Representative Survey on the Public Opinion and Attitudes Toward Uterus Transplantation in Hungary

1. Introduction

Uterus transplantation (UTx) is a novel method to treat a specific group of women with infertility—those with absolute uterine factor Infertility (AUFI). In this rare condition, the uterus is either anatomically or functionally impaired, leading to infertility [1]. An estimated 150,000 women are affected by AUFI in Europe; extrapolating these data to Hungary, a country with 9,765,000 citizens, AUFI affects approximately 1500–2000 patients. The only options for patients with AUFI seeking motherhood are adoption or surrogacy. In Hungary, adoption is a slow and very bureaucratic process, and all forms of surrogacy are illegal, falling under the legal umbrella of human trafficking. However, UTx may be a valid option [2]. Nearly a decade after the landmark clinical experiment by Brännströmm et al. in 2013, which resulted in the first live birth after live-donor UTx, this procedure became a clinically accepted concept [3]. By 2022, over 80 UTx procedures had been performed at almost 20 centers in Europe, North America, Latin America, and Asia, resulting in over 40 live births [4]. UTx has been incorporated into the national health system in Germany (2020), and it is in the process of implementation in Sweden and the Czech Republic [4,5]. To monitor global activities, the International Uterus Transplantation Society (ISUTx) launched an international quality registry on UTx in 2020 [6]. Despite the global spread of UTx, the procedure is not yet available in Hungary.

To date, only a few studies carried out in the USA, the UK, France, Sweden, and Japan have assessed public opinion on UTx [7,8,9,10,11,12]. These studies demonstrate divergent opinions toward UTx; most of the general population supports UTx as a treatment option for patients with AUFI patients, although concerns arise regarding the ethical aspects of the procedure, including medical and surgical complication risks, and some consider UTx a non-vital organ transplant that does not enhance quality of life [13,14]. However, physicians’ opinions seem to be more critical, and some surveys indicate that fewer than half of respondents believe UTx raises ethical concerns [7,15]. As UTx shifted from the early experimental phase to a well-developed technique and healthcare providers became more aware of the procedure, attitudes became more supportive in general, despite showing regional variation [13].

Our multidisciplinary team is dedicated to implementing UTx in Hungary soon and is willing to provide it to eligible patients with AUFI. In preparation for a clinical trial, we have carried out several animal and cadaver studies [16,17]. This study assessed public attitudes and opinions regarding UTx in Hungary. We hypothesized that in a country characterized by a declining population in which infertility is a major public concern, the public would have a positive, supportive opinion of a novel, innovative treatment option for this special group of women with infertility. We intend to use the results of this study to promote discussion on UTx among medical professionals, politicians, and women with infertility women so that it can be introduced as a treatment for AUFI in Hungary.

2. Materials and Methods

2.1. Survey Development

This prospective cross-sectional study was carried out by the Nezopont Institute, Budapest in collaboration with a focus group of members from the University of Pecs, Department of Obstetrics and Gynecology, Pecs, Hungary. Because survey participation was voluntary, anonymous, without financial compensation and no personal data was collected the University of Pecs Institutional Ethical Review Board considered this study exempt from review. All participants provided written informed consent, by clicking “agree terms and conditions”, before accessing an online survey comprising 24 questions, which was created using the Microsoft Forms platform (Microsoft Corporation, Redmond, Washington, USA); the questions were based on a previously published article that evaluated the perception of UTx among the general population in another country after consultation with medical professionals (BF, KSP, SK, GF). The survey contained a brief introduction to the center conducting the study, the purpose of the study, a brief professional explanation of UTx, eight demographic questions, and sixteen statements about infertility, transplantation, surrogacy, and UTx. Answers were provided as single-choice or Likert-scale responses (S1 and S2 Appendices).

2.2. Survey Distribution

The survey was distributed to 41,000 Hungarian men and women aged 18–70 via email from December 18, 2024, to January 5, 2025. A total of 3114 people clicked the questionnaire link, and 2896 completed the full questionnaire. Of the pool of respondents who participated, a final sample of 1500 people was selected for analysis to ensure that the sample reflected the demographic characteristics (age, gender, education level, family status, and region of inhabitance) of Hungary; thus, the survey was representative of the Hungarian public. The inclusion criteria were Hungarian citizenship, an age of 18–70 years, literacy in Hungarian, and access to the Internet. The University of Pecs Reginal Ethical Review Board considered this study exempt from review. A pilot investigation was performed among a group of medical and non-medical individuals, who reviewed the content and clarity of the survey before distribution.

2.3. Statistical Analysis

Descriptive statistics were compiled, and reference groups were established using the most logical comparison groups or the largest group for nominal predictors and the lower tail for ordinal (numerical) characteristics. Respondents who supported UTx were compared with those who opposed it using log binominal regression adjusted for age and income, and the relative risk (RR) and 95% confidence intervals (CIs) were calculated. All analyses were performed using SPSS software.

3. Results

3.1. Demographic Characteristics

The demographic characteristics of the participants are presented in Table 1. A total of 1500 participants who completed the survey were selected for analysis. The regional distribution of the participants was homogenous; 31% (465/1500) lived in Western Hungary (Vas, Gy-M-S, K-E, Zala, Somogy, Baranya, Tolna, Fejer, and Veszprem Counties), 30% (450/1500) lived in the capital area (Budapest and Pest County), and 39% (585/1500) lived in Eastern Hungary (B-K, B-A-Z, J-N-Sz, Cs-Cs, Heves, Bekes, Sz-Sz-B, H-B, and Nograd Counties). Two-thirds (66%, 990/1500) of the respondents were parents, 34% (336/990) had one child, 43% (426/990) had two children, 17% (168/990) had three children, and 6% (59/990) had four or more children.

A small percentage of the respondents (8%, 120/1500) considered themselves strictly religious (“true believers”), whereas a large percentage (45%, 675/1500) classified themselves as religious in their own way (not practicing religion a daily or weekly basis). Over one-third self-identified as non-religious (34%, 510/1500), and 12% (180/1500) did not answer to the question related to religion.

3.2. Infertility as a Major Concern in Hungary

We found that 12% of participants (180/1500) aged 18 and older had fertility problems or were infertile (to their knowledge), and 43% (645/1500) reported knowing someone who cannot have children naturally.

Regarding sociodemographic characteristics, those with diagnosed and reported fertility problems or infertility were predominately aged 30–39 (17%, 44/260) and women (16%, 123/768). Among respondents who were unable to have children naturally, 84% (152/181) know someone with a known fertility problem.

All of the questions related to having children, Hungarian medical practice, and organ transplantation had a level of agreement above 80%. The overwhelming majority of Hungarians aged 18 and older thought that support should be provided for those who cannot have children naturally (94%, 1410/1500) and that newer technologies and innovative methods should be used in Hungarian medical practice (93%, 1395/1500). Compared with all respondents (75–74%), the proportion of those who fully agreed with these statements was significantly higher among those who knew someone who could not have children naturally (98–97%, p < 0.05) (Figure 1).

3.3. Opinions and Attitudes Regarding Uterine Transplantation

Most participants (77%, 1155/1500) agreed that UTx should be performed (strongly agree 44%, 660/1500; agree 33%, 495/1500). According to the sociodemographic characteristics, the highest proportion of participants in favor of UTx was among those with higher education levels (83%). In the overall sample, most participants strongly agreed with UTx (44%, 660/1500); this proportion was significantly lower among 18–29-year-olds (35%, p < 0.05) (Figure 2).

Agreement that UTx should be performed was higher (84%, 152/181) among those personally affected by fertility problems, with 51% (92/181) strongly agreeing that UTx should be performed. Among respondents who knew someone who could not conceive naturally, 83% (534/648) agreed that UTx should be performed, with most of these respondents strongly agreeing (51%, 330/648). Among respondents who were organ donors or who had friends who were organ donors, 89% (150/168) agreed that UTx should be performed, with 56% (94/168) strongly agreeing. Acceptance of UTx (agree or strongly agree) was particularly high (91%, 206/226) among respondents who were aware that UTx operations have been successfully performed abroad, with 67% (151/226) strongly agreeing (Figure 3).

Over one-third of all respondents (42%, 630/1500) supported UTx using donations from both living and deceased. Respondents with the highest levels of agreement lived in the capital (52%, 140/270) and had higher levels of education (52%, 189/364). However, 17% of all respondents (255/1500) supported only deceased-donor (brain dead) UTx, except residents over the age of 60 years, who showed a support rate of 22% (81/368) (Figure 4).

Most participants supported both living- and deceased-donor UTx (55%, 825/1500), especially those who had heard about UTx procedures performed abroad (53%, 120/226), those who accept UTx in general (53%, 616/1163), and those who knew someone who with fertility problems (47%, 83/181).

Respondents who accepted UTx perceived the benefits of the procedure, as it provides hope for people with infertility (70%, 814/1163). A high proportion (65%, 756/1163) responded that it is favorable that this medical intervention can help people who have been longing to have children (Figure 5,6).

3.4. Figures and Tables

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4. Discussion

This study is the first to investigate public opinion toward UTx in Hungary. Our study comprised an online assessment of public opinion and was sociodemographically representative of the Hungarian general population; therefore, it is a reliable indicator of Hungarian public opinion on this subject.

One of the main findings was that around 10% of Hungarian adults reported having fertility problems or infertility, and over 40% knew someone with these problems. This aligns with the infertility rates of Western European countries, which range from 10 to 15% [18], as well as global infertility rates of 8–12% [19,20]. Compared with the overall sample, women and individuals aged 30–39 years were more likely to knowingly be affected by these problems themselves or know someone with them.

Because the population in Europe and developed countries is declining, infertility represents a major health challenge. A recent survey revealed that providing support and alternatives for infertile patients is suggested [21]. We found that among Hungarians aged 18 and older, 94–93% agreed that support should be provided to those who cannot have children naturally and that new technologies and innovative methods should be used, following global trends.

The main focus of this investigation was public attitudes toward UTx, which may be the only legal option for biological motherhood for patients with AUFI patients in Hungary and the EU, as all forms of surrogacy are banned by EU Commission directive E-001332/2024 [22]. Notably, only 60% of the respondents knew that surrogacy is not currently allowed in Hungary, even though the Hungarian Superior Court banned all forms of surrogacy in 2020, considering it a form of human trafficking [23].

Although public opinion toward UTx varies between countries, we believe that an introduction to the concept of UTx is needed. Our results demonstrated that nearly 80% of participants accepted UTx, mostly those with higher education levels, those who were aware of previous UTx abroad, those who were organ donors or knew someone who was, and those who were affected by infertility/fertility problems or knew someone who was. The favorable opinion toward UTx aligns with data from the UK demonstrating that 43% of respondents were willing to donate their uterus after death [8]. In the US, 74.4% of women were willing to donate their uterus [24]. Recently published data from Japan showed that 36.5% of women agreed that UTx should be performed, and 31.0% agreed that gestational surrogacy should be legal [11]. In Sweden, UTx was more acceptable than surrogacy (80% vs. 47%) [10]. These studies indicate that overall public opinion worldwide is positive toward UTx, aligning with our results in Hungary.

Although more than a decade has passed since the first baby was born from a transplanted uterus in Sweden, general awareness of UTx is low. In a UK study, 71% of the investigated cohort never heard of UTx, and our results showed that only 15% of respondents had heard of previous transplants abroad [8]. Because the proportion of UTx supporters is high, we believe that more information should be distributed about UTx through both social and printed media and on scientific platforms in the future.

We found that those who accept UTx see the benefits of this medical intervention, primarily the hope it can give to people with infertility who have been longing for a child. However, 4% of the respondents rejected UTx. This could be explained by the ethical concerns that arise from the procedure, including medical and surgical risk, and some regard UTx as a non-life-saving organ transplant that does not enhance quality of life [4]. Other explanations include religious beliefs and attitudes toward organ donation and transplantation, as Hungary is a mostly Christian country (62% of the population identifies as Catholic) [25].

5. Conclusions

In conclusion, UTx—a novel treatment method for a special subpopulation of women with infertility for whom UTx may be the only legal option for biological motherhood—is considered a favorable method in Hungary. However, to achieve wider knowledge about UTx, public awareness about UTx must be increased through the media, scientific publications, and open debates.