages (n = 152) 0 115 76
1 19 13
2 10 7
3+ 8 5
No. of children (n = 152) 0 56 37
1 11 7
2 36 24
3 30 20
4+ 19 13
No. of cesarean section (n = 96) 0 70 73
1–2 23 24
>2 3 3
Problems encountered in
pregnancy (n = 96)
No problems
Preterm delivery <37 wk
Preeclampsia
Gestational diabetes
Heavy bleeding after delivery
Obstetric cholestasis
74
11
3
4
2
2
77
11
3
4
2
2
4 Transplantation DIRECT ■ 2021 www.transplantationdirect.com
Understanding and Perceptions of Uterine
Transplantation
Although 79% (n = 120) of individuals “strongly
agreed” or “agreed” that adoption and surrogacy were
suitable methods to have children, all participants (n = 152;
100%) felt that women should be freely able to voluntar-
ily donate their uterus for UTx if adequately informed of
the process. The majority of respondents reported know-
ing “a fair amount” or “a lot” about UTx (n = 8; 58%),
around a third had “heard it discussed only a few times”
(n = 52; 34%), and a minority admitted to “knowing noth-
ing” (n = 12; 8%). The majority of individuals, however,
“strongly agreed” or “agreed” that they understood the
potential benefits (n = 143; 94%) and risks (n = 131; 86%)
of uterus donation.
Nearly all respondents “strongly agreed” or “agreed”
that they would consent to undergoing the necessary preop-
erative investigations (n = 150; 98%) and held the expected
recovery process, including a 4-d inpatient admission and
an 8-wk recovery period, to be acceptable (n = 148; 97%).
All but 1respondent understood that future pregnancies in
the recipient would not be genetically related to the uterus
donor (n = 151; 99%). All participants reported completion
of their family (n = 152), with over a third of these being nul-
liparous (n = 55; 36%). All premenopausal respondents under-
stood that they would be unable to gestate a pregnancy after
uterus donation (n = 126). The majority of these understood
that the intended operation involved ovarian conservation,
which would result in normal hormone levels postoperatively
(n = 121; 96%). Ninety-six percent of respondents (n = 122)
“strongly agreed” or “agreed” that donation of their uterus
would cease future menstruation and the majority “strongly
agreed” or “agreed” that cessation of menstruation would
improve their quality of life (n = 113; 89%). Of those par-
ticipants who were postmenopausal (n = 26), the majority
“strongly agreed” or “agreed” that they would accept 3–6
mo of hormone replacement therapy to demonstrate endome-
trial function by inducing withdrawal bleeds preoperatively
(n = 24; 92%).
Motivations for Uterine Donation
Factors motivating consideration of uterus donation are
depicted in Figure1. The overwhelming majority of respond-
ents “strongly agreed” or “agreed” that they were motivated
to donate to help someone else carry and give birth to their
own baby (n = 150; 99%), help others (n = 147; 97%), and
because they no longer need their womb (n = 147; 97%).
Nearly three-quarters of the cohort “strongly agreed” or
“agreed” that they were already organ donors and wanted to
donate another organ (n = 110; 72%). Twenty percent (n = 30)
“strongly agreed” or “agreed” that they wanted to donate
because of previously considering or being a surrogate. Only
15% (n = 23) of the cohort “strongly agreed” or “agreed”
to personally knowing someone infertile who they wanted
to donate their uterus to. Using a weighted scoring system,
Figure 2 represents the importance respondents placed on
each inuencing factor. The 2 most inuential factors were the
desire to help someone else carry and give birth to a child and
wanting to help others. The least inuential factors were per-
sonally knowing someone who was infertile that they wanted
TABLE 3.
Medical, psychological, and surgical history of study cohort
Number (n) % of cohort
Previous medical history No medical issues 91 61
Asthma 12 8
Hypertension 4 3
Diabetes 4 3
Thyroid disorders 11 7
Clotting disorder 1 1
Neurological disorders 3 2
Rheumatology disorders 10 6
Inflammatory bowel disease 1 1
Hepatobiliary disorders (minor) 2 1
Previous malignancy 1 1
Other minor medical disorders 29 19
Previous mental health history No mental health issues 116 76
Depression 26 17
Bipolar 2 1
Generalized anxiety 18 12
Posttraumatic stress disorder Obsessive 5 3
compulsive disorder borderline 1 1
Personality disorder 5 3
Autism 2 1
Previous abdominal or pelvic surgery No previous abdominopelvic surgery 90 59
1× cesarean section 10 6
2× cesarean section 11 7
3× cesarean section 3 2
1× exploratory laparotomy 1 1
1× laparoscopy 28 18
2× laparoscopy 2 1
© 2021 The Author(s). Published by Wolters Kluwer Health, Inc. Jones et al 5
FIGURE 1. Motivating factors for consideration of uterine donation.
FIGURE 2. Perceived importance of each factor influencing motivation to donate.
6 Transplantation DIRECT ■ 2021 www.transplantationdirect.com
to donate to and wanting to donate because of considering or
being a surrogate previously.
More than three-quarters (n = 117; 77%) of respondents
were aware that UTx recipients would be at greater risk of
malignancy and infection because of the immunosuppressive
medications required to be taken postoperatively. However,
just 9% (n = 4) agreed or strongly agreed that this knowledge
would impact their decision to donate. More than two-thirds
of the cohort wanted to be kept informed of the future pro-
gress of recipients of their uteri (n = 105; 69%), around a
quarter (n = 40; 27%) were undecided, and 3% (n = 5) would
not want to know. Most respondents “strongly agreed” or
“agreed” to understanding they would not receive any pay-
ment for donating their uterus (n = 145; 95%); however, 4
(2%) individuals “strongly disagreed” or “disagreed.” Given
the likely media interest in the process due to its novelty, the
majority (n = 129; 85%) “strongly agreed” or “agreed” that
uterus donation would risk unwanted media attention.
After reading the information and considering the risks,
nearly all participants were still keen to donate their uterus
(n = 144; 95%). Eight (4%) remained undecided, with the
majority expressing a desire to know further information.
One participant, however, disagreed, citing the desire for
further counseling to help not develop an attachment to the
recipient’s family.
Suitability
Figure 3 summarizes a systematic process of exclusion,
using the donor selection criteria we have implemented for the
UK UTx LD program (Table4). In accordance with this cri-
terion, 25 (17%) respondents would be excluded from uterus
donation because of age ≥60 y or body mass index >35 kg/m2.
Seventeen (12%) more would be excluded for being current
smokers. A further 11 (8%) would be excluded because of
signicant preexisting medical conditions and 4 (3%) more
would be excluded because of multiple or signicant previ-
ous surgical history. More than a quarter (n = 38; 26%) would
not be eligible because of nulliparity, previous preeclampsia,
or preterm delivery. Three (2%) respondents would be con-
sidered unsuitable because of recurrent miscarriage, and 4
(3%) would be excluded because of previous cervical sur-
gery for abnormal cells or a recent abnormal cytology result.
Following the implementation of the selection criteria, 42
respondents (29%) would be considered suitable to proceed
with further clinical evaluation, counseling, and further inves-
tigation to determine suitability to donate.
DISCUSSION
The data presented herein demonstrate novel insight into
the perceptions of potential UTx LDs and portray robust and
diverse motivations and desires to proceed with the donation
process following an understanding of the risks involved and
a realistic awareness of the expected process and recovery.
This reinforces the generally supportive previously reported
public perceptions of UTx. When considering the public, a
web-based questionnaire completed by 1247 US residents
identied that more than three-quarters (78%) supported
UTx.24 Similar levels of support were seen in a European
study including 2000 Swedish women, wherein 80% were
found to be in favor of UTx and considered it to be more
acceptable than surrogacy.25 However, a study in 3098 women
of reproductive age in Japan demonstrated less favorable sup-
port, with just 44.2% being in favor of UTx. However, 47.5%
had no opinion, which highlights a potential lack of aware-
ness of UTx in those surveyed, particularly when the vast
majority (93.3%) felt that UTx should be permitted either
with or without further discussion.26 In the context of DD,
more than a decade ago, before the rst live birth following
UTx was reported,1 just 6% of donor families agreed to uter-
ine procurement as part of deceased donation.27 However, 10
y later, attitudes to uterine donation appear to have improved,
with three-quarters of women agreeing to donation of their
uterus at the time of their death, which increased to 87% after
becoming informed about the purpose of the transplant.28 In
addition, a recent European study demonstrated that dona-
tion of the uterus was readily accepted, with no refusals
observed in 7 cases.29
In the context of LD, it is essential to understand prospec-
tive donors’ motivations and expectations to ensure com-
prehension of the harms, risks, and likely benets of the
procedure on the part of the donor and that willingness to
donate is not coerced or induced, for example, with expec-
tation of payment. As shown in the data presented herein,
nearly all respondents appeared to understand that they
would not receive payment for their donation, which is reas-
suring. Prospective LDs should be nonetheless provided with
clear information regarding the nancial implications of a
decision to donate such as the prohibited status of payment
for organs and any reimbursement they may claim to offset
the costs of donation.
If of childbearing age, potential donors’ future reproductive
plans need to be explored, as does the possibility that their
aspirations and plans could change if they met a new partner
in future. We demonstrate that, of those included in the sur-
vey, the most common motivation for donation was to help
someone else carry and give birth to a child, closely followed
by a desire to help others, which is consistent with the primary
reported motivations underpinning donation in the rst 6 non-
directed UTx donors in the Dallas UtErine Transplant Study
(DUETS).30 Moreover, this is in line with motivations expressed
in the nondirected donation of other organs, such as kidney
donation, wherein the desire to donate has been described by
donors as “compelling,” and donation is associated with signif-
icant psychological motives and gains.31 Qualitative interviews
with nondirected kidney donors identied that donors want
to offer someone else a chance at a normal life32 and that the
altruistic value gained from the gift of donation outweighs the
fears and risks associated with the surgery.33
Our ndings, however, also suggest that the underpinning
motives of potential living uterus donors may be mixed, with
further consideration of self-regarding interests. A signicant
majority of respondents (89%) “agreed” or “strongly agreed”
that the cessation of menstruation would improve their qual-
ity of life, suggesting that they would expect physical benets
from donation. This inference is supported by work exploring
the motivations of living organ donors more generally, which
shows that, despite the narratives often imposed on them,
“many organ donors are not pure altruists: willing to sacrice
their own interests for the sake of another with no expecta-
tion of, or desire for, benet … they hold mixed and compli-
cated motivations for donation.”22
We also clearly demonstrate the anticipated decline in
numbers of potential donors in the context of using proposed
© 2021 The Author(s). Published by Wolters Kluwer Health, Inc. Jones et al 7
standard donor criteria. These gures can be used to esti-
mate eventual donor availability and also manage expecta-
tions in potential UTx donors. In DUETS, 79 women initially
expressed interest in donating their womb and 62 were sub-
sequently screened by telephone.34 Following prescreen, 30
donors completed a detailed health history questionnaire, in
a similar fashion to our study, in which 12 women eventually
proceeded to be clinically evaluated.34 This presents an over-
all conversion from screening to being clinically evaluated of
19%, which compares with 28% in our cohort. In DUETS,
following clinical evaluation, 50% of potential donors
eventually proceeded with donation (n = 6) due to a combina-
tion of unsuitability or self-withdrawal. Thereby, within our
cohort, using a 50% dropout rate, it would be anticipated
that approximately 21 women may eventually be suitable to
proceed with donation from the initial 152 women.
In UTx cases performed internationally so far, the mean age
is 44 y, and the mean age of the potential donors evaluated in
DUETS was 40 y.2 Although the precise ages were not elicited
in this dataset, as 61% of the cohort were aged between 30
and 50 y, they appear broadly similar. In UTx cases performed
so far, the vast majority (93%) have had children previously,
FIGURE 3. Systematic process of exclusion using the UK uterine transplant living donor selection criteria. BMI, body mass index.
8 Transplantation DIRECT ■ 2021 www.transplantationdirect.com
which is likely to have been skewed following multiparity
being an initially recommended inclusion criteria for donors,
as it is the only way to demonstrate uterine functionality with
certainty.35 However, 90% of the potential donors evalu-
ated in DUETS were also multiparous, which is signicantly
higher than the 63% demonstrated herein. This identies that
despite more than a third of our cohort not having children
themselves, they still had insight into the potential benets of
donating their uterus to someone who desires children.
Although the use of marginal organs is acceptable in life-
saving organ transplants, owing to the signicant risk of death
while on transplantation waiting lists,36 it is harder to justify
the use of suboptimal grafts in quality-of-life–improving trans-
plants, such as UTx. However, it is currently difcult to deter-
mine which donor selection criteria result in a suboptimal graft.
Although various selection criteria have been used in trials to
date, ongoing discussion in the context of outcomes follow-
ing UTx is required to determine which criteria optimize graft
quality and which criteria are of negligible benet and therefore
unnecessarily limit donor availability. Recent donor criteria
have been suggested for implementation in the context of DD.37
If extrapolated into LD, their suggested standard donor criteria,
which excludes women with miscarriage or cesarean section,
would reduce the number of suitable donors to just 25, before
comprehensive clinical evaluation and investigation, represent-
ing just 16% of the initial cohort. Given that the majority of
miscarriages are sporadic and because of problems completely
unrelated to the uterus, such as embryonic aneuploidy,38 and
that 15%–20% of women experience miscarriage,39 accept-
ing donors with previous sporadic miscarriages could increase
donor availability without detracting from the quality of the
graft. Moreover, given that around a quarter of deliveries in the
United Kingdom are performed via cesarean section, removing
this as an exclusion would improve donor availability.
This is the largest study of its kind to determine the back-
ground, perceptions, and motivations of potential UTx LDs,
and the rst of its kind in a UK population. Its ndings dem-
onstrate that nondirected altruistic donation could be a solu-
tion to the anticipated shortage of DDs, and lack of availability
of living-related donors for women with absolute uterine fac-
tor infertility. A weakness of this study includes the fact that
participants were self-selected, because they all directly con-
tacted Womb Transplant UK to inquire about uterine donation.
As such, the results presented herein are not directly applica-
ble to all women but relate specically to women interested
in donating their uterus. Additionally, the exclusive use of self-
reported data and closed-ended questions introduces the poten-
tial for bias.
Altruistic nondirected LD UTx donation appears to be
ethically and medically acceptable, provided that compre-
hensive physiological and psychological donor evaluation is
undertaken preoperatively, donor risk is minimized as much
as possible, and donors are appropriately counseled, thereby
facilitating informed consent. As suggested by the ndings
presented here, donating an organ can generate a number of
psychological and emotional benets and most potential UTx
donors express a desire to give another woman the opportu-
nity to bear a child herself. Moreover, in the context of the
reported outcomes in cases performed to date, albeit limited
in number, it is reassuring that psychological outcomes appear
excellent and that little regret has so far been reported.8,40
Although the use of DD negates donor risk, the associated
logistical difculties are so complex that they can compromise
the viability of UTx programs.4 Moreover, even in healthcare
systems with well-established DD programs, concerns have
been expressed about the potential availability of donors to
meet future demand.21,37 Although increasing donation after
brain death conversion rates is essential, increasing potential
DD supply may also be possible by considering uterine dona-
tion after circulatory death. However, this is a prospect that
requires further research to determine whether the prolonged
warm ischemic time in such cases is detrimental to UTx out-
comes. As demonstrated herein, given the willingness of some
women wishing to donate their uterus to an unknown recipi-
ent, the use of nondirected UTx donors is a readily available
donor pool that should be explored further.
CONCLUSION
This study provides novel insight into the motivation
of women who wish to donate their uterus to a previously
unknown recipient and displays high levels of acceptabil-
ity after consideration of the risks and expected recovery.
Despite the physical risk and expected lengthy recovery pro-
cess, women who donate their uterus expect to gain psycho-
logical and emotional benet by enabling another woman
to bear a child. In the context of expected shortages in DD
availability, unnecessarily ruling out nondirected LD is not
ethical nor is it sustainable. As such, consideration of the use
of nondirected altruistic living donation offers an alternative,
following comprehensive medical and psychological assess-
ment and extensive counseling. However, as demonstrated
here, despite the desire and motivation to donate, the selec-
tion criteria currently being implemented reduce the number
of potential donors signicantly. Although enhancing out-
comes remains paramount, further work is needed to vali-
date selection criteria to optimize donor availability without
impacting graft quality.
ACKNOWLEDGMENTS
This research was supported by a Wellcome Trust Senior
Investigator Award (grant097897/Z/11/Z) and a Leverhulme
Early Career Fellowship (grant ECF-2018-113).
TABLE 4.
Donor screening criteria for UK living donor uterine
transplantation program
Inclusion Aged 18–60 y
Multiparous
BMI <35 kg/m2
Exclusion History of cancer
Previous multiple/significant uterine surgery
2× cesarean section acceptable
No previous myomectomies
Previous significant cervical surgery (cone biopsy or LLETZ)
HPV positive or abnormal cervical cytology
Significant systemic disease (diabetes, hypertension, autoimmune
conditions, etc)
Previous obstetric problems including preeclampsia and delivery <37/40
Previous recurrent miscarriages (≥3)
Current IV drug abuse
Active bacteremia/fungemia
Active smoker
BMI, body mass index; IV, intravenous; LLETZ, large loop excision of the transformation zone.
© 2021 The Author(s). Published by Wolters Kluwer Health, Inc. Jones et al 9
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