“The dream of being able to carry my own child outweighs anything”: A qualitative study of the UK’s initial womb transplants in real-time

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Data may be preliminary. 11 November 2025 V1 Latest version Share on “The dream of being able to carry my own child outweighs anything”: A qualitative study of the UK’s initial womb transplants in real-time Authors : Daisy Elliott 0000-0001-8143-9549 [email protected] , J Smith , Maeve Coyle , Rhiannon Macefield , Saaliha Vali 0000-0002-7289-0407 , Anni King , Natalie Blencowe , … Show All … , Cynthia Ochieng , Christin Hoffmann , Isabel Quiroga , Benjamin Jones 0000-0002-0391-0443 , Ariadne L'Heveder 0000-0002-1642-3011 , Kerry Avery , and Jane Blazeby M Show Fewer Authors Info & Affiliations https://doi.org/10.22541/au.176285362.21424207/v1 314 views 178 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective: To study uterine transplantation (UTx) being introduced in the UK in real-time, from the perspectives of key stakeholders: eligible women with absolute uterine factor infertility and the multidisciplinary team supporting them and performing the procedure. Design: A qualitative study utilising prospective case study methodology (in-depth, semi‐structured interviews and non‐participant observation) over six years. Setting: Two NHS trusts in England. To date, five UK transplants have been performed; two living donor transplants, and three deceased donor transplants. Three retrievals have also been undertaken that did not proceed to implantation. Methods and sample: Data included 17 audio-recorded consultations with potential recipients and clinicians, 22 interviews with seven clinicians, and eight follow-up interviews with women. Data were synthesised using thematic analytical methods. Results: Women described UTx as a deeply personal and identity-affirming pursuit, shaped by cultural/religious contexts. Clinicians navigated evolving perceptions of risk and the emotional intensity of participating in a pioneering programme—driven by long-term investment, empathy, and the significance of performing the UK’s first uterine transplants. Collaboration was crucial, involving learning from international teams, close multidisciplinary teamwork, and strong relationships between clinicians and recipients. Embedding prospective qualitative research enabled clinicians to reflect on their practice and provided insights into optimising UTx delivery. Findings offer practical examples for discussing uncertainty and risk, and improving support for women undergoing novel procedures. Conclusion: This study provides in-depth insights into the technical, emotional, and ethical complexities of introducing UTx. It highlights the value of dynamic qualitative methods within translational pathways for surgical innovation. “The dream of being able to carry my own child outweighs anything”: A qualitative study of the UK’s initial womb transplants in real-time Authors: Daisy Elliott 1 and Richard J Smith 2,3 (joint first authorship), Maeve Coyle 1 , Rhiannon Macefield 1 , Saliha Vali 2,4 , Anni King 1 , Natalie Blencowe 1 , Cynthia Ochieng 1 , Christin Hoffmann 1 , Isabel Quiroga 5 , Ben P Jones 2,3,6 , Ariadne L’Heveder 2,3,4 , Kerry NL Avery 1 & Jane M Blazeby 1 Planned submission: BJOG Submission category: Research article Running hea d: FOLLOWING THE UK WOMB TRANSPLANTS Word count: 2998/3500 (excluding abstract, tables, and quotes) Corresponding author and guarantor: Daisy Elliott, Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS ; 07584240463 Email addresses: Daisy Elliott – [email protected] ; JR Smith – [email protected] ; Maeve Coyle – [email protected] ; Rhiannon Macefield – [email protected] ; Saaliha Vali – [email protected] ; Anni King – [email protected] ; Natalie Blencowe – [email protected] ; Cynthia Ochieng – [email protected] ; Christin Hoffmann – [email protected] ; Isabel Quiroga – [email protected] ; Benjamin Jones – [email protected] ; Ariadne L’Heveder – [email protected] ; Kerry Avery – [email protected] ; Jane Blazeby – [email protected] Author affiliations: 1 NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS; 2 Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK 3 Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK 4 Cutrale Perioperative and Ageing Group, Imperial College London, London, UK 5 Oxford University Hospitals, Oxford, UK Abstract: Objective: To study uterine transplantation (UTx) being introduced in the UK in real-time, from the perspectives of key stakeholders: eligible women with absolute uterine factor infertility and the multidisciplinary team supporting them and performing the procedure. Design: A qualitative study utilising prospective case study methodology (in-depth, semi‐structured interviews and non‐participant observation) over six years. Setting: Two NHS trusts in England. To date, five UK transplants have been performed; two living donor transplants, and three deceased donor transplants. Three retrievals have also been undertaken that did not proceed to implantation. Methods and sample: Data included 17 audio-recorded consultations with potential recipients and clinicians, 22 interviews with seven clinicians, and eight follow-up interviews with women. Data were synthesised using thematic analytical methods. Results: Women described UTx as a deeply personal and identity-affirming pursuit, shaped by cultural/religious contexts. Clinicians navigated evolving perceptions of risk and the emotional intensity of participating in a pioneering programme—driven by long-term investment, empathy, and the significance of performing the UK’s first uterine transplants. Collaboration was crucial, involving learning from international teams, close multidisciplinary teamwork, and strong relationships between clinicians and recipients. Embedding prospective qualitative research enabled clinicians to reflect on their practice and provided insights into optimising UTx delivery. Findings offer practical examples for discussing uncertainty and risk, and improving support for women undergoing novel procedures. Conclusion: This study provides in-depth insights into the technical, emotional, and ethical complexities of introducing UTx. It highlights the value of dynamic qualitative methods within translational pathways for surgical innovation. Word count: 249 (250 limit) Funding: This study is funded by the National Institute for Health and Care Research (NIHR) Bristol Biomedical Research Centre (BRC; reference number NIHR203315). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. NSB is an MRC Clinician Scientist . Introduction: Women who either do not have a functional uterus or who have had their uterus removed have the options of adoption or surrogacy to acquire motherhood. Uterine transplantation (UTx) offers an opportunity for these women to conceive, experience pregnancy and give birth to a biologically related child. Whilst research began in the late 90’s, it was not until 2014 that the first live birth from a living donor (LD) was reported in Sweden(1, 2) . Although t he first birth from a deceased donor (DD) took place in Brazil in 2017(3), DD cases have been performed less frequently, and remain a concept of ongoing innovation (2). In the UK, the first successful UTx took place in February 2023, using a living donor, and resulted in the first livebirth following UTx in the UK(4). To date, five UK transplants have been performed; two LD transplants, and three DD transplants. Three retrievals have also been undertaken that did not proceed to implantation. With the number of UTx procedures being performed globally growing, it is now a ‘critical time’ for this complex intervention positioned at the cusp of wider clinical adoption(2). Due to the complex and novel nature of the procedure, it is important to understand UTx introduction in different contexts(2). Implementing a new intervention such as UTx in the UK will involve mutual adaptation, with the context changing to fit the intervention, and vice versa(5). Several reviews provide an overview of the clinical components and evolution of UTx (6, 7). The IDEAL framework recommends that qualitative research can be used to capture both clinician and patient attitudes when a new surgical procedure is introduced and evaluated (8). Qualitative interviews have provided important insights with women considering or undergoing the procedure(9-11), although only one study has conducted interviews with healthcare professionals (from Sweden and France)(11). Furthermore existing qualitative research has included only one episode of data collection (in the form of a single interview per participant - as is most common for qualitative research in surgery(12)). The Lotus study utilises a range of qualitative research methods to provide in-depth, real-time insights from multiple stakeholders to understand how innovative surgical procedures are introduced (13). As part of this, we followed the introduction of the uterine transplants to UK. Specific objectives were to capturing the surgical team’s reflections as their experiences evolved, and to learn about women’s journeys as they contemplated – and underwent - the procedure. Design: The Lotus protocol has been published(13). Data for this case study comprised of, i) initial, ‘background’ interviews with the clinical team to understand the endeavour so far and future plans; ii) audio-recording consultations between the clinical team and potential recipients/donors to understand information provision; iii) post-operative interviews with the clinical team after each procedure to investigate how the procedure evolved over time; and; iv) follow-up interviews with these women to explore their decision-making process, and (if relevant) their experience of undergoing UTx. This paper is reported according to Standards for Reporting Qualitative Research (SRQR)(14) (see Supplementary File 1). Recruitment and sampling: JRS was first interviewed and subsequent clinicians were identified via key informant sampling. Women were eligible to take part in Lotus if they were being considered for the procedure (as recipients or LDs). Data collection: Clinicians and women provided full written consent. Clinicians were requested to audio-record all appointments where they discussed the procedure with eligible women. Separate topic guides were developed for healthcare professionals’ and women’s interviews. All interviews were guided by topic guides to ensure that discussions covered the same core issues(15, 16) but were ultimately led by each participant to enable new issues of importance to be followed up and discussed further. These were refined as data collection/analysis progressed(15, 17). DE observed presentations by JRS where he discussed the uterine transplant cases, and several members of the team (DE, RM, MC) observed UTx planning meetings DE conducted interviews with JRS to become immersed in the case study and maintain strategic oversight for data collection. As the interviews progressed, DE’s interviews became intertwined with JRS dictating his own notes, whereby he would record his reflections whilst DE would probe for further insights on particular issues. Experienced qualitative researchers (MC, CO, KNLA) conducted one-to-one interviews at a time and date convenient for all other participants (for each interviewer’s background and roles, see Supplementary File 2). Analysis: All interviews and consultations were audio-recorded using an encrypted recorder and transcribed verbatim. Data were analysed using reflexive thematic analysis methods, whereby researchers actively reflected on their own influence in the analytic process(18, 19). This was interwoven with a critical realist approach, which assumes that truths exist independently but are interpreted through individuals’ subjective experiences and knowledge(20, 21). An outline of the analytical process is provided in Supplementary File 3. It was felt that having captured the consecutive cases included herein, over six years, the data generated provided meaningful and unique insights, from a range of perspectives, to achieve theoretical sufficiency in regards to sample specificity, quality of dialogue and analysis strategy. Results: Data: Twenty-two interviews were conducted with seven key health care professionals between December 2019 and June 2025 (six pre-UTx and 16 post-operative; mean length = 55 minutes, range=26-86)). Seventeen consultations were recorded between September 2022 and September 2025 (mean length = 63 minutes, range=39-100). These were discussions with the potential recipient and their partners and/or relative (and potential donor). Potential recipients were at various points of the in vitro fertilisation (IVF) journey at the time of their UTx consultation. Three were considering LD transplants (via sister/mother), whilst the remaining women were exploring DD transplants as they had no suitable LD available. Alongside this, we conducted follow-up interviews with eight women between July 2022 and June 2025. Six women had received a diagnosis of Mayer-Rokitansky-Küster-Hauser (MRKH), where they were born with an underdeveloped or absent uterus. Two had developed or been diagnosed with absolute uterine factor infertility in adulthood. Of the eight women, one potential recipient withdrew from the programme, three were awaiting the procedure, and four recipients underwent the procedure (three DD, one LD). Mean length of interviews was 39 minutes (range = 11-75). Recipients were interviewed post-operatively between 10 and 30 weeks after transplantation. Figure 1 provides a timeline of UTx cases and Lotus data collection. Findings: Navigating uncertainty and hope In both their interviews and consultations, women considering UTx described complex emotions and difficult experiences as they navigated infertility and the prospect of a resolution. For many, the diagnosis had profound consequences beyond not having a pregnancy or giving birth – rather, these women described feeling as though there was something missing in their self-identity as a woman (Table 1). All had explored, and often negated, other options for having a family before considering a uterine transplant: “In Islam, if there are embryos going to another woman who’s not married to my husband, it’s almost like infidelity. That’s how we see it”. (Potential recipient, 6017, consultation) There was strong belief amongst the clinical team that transplants from DD cases were preferable (particularly in the earlier interviews), given that there were no risks to donors and because of the perceived ability to retrieve more of the uterus Most of the women were participating in the DD programme (as part of a research study, INvestigational Study Into Transplantation of the Uterus; INSITU). However, these women struggled with enormous uncertainties around DD transplants which were emphasised to be particularly ‘new’ and in ‘very early’ stages: “Now, you understand that we have not done this operation ourselves in the UK yet. It has been done across the world, in multiple locations. We know that the best outcomes so far have been with living donors. I understand you don’t have a living donor. The outcomes from deceased donors, i.e., dead people, have not been as good yet. But I suspect that there is a lot of refining of the technique. Like in many other things in the area, in the field of transplantation, as time goes by, these organs, these transplants, become more successful […] By the time, when it comes to you, we might have done already a few, but you might be the first one. We will not know”. (HP, Consultation 6003) Conversely, those considering the LD programme described feeling particularly conflicted with ‘fear’ for their relatives (their mother or sister, or this instance). “We knew that there would be risks but the potential outcome was just so worth it that I don’t think there was anything I was expecting to hear that would’ve put me off… My concern wasn’t really for myself. I think I asked more questions about my [relative’s] procedure, just wanting to know how that would be for her.” (Recipient, interview 6004) In their interviews, all women described feeling well-informed about what UTx might involve. Examples of the key risks discussed in consultations are captured in (Supplementary File 4). This included established known risks, possible risks and ‘unknowns’. One potential recipient emotionally relayed her decision not to proceed with the transplant after four years of being in contact with the UTx team, describing her fears about the novelty of the procedure, risks to herself and her mother, and the ‘aftermath’ of the transplant on her psychological and physical health (Table 2). Those who did proceed to the waiting list acknowledged the extensive risks of the procedure, but described being ‘adamant’ that they wanted to go ahead nonetheless (‘other things were considered, but we wanted to be on this journey’). However, whilst Health Research Authority (HRA) ethics approval for transplants via DD was granted in 2015 (with the LD programme running alongside this), many potential DDs were later deemed unsuitable, or consent for any organ retrieval had not been provided. Plans were then significantly disrupted by the Covid-19 pandemic. Indeed, most of the women involved in the programme had been in contact with the clinical team for many years and acknowledged the entire process had been ‘a rollercoaster of emotions’ with ‘many setbacks’. ”It’s like a constant dangled carrot…This is an emotional rollercoaster.” (Recipient, interview 6003)“It has all been very challenging … The thing which has actually kept us going is, we’ve got all these women who we’ve met who are desperate. It’s blighted their lives, right? It’s terrible for them. And that’s kind of kept us going.” (HP interview 2, pre-UTx) “We crossed the divide”: Bridging gynaecology and transplantation The clinical team described how they had learned a great deal from international teams, in terms of studying reported cases, observing the procedure and building relationships. This enabled them to ‘sequentially tweak’ their protocols as cases expanded worldwide. This appeared to be tentatively balanced between adhering to the latest ethically approved protocols and finding common ground, and thereby, comfort between internationally practiced techniques and their own preferences. “We hope that our learning curve will not be as hard as that of others that have already done it so that we can draw from them – from their experience.” (HP interview 4, Pre-UTx) The gynaecological team sought reassurance in conceptualising the retrieval as a radical hysterectomy. Similarly, the transplant team identified components of other procedures that they were familiar with. “Although it’s very novel and it’s new for the team, in fact the type of surgery that will be required to take the womb out of the donor is the type of operation that has been done hundreds and hundreds of times before in a hysterectomy procedure [.] It’s important to remember that mindset is everything. We will of course have our slight guard up as well ‘cause it’s relatively new, but just for confidence, we know we ought to just follow those steps … and hopefully all will be well.” (HP interview 3, Pre-UTx)“I work with little vessels quite a lot, so it was just using the techniques that we use often on kidney transplants […] it was just using this for a different organ.” (HP interview 11, Case 2) In late 2022, the first DD who could be paired with a recipient was identified (Case 1). Whilst there had been an underlying anticipation of logistical challenges, the gynaecological team reported that the actual experience of operating on the deceased donor had been far more ‘emotional’ than they could have imagined. This was particularly exacerbated as they learned about the circumstances surrounding each donor losing their life. Despite the logistical (and emotional) challenges, and after years of planning and a myriad of emotions, there was a strong belief that the retrieval of the uterus had been technically successful. The uterus was felt to be very healthy and the team commented that they had been able to get a ‘good length of vessels’. After years of assembling the appropriate team and planning the procedure, there was a fundamental relief at the cohesion between the gynaecology and transplantation teams: ‘We have a complementary set of skills. I’m a gynae cancer surgeon, who is used to using electrosurgical devices to cut around the side and get good margins on tumours. Transplant surgeons don’t want big margins, they want good vessels. So a combination of the techniques makes for absolutely just a perfect surgical duo at the table […] it’s a completely joint equality between the two. Entirely complementary’. (HP interview 7, Case 1) However, before the implantation started, it was discovered that the left uterine artery was occluded with atherosclerosis, thereby making it unsuitable to implant. Consequently, a difficult decision was made to abandon the transplant. Despite widespread disappointment, it was evident that this case represented a pivotal moment that fuelled hope in both the women and clinicians (described in one interview as ‘like crossing a Rubicon’ in terms of ‘passing the point of no return’). “But thank God we got to do it. Because I’ll tell you something, we all know now that we can do it, for sure… It’s amazing […] And [the recipient and her partner] knew- They just said, “We know now that this is for real, and we know you guys are going to do it for us. And of course, we’re gutted you can’t do it today, but we damn know this is not some fantasy.” She said, “When I was a little girl, I never, ever thought I could have a baby. I now know that I may well be able to have a baby.” (HP interview7, Case 1)) Reflections on (steep) technical learning In February 2023, following the first DD case, the team performed their first LD transplant (Case 2). Those interviewed explained that the build-up to this pre-planned case was intensely stressful, with growing sense of apprehension and pressure. “I’m normally not particularly anxious walking into theatre but it was quite difficult not to be anxious that morning. It was a complete rollercoaster of a day… the stress levels were huge.” (HP interview 9, Case 2)“In all honesty, I was very, very, worried that it wasn’t going to happen […] And the pressure of, “If this doesn’t work then this is the end of it.” ” (HP interview 11, Case 2) The team acknowledged that this case had been ‘much harder’ than they could have possibly envisaged. Whereas a standard radical hysterectomy would usually take between 2.5-3 hours, the retrieval alone lasted eight hours. This was partly due to the technical complexity of the procedures and the team adopting a particularly ‘cautious’ and ‘careful’ approach given their limited experience. Post-operatively, they reflected on ‘many lessons learned’. For instance, in line with most international cases, a midline laparotomy incision had been planned for the retrieval. However, they had opted for a transverse muscle cutting (Maylard) incision instead, which resulted in ‘very good visibility and actually worked very well’. Equally, they had not anticipated to stent the ureters in the recipient, but later described why they were convinced by the value of this: “We hadn’t quite anticipated the amount of work that needed to be done in the ureteric tunnels and the fact that we need to stent. Intraoperatively we realised that the moment we did decide to put the stents in, it just made the dissection so much easier and we were able to visualise the ureters and, yeah, it just felt a bit more comfortable […] At that point my confidence in dissection of course rocketed so from here we will put ureteral catheters up at the start of every retrieval, guaranteed, that’s what’s going to happen” (HP interview 9, Case 2) Post-operative reflections also captured surprise at just how fragile the uterine and ovarian veins were and the necessary strategies to mitigate this during implantation: “You need to do loads of knots, it’s a material that sort of unravels if you don’t. So I’m at the end, my brain says, “Just one more.” That was a mistake, I should have just stayed put. The final one, that final suture, broke. If that breaks, it could totally unravel the anastomosis. Many people around me were saying, “Oh, it doesn’t matter because it’s a vein.” It’s with the artery that you have that high pressure, the vein doesn’t have pressure so it wouldn’t be under a lot of tension. No, the stakes were too high, so I did take the decision that I needed to start the anastomosis again. I think it was the right decision.” (HP interview 11, Case 2) Cases 2-6 were successfully completed (two LD and three DD transplants). Within each case, the team identified unusual or unexpected characteristics of the patients’ pelvic anatomy that needed to be navigated. For instance, a key realisation was that the recipients with MRKH often needed a differently sized vaginal cuff to be created which increased the complexity of completing the anastomosis. Further examples are captured in Supplementary File 5. The team also identified many technical modifications to the procedure. For instance, during implantation, whilst the initial plan had been to cannulate one of the iliac arteries it was decided to cannulate both. IQ also created a different method of approaching the graft (described by colleagues as the ‘Quiroga patch’: ‘connecting the vessels at 90 degrees rather than end to end’, to potentially reduce the chance of a breakdown’.) Further lessons learned across the cases are highlighted in Supplementary File 6, alongside ongoing uncertainties (Supplementary File 7). There was evidence of these ‘refinements’ being discussed with the women: “Even if at any point, touch wood, something goes wrong and it doesn’t work, I know that I’ve still done six months, nearly seven of a uterus transplant and they’re going to learn from that …like there’s been a little bit of a problem with the graft and the length of tissue. We do joke about it, but it is very annoying, but it’s like they learnt from that and then the next person they’re like right okay we need to make sure that that’s shorter. So they learn things from different things and like I know from the first one they only put one drain in post-surgery, whereas for me they put two in because they learnt that actually there’s quite a lot of lymphatic fluid that comes out post-op, so they’re constantly learning things from us. Yes, we’re a part of research and we’re still a patient but you’re different, you’re a research patient which is a whole different ball game” (Recipient, Interview 6003) One of the prominent insights from the clinical interviews was that good working relationships were essential to perceived successful outcomes, helping to build confidence and further develop surgical skills. Within this, there was a strong emphasis on ‘collaboration rather than ego’. As each case progressed, there was enhanced clarity about each person’s roles within the operating theatre. A key part of this was the need for two, equal co-leads, one gynaecology surgeon and one transplant surgeon to work alongside each other collaboratively: “I think it was all about the fact that I had a team that I really respected and respected me as well… On the day, we worked tremendously well. There was at no point any, “This is my bit, this is yours” or interference between any of us. I thought we worked very, very, very, well together, helping each other.” (HP interview 11, Case 2) Alongside this, it was evident that the team were becoming more familiar with each other and the procedure (‘a dance going on, which is much more well-choreographed’). Table 3 provides an insight into how the procedure might continue to evolve in the future. Whilst the procedural techniques were becoming more established, the team acknowledged a delicate balance between building expertise within the core team and supporting others’ training to ensure the UTx programme was ‘sustainable’ at a wider level in the UK. “We’re very conscious that that skill is disseminated across the board. [JRS] will do the first few […] but we’ve got to get a number of people trained up when we get to the end”. (HP interview 3, Pre UTx) Overall, the qualitative interviews were regarded as ‘a safe space’ that provided clinicians with a valuable opportunity to reflect on the transplant programme as a whole in addition to their own experiences between cases. “It’s been very positive… It’s helped me to reflect on the weaknesses and strengths of the programme.” (HP interview 19, Case 6)“It is helpful to just take stock a bit and be like, okay, what did I actually learn.” (HP interview 22, Case 6) “A partnership”: Leaning on each other through the unknowns All recipients each relayed the ‘surreal’ and ‘emotional’ moments leading up to the transplant. For those participating in the DD programme, this was further exacerbated by uncertainty around if and when a matching donor would be identified. However, most of the recipients had never experienced a major surgical procedure before and found the immediate aftermath of the operation and time spent in hospital to be the most challenging aspects of the recovery process. “Oh my god, I felt all the emotions in the world, it was just very, very painful and I think as well, after being in hospital in that hospital bed for so long, it just… laying in that bed constantly, there was a few times I must admit I was like what have I done, you know, what have I actually done here.” (Recipient, interview 6008) Alongside feeling powerless in the aftermath of major abdominal surgery, all recipients had to face major physical transformations. For instance, women who had been diagnosed with MRKH experienced menstruation for the first time in their lives. “Being a 31 year old and getting your first period and you’re like wow. In hospital I was not prepared for a period, it was an experience and a half. So then afterwards I did a little ‘your first period after uterus transplant’ book for the team to give to other women ‘cos I was like this is mental… because there’s so many unknowns. You’re having a uterus transplant and you may be in hospital for a few days but actually you’re probably going to be in there ten days […] it’s just an emotional rollercoaster all the time”. (Recipient, interview 6003) Whilst the gynaecological team were more comfortable with how recovery after hysterectomy would go, they acknowledged that seeing recipients on immunosuppressant therapy and a plethora of other drugs following a transplant had been a ‘shock’ and represented another area of ‘nerve wracking’ unfamiliarity. For all involved, and as cases accumulated, there appeared to be a tremendous sense of relief and anxiety with each milestone; from the first few days where the uterus might be rejected, having the first period, transferring embryos, becoming pregnant, carrying a child through pregnancy, the birth, and determining whether the baby was healthy. “I think, with each milestone, it feels like it’s safer to have those hopes or expectations.” (Recipient, 6004) However, several clinicians reflected that even though the technical procedure was becoming more comfortable, there were many uncertainties about the optimal UTx processes beyond the actual procedure. This included the timing of immunosuppression regimes prior to embryo transfer, when the caesarean section should be, and optimal time between pregnancies. Furthermore, later clinical interviews captured how some DD recipients had endured a failed embryo transfer or had experienced a miscarriage. This further exacerbated concerns about the DD programme, and the team described needing to investigate reasons for this to establish optimal practices. “I think still the concern is people going through all of this to not get a baby at the end… Of course, that is going to be… is going to be the way for some of them. But it will be tough”. (Interview 21, Case 6)“We’ve always felt that deceased should be as good or better. We’ve done three [DDs], we haven’t got babies yet. And we are at a point in which we’re saying, why don’t we have babies and is there something that we need to change… Because ultimately this transplant is not just to have a period, it’s just to have a baby - that’s the only thing we want, to have a baby. So the fact that we’re not having it, it’s not a failure … but it’s not the success that we’re working for”. (HP, consultation 6016) The novel and complex nature of the procedure meant the women and many of the health professionals involved in their care developed close, symbiotic relationships to carefully monitor post-operative recovery and navigate arising complications. This was described in the consultations as a ‘partnership’ between the clinical team and recipients. Nonetheless, several of the women felt that they would have benefitted from more knowledge about what to expect post-operatively, with one woman describing herself as ‘the unknown’. It was evident that having the clinical team putting willing recipients in touch with one another had therefore been ‘hugely reassuring’ for comparing experiences and managing expectations. The women described this peer support as immensely positive and key to their recovery journey. “It was the best thing ever because she understood where I was coming from and I understand where she’s coming from… We talk about everything and everything… never been more open with someone.” (Recipient, interview 6003) Much like the underlying hope had helped overcome the logistical challenges of starting the transplants in the UK, recipients and clinicians alike described navigating this next phase with by remaining cautiously optimistic about the future: “I woke up this morning to be told that the patient looks well and that [recipient] had a positive pregnancy test this morning… Quite something isn’t it? So hopefully there’ll be a baby in nine months. I mean it’s very early days obviously… it could all still fall apart […] ‘cos we’ve staked our careers on this really in many ways and you can’t… there’s a vulnerability to it […] It’s fragile, that what it is. It has a sense of fragility about it and it would be awful if it went wrong at this point, you know… it’s a huge fear […] but I’m a big optimist. I kind of always think it’ll all turn out okay.” (HP interview 16, Case 5) Discussion: Main findings This study provides rich and contemporaneous perspectives into the introduction of UTx in the UK. Our findings captured how the clinical team and women considering/undergoing the procedure grappled with risks and unknowns, with findings showing differing apprehensions for LD and DD cases. These complex emotional and logistical challenges were endured with an underlying sense of hope and desperation. Longitudinal interviews captured the surgical team’s candid experiences and views in real-time, providing an opportunity to reflect on arising technical challenges and to understand evolving strategies to optimise delivery of the procedure. Close collaboration was crucial to navigating uncertainties comprising of initial learning from international cases, clinical teams working across specialties from donor selection to post-operative management , and the women involved building strong relationships with the clinical team (and, at times, each other). Interpretation Over 135 transplants have been performed internationally (two thirds are LD cases), with over 40 babies born(22). There are published clinical series that summarise existing evidence for UTx(6, 7). The IDEAL framework recommends that qualitative research can be used to capture both clinician and patient attitudes when a new surgical procedure is introduced and evaluated(23). However, qualitative research exploring experiences and views of healthcare professionals, donors and recipients is very limited. Using in-depth interviews and observations over a long period of time, w e were able to understand important reflections on differing patient anatomy between cases and explore how this shaped surgical plans for subsequent procedures. These insights are critical to enabling surgeons to determine which patients are most suitable for surgical innovations, and to identifying when a procedure has stabilised and is ready for the next phase of its evaluation. Using qualitative methods in this way has, to our knowledge, not been hitherto reported. Capturing patients’ lived experiences of considering and undergoing the procedure showed that developing robust support systems, including support from other recipients, helped people considering the UTx to navigate the challenges. Previous research has found that clinicians may not express uncertainty about the risks of novel operations, and as a result, patients are not fully informed(24). Indeed, qualitative interviews within other UTx programmes have highlighted a potential lack of awareness of the risks associated with the technique(11). In the current study, the clinical team navigated this uncertainty by carefully managing patient expectations about the anticipated pathway and processes, discussing the latest available evidence and own experiences (and, crucially, highlighting the limits of knowledge of these), and ensuring patients understood all risks (including established known risks, possible risks and unknowns). Crucially, much like the procedure was an evolving process, information provision also changed across the consultations as cases progressed. Given that clinicians can find it challenging to discuss innovative invasive procedures with patients(24, 25), these findings provide practical examples for how clinicians might navigate discussing uncertainty and risks for novel procedures. Strengths and limitations: A key strength of this study is the use of a range of dynamic qualitative research methods to study the introduction of UTx as it was happening. Although a single interview approach is most commonly used for qualitative research in surgery(12), longitudinal interviewing, in the form of a scene-setting ‘background’ interview and subsequent post-operative interviews with surgical teams, provided in-depth exploration and valuable opportunities to reflect on how the procedure was evolving. Additionally, observing interactions between clinical teams and potential recipients provided unique insights into informed consent and decision making. Combining these qualitative data from different methods synergistically further enriched research findings. The value of qualitative research in enhancing randomised controlled trials (RCTs) has been documented(26). This study highlights that these methods are well positioned to elicit meaningful insights into innovative and evolving surgical procedures where modifications are continually occurring. Further research is needed to refine their critical role in the translational pathway. One limitation is the sample upon which this study is based. Five retrievals were from DDs, so findings may be less generalisable to LD contexts. As the use of DD grafts is an area of ongoing investigation given the modest numbers of deceased donor transplants(2), these findings still provide valuable insights. W e were not able to interview more potential recipients, although as with any qualitative study, the findings are not intended to be numerically representative and numbers of eligible patients are typically small for innovative procedures. Overall, findings demonstrated that w e were still able to capture a range of clinical roles in the transplantation process, alongside varying experiences of women considering the procedure, to understand participants’ divergent views and to enhance the credibility of the results. A second limitation is that having the consultations audio-recorded may have resulted in clinicians altering their practice, although most of the women had been in contact with the clinical team for many years and interviews suggested consistencies in informed consent practices. Whilst we were able to capture perspectives for UTx cases presented herein, future research is warranted to continue to explore teams and patients’ experiences in the longer term. It is also important to continue to explore qualitative research in a range of contexts to facilitate a better understanding of the process of surgical innovation. Conclusion: The introduction of UTx represents a significant advancement in reproductive medicine in the UK, offering new hope for women with absolute uterine factor infertility. Our study provides insights into how women made the complex and emotional decision to undergo UTx, weighing up the plethora of risks alongside desperation and hope, and how several then navigated the unknowns of undergoing this innovative surgical procedure. Furthermore, this study demonstrates that embedding prospective qualitative research enables surgeons to reflect on their own practice and techniques. Taken together, this illustrates the potential of prospective qualitative research methodology in understanding complex, novel and emotive procedures such as UTx. Contributions to authorship: Study guarantor: DE Conceptualisation: DE, JMB Data collection: DE, JRS, KNLA, CO, AS, RM, SV, NB, IQ, AL, BPJ, JMB Data analysis: DE, MC, NB Funding acquisition: JMB Project administration: DE, MC, RM, CH, AS, KNLA Writing – original draft: DE Writing – reviewing and editing: ALL Acknowledgments: The authors wish to thank the generosity of the donors and their families. Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf. We declare the following financial activities outside of this work: JRS is chairman of Womb Transplant UK charity, and BJ and IQ are trustees. Data availability statement: To preserve the anonymity of the participants, the transcribed data are not available for sharing. Dissemination to participants and related patient and public communities: Findings have been shared with healthcare professionals participating in the study. Ethics: The Lotus study was approved by the HRA and Health and Care Research Wales Frenchay Research Ethic Committee (Ref 18/SW/0277). References: 1. Brännström M, Johannesson L, Bokström H, Kvarnström N, Mölne J, Dahm-Kähler P, et al. Livebirth after uterus transplantation. 2015;385(9968):607-16.2. Jacques A, Testa G, Johannesson L. Uterus transplantation: current status in 2024. European Journal of Transplantation. 2024(2):77-84.3. Ejzenberg D, Andraus W, Mendes LRBC, Ducatti L, Song A, Tanigawa R, et al. Livebirth after uterus transplantation from a deceased donor in a recipient with uterine infertility. The Lancet. 2018;392(10165):2697-704.4. Jones BP, Vali S, Saso S, Devaney A, Bracewell-Milnes T, Nicopoullos J, et al. Living donor uterus transplant in the UK: A case report. 2024;131(3):372-7.5. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. 2021;374.6. Jones BP, Saso S, Bracewell-Milnes T, Thum MY, Nicopoullos J, Diaz-Garcia C, et al. Human uterine transplantation: a review of outcomes from the first 45 cases. BJOG. 2019;126(11):1310-9.7. Brännström M, Racowsky C, Carbonnel M, Wu J, Gargiulo A, Adashi EY, et al. Uterus transplantation: from research, through human trials and into the future. Hum Reprod Update. 2023;29(5):521-44.8. Pennell CP, Hirst AD, Campbell WB, Sood A, Agha RA, Barkun JST, et al. Practical guide to the Idea, Development and Exploration stages of the IDEAL Framework and Recommendations. 2016;103(5):607-15.9. Guntram L. May I have your uterus? The contribution of considering complexities preceding live uterus transplantation. Med Humanit. 2021;47(4):425-37.10. Wall AE, Johannesson L, Testa G, Warren AM. Two cases of pregnancy following uterine transplant: an ethical analysis. 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Britten NJB. Qualitative research: qualitative interviews in medical research. 1995;311(6999):251-3.17. Charmaz K, Belgrave LJTShoirTcotc. Qualitative interviewing and grounded theory analysis. 2012;2:347-65.18. Saunders CH, Sierpe A, Von Plessen C, Kennedy AM, Leviton LC, Bernstein SL, et al. Practical thematic analysis: a guide for multidisciplinary health services research teams engaging in qualitative analysis. BMJ. 2023;381.19. Terry G, Hayfield N. Essentials of thematic analysis: American Psychological Association; 2021.20. Braun V, Clarke V. Successful Qualitative Research: Sage; 2013 April 5th, 2013. 400 p.21. Bhaskar R, Danermark BJSJoDR. Metatheory, interdisciplinarity and disability research: a critical realist perspective. 2006;8(4):278-97.22. Brännström M, Bokström H, Hagberg H, Carlsson Y. Maternal and perinatal outcomes of live births after uterus transplantation: A systematic review. Acta Obstet Gynecol Scand. 2025;104(3):559-78.23. Bilbro NJBJoS. New reporting guidelines for IDEAL studies. 2020;107(10):1241-2.24. Elliott D, Ochieng CA, Zahra J, McNair AG, Main BG, Skilton A, et al. What are patients told about innovative surgical procedures? A qualitative synthesis of seven case studies in the UK. 2022:10.1097.25. Angelos PJBJoS. Double-edged sword of surgical innovation: ethical issues of early and late adoption of novel techniques. 2021;108(2):107-8.26. Donovan JL, Lane JA, Peters TJ, Brindle L, Salter E, Gillatt D, et al. Development of a complex intervention improved randomisation and informed consent in a randomized controlled trial. J Clin Epidemiol. 2009;62. Supplementary Material File (figure 1 - timeline.docx) Download 112.97 KB File (tables.docx) Download 16.38 KB Information & Authors Information Version history V1 Version 1 11 November 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Collection BJOG: An International Journal of Obstetrics and Gynaecology Keywords general obstetrics gynaecological surgery: general health services research infertility: basic science psychology qualitative research translational research Authors Affiliations Daisy Elliott 0000-0001-8143-9549 [email protected] NIHR Bristol Biomedical Research Centre View all articles by this author J Smith Imperial College London Department of Metabolism Digestion and Reproduction View all articles by this author Maeve Coyle NIHR Bristol Biomedical Research Centre View all articles by this author Rhiannon Macefield NIHR Bristol Biomedical Research Centre View all articles by this author Saaliha Vali 0000-0002-7289-0407 Imperial College London Department of Metabolism Digestion and Reproduction View all articles by this author Anni King NIHR Bristol Biomedical Research Centre View all articles by this author Natalie Blencowe NIHR Bristol Biomedical Research Centre View all articles by this author Cynthia Ochieng NIHR Bristol Biomedical Research Centre View all articles by this author Christin Hoffmann NIHR Bristol Biomedical Research Centre View all articles by this author Isabel Quiroga Oxford University Hospitals NHS Foundation Trust View all articles by this author Benjamin Jones 0000-0002-0391-0443 Imperial College London Department of Metabolism Digestion and Reproduction View all articles by this author Ariadne L'Heveder 0000-0002-1642-3011 Imperial College London Department of Metabolism Digestion and Reproduction View all articles by this author Kerry Avery NIHR Bristol Biomedical Research Centre View all articles by this author Jane Blazeby M NIHR Bristol Biomedical Research Centre View all articles by this author Metrics & Citations Metrics Article Usage 314 views 178 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Daisy Elliott, J Smith, Maeve Coyle, et al. “The dream of being able to carry my own child outweighs anything”: A qualitative study of the UK’s initial womb transplants in real-time. 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