Abstract and Introduction
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.
The first childbirth after uterus transplantation (UTx) took place in Sweden in September 2014 (Brännström et al., 2015), and this has been followed by many more births in several centres around the globe (Brännström et al., 2019). In this study, the measure of a successful UTx is the birth of a child. It should be noted that UTx was and remains the first true infertility treatment for absolute uterine factor infertility (AUFI), a condition which is caused either by the absence of the uterus or the presence of a non-functional uterus. Hysterectomy is recommended after the birth of the first or second child following UTx to avoid the long-term side effects of immunosuppression (Brännström et al., 2015; Chmel et al., 2018; Testa et al., 2020).
Quantitative data regarding the health-related psychosocial well-being of participants up to 3 years after UTx have already been presented (Järvholm et al., 2019; Järvholm et al., 2020a). The recipients were psychologically stable over the period of the study but reported stress during the period when they were trying to become pregnant and when outcomes were unsuccessful. In the previous qualitative follow-up study after UTx, we showed that having a uterus affected the women's self-image in a positive way, but this was also associated with strain when it came to body image and sexuality (Järvholm et al., 2020a): this previous study did not evaluate the recipients' psychological experiences of pregnancy attempts and parenthood.
The vast majority of women who have undergone UTx to date (in 2021, there are ~90 women worldwide who have undergone UTx) have Mayer–Rokitansky–Küster–Hauser syndrome (MRKH), which is characterized by the congenital absence of the uterus and upper part of the vagina (Herlin et al., 2020). MRKH has a negative psychological impact, particularly when individuals receive the diagnosis, typically during adolescence. Later in life the general psychological well-being of women with MRKH is almost comparable with the general population (Heller-Boersma et al., 2009) but sexual self-esteem is reported as being negatively affected (Weijenborg et al., 2019). MRKH-associated infertility may lead to a less positive self-image (Heller-Boersma, 2006).
There are a few studies about how women with MRKH reflect on the possibility of becoming mothers. One study from a German cohort of around 50 women with MRKH (Fliegner et al., 2018) showed that the women were sad about their inability to bear children. Only one had adopted a child and about half of the women considered surrogacy to be an option. Two recent studies, from the UK and Australia, found that women with AUFI preferred the novel, and still experimental, UTx procedure to surrogacy and adoption (Saso et al., 2016; Pittman et al., 2020).
Infertility and IVF are associated with emotional strain, and in particular marital satisfaction and psychological well-being are adversely affected (Chachamovich et al., 2010; El Kissi et al., 2013; Martins et al., 2014; Massarotti et al., 2019). However, the emotional strain associated with infertility is not found to affect outcome negatively (Boivin et al., 2011). In a comprehensive review, it was found that distress frequently occurred after unsuccessful IVF attempt(s) but declined during pregnancy (Verhaak et al., 2007). A more recent study reached a similar conclusion and also noted that following treatment failure there were adverse psychological outcomes affecting marital satisfaction and general well-being (Milazzo et al., 2016). Moreover, when treatment fails and desires for parenthood are unlikely to be realized, the mental health and well-being of individuals seeking to create a family suffers and it is recommended that they receive extended psychosocial care (Gameiro and Finnigan, 2017). In the event of reaching the goal of parenthood, most first-time parents experience decreased psychological well-being (McKenzie and Carter, 2013). The origin of this decrease is most likely multifactorial (Östberg et al., 2007; Pripp et al., 2010).
The aim of the present study was to increase our in-depth knowledge of women's experiences of pregnancy attempts, pregnancy and the first years of motherhood after successful UTx. Understanding the road to motherhood of women undergoing UTx will be helpful when tailoring optimal support for this group.
Hum Reprod. 2022;37(2):274-283. © 2022 Oxford University Press