For the first time, in May a woman with a transplanted uterus gave birth via uterus transplant outside of a clinical trial. Spokesmen for the Hospital of the University of Alabama at Birmingham where the process has been carried out, have recently communicated the news.
Mallory, who was born with a congenital absence of a uterus, suffered from Mayer-Rokitansky-Küster-Hauser syndrome, a condition that occurs in 1 in 5,000 women.
Her eldest daughter was born through a surrogacy in which the surrogate mother was her sister.
Upon receiving a uterus transplant from a deceased donor, she and her family moved to Birmingham, as it was a necessary step to enter the UAB’s uterus transplant program, as she would need constant medical and clinical supervision. The process lasted about 18 months from the organ transplant to the implantation of the embryo and the birth of her child.
As occurs in patients undergoing organ transplants, in this case it was also necessary to subject the patient, from the moment it occurred and throughout the pregnancy, to immunosuppressive treatment to avoid rejection of the uterus, which would have prevented pregnancy.
It should be noted that to achieve motherhood after transplantation, in vitro fertilization and transfer of the embryo to the transplanted uterus must be used. The birth is by cesarean section and after that the organ is removed. This is because it is not a vital organ for the recipient and its maintenance with a view to a next pregnancy would require maintaining immunosuppressive treatments, with the risks that they entail for the patient.
After the birth of this baby gestated with a transplanted uterus, and since in this case it was not a clinical trial for the first time, the possibility of extending this technique to other women who are unable to gestate for different reasons is now open. They should undergo a physical and psychological evaluation to ensure that they understand the risks of the procedure and to verify that they have previously considered other alternatives for having offspring.
As we have already published on previous occasions in which we have discussed this topic, in October 2020 the first uterus transplant from a living donor was performed in Spain at the Clinic hospital in Barcelona.
The first uterus transplant was performed in Saudi Arabia in 2000 and the second was not performed until 2011, in this case in Turkey. The first transplant in Europe was carried out in Sweden in 2014 and to date 70 uterus transplants have been performed in the world and 14 children have been born.
From a medical point of view, uterus transplantation is a complex operation, so in this case 12 hours were required for the extraction of the uterus from the donor and 4 for its implantation in the patient. 20 people participated in the surgical team.
In the case at hand, there are several bioethical dilemmas that must be analyzed. Firstly, those related to the type of donor. In this case it was a deceased donor, but organ transplants have been performed from living donors, which means subjecting them to risks that must be carefully evaluated.
Secondly, an organ transplant is a very complex intervention with high risk and very expensive, which requires the implementation of lifelong immunosuppressive treatments, which are not exempt from associated risks.
Thirdly, the process requires resorting to in vitro fertilization techniques, which implies the supernumerary production of embryos, in addition to the possible risk of suffering health problems in children born through IVF, which would be greater than in those born after a natural pregnancy.
Fourthly, delivery must always be by cesarean section, after which the transplanted uterus will be removed to avoid complications associated with immunosuppressive treatments for the patient.
Fifthly, the dedication of a large amount of human and material resources in an intervention that is not vital for the patient seems not to respect the bioethical principles of solidarity and justice, since there are non-invasive alternatives such as adoption to fulfill the wish of maternity.
And finally, it must be clarified that maternity or paternity should not be considered rights whose safeguarding justifies any intervention. Not everything goes to become parents, because the child is a gift that is received, not a good that can be demanded at any price.
Given the limitations in transplant programs, on whose success the survival of many patients depends, it seems that dedicating these necessary resources to interventions such as the one in question may interfere with their effectiveness, in the management of available resources and, finally, in the attention of those who need it most.
Julio Tudela and Cristina Castillo
Bioethics Observatory – Institute of Life Sciences
Catholic University of Valencia