A Comprehensive Review of Ex-Vivo Machine Perfusion in Uterus Transplantation

Uterine transplantation has revolutionized previously incurable causes of infertility. While most transplants are performed with live donors, the use of deceased donors could potentially expand the donor pool and increase the number of transplants performed. One limitation of deceased donor use is warm and cold ischemia time, which may be potentially mitigated by the implementation of ex-vivo machine perfusion (EVMP). This comprehensive review synthesizes the existing literature on uterine EVMP, highlighting both experimental and translational developments up to February 2025. A total of 31 relevant studies were identified from 244 screened articles, most involving human aor large-animal uteri. The majority of studies employed normothermic machine perfusion (NMP) as a model for physiologic conditions, focusing on endocrine or functional analysis, inflammatory reactions, or technical aspects of perfusion. Only in the past 6 years have articles looked at EVMP as a preservation technique for transplantation, or employed hypothermic machine perfusion (HMP). While EVMP has only recently increased in popularity for transplant preservation, uterine EVMP has historically been used in multiple studies as a model for physiologic conditions. While further research is needed to optimize preservation protocols, much can be gleaned from prior models of uterine perfusion.