Confronting complexities of uterus transplantation: Balancing Innovation, Risk and Access

Uterus transplantation (UTx) has evolved from experimental procedure to an increasingly established infertility treatment for women with absolute uterine factor infertility. Despite procedural progress, UTx remains a very complex infertility treatment. Here, we examine key complexities and challenges that will shape the future of UTx. Donor-related considerations include selection criteria for both live and deceased donors to maximize the likelihood of transplantation success. The implications of exposing healthy live donors to risks of postoperative complications, organ availability and logistical challenges with deceased donation are also explored. Recipient-related challenges encompass the historically high risk of graft failure, immunosuppression risks, pregnancy complications, and reproductive planning to prepare for and optimize the chances of achieving the desired family size. The potential expansion of UTx to additional patient populations introduces ethical concerns. Access to UTx remains limited by the need for specialized multidisciplinary expertise and substantial financial resources, resulting in significant geographic and socioeconomic disparities. Comparisons with the alternative pathway, gestational surrogacy, provide important context for discussions of value and resource allocation. The ethical analysis highlights tensions surrounding acceptable risk in a non-life-saving transplant, protection of live donors, equitable access, and balance between reproductive autonomy and societal responsibility. By drawing on perspectives from multidisciplinary UTx-experts, this Views and Reviews article concludes that UTx is an effective and ethically acceptable infertility treatment. Continued accumulation of clinical experience, registry-based outcomes, technological advances, and broader healthcare engagement will be essential to improve safety and efficacy and support integration of UTx into clinical practice.