Uterus Transplantation-Current Evaluation, Monitoring, and Emerging Diagnostics

Uterus transplantation (UTx) is uniquely positioned at the transition from experimental to clinical reality for women with absolute uterine factor insufficiency. As the technique gains wider clinical adoption, there is a growing need for standardization in both protocols and diagnostics.

This review describes the current evaluation, monitoring, and emerging diagnostics in UTx across the main phases of care: (a) preoperative evaluation, which includes fertility evaluation and in vitro fertilization, surgical, psychosocial, and donor assessments, as well as donor-recipient matching considerations; (b) perioperative management, which focuses on acute surgical care, initiation of immunosuppression, and early graft evaluation; (c) posttransplant and pregnancy monitoring, which encompasses ongoing immunosuppression evaluation, biopsy interpretation, management of acute rejection, and detection and management of pregnancy and maternal complications; and (d) long-term follow-up, which addresses the potential for repeat pregnancies and planned graft hysterectomy to facilitate immunosuppression withdrawal.The review further explores future directions for clinical diagnostics in UTx, drawing on broader solid organ transplantation experiences. This includes molecular and allele-level human leukocyte antigen matching for recipient-donor compatibility, strategies for immunosuppression minimization, and the development of noninvasive rejection monitoring tools such as donor-derived cell-free DNA and novel blood and urine transcriptomics approaches.

Standardization of protocols and diagnostics is essential as UTx transitions to routine clinical practice. Emerging molecular diagnostics and noninvasive monitoring tools hold promise for improving graft outcomes and patient care in this evolving field.