Fewer Than 2% of Uterine Transplant Applicants Ultimately Qualified at a Major Referral Center

Only a tiny fraction of women who ask to be considered for a uterus transplant actually make it through the first round of screening, according to a new analysis from one of the busiest referral centers in the United States. Of 368 completed applications received over three years at Texas Children’s Pavilion for Women, 353 — 96.0% — were ruled out on initial screening criteria, and after full evaluation fewer than 2% of all interested applicants ultimately qualified for the procedure. The finding, published in Reproductive Sciences, offers one of the first systematic looks at why so many hopeful candidates are turned away, and it suggests that better counseling before referral could spare many patients disappointment.

Uterine transplantation has moved rapidly from experimental concept to clinically feasible treatment for absolute uterine factor infertility, a condition in which the uterus is absent or nonfunctional and affects roughly 1 in 500 women of reproductive age. The most common causes are Mayer-Rokitansky-Küster-Hauser syndrome, in which the Müllerian ducts fail to develop and the uterus never forms, and prior hysterectomy. For affected women who want genetically related children, the historical option was a gestational carrier — an avenue shaped by legal restrictions that vary by country and state, by considerable expense, and by the fact that it does not fulfill the desire to carry a pregnancy oneself. Births of healthy children to transplant recipients have documented that the procedure can work, but it is not a lifesaving operation, and that distinction shapes everything about how candidates are chosen.

Because a uterus transplant involves major abdominal surgery, subsequent immunosuppression, and — if it succeeds — a deliberately high-risk pregnancy, programs must apply rigorous medical, psychological, and reproductive eligibility criteria. Risks extend not only to the recipient but also to a living donor, if one is used, and to future offspring. The Baylor College of Medicine program, which provided oversight through its institutional review board and is registered on ClinicalTrials.gov as NCT05263076, set out to characterize exactly who applies, who qualifies, and why the rest are excluded.

The study was designed as a retrospective cohort analysis. Between April 2022 and April 2025, anyone interested in uterine transplantation could complete a standardized intake survey hosted on REDCap and accessible through a public link on the Texas Children’s Hospital website. The survey collected demographic details such as age, body mass index, and alcohol and tobacco use; reproductive history including prior children, use of gestational carriers, and any stored eggs or embryos; and medical, surgical, psychosocial, and family history, along with a list of potential donors. Applicants who passed the online screening received a phone call from the transplant nurse coordinator if more information was needed, and those who cleared that stage were invited to Houston for an in-person visit with the multidisciplinary team, which includes transplant surgeons, reproductive endocrinologists, coordinators, social workers, and nursing staff.

During the three-year window, 371 intake surveys arrived; three, or 0.8%, were incomplete. Among the 368 complete applications, the dominant cause of infertility was a history of hysterectomy, reported by 293 patients, or 79.6%. Congenital absence of the uterus — specifically MRKH syndrome — accounted for 60 patients, or 16.3%, and 15 patients, or 4.1%, cited other causes. The mean age of applicants did not differ between those excluded and those who proceeded with evaluation, at 33.8 versus 33.7 years, but the group moving forward had a significantly lower mean body mass index, 27.8 compared with 33.8. MRKH syndrome was significantly more prevalent among those who proceeded, at 70% versus 14.9%, while prior hysterectomy was significantly less common, at 30% versus 81.4%. No significant differences emerged for uterus in situ, previous pregnancy, functioning ovary in situ, children born through surrogacy, or banked embryos.

The exclusion data reveal a clear hierarchy of barriers. Medical contraindications were the leading reason, disqualifying 122 individuals, or 33.8%; these included conditions such as renal disease, diabetes, hypertension, endometriosis, and a history of cancer. Age of 40 years or older came next, ruling out 64 patients, or 17.7%, followed closely by a body mass index of 30 kg/m² or above, which disqualified 61 patients, or 16.9%. Another 51 patients, or 14.1%, were excluded because they could not comply with the demanding study protocol, whether through missed appointments or logistical barriers to completing care requirements at the primary center in Houston. Smaller categories included reproductive contraindications in 18 patients, or 5.0% — such as inadequate ovarian reserve, not yet having undergone hysterectomy, or identification as biologically male — illicit drug use in 15 patients, or 4.2%, tobacco use in 12 patients, or 3.3%, self-withdrawal in 8 patients, or 2.2%, and psychological contraindications in 2 patients, or 0.5%. At the time of analysis, 5 evaluations, or 1.3%, were still pending final review by the transplant committee.

For the small group who proceeded to in-person reproductive evaluation, ovarian reserve markers were broadly favorable. Polycystic ovary syndrome was present in 70% of evaluated patients, a figure the authors note is consistent with the high prevalence of PCOS reported among women with congenital uterine absence. Mean anti-Müllerian hormone measured 7.0 ± 4.9 ng/mL and mean antral follicle count was 22 ± 14.1. Gonadotropins fell within expected ranges, with mean follicle-stimulating hormone of 6.2 ± 2.0 IU/L, available for 8 of 10 patients, and mean luteinizing hormone of 11.6 ± 11.9 IU/L, available for 7 of 10.

The authors argue that the pattern of exclusions carries practical lessons for patients, referring physicians, and emerging programs alike. Body mass index stands out as a potentially modifiable barrier that could be addressed before referral if patients knew the thresholds in advance. Age, by contrast, is non-modifiable, and the authors suggest it could become a hard stop in the online application so that applicants age 40 and older are directed promptly toward appropriate counseling rather than prolonged anticipation. The 14.1% excluded for inability to comply with study requirements underscores how intensive the uterine transplant protocol is, and highlights the importance of psychosocial support throughout evaluation. The authors also point to structured psychological interviews, already used by other transplant programs, as a way to deepen assessment for those who advance past the intake survey.

Looking ahead, the team proposes an ideal evaluation pathway: initial remote screening for basic eligibility, followed by comprehensive in-person multidisciplinary assessment incorporating surgical, reproductive, and psychosocial evaluation, detailed counseling about immunosuppression, obstetric risk, and long-term outcomes, then laboratory testing and formal review by a selection committee before listing. Programs, they note, should plan for the reality that a large proportion of referrals will be ineligible and allocate resources accordingly. The study has limitations the authors acknowledge directly: its retrospective design, reliance on self-reported survey data that may introduce reporting bias, a single institution whose practices may not generalize to all programs, and a handful of still-pending evaluations that could slightly shift the final proportions.

Subject of Research: Reasons for exclusion among applicants screened for uterine transplantation at a large referral center

Article Title: Evaluation and Disposition of Potential Candidates for Uterine Transplantation: Experience From a Large Referral Center

Article References: Ciomperlik, H. N., Alexander, M. V., Reding, A., Galvan, T., Johnson, R. M., Goss, J. A., Detti, L., Belfort, M. A., & Munoz, J. L. (2026). Evaluation and Disposition of Potential Candidates for Uterine Transplantation: Experience From a Large Referral Center. Reproductive Sciences. https://doi.org/10.1007/s43032-026-02251-z

Image Credits: AI Generated

DOI: 10.1007/s43032-026-02251-z

Keywords: uterine transplantation, absolute uterine factor infertility, MRKH syndrome, patient selection, infertility, reproductive medicine, screening criteria, hysterectomy, ovarian reserve, transplant eligibility, retrospective cohort study, counseling