First European live birth following uterine and adnexal transposition for fertility preservation: a case report and overview of reported neonatal outcomes

A 28-year-old nulliparous woman was diagnosed in June 2022 with moderately differentiated low rectal adenocarcinoma, at 7 cm from the anal verge (uT3 N1 cM0, pMMR/MSS). Neoadjuvant treatment followed the PRODIGE 23 protocol, beginning with six cycles of induction FOLFIRINOX. This was followed by long-course chemoradiotherapy: a total dose of 50.4 Gy was delivered (45 Gy pelvic field with a 5.4 Gy tumor boost in 1.8 Gy fractions) using cone-beam computed tomography (CT) guidance, alongside concomitant oral Capecitabine (825 mg/m 2 BID, 5 d/wk). The oncologic management and surgical technique for UT applied in this case have been previously published in detail ( 13 ). During the procedure, both uterine arteries were divided close to the cervix, and uterine perfusion was maintained through the ovarian vessels. Incidentally, stage II endometriosis involving the left uterosacral ligament was identified and excised. The vagina was transected at the cervicovaginal junction, and the uterus and adnexa were transposed to the upper abdomen and anchored to the anterior abdominal wall ( 13 ), with an estimated cranial displacement of the uterus above the pelvic brim of approximately 22 cm ( Fig. 1 ). No cervico-umbilical anastomosis was created. Monthly gonadotropin-releasing hormone (GnRH) agonist injections (Pamorelin 3.75 mg) were administered throughout chemotherapy and until uterovaginal reimplantation, preventing menstruation during displacement. Normal menses returned 2 months after reimplantation. Figure 1 Schematic of uterine and adnexal transposition and reimplantation. ( A ) Pre-operative state: Identification of the rectal tumor and initial surgical planning. ( B ) Transposition phase: The uterus and adnexa are mobilized, the uterine arteries are divided, and the organ is cranially transposed (∼22 cm) to the upper abdomen, anchored outside the planned pelvic radiation field. ( C ) Reimplantation phase: After the completion of chemoradiation, the uterus is returned to the pelvis and reanastomosed to the vaginal cuff during the total mesorectal excision. ( D ) Reproductive outcome: Successful spontaneous conception and subsequent cesarean delivery. Schematic of uterine and adnexal transposition and reimplantation. ( A ) Pre-operative state: Identification of the rectal tumor and initial surgical planning. ( B ) Transposition phase: The uterus and adnexa are mobilized, the uterine arteries are divided, and the organ is cranially transposed (∼22 cm) to the upper abdomen, anchored outside the planned pelvic radiation field. ( C ) Reimplantation phase: After the completion of chemoradiation, the uterus is returned to the pelvis and reanastomosed to the vaginal cuff during the total mesorectal excision. ( D ) Reproductive outcome: Successful spontaneous conception and subsequent cesarean delivery. After chemoradiation, total mesorectal excision with uterine reimplantation and cervicovaginal anastomosis was performed. Pathology confirmed a complete pathologic response (ypT0 N0 R0). The patient remained disease-free through 2024. The chronological timeline of all oncologic, surgical, and reproductive events is illustrated in Figure 2 . Figure 2 Chronological timeline summarizing oncologic, surgical, and obstetric milestones from diagnosis to delivery. Chronological timeline summarizing oncologic, surgical, and obstetric milestones from diagnosis to delivery. A cranial vaginal stenosis developed after reimplantation, likely secondary to radiation-induced fibrosis of the upper vaginal segment. Similar cases have been reported ( 14 ). Pelvic-floor physiotherapy, including manual scar mobilization and relaxation exercises, restored vaginal patency over 8 weeks, with only a minimal asymptomatic residual stenosis. Nineteen months after reimplantation, conception occurred naturally without ovulation induction or assisted reproductive techniques. Fetal growth was normal until 32 weeks + 4 days, with an estimated fetal weight at the 40th percentile and normal amniotic fluid volume. At 36 weeks + 4 days, ultrasound revealed new-onset IUGR (estimated fetal weight at the 10th percentile) associated with oligohydramnios (amniotic fluid index = 5 cm). Elective cesarean section at 37 weeks + 1 day (May 13, 2025) yielded a male neonate weighing 2110 g (<3rd percentile), with Apgar scores of 9/10/10. No pelvic adhesions were observed intraoperatively. The placenta was hypotrophic (270 g, <3rd percentile) and exhibited accelerated villous maturation and increased syncytial knotting, consistent with maternal vascular malperfusion. ( Fig. 3 A and B ). Both mother and child were healthy at the 8-month follow-up. Written informed consent for publication of all clinical details and images was obtained from the patient. Figure 3 ( A ) Representative hematoxylin–eosin section of the placenta showing distal villous hypoplasia (4×), consistent with maternal vascular malperfusion. ( B ) Representative hematoxylin–eosin section of the placenta showing increased syncytial knotting (10×), consistent with maternal vascular malperfusion. ( A ) Representative hematoxylin–eosin section of the placenta showing distal villous hypoplasia (4×), consistent with maternal vascular malperfusion. ( B ) Representative hematoxylin–eosin section of the placenta showing increased syncytial knotting (10×), consistent with maternal vascular malperfusion. We searched MEDLINE (PubMed), Embase, Scopus, and Web of Science for reports of live births after UT from July 1, 2023 (the date of the first reported live birth after UT by Ribeiro et al. [4]) through October 20, 2025. Search terms combined: (“uterine transposition” OR “uterus transposition” OR “uterine relocation” OR “uterine transposition” OR “UOT” OR “utero-ovarian transposition”) AND (pregnancy OR “live birth” OR delivery OR childbirth). We limited to human studies and screened titles/abstracts, then full texts, to include case reports/series or observational studies documenting a live birth after UT (with or without prior pelvic radiotherapy). We excluded studies on ovarian transposition alone, editorials without patient and obstetrics outcomes, and nonhuman studies. Reference lists of eligible articles and forward citations were hand-searched to identify additional reports. Key anchor references included the first live birth after UT ( 9 ) and subsequent narrative/systematic overviews summarizing UT pregnancy outcomes. Two reviewers screened records independently. The PRISMA diagram is presented in Supplemental Figure 1 (available online) [ 15 ].

Daniela Huber: Writing – review & editing, Writing – original draft, Validation, Supervision, Project administration, Methodology, Data curation, Conceptualization. Deborah Wernly: Writing – review & editing, Formal analysis.

Pregnancy and live birth are achievable after a UT and subsequent uterine reimplantation. Among the five live births reported to date, three pregnancies were complicated by IUGR, including the present case, underscoring the need for enhanced third-trimester fetal growth surveillance and systematic placental examination in future pregnancies. Conventional fertility-preservation options should continue to be offered alongside UT to ensure comprehensive reproductive safety. Collectively, these five cases—including this first European-reported live birth—demonstrate that a reimplanted uterus can sustain gestation to term, representing a significant advance in fertility preservation for women requiring pelvic radiotherapy. Future multicenter registries are warranted to define obstetric surveillance protocols and to assess the long-term reproductive potential after UT. D.H. has nothing to disclose. D.W. has nothing to disclose.

Young-onset CRC frequently presents with aggressive features and advanced staging, often necessitating multimodal neoadjuvant chemoradiation. Although lifesaving, pelvic irradiation poses a dual threat to reproductive potential: it carries a high risk of permanent primary ovarian insufficiency and inflicts significant “uterine factor” infertility. Radiation-induced damage to the uterus includes reduced volume, impaired blood flow, and irreversible myometrial fibrosis and endometrial atrophy, which collectively compromise pregnancy maintenance and obstetric safety, even when ovarian function is surgically or pharmacologically preserved. The reproductive prognosis for women receiving standard multimodal pelvic radiotherapy for rectal cancer is exceptionally poor. Although a few pregnancies have been reported after pelvic irradiation for anal or rectal cancer, including a vaginal delivery after a mean uterine dose of 34.5 Gy ( 16 ) and a twin pregnancy after intensity-modulated radiotherapy that limited the uterine body dose to 16 Gy ( 14 ), these cases are clinical rarities. Protecting the uterus during radiotherapy remains a critical challenge in survivorship care. Although conventional strategies such as oocyte or embryo cryopreservation should be performed before treatment, they do not address the loss of a functional uterus. Uterine and adnexal transposition offers a promising solution by temporarily relocating the organ to the upper abdomen, effectively placing it outside the ionizing radiation field while maintaining essential perfusion via the ovarian vessels. Preservation of the uterine arteries during pelvic surgery has traditionally been regarded as essential for subsequent fertility because of their major contribution to uterine perfusion and endometrial receptivity. In the context of UT, however, division of these arteries is unavoidable to allow displacement of the uterus and adnexa outside the radiation field. Uterine perfusion is therefore maintained through the ovarian arteries and their utero-ovarian anastomoses. Despite reports of frequent postoperative uterine-artery occlusion after radical trachelectomy (87%–88%) ( 17 ) or intentional arterial division in certain surgical techniques, published cohorts have not demonstrated a consistent difference in pregnancy rates attributable to uterine artery patency. Instead, conception success appears to depend primarily on the surgical approach (vaginal vs. abdominal), residual cervical length, postoperative adhesions, complications such as uterine or ovarian necrosis and infections, and the use of assisted reproduction techniques ( 18 ). Evidence from benign gynecology supports the physiological tolerance to uterine artery interruption: in a randomized controlled trial with 2-year follow-up, Streuli et al. ( 19 ) confirmed unchanged serum antimüllerian hormone (AMH) and antral follicle count after laparoscopic myomectomy with definitive bilateral uterine artery occlusion. These findings support the concept that ovarian-based collateral flow is sufficient to sustain endocrine and reproductive activity, although it may limit uterine vascular remodeling during pregnancy. Across the four previously published UT pregnancies and our case, neonatal outcomes were overall favorable ( 9 , 10 , 11 , 12 ) ( Table 1 ). However, IUGR occurred in three pregnancies [ 10 , 14 ], one associated with maternal hypertension. These observations provide important insights into the gestational potential and obstetric safety of a uterus temporarily displaced outside the pelvis and later reimplanted, confirming that successful pregnancy and delivery are possible even after bilateral uterine-artery division. Our case provides the first histopathologic evidence of placental maternal vascular malperfusion, supporting the hypothesis of impaired uteroplacental remodeling after reimplantation. Similar vascular abnormalities have been reported after uterus transplantation ( 20 ), suggesting shared mechanisms of adaptive revascularization. Conventional fertility-preservation strategies (e.g., oocyte/embryo cryopreservation) should be offered alongside UT, particularly given the theoretical risk of thrombosis or ischemia of the transposed uterus. Table. 1 Obstetric and perinatal outcomes of reported live births after uterine transposition. Study PMID Indication GA at delivery Birth weight Perinatal findings Ribeiro et al. 2023 ( 9 ) 36863432 Low-grade myxoid liposarcoma 36 wk + 2 2,686 Normal Lopez et al. 2023 ( 10 ) 37549972 Rectal adenocarcinoma 36 wk 2,500 IUGR, oligohydramnios Ribeiro et al. 2023 ( 12 ) 37898483 Rectal adenocarcinoma 38 wk NR NR Moretti-Marques et al., 2024 ( 11 ) 39138911 Cervical adenocarcinoma 36 wk + 3 2,255 IUGR, maternal hypertension Present case, 2025 Rectal adenocarcinoma 37 wk + 1 2,110 IUGR, oligohydramnios Note: Birth weights are expressed in grams. GA = gestational age; IUGR = intrauterine growth restriction; NR = not reported; PMID = PubMed IDentifier. Obstetric and perinatal outcomes of reported live births after uterine transposition. Note: Birth weights are expressed in grams. GA = gestational age; IUGR = intrauterine growth restriction; NR = not reported; PMID = PubMed IDentifier. All reported live births resulted from spontaneous conception. Assisted reproduction may be considered after 6–24 months of unsuccessful attempts, guided by patient preference, fertility assessment, and oncologic safety. Consistent with radical trachelectomy literature ( 21 , 22 , 23 , 24 ), cesarean delivery remains the safest mode of birth after uterine reimplantation, minimizing mechanical stress on the cervicovaginal anastomosis. Furthermore, prior pelvic radiotherapy may induce fibrosis and decrease the elasticity and compliance of the pelvic floor and vaginal canal, thereby contraindicating vaginal delivery. To date, no cases of uterine rupture or other maternal morbidity related to UT during pregnancy have been reported. Pregnancies after UT should be considered high risk. Enhanced third-trimester fetal-growth surveillance and Doppler velocimetry may enable early detection of growth impairment. In the absence of other obstetric complications, elective cesarean delivery between 36 and 38 weeks should be planned to minimize the risk of anastomotic rupture and pelvic floor trauma, consistent with the timing routinely adopted after radical trachelectomy. To date, no second pregnancies have been reported after UT. In the absence of a genetic condition requiring a delayed hysterectomy, such as Lynch or Li-Fraumeni syndrome, subsequent gestation appears theoretically feasible.