by Craig Klugman, Ph.D.
Almost like Aphrodite herself, surgeons at the Cleveland Clinic this week may have given fertility to a 26-year-old woman through a 9-hour uterus transplant operation. The transplanted uterus was from a deceased woman. This was the first such surgery in the United States, though it has been performed previously in Sweden and Turkey. Of the 9 women in Sweden who had the procedure, 4 have given birth.
The American patient had uterine factor infertility, which result from fibroids, scarification, genetics, or not having developed a uterus. For the surgeons and patients, this technique offers a way for the patient to potentially carry a child to term.
In the U.S., the Cleveland Clinic’s method involved the patient undergoing in vitro fertilization techniques to produce at least 10 frozen embryos. Then a donor was sought and her next of kin had to sign a special informed consent document for the procedure. The patient and her new uterus will be given a year to heal at which point an embryo will be defrosted and doctors will implant it. The embryos will be transferred one at a time. If one does implant, the resulting baby will be delivered by Caesarean section.
The benefit to this involved operation is clear, a woman is given the ability to gestate an embryo. She has a genetically-related child which she carried.
The risks are not slight. The potential mother will have to take immune suppressants—drugs that in the long term are known to include greater risk of infection, cancer, cardiovascular disease, and bone marrow suppression. During pregnancy, women on these suppressants may have greater risk of maternal diabetes, hypertension, anemia, cholestasis, pyelonephritis and pre-eclampsia (depending on the drug). In regards to risks to the fetus, not a great deal is known, but many suppressants cross the placenta and may be associated with myelsuppression, low birth weight, prematurity, jaundice, respiratory distress among other issues.
As with all transplant recipients, these patients have a risk of rejecting the uterus. Therefore, the protocol recommends monthly biopsies. In order to limit the lifetime risk of these drugs and of rejection, the protocol calls for the uterus to be removed after the patient has given birth to one or two children. Thus, the transplant is only viewed as temporary.
One can argue that there are alternatives to motherhood—surrogacy (where legal) and adoption. But as the popularity of IVF has shown with 174,962 procedures and 41,526 babies born in 2013 many people are compelled to have their own genetic children and carry them. This transplant is also not for cosmetic purposes (as a penis transplant would be) since a uterus is not visible.
The danger from surgery and use of the drugs (for a minimum of 2 years if she has 1 child; 3 years if she has 2) is not small. If the informed consent process is rigorous though, then the patient is exercising her autonomy by choosing these techniques. Whether pursuing this research is the best investment of resources is another question. Although the U.S. Supreme Court in Bragdon v. Abbot ruled that procreation is a major life activity, one can live physically healthy without giving birth (though mental and social health are another matter).
By removing the uterus after the desired child is born, the risks are minimized. But are the risks to the potential children minimized? Certainly, many would argue, being born is a benefit greater than the risk of not being born—though this logical fallacy is not helpful. But the exposure to immunosuppressant drugs needs to be studied more carefully to ensure that these children are not at undue risk and how choosing the least dangerous drugs can minimize those risks.
As the potential of this procedure grows and it becomes more common (assuming good outcomes in this trial), future debates will hinge on whether insurance will cover it, and whether there is a right to positive procreative liberty (a person being owed every opportunity to have a child).
In one version of the Aphrodite myth, the goddess arose from the sea on a giant shell after Uranus was castrated and his genitals tossed into the sea. A donated uterus gives a woman the potential for motherhood. But the images and promises should not overshadow the medical realities. This technology must move forward slowly as research first to protect the potential mother and her potential children.