Reuse of the same uterine graft: Emerging considerations in allotransplantation

Uterus transplantation has emerged as a promising treatment option for patients with absolute uterine factor infertility who desire gestation. Unlike solid organ transplantation performed for life-preserving indications, uterus transplantation is a temporary procedure, with graft removal planned after completion of childbearing. This distinctive feature raises a novel question: whether the same uterine graft could be recovered and reused in a subsequent recipient. In this review, we examine uterine graft reuse as a potential strategy to increase graft availability and broaden access in selected settings. Existing uterus transplantation outcome data establish that transplanted uteri can support menstruation, pregnancy, and live birth and that pregnancy after uterus transplantation carries meaningful maternal and perinatal risks. However, no clinical data establish the feasibility or safety of reusing a uterine graft in another recipient. We therefore frame graft reuse as an exploratory hypothesis requiring preclinical validation. Key considerations include the donor pathway, donor-recipient immunologic and virologic compatibility, the effects of prior transplantation and pregnancy on graft quality, vascular and operative feasibility at graft retrieval, postpartum timing, and the obstetric implications of prior cesarean delivery. Additional issues include ischemic tolerance, consent for serial graft use, and equitable allocation. Overall, uterine graft reuse represents a speculative extension of the temporary-graft model that distinguishes uterus transplantation from other transplant disciplines. Further progress will depend on animal studies, surgical modeling, and careful ethical, infectious, immunologic, and obstetric assessment. By separating established clinical observations from unanswered questions, this article provides a framework for future investigation of uterine graft reuse.