The possibility of uterine transplantation has been postulated for some time. In 2002 the first successful uterine transplant was achieved. It has taken more than 10 years since then for the first successful delivery after uterine transplantation.
Last month, Prof Brännström and colleagues reported the case of a successful delivery of a healthy male newborn at 31 weeks following uterine transplantation.
10 to 15% of all reproductive-age woman are affected by infertility. Uterine reasons are important in only a small proportion of these.
Anyone without a uterus, be it congenital, or acquired, or someone with significant intrauterine adhesions, may be candidates.
The only choices couples had previously were adoption or surrogacy. There are some major legal issues surrounding surrogacy and this is not available everywhere, therefore Uterine transplantation could well become a very important choice for some couples.
Obviously it will be extremely important to assess ovarian function before even considering a transplant (and a partners semen analysis might be an important consideration as well). Most Couples will probably require assisted reproduction following the transplant surgery.
The assisted part should probably be done before the procedure as there is no point in proceeding if one is unable to get to the stage of having viable embryos.
Choosing the donor is fairly important.
Family members would be preferable because there is less risk for rejection with human leukocyte antigen (HLA) sharing. Age is important as an older postmenopausal uterus may limit the success. In contrast with younger donors, the donor needs to remember that she then loses the ability to become pregnant. There is also the surgical risk which might require more intensive sugery, including adequate
, vessel excision , compared to a simple hysterectomy. A “brain-dead” donor, therefore, may be ideal providing damage to the uterus is not suspected in the incident that caused them to become brain dead.
Other issues like endometriosis, adhesions, tubal function etc all need to be carefully ascertained from the donor before surgery as these both influence the surgery required as well as the likelihood of success.
There is still much more research that is going to be required before this becomes mainstream.
Unlike lung, kidney, or heart transplantation. Uterine transplantation is not a life saving procedure. Whilst a patient’s life may feel incomplete, because they are unable to bear children, the procedure is not without risk, and there are some who would argue strongly against this.
However many people undergo high risk procedures to improve the quality of life. Others would argue that there is the option of surrogacy, which will allow parents their own genetic children, however there are arguments that this would not allow the emotional and psychological link that develops during pregnancy and childbirth. Surrogacy itself raises legal and its own ethical issues.
The procedure is not without risk. And there are ongoing risks in the need to take anti-rejection (immunosuppressive) drugs. In this instance so far, there was a need for assisted reproduction which in itself carries it’s own risks. Not to mention organ rejection and embryo rejection and also the teratogenic effects that might be associated with the use of Immunosuppressive therapy. Also toxic effects related to immunosuppressive therapy, such as renal toxicity and hypertensive complications.
There are also the normal risks associated with pregnancies, including miscarriages, intrauterine growth retardation, and preterm delivery. The pregnancy in the report by Prof Brännström and colleagues resulted in the birth of a healthy boy, but at 31 weeks and following a pregnancy affected by hypertensive complications.
A Step Forward
This is a major advance but should just be considered one more weapon in our armoury to combat infertility and there should and will be many “guidelines” developed over the next decade whilst this becomes more readily available and the techniques will no doubt improve over time.