For many women and their partners, the chance to conceive, carry and give birth to a biologically related child is a highly desirable opportunity. Many individuals in countries such as Australia have had access to support and resources to help them achieve their reproductive goals since the development of IVF in 1978.
Some women did not take advantage of this opportunity because they did not have a working uterus. This includes those who have had a hysterectomy for medical reasons, as well as those with a congenital disorder such as Mayer-Rokitansky-Küster-Hauser syndrome.
The only parenting options for these women so far have been through surrogacy or adoption. Access to both is often difficult.
Uterine transplant changes this situation. Uterine transplants are starting to be tested in Australia from next year. However, there are dangers and ethical issues that need to be resolved before it becomes a common clinical treatment.
A series of medical operations known as womb transplants involve the surgical removal of a donated uterus from a qualified donor and implanting it in a qualified recipient.
After the recipient's uterus begins to function normally, an IVF-created embryo is inserted into the woman's uterus to initiate menstruation.
The baby is born by cesarean section after successful implantation and good development. This is because of the high danger of a uterine transplant pregnancy and the possibility that the mother may not feel the contractions. Women born without a uterus will not be able to have a vaginal delivery.
To prevent the body from rejecting the donor organ, as in other transplants, the recipient of the uterus is given immunosuppressive drugs. These drugs are given in dosages considered safe for developing fetuses. Close observation is maintained throughout pregnancy to ensure the health of both mother and fetus.
Immunosuppression is continued until a maximum of two healthy children are born or for five years after transplant, whichever comes first.
After hysterectomy, the uterus is surgically removed and immunosuppression with its dangers and negative consequences ceases. Infection, decreased blood cell count, heart disease, and decreased bone marrow growth are risks associated with suppression of the immune system. These dangers get worse over time.
Uterine transplant is a “temporary” transplant; It is a short-term, non-life-saving procedure done only to facilitate reproduction. Because of these features, it is different from other transplants in terms of medicine and ethics.
In the 1970s, researchers began testing womb transplants on animals. The first human trials were conducted in Turkey in 2011 and in Saudi Arabia in 2000, but both were unsuccessful.
The world's first human trials were initiated in 14, after 2013 years of work, by Professor Mats Brannstrom and his group at Sahlgrenska University Hospital, Sweden. The first healthy child was born in 2014.
It is estimated that at least 80 surgeries have been performed to date and more than 40 healthy live babies have been born, and womb transplants are currently performed or planned in more than 25 countries. Although not every transplant is successful, it is reported that the rate of live birth from a normally functioning uterus is over 80% after transplant.
Two trials have been approved in Australia and are scheduled to begin in the next 12 to 18 months.
Until now, the vast majority of uterus transplants have been performed by self-sacrificing living donors, sometimes as a mother donates a uterus to her daughter or an aunt to her niece.
However, there have also been cases where wombs from deceased donors were used, resulting in at least four healthy live babies.
Most uteruses from deceased donors are procured for medical study through the usual family approval processes. However, they may be made available in the future through uterus-specific organ donor registration procedures.
Currently, only premenopausal women can donate their wombs, and living donors must have delivered a healthy baby to be eligible. But for cadaver donors this may not be necessary, potentially allowing younger donors and increasing the number of uteruses available for transplant.
Only one of the two approved Australian trials conducted by the Royal Hospital for Women, for which I have provided impartial ethical advice, will use both living and cadaveric donor wombs. The other will test only living donor transplantation.
Availability of money will determine how many people can participate in these womb transplant trials while the procedure is still being investigated.
What dangers can a living donation pose?
The main surgical hazards for patients are the risks associated with the long (average 5 hours) procedure itself, such as organ rejection, infection, blood clots or thrombosis, as well as blood clots (especially in the lung) and immunosuppression.
While difficult to manage, these risks have been reduced by careful observation, early treatment with blood-thinning medications, and encouraging patients to move around soon after surgery.
The physical risks for living donors come from the length of the surgery (6-11 hours) and the most common are infection and operative and post-operative problems that damage the urinary tract.
There are also additional risks associated with ethics and psychology. These include the potential for a potential donor to feel pressured to donate to a family member, and feelings of failure and embarrassment if the transplant fails or has negative consequences.
With the right advice and assistance, these hazards can be minimized. However, as with all forms of charitable organ donation, they cannot be eliminated entirely.
What will be the contribution of the deceased person?
Although cadaver donor transplants also carry dangers, normally the surgery takes 1-2 hours to complete than a living donor transplant, putting less strain on staff and resources.
Transplants from deceased donors may be less morally dubious. The deceased donor must have been brain dead and be a candidate for multiple organ donation; there is no pressure, no guilt, or the possibility of surgical danger on these people. Organs may be removed only if they give sufficient consent and in accordance with established protocols and procedures.
There is a shortage of organ donors everywhere, including in Australia. However, current donation records and authorization procedures, such as those run by DonateLife and NSW Organ and Tissue Donation Services, can help identify dead donors.
Why should we study both types of donations?
Comparison of live and cadaver donation results in similar recipients and situations is very important.
This will help shape future womb donation legislation and regulations and determine whether it can become common treatment practice.
There is growing evidence to suggest that cadaver donation can bring greater benefits to recipients. Longer veins and arteries can be removed from cadaver donor organs, improving blood flow to the uterus and possibly increasing the success of transplants and pregnancies.
Thus, although cadaveric donors are now less common, womb transplant research in Australia with both cadaveric and living donors is justified for both ethical and medical reasons.