The vaginal microbiome in uterine transplantation

Abstract

Women with congenital absolute uterine factor infertility (AUFI) often need vaginal restoration to optimise sexual function. Given their lack of procreative ability, little consideration has previously been given to the resultant vaginal microbiome (VM). Uterine transplantation (UTx) now offers the opportunity to restore these women's reproductive potential. The structure of the VM is associated with clinical and reproductive implications that are intricately intertwined with the process of UTx. Consideration of how vaginal restoration methods impact VM is now warranted and assessment of the VM in future UTx procedures is essential to understand the interrelation of the VM and clinical and reproductive outcomes.Tweetable abstract The vaginal microbiome has numerous implications for clinical and reproductive outcomes in the context of uterine transplantation.

Options for acquiring motherhood in absolute uterine factor infertility; adoption, surrogacy and uterine transplantation

“…While dilator therapy, 86 or the Vecchietti procedure, 87 would create a physiologically functioning mucosal vagina, the creation of a neovagina using skin, peritoneum or intestine would probably create a dysbiotic environment that might affect future clinical and reproductive outcomes following UTx. 88 As such, some UTx programmes currently exclude women with intestinal neovagina from undergoing UTx. 81 MRKH is traditionally considered a sporadic condition, owing to previously reported discordance between identical twins 89 and the fact no females with MRKH have been born from surrogate pregnancies using oocytes from women with MRKH.…”

“…Given the rapid progress and demand for UTx among women with AUFI, and considering the anticipated transition into clinical care, the potential impact of the vaginal restoration method on future suitability for UTx should be contemplated. While dilator therapy, 86 or the Vecchietti procedure, 87 would create a physiologically functioning mucosal vagina, the creation of a neovagina using skin, peritoneum or intestine would probably create a dysbiotic environment that might affect future clinical and reproductive outcomes following UTx 88 . As such, some UTx programmes currently exclude women with intestinal neovagina from undergoing UTx 81 …”

Anaesthetic considerations for fertility‐sparing surgery and uterine transplantation

“…Individualised assessment for the continuation of the above prophylaxis will depend on organ perfusion and microbiology results. However, it is important to balance this with the risks of vaginal microbiome dysbiosis and infection, possible associated risks in the context of immunosuppression [73].…”

Uterine Transplantation

“…17 These immunomodulatory mechanisms contribute to the maintenance of a commensal microbiome, which have clinical and reproductive implications that may impact outcomes in UTx. 18 For example, the second global UTx case was performed in a woman with an intestinal neovagina, 19 where despite numerous failed in vitro fertilisation attempts and multiple miscarriages, a live birth has yet to occur. 20 Women with atypical MRKH, specifically those with renal abnormalities, may also be considered for UTx.…”

“…Vaginal epithelium also contributes to the innate immune response by facilitating the recognition of pathogens and stimulating the production of antimicrobial peptides and proinflammatory cytokines 17 . These immunomodulatory mechanisms contribute to the maintenance of a commensal microbiome, which have clinical and reproductive implications that may impact outcomes in UTx 18 . For example, the second global UTx case was performed in a woman with an intestinal neovagina, 19 where despite numerous failed in vitro fertilisation attempts and multiple miscarriages, a live birth has yet to occur 20 …”