TRANS.00037 Uterine Transplantation Form

This document addresses uterine transplantation, which has been proposed as a treatment of uterine factor infertility. This procedure involves the transplantation of a healthy donor uterus obtained from living or recently deceased donor into an individual with a nonfunctioning or absent uterus. The scope of this document is limited to the transplant procedure only, and does not address other related infertility treatment or obstetric services.

Note: Please see the following for additional information:

• CG-SURG-34 Diagnostic Hysteroscopy for Infertility

Position Statement

Investigational and Not Medically Necessary:

Uterine transplantation is considered investigational and not medically necessary for all uses, including but not limited to the treatment of uterine factor infertility due to nonfunctioning or absent uterus.