Times are changing in reproductive health. Now, post-hysterectomy women or women who are barren due to injury or illness may be able to have a baby by not only using someone else's frozen embryos but also a deceased donor's uterus.
While the United States transplants just about any organ, limb or tissue, a uterine transplant has never been attempted in this country — until now. Many physicians in obstetrics, gynecology and reproductive medicine are debating whether a uterus transplant would be ethical or even outweigh the risk when it's not a life threatening need.
Questions started being raised in January when a team at New York [City] Downtown Hospital announced they were beginning to screen women who were unable to have children for the first uterus transplant ever in the United States.
The March 20002 issue of the International Journal of Gynecology & Obstetrics reported that doctors from the King Fahad Hospital and Research Center in Jeddah, Saudi Arabia, performed a similar procedure in 2000. In that procedure, a healthy uterus of a 46-year-old woman with ovarian cysts was transplanted into a 26-year-old woman who had undergone a hysterectomy due to uncontrolled bleeding after her first child. Her body first rejected the strange new organ, but 10 days of intensive immunosuppressive therapy eliminated the reaction. Although the organ had to be removed after 99 days, it was considered a first step toward success. It has also been performed in small animals, but only rodents have been able to give birth from the donated uterus.
Dr. Earl Stubblefield, an OB/GYN with Jackson, Miss.-based Jackson Healthcare for Women, said without more research having been done or background knowledge of the procedure in question, he couldn't see the logic behind a uterus transplant.
"People having transplants usually have to take a lot of transplant medications to keep them from rejecting the organ," Stubblefield explained. "It's very likely that those medications may not be compatible with a safe pregnancy. Even if they were able to keep the uterus or fetus, if the objective is to have a safe pregnancy, then it would be unlikely to reach that objective. So, unless you satisfy the concerns about the use of anti-rejection medications, it doesn't seem logical to me to transplant the uterus."
The transplant protocol would require doctors to wait three months after the transplant is complete to ensure proper functioning in the recipient. If all goes well, in vitro fertilization would then be performed to attempt pregnancy. If pregnancy were achieved, the fetus would be delivered through a caesarean section. Doctors would remove the transplanted uterus after the birth or after two years if pregnancy attempts are not successful, to minimize more risks from antirejection drugs.
Dr. Robert Yelverton, CEO and medical director of Florida's Tampa Bay Women's Care, said he was aware of the transplant in Saudi Arabia and that the New York group was going to attempt it in the United States.
"I don't think anyone dealing with women's healthcare would object if they knew it would be a safe uterine transplant that could be retained for a period of time for insemination and the delivery of a healthy baby. But, there are too many unknowns here," Yelverton said. "Even though there have been animal experiments of uterine transplants, it was primarily to work out technique and not how well a pregnant animal would do or human would do in nine months of pregnancy.
"The outcry is that it's still unknown about what the level of rejection would be and the impact of the medications would be on the fetus. For a group to comment that they are ready to do that transplant and do all of these things without careful research when there's not a life threatening reason is raising a lot of questions, not so much about the transplant technique itself or insemination. We can do the technique, that's exciting. But, that can we carry them safely through nine months of pregnancy? We don't have that information. That's my opinion and the opinion of those objecting to the announcement by the group in New York.
"I think the media needs to understand that the consensus of the medical profession is that we don't have enough research. We feel it may unnecessarily jeopardize the life of the woman and the health of the fetus."
Even if the transplant and a subsequent birth are considered successful and all questions are positively addressed through research first just as is necessary with any new transplant procedure before becoming mainstream, the questions still exist: Who will donate the organs? Will they be harvested upon death as with hearts, lungs and kidneys? Will there, one day, be a uterine needs list as with other necessary organs? And, if so, will there be enough donors to go around?
In a recent six-month trial to determine willingness to donate organs, the New York Organ Donor Network found that only nine out of 150 families agreed to donate a relative's uterus. Some experts also have questioned whether a woman should have to consent to have her uterus donated after her death.
Lori Andrews, a bioethicist at Chicago-Kent College of Law, said, "This is not like a kidney transplant — it's not medically necessary to the woman's life. Without it, the woman can live a healthy life. She still has options. She can adopt. She can even still have her own biologic child with a surrogate."
The New York Downtown Hospital ethics board has approved plans for the procedure, but said it will look at it again once a patient is chosen from almost 50 women being screened. Prime candidates are women who were born without a uterus, those who have lost their uterus due to secondary obstetric complications, or those who have lost theirs due to benign causes like pelvic inflammatory disease or due to malignancies at an early age.
