For the first time in Spain, a woman has given birth to a baby after undergoing a uterus transplant. Previously, in October 2020, Tamara Franco had undergone uterine surgery at the Hospital Clínic de Barcelona in an operation that lasted 20 hours. The donor was her sister, since she suffers from Rokitansky syndrome, for which she was born without a uterus or fallopian tubes, but with ovaries. Women with this disorder (1 in 5,000 in the world) are unable to get pregnant.

It all started when, in 2015, the Hospital Clinic was authorized by the ethics committees of the Department of Health to carry out an experimental program for uterine transplantation in five cases of women with Rokitansky syndrome.

Embryo transfer

Two months after undergoing the transplant, Tamara had her first menstruation, according to the head of the Gynecology Service at the Hospital Clínic, Francisco Carmona. Eight months later, she underwent an embryo transfer.

The young woman was unable to get pregnant on the first attempt, as she suffered a miscarriage, and it was necessary to repeat the embryo transfer process. After becoming pregnant, Tamara suffered preeclampsia, a complication that involves an increase in blood pressure possibly derived from the medication she was taking to prevent rejection of the transplanted uterus.

It was at that moment that the doctors decided to schedule a conventional cesarean section at week 30 of gestation. The baby was born without problems weighing about one kilo and after being admitted to the neonatal ICU for two months, he was discharged from the hospital when he reached 3.2 kilos.

After delivery, the woman’s transplanted uterus was removed to avoid having to maintain immunosuppressants for life to avoid the usual rejection of transplanted organs.

The first in the world

On October 5, 2014, The Lancet already reported the first child born to a woman who had undergone a uterus transplant. It was a 35-year-old woman, who also suffered from Rokitansky syndrome.

Previously, this type of transplant had been tried in Saudi Arabia in 2000, and in Turkey in 2011. Neither was successful.

After these first two transplants, Matts Brännström and his team, from the Department of Obstetrics and Gynecology at the University of Gothenburg and several colleagues from other universities, obtained the required permission to perform this type of transplant in Sweden.

They were authorized to carry out nine transplants. In the spring of 2013 the last of them was completed. In five cases, the donors were the mothers of the recipients and in the rest relatives or friends.

Of the nine transplants performed, two failed due to thrombosis or infection in the transplanted women. The second phase of the project involved the implantation of embryos produced by in vitro fertilization in the remaining seven women.

In our Observatory we have already reported the first case in the world of a child born after a mother-daughter uterus transplant and the second one performed using a donor uterus. The pregnancy was achieved after the transfer of the first embryo and proceeded without problems until week 34, when the patient developed cholestasis (obstruction of bile flow outlet) and pruritus. For this reason, she underwent a cesarean section in the 35th week of pregnancy, giving birth to a healthy child, who weighed 2,335 grams.

Bioethical assessment

From a medical and social point of view, the fact that a woman who does not have a uterus can have a child deserves a positive judgment. However, this case also requires additional ethical reflection.

Apart from the risks-benefits that this intervention may have for the donor, the recipient woman and the child, the high cost of this type of intervention must also be considered. In addition to the economic implications of all the previous work that has had to be carried out in order to approach the surgical intervention that the transplant entails with the greatest possible safety.

The surgery can last between 10 and 13 hours, with the risks that this implies, especially with regard to the dissection of the pelvic veins, which is technically difficult and also the possibility of damaging their ureters.

Apart from the surgical difficulty of removing the uterus, there may also be complications derived from infections or haemorrhages, which in some cases have required repair surgery.

Normally all the donors are menopausal, but if any of them were not, it would also be necessary to consider that they lose the possibility of new pregnancies.

As for the recipient of the uterus, she must be informed of the risks of the intervention itself and that after the transplant she will have to undergo immunosuppressive therapy, both during pregnancy and after it. Failure to do so could facilitate rejection of the transplanted organ.

It will also be necessary to take into account the possible damages that she could suffer as a result of the pregnancy. In this sense, it is now known that the woman in question has suffered three episodes of rejection and one preeclampsia, as has already been mentioned when describing the clinical case.

Another medical problem, also unavoidable, is that the transplanted uterus must be removed after the birth of the child to prevent the transplanted woman from being subjected to immunosuppressive therapy, which would undoubtedly be an additional problem for her.

Apart from the foregoing, something that cannot be ignored is that in order to achieve the desired child, in vitro fertilization must be used, with the moral difficulty that this practice entails due to the large number of embryos that are lost (Medicina e Morale 4; 613-616, 2012).

In addition to these considerations, there is no doubt that the positive side of the uterus transplant must include the woman’s satisfied desire to have a child. However, a child is always a gift, not a right of the woman who wants it, which will undoubtedly have to be taken into consideration when ethically assessing the risk-benefit balance of this type of intervention.

Julio Tudela and Cristina Castillo

Bioethics Observatory – Institute of Life Sciences

Catholic University of Valencia

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