*Purpose: Uterus transplantation has recently proven to be the first successful treatment for absolute uterine factor infertility with demonstration of live births. All reported episodes of rejection have been subclinical and only detected by cervical biopsies. We aim to show our clinical response to pathological finding in uterus transplantation and the relevance of treatment.

*Methods: Uterus transplantation was done in five women from both deceased and living donors. Ectocervical biopsies (ECB) collected at predetermined timepoints were used to diagnose acute rejection (ACR). ECB were scored as: negative, borderline, grade 1, grade 2, or grade 3 for ACR. Clinical responses were recorded as: no action, increase in existing immunotherapy or steroid recycling. Protocol immunotherapy included antithymocyte globulin induction and calcineurin inhibitor with either mycophenolate (prior to pregnancy) or azathioprine as maintenance.

*Results: In total, 86 ECB (the majority as per protocol biopsies) were taken to detect histopathological signs of rejection. Two episodes of ACR were diagnosed in two recipients: one as grade 1 and one as grade 2. Twenty-nine ECB were categorized as borderline ACR. Steroid recycling was used to treat the two episodes of ACR and two borderline cases with complete resolution. All other borderline ACR episodes (n=27) reversed without treatment. One of the treated women with borderline ACR delivered a healthy baby.

*Conclusions: Rejection in uterus transplantation if detected early appears to be easily treated. Borderline rejection appears to spontaneously resolve in most cases. More experience and a modification of the existing scoring system are needed for a proper clinical response to histological changes.

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