2.1 Candidates

Ten candidates were on the waiting list for uterus transplant in 2021 (Figure VCA 1). Most uterus transplant candidates have been younger than 35 years (Figure VCA 2) and White (Figure VCA 3), with blood types A or O (Figure VCA 4).

2.2 Transplants

As of December 2021, 33 uterus transplants were performed (Figure VCA 5). Most uterus transplants were performed in White (29 of 33 recipients; Figure VCA 7) women younger than 35 years (28 of 33 recipients; Figure VCA 6). Uterus transplant recipients were predominantly blood types A or O (29 of 33 recipients; Figure VCA 8). Primary diagnosis of absolute uterine factor infertility due to congenital absence of the uterus was present in 25 of 33 recipients (Figure VCA 9).

2.3 Donors

Unlike transplants for other VCA organs that use only deceased donor organs, living donor uterus transplants are performed: 64% of uterus transplants (21/33) since 2016 used living donors (Figure VCA 10). All deceased donor uterus transplants were performed with donors younger than 50 years, with most using donors aged 18-34 years. All but one of the living donors were younger than 50 years (Figure VCA 11).

2.4 Posttransplant Outcomes

Unlike other organ transplants, uterus grafts are always removed after the recipient has finished having children. Data reported to the OPTN show 21 functioning grafts and 8 uterus grafts failed (24% of 33 transplants; Figure VCA 12). However, uterus transplantation is a small and growing field, and the authors are aware of 17 uterus grafts that have, in fact, been removed after successful child delivery. The essential outcome variable for a uterus transplant is a live birth. While number of births is not yet captured in the data, as of December 2021, the authors are aware of 21 children who have been born to 19 uterus transplant recipients.

2.5 Access

Uterus transplants through 2021 were performed at centers in three states: Ohio, Pennsylvania, and Texas. Of these, most transplants have been performed in Texas (67%, 22/33; Table VCA 1).

3.1 Candidates

The total number of candidates listed for non-uterus VCA has remained stable since 2014 when the OPTN VCA waiting list was established, with 18 total candidates ever waiting in 2021 (Figure VCA 13). Since 2014, candidate listings by organ type show that the most common has been upper limb (43%, 23/53) and the least common has been “other/multiple” (13%, 7/53). Annual data are difficult to evaluate due to sample size; however, at the end of 2021, seven patients were waiting for abdominal wall transplant, three were waiting for face transplant, six were waiting for upper limb transplant, and two were waiting for other/multiple transplant (Figures VCA 13 and 14).

Similar to last year’s report, most non-uterus VCA candidates listed since 2014 were aged 18-34 years (32%, 17/53), 35-49 years (26%, 14/53), and 50-64 years (30%, 16/53) (Figure VCA 15). By race and ethnicity, most non-uterus VCA transplant candidates identified as White (74%, 39/53), followed by Hispanic (13%, 7/53), Black (11%, 6/53), and other (2%, 1/53) (Figure VCA 16). Since 2014, non-uterus VCA transplant candidates have predominantly been male (70%, 37/53) (Figure VCA 17) with blood type O (45%, 24/53), followed by type A (34%, 18/53), type B (17%, 9/53), and type AB (4%, 2/53) (Figure VCA 18). In addition, when evaluating median days to transplant by organ type since 2014, the longest time to transplant was scalp (355 days). Median days to transplant for face, penis, other/multiple, upper limb, and abdominal wall were 342 days, 262 days, 238 days, 186 days, and 125 days, respectively (Figure VCA 19).

3.2 Donors

With respect to age, most donors from 2014 through 2021 were within the 18- to 34-year age group (52%, 16/31). Data for the remaining age groups are as follows: 13% (4/31) were younger than 18 years, 32% (10/31) were aged 35-49 years, and 3% (1/31) were aged 50-64 years (Figure VCA 27).

3.3 Recipients

Since July 3, 2014, of the 53 total non-uterus VCA transplant candidates listed, 31 (58%) have undergone transplants. While it continues to be difficult to evaluate data trends due to sample size limitations, no substantial change has been seen in VCA transplants performed annually from 2014 through 2021 (Figure VCA 20). The most commonly transplanted non-uterus VCA was upper limb (48%, 15/31), followed by face (35%, 11/31), other (including penis and scalp; 10%, 3/31), and abdominal wall (6%, 2/31) (Figures VCA 20 and 21).

Demographic data for patients who underwent non-uterus VCA transplant in 2014 through 2021 are as follows. The three most common causes of need for VCA transplant were trauma (45%, 14/31), infection (26%, 8/31), and burn/explosion (6%, 2/31). However, 10% (3/31) of data was missing (Figure VCA 26), which was similar to our previous (2020) report. The most common age group among non-uterus VCA transplant recipients was 18-34 years (39%, 12/31), followed by 50-64 years (29%, 9/31), 35-49 years (19%, 6/31), 65 years or older (10%, 3/31), and younger than 18 years (3%, 1/31) (Figure VCA 22). Due to small numbers of non-White recipients, race within the non-uterus VCA transplant recipient group has continued to be presented differently from that in the listed non-uterus VCA candidate group; for recipients, race is stratified as White and non-White. The proportions of White and non-White non-uterus VCA transplant recipients were 81% (25/31) and 19% (6/31), respectively (Figure VCA 23). Non-uterus VCA transplant recipients were mostly male (74%, 23/31) (Figure VCA 24) with blood type O (48%, 15/31), followed by type A (29%, 9/31) and type B (23%, 7/31). No transplants were performed in patients with type AB blood (Figure VCA 25).

3.4 Access and Outcomes

Nineteen centers in 11 US states have performed non-uterus VCA transplants since July 2014 (Table VCA 3). In terms of the number of centers performing VCA transplants by organ, upper limb is the most common (nine centers), followed by face (five centers), abdominal wall (two centers), penis (two centers), and scalp (one center) (Figure VCA 28). Compared with last year’s report, centers performing upper limb and face VCA transplants since 2014 have slightly increased (8 to 9 and 4 to 5, respectively).⁴

Regarding patient outcomes for non-uterus VCA transplant, end points were broken into two groups per organ type: “functioning graft” and “failed graft.” In the period being discussed (2014-2021), only 7% of upper limb VCAs (1/15) failed, and there was a 100% functioning graft rate in abdominal wall, face, penis, and scalp VCA transplants (Table VCA 2).