Management of cytomegalovirus reactivation and immunosuppression following uterus transplantation.

Uterus transplantation (UTx) is an emerging therapeutic option for women with absolute uterine factor infertility, requiring intensive immunosuppression that increases susceptibility to opportunistic infections such as cytomegalovirus (CMV). Evidence guiding CMV management in UTx remains limited. The authors report a case of CMV reactivation in a 34-year-old woman with Mayer-Rokitansky-Küster-Hauser syndrome who underwent successful living-donor UTx. The patient received induction with methylprednisolone and basiliximab, followed by maintenance immunosuppression with tacrolimus, azathioprine, and prednisone. Antiviral prophylaxis with ganciclovir/valganciclovir was administered for three months. After prophylaxis discontinuation, routine surveillance detected CMV DNAemia approximately five months post-transplant, leading to treatment with valganciclovir and temporary postponement of embryo transfer. Following viral clearance, embryo transfer was successfully performed. During early pregnancy, low-level CMV DNAemia recurred. Given concerns about antiviral teratogenicity, management focused on the reduction of immunosuppression, including tacrolimus dose adjustment and discontinuation of azathioprine, with close monitoring via cervical biopsies. CMV DNAemia resolved spontaneously without antiviral therapy, and no rejection episodes or CMV disease occurred. This case highlights the complex balance between infection control and graft preservation in UTx recipients, particularly during pregnancy. It suggests that individualized reduction of immunosuppression may be a safe and effective strategy for managing CMV reactivation when antiviral therapy is contraindicated. Additionally, it supports the concept that the uterine graft may exhibit relatively low immunogenicity. Further studies are needed to define optimal immunosuppressive thresholds and standardized CMV management protocols in this unique transplant population.