Uterus Transplant in India and UAE | Complete Patient Guide

• ELIGIBLE PATIENTS:

• Women of reproductive age (typically 18–40 years) with confirmed absolute uterine factor infertility (AUFI)

• Congenital uterine absence: Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome Type I or Type II (with normal ovarian function confirmed)

• Acquired uterine absence: post-hysterectomy (benign or oncologic indication, with oncologic patients requiring minimum 5-year disease-free survival certification)

• Severe Asherman's syndrome (Grade IV, complete obliteration) unresponsive to hysteroscopic lysis and estrogen priming

• Confirmed functional ovarian reserve (AMH ≥ 0.5 ng/mL, AFC ≥ 5) permitting oocyte retrieval and embryo banking prior to transplant

• Psychologically evaluated and cleared by a certified psychiatrist or clinical psychologist with transplant experience

• Partner (or sperm donor) evaluated and cleared; embryos typically cryopreserved before transplant surgery

• BMI within acceptable surgical range (generally 18–30 kg/m²; individual centre criteria apply)

• Non-smoker or confirmed cessation ≥ 6 months prior to listing

• Medically fit for major abdominal surgery and chronic immunosuppression (cardiopulmonary clearance required)

• REQUIRED DIAGNOSTIC WORKUP (PRE-TRANSPLANT):

• Pelvic MRI with contrast: uterine anatomy, vascular mapping of iliac vessels, vaginal vault assessment

• CT Angiography (CTA) of the pelvis: recipient iliac vessel calibre and patency to plan vascular anastomosis

• Transvaginal/transabdominal ultrasound with Doppler: ovarian reserve and pelvic vascularity

• Hormonal panel: FSH, LH, AMH, estradiol, progesterone (day 2–3 of cycle)

• Comprehensive metabolic panel, renal function (eGFR), liver function tests

• Full immunological workup: HLA typing (A, B, C, DR, DQ), Panel Reactive Antibody (PRA) titre, crossmatch with potential donor

• Infectious disease serology: HIV, Hepatitis B surface antigen & core antibody, Hepatitis C antibody, CMV IgG/IgM, EBV, HSV, Toxoplasma, Syphilis (VDRL/RPR)

• Cervical cytology (Pap smear) and HPV testing (if cervix present or remnant present)

• Bone mineral density (DEXA scan): baseline before initiation of chronic immunosuppression

• Echocardiogram (ECHO) and resting ECG: cardiopulmonary surgical clearance

• Psychological and psychiatric evaluation (minimum two independent assessments per ISUTx guidelines)

• Genetic counselling (mandatory for MRKH and Müllerian anomaly patients)

• Nutritional assessment and optimisation

• CONTRAINDICATIONS (ABSOLUTE):

• Active or incompletely treated malignancy (except non-melanoma skin cancer)

• Severe systemic disease precluding major surgery or immunosuppression (e.g., advanced heart failure, ESRD on dialysis without transplant candidacy, uncontrolled diabetes with end-organ damage)

• Active systemic infection or sepsis

• Severe psychiatric illness not adequately controlled (e.g., active psychosis, untreated major depression, active substance use disorder)

• Absence of functional ovaries or severe diminished ovarian reserve without donor egg agreement (programme-specific)

• HIV-positive status with detectable viral load (some centres accept undetectable VL; programme-specific)

• Inability to comply with post-transplant immunosuppression regimen and surveillance schedule

• Coagulation disorders not amenable to perioperative management

• RELATIVE CONTRAINDICATIONS (REQUIRING MULTIDISCIPLINARY REVIEW):

• BMI > 35 kg/m²

• Prior complex pelvic surgery with dense adhesions

• Autoimmune conditions requiring immunosuppression (may simplify or complicate post-transplant management)

• Advanced maternal age (> 40 years; centre and ethics board discretion)

PROGRAMME PHASES OVERVIEW:

Uterus transplantation is not a single operation but a structured multi-year clinical programme encompassing five distinct phases: (1) IVF and embryo banking, (2) donor selection and workup, (3) transplant surgery, (4) pregnancy achievement and obstetric management, and (5) planned uterus explantation.

PHASE 1 — IVF AND EMBRYO CRYOPRESERVATION:

Before any surgical listing, the recipient undergoes controlled ovarian stimulation (COS) using a GnRH antagonist protocol (e.g., Cetrotide/Ganirelix) or a long agonist downregulation protocol, followed by oocyte retrieval under transvaginal ultrasound guidance. Embryos are created via conventional IVF or Intracytoplasmic Sperm Injection (ICSI) and vitrified using the Cryotop/Kitazato vitrification system, which achieves > 90% post-thaw survival rates. A minimum of 3–5 vitrified blastocysts (Day 5/6 embryos, PGT-A tested where indicated) is recommended before transplant listing, as embryo transfer cannot occur until 6–12 months post-transplant and only during stable immunosuppression.

PHASE 2 — DONOR TYPES AND SELECTION:

• LIVING RELATED DONOR (LRD): Most commonly a mother, sister, or close relative who has completed her own family. Donors undergo identical vascular mapping, HLA typing, immunological crossmatch, and psychological evaluation. The LRD programme offers superior graft quality due to minimal cold ischaemia time.

• LIVING UNRELATED DONOR (LURD): Altruistic donors evaluated under strict ethics board oversight; legal frameworks vary by country (permitted in India under the Transplantation of Human Organs and Tissues Act, THOTA, with ROTTO/SOTTO approval).

• DECEASED DONOR (DD): Utilised in UAE programmes and in Indian centres with active deceased donor programmes. DD grafts require meticulous preservation with University of Wisconsin (UW) or Custodiol HTK solution and are associated with longer cold ischaemia times, necessitating rapid coordination. DD transplantation expands access for women without suitable living donors.

PHASE 3 — SURGICAL TECHNIQUES:

a) STANDARD OPEN UTERUS TRANSPLANT (Gold Standard):

The current globally accepted standard involves a midline or Pfannenstiel laparotomy in both donor and recipient. In the donor, the uterus is procured with long uterine pedicles including the uterine arteries and veins, preserved with segments of the internal iliac or uterine artery origin, and the vaginal cuff is harvested. Cold ischaemia time is minimised (< 3 hours in living donor cases). In the recipient, the external iliac vessels are anastomosed end-to-side to the uterine vessels using microsurgical technique (operating microscope or high-magnification loupes, 7-0 or 8-0 Prolene sutures). The vaginal cuff of the graft is sutured to the recipient's vaginal apex. No tubal anastomosis is performed. Operative time: 6–10 hours (recipient surgery); 3–5 hours (donor surgery).

b) ROBOTIC-ASSISTED LAPAROSCOPIC UTERUS TRANSPLANT (EMERGING — LIVING DONOR PROCUREMENT):

Pioneered at centres including Baylor University Medical Center (Dallas), robotic-assisted procurement using the da Vinci Xi Surgical System allows minimally invasive donor hysterectomy with uterine artery dissection, dramatically reducing donor morbidity, blood loss, and recovery time. Recipient implantation currently remains open due to the complexity of microvascular anastomosis, though robotic-assisted recipient surgery is under active investigation. India's top robotics centres (using da Vinci Xi) are exploring robotic procurement protocols.

c) LAPAROSCOPIC/HAND-ASSISTED LAPAROSCOPIC DONOR PROCUREMENT:

Minimally invasive laparoscopic or hand-assisted laparoscopic procurement offers a middle ground between open and fully robotic approaches, with reduced donor incision length and shorter hospital stay compared to open procurement.

IMMUNOSUPPRESSION PROTOCOL:

Induction: Basiliximab (anti-IL-2 receptor antibody, 20 mg IV on days 0 and 4) plus methylprednisolone intraoperatively.

Maintenance triple therapy (standard): Tacrolimus (target trough 10–15 ng/mL initially, weaned to 5–8 ng/mL in stable phase) + Mycophenolate Mofetil (MMF, 1000–1500 mg twice daily) + Prednisolone (tapered to 5 mg/day). MMF is discontinued and replaced with Azathioprine upon confirmed intrauterine pregnancy due to teratogenicity.

CMV prophylaxis: Valganciclovir (Valcyte) for 3–6 months post-transplant in CMV donor-positive/recipient-negative pairs.

Pneumocystis prophylaxis: Trimethoprim-Sulfamethoxazole (Co-trimoxazole) for 6–12 months.

Monitoring for rejection: Monthly or bimonthly transcervical endometrial biopsy (Pipelle or hysteroscopic-directed) with Banff classification histology for acute T-cell mediated rejection or antibody-mediated rejection. Rejection episodes are treated with pulse IV methylprednisolone (500–1000 mg × 3 days) ± anti-thymocyte globulin (ATG) for steroid-refractory rejection.

PHASE 4 — EMBRYO TRANSFER AND PREGNANCY:

Embryo transfer is attempted no earlier than 6–12 months post-transplant, after confirmed uterine viability (Doppler flow, regular menstruation, absence of rejection on biopsy). Endometrial preparation uses estradiol valerate and progesterone supplementation. Frozen embryo transfer (FET) of a single euploid blastocyst (PGT-A tested) is the standard of care. All pregnancies are monitored as high-risk with weekly/fortnightly ultrasound surveillance, Doppler velocimetry of the transplanted uterine vessels, maternal tacrolimus trough monitoring, and obstetric consultation. Delivery is exclusively via planned Caesarean section (lower segment; typically at 37–38 weeks gestation) to avoid uterine rupture risk.

PHASE 5 — UTERUS EXPLANTATION:

After completing the desired number of live births (programme maximum: typically 2 deliveries), the transplanted uterus is electively removed by hysterectomy, allowing discontinuation of all immunosuppression and eliminating the cumulative risks of long-term immunosuppressive therapy. Explantation is typically performed at the time of or after the Caesarean delivery of the final planned pregnancy.

STEP 1 — INITIAL CONSULTATION AND GAF HEALTHCARE CASE REVIEW (Weeks 1–4, Remote): The patient submits medical records, imaging (pelvic MRI, hormonal panels), and prior reproductive history to GAF Healthcare's clinical team. A teleconsultation is arranged with the lead transplant surgeon and reproductive endocrinologist. Eligibility is assessed against ISUTx criteria. A preliminary treatment roadmap and cost estimate are provided.

STEP 2 — IVF AND EMBRYO BANKING (Months 1–3, In-Country or Home Country): Controlled ovarian stimulation and oocyte retrieval are performed — ideally at the destination centre or at the patient's home fertility clinic under a shared-care protocol. A minimum of 3–5 vitrified blastocysts are created and banked. PGT-A (preimplantation genetic testing for aneuploidy) is recommended to maximise the chance of successful embryo transfer post-transplant.

STEP 3 — DONOR EVALUATION AND WORKUP (Months 2–4, Concurrent with IVF): Living donor (or deceased donor coordination) workup is completed: HLA typing, PRA/crossmatch, vascular imaging (CTA pelvis), psychological evaluation, ethics board approval (mandatory under THOTA in India; DHA/HAAD regulations in the UAE), and ROTTO/SOTTO registration in India. This phase requires 2–3 in-person visits to the transplant centre.

STEP 4 — PRE-OPERATIVE ADMISSION AND FINAL WORKUP (Days –5 to –1): Both recipient and living donor are admitted. Final crossmatch is performed. Anaesthesia assessment, bowel preparation, and prophylactic antibiotic and antifungal regimens are initiated. IV tacrolimus loading (or oral tacrolimus initiation) begins 48–72 hours pre-transplant to achieve therapeutic trough levels. Psychological support and pre-operative counselling are provided.

STEP 5 — TRANSPLANT SURGERY (Day 0): Donor and recipient surgeries are conducted simultaneously in adjacent or sequential operating theatres. Donor surgery (living donor hysterectomy): 3–5 hours (open) or 4–6 hours (robotic/laparoscopic). Recipient surgery (uterus implantation): 6–10 hours. Microvascular anastomosis is confirmed intraoperatively with Doppler ultrasound. The patient is transferred to the surgical ICU or high-dependency unit.

STEP 6 — ICU AND EARLY POST-OPERATIVE MONITORING (Days 1–5): Hourly uterine Doppler flow assessment is performed for the first 24–48 hours to detect early vascular thrombosis (the most critical early complication). Tacrolimus trough monitoring twice daily. IV hydration, DVT prophylaxis (low molecular weight heparin — LMWH, e.g., Enoxaparin), proton pump inhibitor coverage, and antimicrobial prophylaxis. The donor is managed on the standard post-hysterectomy recovery pathway and is typically discharged by Day 4–6.

STEP 7 — WARD RECOVERY AND FIRST MENSTRUATION (Days 6–21): Transfer from ICU to transplant ward. Oral immunosuppression stabilisation. Physical therapy begins (ambulation, respiratory physiotherapy). First menstrual bleeding from the transplanted uterus — a critical milestone confirming endometrial viability — typically occurs 4–8 weeks post-transplant. The first endometrial biopsy (transcervical Pipelle) is performed at 4–6 weeks to exclude subclinical rejection.

STEP 8 — DISCHARGE AND IN-COUNTRY MONITORING (Weeks 3–12): Patient is discharged from hospital at approximately Day 14–21 and resides in serviced accommodation near the transplant centre (arranged by GAF Healthcare). Monthly outpatient visits include: tacrolimus trough levels, renal and hepatic function, blood pressure monitoring, endometrial biopsy (Pipelle), and gynaecological ultrasound with Doppler. CMV surveillance PCR is performed every 2–4 weeks.

STEP 9 — FIT-TO-FLY AND RETURN HOME (Weeks 8–12): Long-haul international flight is medically cleared after minimum 8 weeks, confirmed by: stable tacrolimus levels, absence of rejection on most recent biopsy, no active infection, satisfactory wound healing, and haemodynamic stability. A comprehensive discharge summary, immunosuppression prescription, monitoring schedule, and shared-care protocol for the patient's home physician/nephrologist are provided by GAF Healthcare.

STEP 10 — CONTINUED SURVEILLANCE AND EMBRYO TRANSFER (Months 6–12 Post-Transplant): Embryo transfer is attempted at the destination centre at 6–12 months post-transplant (patient returns to India or UAE for the procedure, typically a 1–2 week visit). Monthly surveillance continues remotely via the shared-care pathway with GAF Healthcare teleconsultation support.

STEP 11 — PREGNANCY, DELIVERY, AND EXPLANTATION: Confirmed intrauterine pregnancy managed as high-risk. MMF replaced with Azathioprine at confirmed pregnancy. The patient is typically expected to reside in-country from approximately 28–30 weeks gestation through delivery (planned Caesarean at 37–38 weeks) and 4–6 weeks postpartum. Explantation is performed after the final desired delivery, completing the programme.