Which Donor for Uterus Transplants: Brain-Dead Donor or Living Donor? A Systematic Review.
BACKGROUND
The aim of this systematic review was to evaluate and compare the pros and cons of using living donors or brain-dead donors in uterus transplantation programs, 2 years after the first worldwide live birth after uterus transplantation.


METHODS
The Medline database and the Central Cochrane Library were used to locate uterine transplantation studies carried out in human or nonhuman primates. All types of articles (case reports, original studies, meta-analyses, reviews) in English or French were considered for inclusion.


RESULTS
Overall, 92 articles were screened and 44 were retained for review. Proof of concept for human uterine transplantation was demonstrated in 2014 with a living donor. Compared with a brain-dead donor strategy, a living donor strategy offers greater possibilities for planning surgery and also decreases cold ischemia time, potentially translating into a higher success rate. However, this approach poses ethical problems, given that the donor is exposed to surgery risks but does not derive any direct benefit. A brain-dead donor strategy is more acceptable from an ethical viewpoint, but its feasibility is currently unproven, potentially owing to a lack of compatible donors, and is associated with a longer cold ischemia time and a potentially higher rejection rate.


CONCLUSIONS
The systematic review demonstrates that uterine transplantation is a major surgical innovation for the treatment of absolute uterine factor infertility. Living and brain-dead donor strategies are not mutually exclusive and, in view of the current scarcity of uterine grafts and the anticipated future rise in demand, both will probably be necessary.
1 Department of Gynecology, Rennes University Hospital, Rennes, France. 2 Faculty of Medicine, University of Rennes 1, Rennes, France. 3 ER 440, OSS, CRLCC Eugène Marquis, Rennes, France. 4 Department of Nephrology, Hôpital Pontchaillou, Rennes University Hospital, Rennes, France. 5 Institute for Environmental, Health and Labor Research (IRSET), Rennes, France. 6 Rennes University Hospital, Department of Liver Surgery, Hôpital Pontchaillou, Rennes, France. 7 Department of Gynecology and Obstetrics, Hôpital Mère-Enfant, CHU Dupuytren, Limoges, France. 8 Pharmacology, Toxicology and Drug Safety Monitoring, INSERM, Limoges, France.
Vincent
V
Lavoué
Cécile
C
Vigneau
Solène
S
Duros
Karim
K
Boudjema
Jean
J
Levêque
Pascal
P
Piver
Yves
Y
Aubard
Tristan
T
Gauthier
D001926:Brain Death; D046148:Donor Selection / Q000941:ethics; D005260:Female; D005298:Fertility; D006085:Graft Survival; D006801:Humans; D007247:Infertility, Female / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D050498:Live Birth; D019520:Living Donors / Q000941:ethics; D016377:Organ Transplantation / Q000009:adverse effects / Q000941:ethics / Q000379:methods*; D011247:Pregnancy; D012307:Risk Factors; D014019:Tissue Donors / Q000941:ethics / Q000600:supply & distribution*; D016896:Treatment Outcome; D014599:Uterus / Q000473:pathology / Q000503:physiopathology / Q000637:transplantation*