Striving for motherhood after uterus transplantation: a qualitative study concerning pregnancy attempts, and the first years of parenthood after transplantation

Abstract

STUDY QUESTION How do women experience attempts to become pregnant, and the first years of motherhood, after uterus transplantation (UTx)? SUMMARY ANSWER Women who try to become pregnant after UTx experience the general strains typically associated with infertility and childlessness, such as failure of embryo transfer (ET), and specific worries about graft survival but when they become mothers they essentially feel like other mothers, with the associated rewards and stresses. WHAT IS KNOWN ALREADY UTx has proven to be a successful treatment for absolute uterine factor infertility (AUFI). Although UTx seems to have a positive effect on self-image there is a lack of knowledge about how women who have received uterine grafts experience pregnancy attempts, pregnancy itself and the first years of motherhood. STUDY DESIGN, SIZE, DURATION This prospective cohort study included the seven participants in the first UTx trial who had experienced surgically successful grafts. Pregnancy was attempted using ET 12 months after transplantation. Structured interviews were performed once a year for 5 years after transplantation. PARTICIPANTS/MATERIALS, SETTING, METHODS Six of the seven participants (mean age 29.3 years at UTx) had AUFI owing to the congenital absence of the uterus, while the seventh woman had undergone a hysterectomy. Post-transplantation, yearly interviews (2013–2018) were performed, comprising a total of 34 interviews. Interview data were analysed thematically. MAIN RESULTS AND THE ROLE OF CHANCE All seven participants achieved pregnancy during the study period and six became mothers. Experiencing the previously unimaginable was classed as an overarching theme with the following underlying themes: The yoke of childlessness; Going through the impossible and Motherhood as surreal and normal. The results showed that the women who try to achieve motherhood after UTx generally describe their situation as manageable and present strains comparable to other women undergoing infertility treatments. LIMITATIONS, REASONS FOR CAUTION The fact that all participants came from one centre is a limitation. WIDER IMPLICATIONS OF THE FINDINGS There are real psychological strains in motherhood after UTx, such as the concern the women expressed relating to health of the child and the effects of immunosuppressants. These findings are in line with those of other women who became pregnant after transplantation of organs other than the uterus. The results show that extra psychological support and attention should be given to those with repeated pregnancy failures or unsuccessful outcomes. In the cases where women became mothers, attention needs to be given to the possible worries connected to the UTx, but in other respects, they should be treated like any mother-to-be. STUDY FUNDING/COMPETING INTEREST(S) Funding was received from the Jane and Dan Olsson Foundation for Science; Knut and Alice Wallenberg Foundation. A.L.F. grant from the Swedish state under an agreement between the government and the county councils; Swedish Research Council. The authors have no competing interests. TRIAL REGISTRATION NUMBER NCT01844362.

Uterus transplantation: from research, through human trials and into the future

“…It was concluded that the self-image was in general positively affected. The other study explored experiences of attempting pregnancy and of motherhood, identifying an overarching theme of ‘experiencing the previously unimaginable’, with underlying subthemes of ‘the yoke of childnessness’, ‘going through the impossible’, and ‘motherhood as surreal and normal’ ( Järvholm et al , 2022 ). It was summarized that women with UTx experience the common worry about implantation failure at ET, specific worries of graft failure and, when they become mothers, they feel like other mothers, with the associated stresses and rewards.…”

Vascularized composite allotransplantation: emerging psychosocial issues in hand, face, and uterine transplant

“…Most women with MRKHs later in life are almost comparable to the general population regarding QOL [52], but questions regarding fertility and sexual self-esteem are reported to be negatively affected [53]. UTx is mainly experienced as a road to motherhood [34 ▪▪ ], but the time with the uterus also provides a change in self-perception when having the bodily changes like everyone else [17 ▪▪ ,18 ▪▪ ]. Follow-up with standardized questionnaires have, so far, shown that the group of women who have undergone the procedure are fairly stable [42 ▪ ,43].…”

“…Another important difference between the UTx and other VCA procedures is the temporary adjustment to the graft as the graft will be removed after achieving its purpose, delivery of children. The removal of the uterus, if it has to be successful, can result in an experience of ‘being back to me’ [34 ▪▪ ] or a negative impact on self-esteem [18 ▪▪ ]. The exit strategies must be discussed at several time-points both with those who become parents as well with those with graft-failure.…”

“…Pregnancy and delivery should be monitored as close to a general program as possible, this striving to give the woman the possibility to experience pregnancy and attachment as close to normal. In the group of UTx, it is a fine balance between providing medical safety and at the same time psychological normality, and this dilemma was stated by a participant as an experience of pregnancy as ‘a part of my own, a part of healthcare’ [34 ▪▪ ].…”

Long-term health-related quality-of-life and psychosocial outcomes after uterus transplantation: a 5-year follow-up of donors and recipients

“…Declines were reported and may have been associated both with unsuccessful outcomes of the graft as well with general life changes, such as retirement ( Järvholm et al , 2019 ). Qualitative follow-up studies showed that the state of having a uterus affected the recipient’s self-image in a positive way, but this was also associated with strains regarding body image and sexuality, and after giving birth the recipients saw themselves as almost like everyone else but with a special experience in their road to motherhood ( Järvholm et al , 2020 , 2022 ). From a large UTx centre in USA, a 2-year follow-up study with qualitative data of recipients reported positive impacts regarding their reproductive autonomy and female identity ( Wall et al , 2022 ).…”