Last 5th October, the birth of the first child born to a woman who had received a uterus transplant was published in medical journal The Lancet (doi:10.1016/S0140-6736(14)61728-1).

The birth occurred on 4th September. From a medical point of view, this is clearly an important event, as it made it possible for a woman who had no uterus (as a result of Rokitansky syndrome, in which women are born without a genital tract, including the uterus) to have a child, which she could never have achieved naturally.

News of uterus transplants have been discussed previously in Provida Press (Nº 434, 439, 440), but at that time it was not yet known whether the recipients would be able to become pregnant, and above all give birth to a child, which of course has now been achieved.

In the aforementioned articles in Provida Press, we discussed how the first uterus transplant was performed in Saudi Arabia in 2000, and the second in Turkey in 2011, neither of which had a successful outcome.

After these first two transplants, Matts Brännström and his team from the Department of Obstetrics and Gynaecology at the University of Gothenburg, together with various colleagues from other universities, obtained the required permission to perform this type of transplant in Sweden. They were authorised to carry out nine transplants, the last of which was completed in Spring 2013. In five cases, the donors were the mothers of the recipients, and the rest were relatives or friends. Of the nine transplants performed, two failed because of thrombosis or infection in the recipient. The second phase of the project was to be the transfer of embryos produced by in-vitro fertilisation in the remaining seven women. Now the birth of the first child from one of these pregnancies has been achieved.

The patient was a 35-year-old woman with Rokitansky syndrome. The uterus was donated by a 65-year-old woman who had had two previous pregnancies. One year after the transplant, 11 embryos were produced by IVF using the patient’s eggs and sperm from her partner, one of which was transferred.  As in all transplant cases, the woman was placed on immunosuppressants, which she continued to take during the entire pregnancy. It is important to highlight that during the pregnancy , she suffered three episodes of rejection, which were resolved using corticosteroid treatment. She also suffered pre-eclampsia at 31 weeks and 5 days, for which an emergency caesarean section was performed. A premature boy was born, weighing 1775 grams. This is the case description so far.

Medical and social point of view

From a medical and social point of view, an initial evaluation of the case merits only a positive assessment. That a woman without a uterus can manage to have a child cannot be viewed any other way. However, we believe that this case also requires an additional ethical reflection.

The same year, Farrell and Falcohe from the Cleveland Clinic published an article in Fertility and Sterility (2014; 101: 1244-1245) in which they assessed the ethics of uterus transplant, mainly from a medical point of view, essentially referring to the risks-benefit for the donor, recipient and newborn.

As far as the donor is concerned, say the authors, there are serious considerations to take into account, namely the surgical difficulty of harvesting the uterus (a procedure that can last between 10 and 13 hours) with its inherent risks, especially as regards dissection of the pelvic veins, which is technically difficult and also the possibility of damaging the patient’s ureters. Moreover, there may also be complications derived from infections or haemorrhages, which in some cases have required reparatory surgery.

All donors are normally menopausal, but if they are not, we would also have to consider that they will lose the chance to have any further pregnancies.

As regards the uterus recipient, the patient should first be informed of the risks of the surgery itself, and in particular that she must take immunosuppressants after the transplant, both during the pregnancy and after, as not to do so could result in rejection of the transplanted organ.

Possible damage that she may suffer as a result of the pregnancy must also be taken into consideration. In this sense, it is now known that the woman in question suffered three episodes of rejection and one of pre-eclampsia, as we mentioned in the case report.

Another medical problem, also unavoidable, is that the transplanted uterus must be removed after the birth of the child, so that the patient no longer has to continue the aforementioned immunosuppressant treatment, which undoubtedly is an additional problem for her.

In relation to the child, only the fact that he was born prematurely is noteworthy. However, it is difficult to issue an ethical opinion about the well-being of the child born, without evaluating his medical progress in the longer term.

An ethical assessment

In any case, we believe it can be said that when the results of only one of the nine transplants are known, it is very premature to make an ethical assessment of this surgical procedure.

Besides the risks-benefits that this intervention may have for the donor, recipient and child, we must also consider the high cost of these types of procedures, in addition to the costs of all the previous work that had to be done in order to ensure the safest surgical approach to the transplant. Similarly, another ethical aspect to consider is that these types of surgeries are in a very experimental phase, so they could be included within so-called “compassionate therapy”, a practice which, as we know, can be applied without the required previous studies on safety and possible negative effects.

Finally, something that should not be ignored is that to obtain the desired child, IVF must be used, with the moral difficulties inherent to this practice, not least the many embryos lost (Medicina e Morale 4; 613-616, 2012).

Besides these considerations, it is clear that on the positive side of uterus transplant, we must include the satisfied desire of the recipient to have a child. Nevertheless, a child is always a gift, not a right of the woman may want it, which certainly must be taken into consideration when ethically assessing the risks-benefits of this type of intervention.

 

  JUSTOAZNARPR03

Justo Aznar

 Life Sicence Institute 

Universidad Católica de Valencia

Member of the Pontifical Academy for Life