We must reflect on the uterus transplantation ethical problems that may accompany it, in relation to both the donor as well as the recipient and the child

The results of the first clinical trials on living donor uterus transplantation have been published, which included nine transplants, in which most of the donors were the mothers of the transplant recipients.

The results were evaluated six months post-transplant. It was found that the duration of the surgical procedures was from 10 to 13 hours for the harvesting of the uterus, and from 4 to 6 hours for its implantation. No immediate negative side effects were detected in any of the cases.

After 6 months, seven uteri remained viable, with regular menstruation. However, mild rejection symptoms occurred in four cases. The two cases in which the transplant failed were due to bilateral thrombosis of the uterine artery and persistent intrauterine infections (Fertil Sterility 2014; 101: 1228-1236).

As we can see, there is both light and dark in these results, which merit not only a clinical commentary, but an ethical one. To that end, we will follow on from the comments made by Farrell and Falcone of the Cleveland Clinic, Cleveland, Ohio (USA) (Fertil Sterility 2014; 101:1244-1245). These authors state that, as with any other type of transplant, the decision to perform it should be taken after weighing the risks and benefits. However, in the case of uterine transplantation, other aspects must also be considered.

They continue by saying that a technical evaluation of the surgical procedure itself is not enough, as performing these types of transplants raises many other topics for discussion. Any analysis should include not only the risks and benefits for the donor and recipient but also for any child that might be born.

In relation to the donor, they may be complications derived from infections or bleeding at the surgical site, which may even require surgical repair. Another objective difficulty is that the donor loses the ability to become pregnant again unless assisted reproduction techniques are used.

The uterus recipient must be informed of the risks of the surgery

The uterus recipient must be informed of the risks of the surgery, and in particular, that she must take immunosuppressive therapy after the transplant, which if ineffective, could result in rejection of the transplanted organ. It must also be taken into account that the possible risks for the recipient, should the pregnancy progress, and for the development of the future child are unknown. As has been previously mentioned though, there are well-documented objective risks in this first clinical trial, to which must be added to the possible problems inherent to the birth itself, which are unknown at present.

After the hypothetical birth of the child, the transplanted uterus must be removed

Another important aspect to take into consideration, and of which the recipient should be informed, is that after the hypothetical birth of the child, the transplanted uterus must be removed, so that the patient no longer has to continue immunosuppressive treatment, which carries obvious risks, as we know. It is evident that this latter surgical procedure has additional risks in itself. Therefore, as the authors of this article state, “any plan to remove the uterus as part of the transplantation protocol must be subject to careful ethical analysis”.

In relation to the donor

Also in relation to the donor, it must be taken into consideration, when making an ethical assessment of the case, that the surgery for harvesting the uterus may take between 10 and 13 hours, with the risks that this entails. Dissection of the pelvic veins is technically difficult, which adds objective risks to the surgical procedure in question, which could certainly lead to the donor suffering ureteric complications. Moreover, according to Farrell and Falcones, there are other ethical aspects to consider that are unrelated to the clinical trial mentioned here, such as the high cost of the surgery. Additionally, the donor’s post-operative recovery may also have a high economic cost, which should be taken into account in the future.

Finally, the authors state that uterus transplant remains in the experimental phase, which should be pointed out to both the donor and recipient, explaining the uncertainties of this type of surgery.

In conclusion, living donor uterus transplant may be a medically promising technique, but we must reflect on the possible ethical problems that may accompany it, in relation to both the donor as well as the recipient and the child.

Justo Aznar

Bioethics Observatory Institute of Life Sciences