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American Society for Reproductive Medicine position statement on uterus transplantation: a committee opinion (2018)


KEY POINTS

  • Uterus transplantation is an experimental procedure for the treatment of absolute uterus-factor infertility (UFI).
  • Uterus transplantation should be performed within an Institutional Review Board (IRB)–approved research protocol.
  • Uterus transplantation teams should be well-coordinated and multidisciplinary.
  • Surgical training with animal models and/or cadaver labs is necessary prior to attempting transplantation in human subjects.
  • The organ used during uterus transplantation can be from living or deceased donors.
  • Transparent inclusion and exclusion criteria should guide selection of transplantation recipients.
  • Standardized reporting on outcomes of uterus transplantation is desirable to assess the true risks, benefits, and outcomes associated with this procedure.
  • Consistent with all organ transplantations, the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) is the supportive organization for data collection. However, neonatal and long-term pediatric outcomes need to be collected.


BACKGROUND

Until the first live birth after uterus transplantation in Sweden in 2014, there were no treatment options available for women with an absent or nonfunctional uterus to carry their own child. Internationally, an attempt at uterus transplantation in 2000 resulted in the uterus being removed and another attempt in 2011 did not produce a live birth (1, 2). Women with UFI who have a nonfunctional or absent uterus historically have been advised to explore in vitro fertilization (IVF) with a gestational carrier (where legal), adoption, foster parenting, or to lead a life without children. The number of women with UFI is significant. In the United States, UFI affects 1%–5% of reproductive-aged infertile women and may result from major congenital uterus malformations (e.g., Mayer-Rokitansky-K€uster-Hauser syndrome); benign, obstetrical, or oncologic hysterectomy; or an acquired uterus condition that leaves the uterus in situ but renders it nonfunctional such as severe Asherman syndrome (3, 4). It is not clear what percentage of these patients have an irreversible cause of UFI. Some women with UFI find adoption or the use of a gestational carrier impossible or unacceptable due to legal, religious, financial, or ethical concerns. Although the surgical approach to uterus transplantation is still in its infancy, there is widespread public interest and support for uterus transplantation and gestational surrogacy (5–12). More than 30 uterus transplantations have been performed worldwide (13) as of the publication of this document, indicating the rapid tempo of developments in this field. There are several programs initiating or conducting clinical trials of uterus transplantation using both living and deceased donor models in the United States (14). There have been 11 reported deliveries worldwide, all through IVF, with 8 in Sweden, 2 in the United States, and 1 in Brazil (the first reported birth from a deceased donor), at the time of this writing. The mean gestational age at delivery in the Swedish trial of eight births was 35 weeks and 1 day with a birth weight of 2.5 kg. No birth defects were reported. The main obstetrical complications were preeclampsia and cholestasis. Follow-up between 2 months and 3 years has not revealed any significant infant disorders.

Composition of an Appropriate Research Team

Uterus transplantation is currently considered an experimental procedure and should not be performed outside of an IRB–approved research protocol. These trials should be listed on Clinicaltrials.gov. Due to the medical and surgical complexity of uterus transplantation as well as the need for long-term maternal-fetal-neonatal follow-up, these protocols appear to be most appropriate for tertiary medical centers. Teams embarking upon such protocols should be multidisciplinary with recommended representation as listed in Table 1. The primary surgeon/physician for the program should be clearly identified. This concept applies solely to the transplantation component and others will take the lead for the reproductive and obstetrical aspects of the procedure.

Uterus transplantation is unique in its temporary nature; the graft is not intended to last for the life of the recipient, only for as long as necessary to achieve childbearing goals. However, institutions must be prepared to follow a uterus transplantation recipient through four or more abdominal surgeries, including initial implantation of the uterus, one or more cesarean deliveries, and ultimate hysterectomy once childbearing is complete. For an individual recipient, this cycle may take several years to complete; therefore, ensuring the infrastructure for long-term follow-up is essential. Follow-up of the offspring will take even longer. As a surgical team prepares for transplantation attempts in human subjects, surgical practice specific to uterus transplantation is required. Teams in both Sweden and the United States have prepared for human clinical trials with prior surgical training in rats, sheep, pigs, and nonhuman primates (15, 16). Surgical training and preparation may involve either large animal research or cadaver practice to optimize the surgical approach and team training for obtaining and implanting a uterus graft. The surgical complexity surrounding uterus transplantation lies mainly with the highly difficult dissection of the uterus vein, if used, to provide optimal drainage of the graft (17). As with all innovative surgical procedures, adaptations may be necessary to obtain optimal results (18, 19). Surgeons should possess considerable expertise in vascular dissection and anastomosis as well as navigating the pelvic, vaginal, and retroperitoneal pelvic anatomy. Transplantation teams and recipients must understand that postoperative complications such as graft thrombosis and infection may necessitate hysterectomy in the immediate postoperative period. In addition, other complications, such as graft rejection, may also occur prior to the recipient completing any pro creative treatment and childbearing. Psychosocial team members should have experience either with the psychosocial assessment and care of solid-organ transplant candidates and solid-organ donors or be willing to be mentored by psychosocial team members from existing uterus vascularized composite allograft (VCA) programs.

Table 1. Recommended composition of the uterus transplantation team.


Team member
Reproductive endocrinologist
Transplant surgeon
Gynecologic surgeon
Maternal-fetal medicine specialist
Anesthesiologist
Infectious disease specialist
Psychiatrist or psychologist
Neonatologist
Pathologist
Radiologist
Bioethicist or professional with bioethics expertise
Social worker
Living donor advocate as described by UNOS regulations
Research nurse/coordinator
Transplant medicine specialist

Issues of Ethics, Consent, and Subject Selection

Human uterus transplantation is considered a VCA, similar to transplantation of the face, limbs, abdominal wall, and other non-lifesaving organs. These transplants can be substantially life-enhancing. However, they do present unique ethical and logistical considerations. VCAs are regulated in a manner similar to other solid organs and require specialized consent to allow removal of the specified organ as well as its use in research. UNOS provides oversight for organ procurement organizations, which obtain the appropriate consent for VCAs from either the donor in living-donor transplants or the donor's family in deceased-donor transplants. Living donors should be specifically counseled regarding the risks of injury, as the hysterectomy required for a living-donor uterus transplantation approximates a radical hysterectomy and injuries have been reported to donors in all series of living donors to date (18, 19). Care should be taken to avoid undue emotional and psychological pressure in living donors, who are often family members of the recipient seeking transplantation. Recipients must be counseled carefully and thoroughly, as women hoping to achieve pregnancy are considered a vulnerable population. Counseling must highlight the experimental nature of this type of clinical research rather than potential pregnancy as the central focus. Recipients must be advised of both known and unknown risks of transplantation and the accompanying anti-rejection medical treatments. As bioethical issues in uterus transplantation (including reproductive and obstetrical components) are a foremost concern, bioethicists or those with bioethics expertise should be included in research protocols from the outset (20, 21).

Careful consideration should be given to inclusion of appropriate subjects. Common inclusion and exclusion criteria for recipients are listed in Table 2. As most protocols in IVF and embryo cryopreservation (freezing) prior to transplantation require, recipients should be excellent IVF candidates. The need for routine use of preimplantation genetic testing in this patient population has not been defined. The optimal number of cryopreserved embryos necessary prior to proceeding with the uterus transplant is undefined, but it seems reasonable that it would be the total number of embryos that would result in at least one live birth (based on the recipient's age, embryo quality, and the statistics of the IVF program). A single embryo should be transferred each time.

Inclusion and exclusion criteria for donors have not been well established and will depend on whether living or deceased donors are used. All donors must be blood-type compatible with their intended recipient. All recipients should be screened for preformed anti human leukocyte antigen (HLA) antibodies prior to transplantation using single-antigen beads or other solid-phase methodology as currently performed by the transplant center's HLA laboratory. When living-donor liver transplantation is performed, the HLA donor-recipient compatibility can be tested electively. Strong B and T cell crossmatch positivity should be avoided, as the effects of a strong immunological reaction on graft outcomes are unknown. The use of virtual crossmatch can be used to optimize donor-recipient HLA matching in cadaveric uterus transplantation, where the actual cross match result can be available for logistical reasons only after the transplant has occurred.

Deceased donors of reproductive age will have met criteria for brain death or donation after cardiac death. It is unclear whether increased-risk donors should be used (such as those who have died fromintravenous drug overdose). Living donors should bemedically healthy before donation, parous, and have a favorable obstetric history. Donors should not have a history of gynecologic conditions that would impact reproductive outcomes such as submucous, intracavitary, or large intramural leiomyomas; clinically significant adenomyosis; uterus anomalies; or endometrial pathology. Donors should not have active human papillomavirus or active cervical dysplasia present. Importantly, donors should be free of conditions associated with vasculopathy, such as diabetes, hypertension, and significant lipid abnormalities. Critical infectious diseases must be ruled out in all donors.

Table 2. Suggested inclusion and exclusion criteria for recipients of a uterus transplant.


Inclusion Exclusion
  • Meets criteria for an absent or a nonfunctional uterus
  • Reproductive-aged female (18–45 y) with sufficient number of goodprognosis embryos
  • Willing and able to undergo criteria of the study including psychiatric and social-work evaluation
  • Willing and able to undergo general anesthesia, in vitro fertilization, major gynecologic surgery, pregnancy with potential high-risk complications, cesarean delivery, and eventual hysterectomy to remove the graft
  • Willing and able to receive immunosuppressive medications
  • Willing to receive standard vaccinations
  • Social support and ability to sign informed consent
  • Nonsmoker
  • Approval of multidisciplinary treatment team
  • Willing and able to follow infection prophylaxis protocols associated with solid-organ immunosuppression practice, including but not limited to cytomegalovirus and pneumocystis pneumonia prophylaxis
  • Age >45 y or poor reproductive status of embryos
  • History of hypertension, diabetes, or significant systemic illness, including serious abnormalities of the heart, liver, kidney, hematologic, or central nervous system
  • Any medical diagnosis placing the subject at high risk of surgical complications based on the transplantation team's review of medical history
  • Smoker within 3 mo of study enrollment
  • History of prior malignancy (excluding early-stage cervical cancer or other cancers at low risk for recurrence)
  • History of human immunodeficiency virus or any history of mycobacterial infection (treated or untreated)
  • Presence of active documented systemic infection or recent systemic infection within the past 3 mo
  • Active chemical and/or alcohol dependency or abuse
  • Anatomical abnormality which would make the pelvic transplantation surgery unlikely to be successful
  • Body mass index >30 kg/m2
  • Relative or absolute contraindication to immunosuppression
  • Untreated hepatitis C or active hepatitis B viremia or carrier state

Immunosuppression

State-of-the-art immunosuppression should be provided based on the principles established in solid-organ transplantation and composite-tissue transplantation.


Surveillance of Rejection

Cervical punch biopsies from the ectocervix are used to monitor rejection and can also be used in pregnancy (22). Periodic biopsies will be performed at scheduled intervals as well as at the discretion of the program.


Surgical Considerations and Future Directions

It is currently unknown whether living-donor or deceased-donor uterus transplantation represents the superior approach. It is possible that both surgical techniques will be relied upon, similar to what has been recognized in liver and kidney transplantation. Each approach has distinct advantages and disadvantages, as outlined in Table 3. At this stage, it appears ethically sound to pursue both deceasedand living-donor approaches based on the experience and preferences of the institution and research team.

Ischemia-reperfusion injury is a significant concern in both living- and deceased-donor protocols and neither optimal cold nor warm ischemic times for uterus transplantation have been determined to date. Although several studies have demonstrated resistance to cold ischemia in uterus myometrial cells (23, 24), consideration should be given to limiting both cold and warm ischemia times. Deceaseddonor programs may benefit from approximating livingdonor techniques as closely as possible. This may include selecting donors in close geographic proximity to the recipient in order to limit transit and ischemia time for the graft. It may also be advantageous to have two different teams for organ procurement and implantation, as is commonly coordinated in solid-organ living-donor models. Postoperative surveillance for both infection and thrombosis should be intensive as these appear to be the leading causes of immediate post-transplantation hysterectomy (13). Ideal graft monitoring and follow-up should include a combination of laboratory studies, imaging, and cervical biopsies; however, an optimal strategy for either short- or medium-term posttransplant surveillance has not been established to date.

As the technique of uterus transplantation is quickly evolving, several key issues remain to be determined. Foremost is whether a uterus obtained through minimally invasive techniques can result in a live birth and mitigate some of the risks associated with open living-donor surgery (25). Robotic and laparoscopic approaches have been described recently (26, 27). The use of ovarian or utero-ovarian vessels for venous outflow has been a novel application to circumvent the dissection and use of the uterus veins (19P). However, it is generally not recommended to use the ovarian vessels if this results in the loss of ovaries in premenopausal women. Techniques have been established to use the utero-ovarian veins that allow preservation of the ovaries. In addition, although fetal exposure to immunosuppressive medications is similar in uterus transplantation to other well-studied solid-organ transplants such as kidney, neonatal assessment and future strategies to decrease potential harm to the offspring should be investigated.

As uterus transplantation becomes a more common therapeutic procedure in the United States, there is a need for uniform reporting and evaluation of outcomes. At a minimum, surgical centers should report the short-term parameters listed in Table 4 to their IRB. As longer-term follow-up on a greater number of procedures becomes available, a cautious assessment will be necessary to determine the appropriateness and impact of this procedure on the physical and mental health of recipients and offspring as well as of donors. Although an international registry is planned, programs in the United States are obligated by OPTN/UNOS to carefully track and report on data related to ongoing uterus function, safety, and reproductive outcomes. Established research programs are encouraged to maintain transparency and cooperation both with each other as well as with newly established centers. It should be noted that, as a uterus transplant is classified as a VCA, reporting is mandated by UNOS to allow for data to be submitted and analyzed by the Scientific Registry of Transplant Recipients. The breadth of the data mandated and reported should be extensive enough to allow the needed analysis of the effectiveness, risks, and overall utility of this emerging and rapidly proliferating organ transplant.

Table 3. Living- versus deceased-donor models.


Donor Type Advantage Disadvantage
Living
  • Opportunity to obtain detailed medical/surgical history
  • Donor and recipient in close geographic proximity
  • Convenient scheduling and assessment
  • Procedural risks associated with pelvic surgery
  • Undue pressure to donate
  • Possible ‘‘donor guilt’’ if unsuccessful
  • Potential risks with older uteri/vascular grafts
  • Use of ovarian vessels may require oophorectomy
Deceased
  • No donor risks
  • Grafts from younger-aged donors
  • Greater variety of vascular pedicles available,
    including ovarian vessels
  • Limited preoperative assessment
  • Scarcity of suitable organs and inconvenient scheduling/geography
  • Possible difficulties in obtaining consent from next of kin

Table 4. Standards for consistent reporting for uterus transplantation surgeries.


Information Source Data to Collect
Donor
  • Age and body mass index of donor
  • Surgical times for uterus procurement
  • Route of surgery (abdominal versus laparoscopic or robotic)
  • Living-donor complications and length of stay
Graft Recipient
  • Cold and warm ischemia times for the graft
  • Surgical times for uterus reimplantation
  • Blood transfusion
  • Length of stay post-transplantation
  • Postoperative complications
  • Outcome of surgery (i.e., graft in situ versus post-transplantation hysterectomy)
  • If hysterectomy is performed, what was the indication (thrombosis, infection, etc.)
  • Presence of vaginal stenosis
  • Episodes of rejection based on cervical biopsy and method of management
  • Pregnancy
  • Long-term follow-up
  • Outcomes for offspring

SUMMARY

  • Uterus transplantation is an experimental procedure for the treatment of absolute uterus-factor infertility.
  • Uterus transplantation should be performed within an IRBapproved research protocol.
  • A uterus transplant program requires a multidisciplinary team experienced with the technique prior to attempting transplantation in human subjects.
  • The organ used during uterus transplantation can be for living or deceased donors; each approach has its own challenges and strengths.


CONCLUSION

Uterus transplantation is an experimental procedure that may allow women with absolute uterus factor infertility to achieve a pregnancy.


UNANSWERED QUESTIONS

  • Is a living- or deceased-donor approach superior for uterus transplantation?
  • In living donors, can the utero-ovarian veins be used in place of the uterine veins for the entire venous return of the uterus?
  • What are the long-term consequences of transplant and anti-rejection drugs on the mother and her baby?

Acknowledgments: This report was developed under the direction of the Practice Committee of the American Society for Reproductive Medicine as a service to its members and other practicing clinicians. Although this document reflects appropriate management of a problem encountered in the practice of reproductive medicine, it is not intended to be the only approved standard of  practice or to dictate an exclusive course of treatment. Other plans of management may be appropriate, taking into account the needs of the individual patient, available resources, and institutional or clinical practice  limitations. The Practice Committee and the Board of Directors of the  American Society for Reproductive Medicine have approved this report.

This document was reviewed by ASRM members and their input was considered in the preparation of the final document. The Practice Committee acknowledges the special contribution of the ASRM Task Force on Guidance for Uterus Transplant whose members include: Megan Allyse, Ph.D.; Hatem  Amer, M.D.; Christos Coutifaris, M.D., Ph.D.; Tommaso Falcone, M.D.; Abimbola Famuyide, M.B.B.S.; Rebecca Flyckt, M.D.; Antonio Gargiulo, M.D.; Julie Heimbach, M.D.; Liza Johannesson, M.D., Ph.D.; Sheila Jowsey-Gregoire, M.D.; Zaraq Khan, M.B.B.S.; Carrie Langstraat, M.D.; Scott Levin, M.D.; Sue McDiarmid, M.D.; Charles Miller, M.D.; David Mulligan, M.D.; Kathleen O'Neill, M.D.; Alan Penzias, M.D.; Samantha Pfeifer, M.D.; Paige Porrett, M.D.; Cristiano Quintini, M.D.; Richard Reindollar, M.D.; Charles Rosen, M.D.; Dan-Arin Silasi, M.D.; Elizabeth Stewart, M.D.; Giuliano Testa, M.D.; Andy Tzakis, M.D.; and Stefan G Tullius, M.D., Ph.D. 

The following members of the ASRM Practice Committee participated in the development of this document. All Committee members disclosed commercial  and financial relationships with manufacturers or distributors of goods or services used to treat patients. Members of the Committee who were found to have conflicts of interest based on the relationships disclosed did not participate in the discussion or development of this document.

Alan Penzias, M.D.; Kristin Bendikson, M.D.; Tommaso Falcone, M.D.; Susan Gitlin, Ph.D.; Clarisa Gracia, M.D., M.S.C.E.; Karl Hansen, M.D., Ph.D.; Sangita Jindal, Ph.D.; Suleena Kalra, M.D., M.S.C.E.; Jennifer Mersereau, M.D., M.S.C.I.; Randall Odem, M.D.; Robert Rebar, M.D.; Richard Reindollar, M.D.; Mitchell Rosen, M.D.; Jay Sandlow, M.D.; Peter Schlegel, M.D.; Dale Stovall, M.D.

REFERENCES

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Senate Budget Hearing is Well Timed Following Alabama IVF Ruling

ASRM statement regarding the Senate Budget Committee’s hearing entitled: No Rights to Speak of: The Economic Harms of Restricting Reproductive Freedom.

View the Press Release
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ASRM Responds to Senate’s Failure to Pass Access to Family Building Act

We are disappointed by the Senate’s failure to meet the moment and pass federal legislation protecting access to in vitro fertilization (IVF).

View the Press Release
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What's New from the Fertility and Sterility Family of Journals

Here’s a peek at this month’s issues from our family of journals! As an ASRM Member, you can access all of our journals.
Read More about the newest articles
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ASRM Condemns Profoundly Misguided and Dangerous Court Decision in Alabama

In LePage v Mobile Infirmary Clinic, the Alabama Supreme Court made a decision that flies in the face of medical reality and the needs of the citizens.

View the Press Release
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NEW from ASRM Academy: Basic Infertility for Healthcare Providers

ASRM is proud to introduce our updated course: Basic Infertility for Healthcare Providers.  Learn more with an overview from Instructional Designer, Harriet Smith, MEd
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What's New from the Fertility and Sterility Family of Journals

Here’s a peek at this month’s issues from our family of journals! As an ASRM Member, you can access all of our journals. Not yet a member? Click here(no link) to learn more. Find More
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ASRM applauds introduction of Access to Family Building Act of 2024

ASRM is thrilled by the introduction of the Access to Family Building Act 

View the Press Release
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Resource Roundup: Thyroid Health

January is Thyroid Health Awareness Month! View the resource roundup!
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Definition of infertility: a committee opinion (2023)

‘‘Infertility’’ is a disease, condition, or status characterized by several factors. View the Committee Opinion
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Diagnostic evaluation of sexual dysfunction in the male partner in the setting of infertility: a committee opinion (2023)

It is the responsibility of the clinician to assess for erectile dysfunction, ejaculatory dysfunction, or diminished libido in men presenting for infertility. View the Committee Opinion
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Journal Club Global - Actualización en la suplementación con progesterona en fase lútea para transferencias de embriones congelados

Efectividad del rescate de progesterona en mujeres que presentan niveles bajos de progesterona circulante alrededor del día de la transferencia de embriones View the Video
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Endometriosis and infertility: a committee opinion (2012)

Women with endometriosis typically present with pelvic pain, infertility, or an adnexal mass, and may require surgery. View the Committee Opinion
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The International Glossary on Infertility and Fertility Care, 2017†‡§ (2017)

Terms and definitions currently used infertility care, infertility and medically assisted reproduction (MAR) can have different meanings that are dependent upon the setting, their usage in research or clinical interventions, or among diverse populations.
View the Committee Joint Guideline
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Surgery Coding

I took the ASRM coding course, and in that course, coding for bilateral neosalpingostomies was coded using only a dx of N70.11 (hydrosalpinx). View the Answer
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Post Vasectomy Infertility

If a husband has had a vasectomy, does the sterilization code apply to the wife's visits? View the Answer
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Pregnancy Of Uncertain Viability Ultrasound

My staff is telling me that I am getting reimbursed for the first sonogram and OB visit (using ICD 10 code for pregnancy of uncertain viability – O36.80X0. View the Answer
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Pregnancy Ultrasound

Our practice does routine ultrasounds (sac check- 76817) at the end of an IVF cycle and bill with a diagnosis code O09.081, pregnancy resulting from ART.  View the Answer
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Self-referred New Patient

A patient self-refers to our physician for an initial new patient consultation instead of referred by another physician, how do we code for the consult? View the Answer
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Telephone Consult

Does a physician need to speak directly to a patient to code for a telephone consult (99371-99373) or can a staff member relay physician notes to patients? View the Answer
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Testing With No History of Infertility

What diagnosis codes should  providers submit to insurance carriers while trying to evaluate fertility issues? View the Answer
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Psychological Evaluation

Many REs require patients (and their spouses/partners) who are considering using donor gametes to see an infertility counselor first. View the Answer
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IUI or IVF

Should other ovarian dysfunction (diagnosis code E28.8) or unspecified ovarian dysfunction (diagnosis code E28.9) can be used for an IUI or an IVF cycle View the Answer
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Infertility Consult

Does ASRM have any examples of evaluation and management documentation for patients being seen for an initial infertility evaluation? View the Answer
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Infertility Consult by Nurse

What code is used for a nurse practitioner seeing a fertility patient for the first time? View the Answer
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Initial Visit for Infertility With No Mandated Coverage

What code would be appropriate for an initial visit for infertility?  View the Answer
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Monitoring E&M

Our group would like to know if others are billing an evaluation and management code for ultrasound and blood draw visits? View the Answer
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New vs Established Patient

How soon can you bill as a new infertility patient? View the Answer
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Hysteroscopy Recurrent Implantation Failure

What is the appropriate ICD-10 code for recurrent implantation failure?  View the Answer
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General E&M Consult

Recently we have received a “re-code” on a new patient (we billed a 99203 and the insurance re-coded it to a 99213).  View the Answer
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D&C Under Ultrasound Guidance

What are the CPT codes and ICD-10 codes for coding a surgical case for a patient with history of Stage B adenocarcinoma of the cervix ... View the Answer
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Diagnosis of Infertility for IVF Procedure

How important is it to have accurate documentation of the type of infertility diagnosis for IVF procedures?  View the Answer
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Diagnostic Testing of an Infertile Couple

The Z31.41 is or is not the correct code to use for diagnostic testing of an infertile couple? And If so can if be used as the primary and only code? View the Answer
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Blood Draws

If a patient comes in only for a blood draw (venipuncture) and is seen only by the lab technician (not an MD, PA, or NP), may we bill for a (minimal) office visit? View the Answer
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Blood Tests

Patients are requesting to have lab work drawn from the female patient moved to the males account due to the female fertility coverage being maxed out.  View the Answer
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Male Infertility

A summary of common codes for Male Infertility compiled by the ASRM Coding Committee. View the Coding Summary
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ASRM müllerian anomalies classification 2021

The Task Force set goals for a new classification and chose to base it on the iconic AFS classification from 1988 because of its simplicity and recognizability. View the Committee Opinion
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Intracytoplasmic sperm injection (ICSI) for non–male factor indications: a committee opinion (2020)

Intracytoplasmic sperm injection is frequently used in combination with assisted reproductive technologies. View the Committee Document
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Moving innovation to practice: an Ethics Committee opinion (2021)

The introduction of new strategies, tests, and procedures into clinical practice raises challenging ethical issues. View the Committee Opinion
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Fertility evaluation of infertile women: a committee opinion (2021)

Diagnostic evaluation for infertility in women should be conducted in a systematic, expeditious, and cost-effective manner. View the Committee Opinion
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Fertility treatment when the prognosis is very poor or futile: an Ethics Committee opinion (2019)

The Ethics Committee recommends that in vitro fertilization (IVF) centers develop patient-centered policies regarding requests for futile treatment.  View the Committee Opinion
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Use of exogenous gonadotropins for ovulation induction in anovulatory women: a committee opinion (2020)

Pretreatment evaluation, indications, treatment regimens, and complications of gonadotropin treatment. View the Committee Opinion
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Reproductive and hormonal considerations in women at increased risk for hereditary gynecologic cancers: Society of Gynecologic Oncology and American Society for Reproductive Medicine Evidence-Based Review (2019)

Providers who care for women at risk for hereditary gynecologic cancers must consider the impact of these conditions. View the Joint Statement
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Guidance for Providers Caring for Women and Men Of Reproductive Age with Possible Zika Virus Exposure (Updated 2019)

This ASRM guidance specifically addresses Zika virus infection issues and concerns of individuals undergoing assisted reproductive technologies (ART). View the Guideline
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American Society for Reproductive Medicine position statement on uterus transplantation: a committee opinion (2018)

Following the birth of the first child from a transplanted uterus in Gothenburg, Sweden, in 2014, other centers worldwide have produced scientific reports. View the Committee Opinion
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Child-rearing ability and the provision of fertility services: an Ethics Committee opinion (2017)

Fertility programs may withhold services on the basis that patients will be unable to provide minimally adequate or safe care for offspring. View the Committee Opinion
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Removal of myomas in asymptomatic patients to improve fertility and/or reduce miscarriage rate: a guideline (2017)

This review evaluates if uterine myomas impact likelihood of pregnancy and pregnancy loss, and if myomectomy influences pregnancy outcomes. View the Guideline
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Improving the Reporting of Clinical Trials of Infertility Treatments (IMPRINT): modifying the CONSORT statement (2014)

Clinical trials testing infertility treatments often do not report on the major outcomes of interest to patients and clinicians and the public. View the Guideline

Topic Resources

View more on the topic of reproductive surgery
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Reimplantation of cryopreserved ovarian tissue

What is the correct code for laparoscopic reimplantation of ovarian tissue?  View the Answer
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Coding for fluid aspiration during HSG

For physician-performed sonoHSG (58340& 76831) and uterine aspiration due to fluid, can an additional code for the aspiration be billed? View the Answer
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Billing 58558 together with 58560

Can CPT codes 58558 and 58560 be billed together? Also, can 58560 be billed with place of service 11? View the Answer
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Coding of identification of sperm in aspirate

During vasovasostomy/vasoepididyostomy procedures, our surgeons perform intra-op sperm identification from aspirate  View the Answer
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Endometrioma

Surgery was performed under anesthesia for Aspiration of right hyrosalpinx fluid and right endometrioma. View the Answer
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Uterine Aspiration of Pregnancy of Unknown Location

What CPT code would be most appropriate for a manual uterine aspiration for a pregnancy of unknown location? View the Answer
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Eligibility to bill for facility fee

We are planning to open a new fertility clinic and I was wondering about the eligibility to bill insurance companies for “facility fee” for egg retrievals. View the Answer
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Resection Adenomyoma

I have a patient with an adenomyoma of the uterine wall that requires surgical excision and uterine repair. View the Answer
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Robotically Assisted Tubal Anastomosis

What is the correct CPT code for laparoscopic tubal anastomosis with robotic assistance?  View the Answer
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Surgery Coding

I took the ASRM coding course, and in that course, coding for bilateral neosalpingostomies was coded using only a dx of N70.11 (hydrosalpinx). View the Answer
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Tompkins Metroplasty

Is there a code for Tompkins Metroplasty? View the Answer
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Multiple Laparoscopic Procedures

Is it appropriate to bill for medically indicated, multiple procedures when performing laparoscopies?  View the Answer
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Office Hysteroscopy Billing

Do you all have a resource that details what all can be billed, or what all is bundled with the 58558 procedure when done in office?  View the Answer
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Ovarian Drilling

Is there a CPT Code for "Ovarian Drilling"? View the Answer
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Ovariopexy

Is there a CPT code for Ovariopexy procedure only, via mini-laparotomy? View the Answer
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Excision Ovarian Endometrioma

What code is used for a laparoscopic excision of endometriosis and an ovarian excision of endometrioma with bilateral ureterolysis is performed. View the Answer
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Hysteroscopic Tubal Cannulation Under Laparoscopic Guidance

How can one code for hysteroscopic transcervical fallopian tube cannulation under laparoscopic guidance?  View the Answer
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Hysteroscopy Polyp Suspected

What ICD-10 code do you use if a diagnostic hysteroscopy is performed for the preoperative diagnosis of uterine polyp? View the Answer
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Hysteroscopy Recurrent Implantation Failure

What is the appropriate ICD-10 code for recurrent implantation failure?  View the Answer
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Hysteroscopy Resection of Retained Products of Conception

What CPT is appropriate for a Hysteroscopy Resection of Retained Products of Conception?  View the Answer
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D&C Under Ultrasound Guidance

What are the CPT codes and ICD-10 codes for coding a surgical case for a patient with history of Stage B adenocarcinoma of the cervix ... View the Answer
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Diagnostic Hysteroscopy

If the doctors do a hysteroscope #58555 in the office with a Endosee Scope, can I still use the same code even though it is in the office? View the Answer
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C-Section Ectopic Pregnancy

I’m writing for advice for CPT advice for managing cesarean scar ectopic pregnancy without concurrent intrauterine pregnancy (ICD-10 O00.80).  View the Answer
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Coding for Ovarian Drilling

Can you provide some information related to ovarian drilling that would assist non-physician administration (coders, billers)? View the Answer
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Coding For Placement Of A Cervical Stitch

Physicians at our practice are placing a stitch and dilating the cervix after egg retrievals for those patients that have cervical stenosis.  View the Answer
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Cycle Monitoring Fertility Preservation

If the patient is undergoing ultrasound tracking visits for fertility preservation, what I ICD-10 code do you use for the monitoring? View the Answer
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SRS Travel Scholar Award for Reproductive Surgery

The objective of the SRS Traveling Scholar Award is to provide for any trainee whose abstract submission focuses on reproductive surgery to expand their educational and networking experience. View the Award Information
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SRS-SMRU Travel Scholar Award for Male Reproductive Surgery

The objective of the SRS-SMRU Traveling Scholars Award is for any trainee whose abstract submission focuses on male reproductive surgery to expand their educational and networking experience. View the Award Information
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SRS In-Training Awards for Research

The purpose of these awards is to recognize outstanding research conducted by individuals in training.
View the Award Information
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DeCherney-Nezhat REI Fellows Traveling Scholars Award in Reproductive Surgery

The objective of this award is to expand educational and networking opportunities for REI Fellows with a  focus on reproductive surgery. View the Award Information
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Journal Club Global: Moving leiomyoma research from bench to bedside

Uterine leiomyomata are benign tumors that develop during the reproductive years with a 70-80% prevalence by menopause.
View the Video
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Role of tubal surgery in the era of assisted reproductive technology: a committee opinion (2021)

This document reviews surgical options for reparative tubal surgery and the factors that must be considered when deciding between surgical repair and IVF.
View the Committee Opinion
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Postoperative adhesions in gynecologic surgery: a committee opinion (2019)

Postoperative adhesions are a natural consequence of surgical tissue trauma and healing and may result in infertility, pain, and bowel obstruction. View the Committee Opinion