On a weekend in mid-September 2012, a team of gynaecologists and transplant specialists at Sahlgrenska University Hospital in Sweden, performed two uterus transplants with living donors. In both cases, a mother donated her womb to her daughter. Both recipients were young women in their early 30s, one had her uterus removed because of cancer and the other was born without one.

Uterus transplantation extends the field of organ transplantation. But perhaps more controversially, it pushes the boundaries of assisted reproduction; it raises questions about the lengths to which we will go to fulfil our desire to bear a child.

The two recipients must now wait for 12 months before doctors will implant embryos previously produced using their own eggs and their partners’ sperm.

A year earlier, surgeons at Akdeniz University Hospital in Turkey transplanted the uterus from a deceased donor into 21-year-old Derya Sert, who was born without a womb. Initially, doctors advised that Derya must wait six months before they would implant her embryo. But it’s now been more than 12 months since her transplant and there has been no news about whether attempts at embryo implantation have taken place.

Uncertain success

In each case, the surgeons involved claim they will only count the transplants a success when the mother delivers a normal healthy baby. But it is far from certain this will happen at all.

Although animal research has been underway for a number of years, so far only genetically identical mice have produced live births. And in non-human primates, the procedure itself has only recently been perfected and no pregnancies – let alone live births – have been reported.

In an interview following the surgeries, the lead surgeon for the Swedish transplant team, Mats Brännström, recounted the experience that prompted his decision to engage in uterus transplantation research.

In 1998, having removed the uterus of a young cervical cancer patient, he informed her that she was free of the cancer but she could never become a mother. The patient asked why he could not transplant her mother’s uterus into her.

In response, Brännström and his team began an animal-based uterus transplantation research project in 1999. Similar research has also proceeded in centres in the United States, with rumours that transplants there are not far behind.

Ethical debates

Although there’s been more than 13 years of this research in Europe and the United States, there’s been little debate about the ethics of human uterus transplants.

Like all transplants, significant risks are involved. These include the risk of death during surgery, and subsequent infection and rejection. There are also longer-term risks of taking anti-rejection drugs, including cancer. And the continuing possibility of organ rejection poses a threat to the woman as well as to her unborn child throughout her pregnancy.

These risks have to be weighed against the likely benefits.

Organ transplants were originally carried out as a heroic last-resort, where the potential benefit was life over death. Although the risks were great and success low, transplants were regarded as ethically justified because of their life-saving capacity.

Since then, advancements in both surgical technique and anti-rejection drugs have significantly improved survival rates. And life-saving transplants, such as those of the heart and the liver, are now routine.

And now, transplantation is moving into more controversial areas such as the hand, face and uterus. The risks with these transplants remain significant but the benefits are not as straightforward.

Controversial transplants

Hand and face transplants arguably take organ transplantation in a new direction. Clearly, improvements in physical functioning are an important goal. Hand and face transplants offer the chance of restoring grip and touch, and swallowing and speech.

But these are not the only considerations. Hand transplant recipients, for instance, speak of the desire to hug their loved ones, emphasising the emotional aspects of touch. Face transplant recipients express a strong desire for a socially acceptable face. Both want to be able to move around unnoticed in public.

In both cases, the individual desires of recipients go beyond mere improvements in physical function and appear central to their decision – but they are difficult to measure and weigh against the risks.

Uterus transplantation is even more complex. Women who lack a functioning uterus do not have health issues in terms of day-to-day physical function. And their lack of a uterus is not visible like missing upper limbs or facial deformities. Their key motivating factor is the desire to bear children of their own.

So there’s another side to the uterus transplant story.

Assisted reproduction

Although technically an organ transplant, the purpose of transplanting a uterus is to resolve an infertility issue. Potential recipients either lack a uterus (congenitally or through hysterectomy) or have a uterus that doesn’t function properly. Either way, these women are unable to carry a pregnancy to term. For them, the transplant is a form of assisted reproduction.

So, one view is that uterus transplantation offers one more technologically advanced way for women to legitimately exercise their right to reproductive freedom – just another tool in the kit.

But uterus transplantation raises an important question about how far we ought to go to enable people who can’t naturally do so to have a genetically-related child.

Many women believe that experiencing pregnancy is a central aspect of their identity as women and a key component of motherhood. This expectation clearly underpinned Dr Brännström’s belief that his patient could not be a mother without a uterus.

But critics argue that assumptions of genetic childbearing as a fundamental aspect of a woman’s life-plan potentially compromise (rather than enhance) women’s freedoms around reproduction.

The prospect of women subjecting themselves to ever more painful, debilitating, risky and uncertain procedures, such as uterus transplants, urges us to reconsider the basis of our drive to reproduce. Whether you consider it to be organ transplant or assisted reproduction, we need to ask whether uterus transplantation pushes the boundaries of medicine beyond women’s best interests.

This is the one part of our short series on motherhood. Click on the links below for other articles in the series:

Part two: He’s my mother: motherhood across gender boundaries

Part three: IVF treatment for older women: is age the greatest concern?

Part four: Hilarious or horrifying? Foetuses Photoshopped onto bellies

Part five: Origins of Love: the reality and ethics of reproductive tourism