tag:theconversation.com,2011:/ca/topics/uterus-transplant-4061/articlesUterus transplant – The Conversation2022-09-15T20:03:29Ztag:theconversation.com,2011:article/1904432022-09-15T20:03:29Z2022-09-15T20:03:29ZWhat are uterus transplants? Who donates their uterus? And what are the risks?<figure><img src="https://images.theconversation.com/files/484725/original/file-20220914-8999-dftuge.jpg?ixlib=rb-1.1.0&rect=0%2C366%2C2069%2C1228&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/ZSS60LG9xw8">Krishh/Unsplash</a></span></figcaption></figure><p>The opportunity to conceive, carry and give birth to a biologically related child is a deep desire for many women and their partners. Since the introduction of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140213/">IVF in 1978</a>, many people in countries such as Australia have accessed support and resources to help realise their reproductive goals.</p>
<p>For some women, the lack of a functioning uterus has kept that opportunity out of reach. This includes those with a congenital condition such as <a href="https://www.rch.org.au/rch_gynaecology/young-women-and-parents-and-carers/RCH_MRKH_information/">Mayer-Rokitansky-Küster-Hauser</a> syndrome, and those who had a hysterectomy for medical reasons. </p>
<p>For these women, the only options for parenthood have been surrogacy or adoption. Access to both is often difficult.</p>
<p>Uterus transplants are changing that. From next year, uterus transplants are being trialled in Australia. However, there are risks involved and ethical concerns which must be addressed before it can become mainstream clinical treatment.</p>
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<h2>How does the process work?</h2>
<p>Uterus transplantation is a <a href="https://pubmed.ncbi.nlm.nih.gov/24582522/">set of medical procedures</a> in which a donated uterus is surgically removed from a suitable donor and transplanted into an eligible recipient. </p>
<p>Hormones are used to stimulate menstruation in the recipient, and once the uterus is functioning normally, an IVF-created embryo is transferred into the woman’s uterus. </p>
<p>Following successful implantation and healthy development, the baby is delivered via caesarean section. This is because a uterus transplant pregnancy is regarded as high risk, and the woman may not be able to feel contractions. Women with the congenital absence of a uterus will not be able to deliver vaginally.</p>
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<a href="https://theconversation.com/explainer-what-are-womb-transplants-and-who-could-they-help-50342">Explainer: what are womb transplants and who could they help?</a>
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<p>As with all transplants, the uterus recipient is prescribed immunosuppression medication to prevent rejection of the donor organ. These drugs are administered at levels deemed safe for the developing foetus. Close monitoring continues throughout the pregnancy to ensure the safety of both woman and foetus.</p>
<p>Immunosuppression continues until the delivery of up to two healthy babies or five years after the transplant, whichever is first. </p>
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<img alt="Pregnant woman holds her dress under her belly" src="https://images.theconversation.com/files/484759/original/file-20220915-13-aw32r5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484759/original/file-20220915-13-aw32r5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484759/original/file-20220915-13-aw32r5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484759/original/file-20220915-13-aw32r5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484759/original/file-20220915-13-aw32r5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484759/original/file-20220915-13-aw32r5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484759/original/file-20220915-13-aw32r5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Donor recipients take immunosuppressing medication at levels deemed safe during pregnancy.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/WI-x1wo_Jm4">Omurden Cengiz/Unsplash</a></span>
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<p>The uterus is then surgically removed via hysterectomy, enabling immunosuppression – which carries risks and side-effects – to be ceased. Risks from immunosuppression include infection, reduced blood cell count, heart disease and suppression of bone marrow growth. And these risks increase with time.</p>
<p>Uterus transplantation is an “ephemeral” transplant: a non-life-saving temporary transplant, aimed solely at enabling reproduction. These features make it medically and ethically distinct from other transplants.</p>
<h2>When did uterus transplants start?</h2>
<p>Scientists started developing uterus transplantation in animals in the 1970s. The first attempts in humans occurred in <a href="https://www.nytimes.com/2002/03/07/world/medical-first-a-transplant-of-a-uterus.html">2000 (Saudi Arabia)</a> and <a href="https://www.reuters.com/article/us-turkey-transplant-idUKBRE94D0P720130514">2011 (Turkey)</a>, both of which failed. </p>
<p>After 14 years of research, Professor Mats Brannstrom and his team at Sweden’s Sahlgrenska University Hospital started the world’s first human trials in 2013. In 2014, the <a href="https://www.bbc.com/news/health-29485996">first healthy baby was born</a>.</p>
<p>With more than 25 countries now performing or planning uterus transplants, it is estimated that <a href="https://pubmed.ncbi.nlm.nih.gov/34636769/">at least 80 procedures</a> have been performed, resulting in more than 40 healthy live births. While not all transplants are successful, the live birth rate from a uterus that is functioning successfully after transplantation is <a href="https://pubmed.ncbi.nlm.nih.gov/34636769/">estimated at over 80%</a>. </p>
<p>In Australia, <a href="https://www.abc.net.au/news/health/2022-09-09/uterus-transplant-australian-first-royal-hospital-for-women/101422018">two trials</a> have been approved and plan to start within the next 12-18 months.</p>
<h2>Who donates?</h2>
<p>Most uterus transplants so far have used altruistic living donors, typically a mother donating to her daughter or an aunt to her niece.</p>
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<img alt="Mother and daughter lay on grass, looking at each other" src="https://images.theconversation.com/files/484757/original/file-20220915-1807-mq1lax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484757/original/file-20220915-1807-mq1lax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484757/original/file-20220915-1807-mq1lax.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484757/original/file-20220915-1807-mq1lax.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484757/original/file-20220915-1807-mq1lax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484757/original/file-20220915-1807-mq1lax.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484757/original/file-20220915-1807-mq1lax.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Donors tend to be mothers or aunts.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/0eErMhzFgvE">Bence Halmosi/Unsplash</a></span>
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<p>But cases using uteruses from deceased donors have also been successful, with <a href="https://www.mdpi.com/2077-0383/11/15/4516/pdf">at least four healthy live births reported</a>. </p>
<p>Uteruses from deceased donors are mostly provided through standard family consent methods for medical research. But in future they could be provided through organ donor registration processes modified to include the uterus. </p>
<p>Currently, only pre-menopausal women can be uterus donors, and living donors need to have had a successful pregnancy to be eligible to donate. But this <a href="https://www.fertstert.org/article/S0015-0282(19)30486-8/fulltext">may not need</a> to be a requirement for deceased donors, potentially enabling younger donors and increasing the availability of uteruses for transplantation. </p>
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<p>Of the two approved Australian trials, only one (led by Royal Hospital for Women, for which I provide independent ethical advice) will conduct both living and deceased donor uterus transplantation. The other (through Royal Prince Alfred hospital) will trial only living donor transplantation.</p>
<p>Participation in these uterus transplant trials will remain limited while uterus transplantation is still in the research phase, and will depend on the availability of funding.</p>
<h2>What are the risks of living donation?</h2>
<p>For recipients, the main surgical risks are organ rejection, infection, and blood clots or thrombosis, as well as risks arising from the surgery duration (average 5 hours) such as blood clots (including in the lung) and from immunosuppression. </p>
<p>While challenging, <a href="https://www.sciencedirect.com/science/article/abs/pii/S1472648322004278">these risks have been minimised</a> through close monitoring and early intervention using blood thinners and encouraging recipients to move around soon after surgery.</p>
<p>For living donors, physical risks arise from surgery duration (6-11 hours) and operative and postoperative complications, the most common being urinary tract injury and infection.</p>
<p>There are also ethical and psychological risks. These include the possibility of a potential donor feeling pressured to donate to a family member, and experiencing guilt and failure if the transplant is not successful or results in adverse outcomes. </p>
<p>These risks may be reduced with appropriate counselling and support. But as with all altruistic organ donation, they cannot be entirely eliminated.</p>
<h2>What about deceased donation?</h2>
<p>Deceased donor transplantation also carries risks but involves less surgical time than living donor transplantation (typically 1-2 hours) and therefore less demand on medical resources and personnel.</p>
<p>Deceased donor transplantation may be less ethically fraught. There is no prospect of pressure, guilt or surgical risk to the deceased donor, who must have been declared brain dead and be suitable for multi-organ donation. Their organs may only be procured with proper consent, following the usual protocols and procedures.</p>
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Read more:
<a href="https://theconversation.com/would-you-donate-your-womb-when-you-die-48693">Would you donate your womb when you die?</a>
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<p>In Australia, as elsewhere, organ donors are in short supply. But deceased donors might be found via existing donation registries and consent processes, such as those managed by <a href="https://www.donatelife.gov.au/">DonateLife</a> and <a href="https://www.seslhd.health.nsw.gov.au/services-clinics/directory/nsw-organ-and-tissue-donation-service">NSW Organ and Tissue Donation Services</a>. </p>
<h2>Why investigate both types of donation?</h2>
<p>It’s important to be able to compare the outcomes of living and deceased donation in similar recipients and contexts. This will inform future guidelines and policies around uterus donation, and determine whether it can become mainstream clinical practice. </p>
<p>Emerging evidence suggests <a href="https://pubmed.ncbi.nlm.nih.gov/35956131/">deceased donation may yield better results for recipients</a>. Using deceased donor organs allows longer veins and arteries to be retrieved, enabling better blood flow for the uterus and potentially greater success in transplants and pregnancies.</p>
<p>So although there are currently fewer cases of deceased donors, there are sound medical and ethical reasons for Australian uterus transplant research with both deceased and living donors.</p><img src="https://counter.theconversation.com/content/190443/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mianna Lotz provides independent ethical advice to the uterus transplant trial at Royal Hospital for Women.</span></em></p>From next year, uterus transplants are being trialled in Australia. But it’s likely to be a while before they becomes mainstream clinical treatment.Mianna Lotz, Associate Professor in Philosophy & Chair of Faculty of Arts Human Research Ethics Committee, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/805812017-07-07T14:38:05Z2017-07-07T14:38:05ZMedical law expert on womb transplants, unisex pregnancy, and the ‘right to gestate’<figure><img src="https://images.theconversation.com/files/177328/original/file-20170707-3035-v0l2yx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Could a womb be transplanted into a transgender woman – or even <a href="http://tsq.dukejournals.org/content/1/1-2/61.full">cisgender</a> (non-transgender) men? Could pregnancy soon be unisex? These questions may sound as though they come from a sci-fi novel, but this week these speculative questions were seriously posed in mainstream media.</p>
<p>Vincent, the first child born following a uterine transplant, was born in Sweden in 2014. This marked the end of a long and hard-fought global race to perform the first “successful” human uterine transplant. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28357688">Swedish research trials</a> recently reported there have now been six healthy live births via womb transplants. These are the only successful human attempts so far, but globally teams are seeking to emulate the success of Sweden. Clinical trials of uterine transplantation are underway in <a href="http://jamanetwork.com/journals/jama/fullarticle/2606524">North America</a>, <a href="http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.13963/abstract">Europe</a> and <a href="http://annx.asianews.network/content/japanese-team-aims-perform-uterine-transplants-36967">Asia</a>.</p>
<p>The primary purpose of a human uterus transplant is to restore fertility in female patients. Prior to the success of these trials, for a woman lacking a functioning uterus the only way genetic motherhood could be achieved is through surrogacy. And, as a path to parenthood, surrogacy is far from unproblematic. It can be an emotionally draining method of founding a family and in the UK the practice is <a href="http://www.jordanpublishing.co.uk/practice-areas/family/news_and_comment/the-regulation-of-surrogacy-in-the-united-kingdom-the-case-for-reform#.WVzYDITyuUk">shrouded in legal uncertainty</a>. </p>
<p>Furthermore, <a href="http://jme.bmj.com/content/medethics/20/2/87.full.pdf">research demonstrates</a> that many women attach a great importance to the experience of gestation and pregnancy. Womb transplantation allows women suffering from <a href="https://www.ncbi.nlm.nih.gov/pubmed/17592442">infertility due to womb abnormalities</a> the unique experience of gestation, pregnancy and childbirth. But the technology also raises broader societal concerns as to whether publicly funded healthcare systems such as the UK’s National Health Service (NHS) <a href="http://jme.bmj.com/content/42/9/559">should fund such procedures</a>. Just as the state helps fund IVF for women who cannot conceive, <a href="http://jme.bmj.com/content/early/2016/03/03/medethics-2015-103231">I have argued</a> that there are strong grounds to allow for public funding for those who cannot gestate.</p>
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<img alt="" src="https://images.theconversation.com/files/177338/original/file-20170707-30715-1hdq5rz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/177338/original/file-20170707-30715-1hdq5rz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/177338/original/file-20170707-30715-1hdq5rz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/177338/original/file-20170707-30715-1hdq5rz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/177338/original/file-20170707-30715-1hdq5rz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/177338/original/file-20170707-30715-1hdq5rz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/177338/original/file-20170707-30715-1hdq5rz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Are womb transplants comparable to IVF?</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>But these developments also raise further questions. Unlike the transplantation of other vast organs, womb transplantation is not intended to save life, but to create life. If women can receive womb transplantation, some have queried whether the procedure may also work in trans women and, even more controversially, in men. Mats Brannstrom, who led the Swedish trial, <a href="https://www.scientificamerican.com/article/how-a-transgender-woman-could-get-pregnant/">has said</a> his inbox is now inundated: “I get e-mails from all over the world on this, sometimes from gay males with one partner that would like to carry a child”. </p>
<p>While in theory a womb transplant in trans women and men may be possible, in practice there are anatomical barriers that would have to be overcome due to differing shape of the pelvis, which in trans women is much narrower than those in cis women. But there is no reason to think such barrier might not be overcome.</p>
<p>In the UK, the Gender Recognition Act 2004 gives trans women who have gender reassigned the same rights as their female counterparts. So if womb transplantation becomes clinical treatment in the UK for women who are unable to gestate, could a trans woman claim, under this legislation, that she too has a right to a womb transplant?</p>
<p>While some have <a href="http://jamanetwork.com/journals/jama/article-abstract/407931">advocated</a> the “reproductive needs” of trans women, who may have strong desires to experience gestational motherhood, it has also provoked opposition. Julie Bindel <a href="https://www.thetimes.co.uk/article/transgender-women-have-a-right-to-be-pregnant-l0ctnpnvp">reportedly stated</a>: “This is not about transgender rights — it’s about a twisted notion as to what constitutes a ‘real woman’.” A <a href="https://academic.oup.com/jlb/article/3/3/636/2327861/Uterus-transplantation-does-procreative-liberty">debate is now needed</a> on whether it can be claimed that there is a right to gestate under the umbrella of procreative liberty or the right to a private family life. And if such a right to gestate does exist, does it applies only to those born female, or trans women and men also?</p>
<h2>A right to gestate</h2>
<p>In light of womb transplant technology we need to address whether or not there is a right to gestate, not whether or not the NHS should fund it – the question that has so far dominated media coverage. Finite public resources should not be invoked as a smokescreen to mask prejudices towards gender reassigned individuals who parliament has given clear rights to. If it is decided that women should be allowed womb transplants on the NHS, it follows given the legislation enacted by parliament that trans women have the same rights as their female counterparts.</p>
<p>In terms of the overblown hype over cisgender men becoming pregnant, even if womb transplantation in a male body becomes scientifically feasible, it would only be possible for men to carry a pregnancy if an IVF embryo was implanted into the womb. In the UK, assisting a male to become pregnant does not fall within the specified activities for which a licence can be granted to a fertility clinic when “bringing about the creation of embryos in vitro” under the <a href="http://www.legislation.gov.uk/ukpga/2008/22/contents">Human Fertilisation and Embryology Act 2008</a>. Therefore, implantation of an IVF embryo in order to assist a man to experience pregnancy, in the absence of a licence, would be liable to imprisonment or a fine upon conviction.</p>
<p>Almost 40 years ago, the birth of Louise Brown, the world’s first “test-tube baby”, prompted ethical and legal discussions and debates. As womb transplants move from science fiction to science fact, it is clear that reproductive science continues to propel us into uncharted territories and tests the very essence of legal and ethical principles, such as the right to procreative liberty and the right to private and family life. Does this encompass a right to gestate? It is clear that not all would interpret such a right, if there is one, as encompassing unisex gestation.</p><img src="https://counter.theconversation.com/content/80581/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amel Alghrani does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As womb transplants move from science fiction to science fact, we need to consider some ethical dilemmas.Amel Alghrani, Senior Lecturer in Medical Law, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/516822015-12-04T12:00:43Z2015-12-04T12:00:43ZShould the NHS pay for womb transplants?<figure><img src="https://images.theconversation.com/files/104134/original/image-20151202-22442-cswvbo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The first <a href="https://theconversation.com/explainer-what-are-womb-transplants-and-who-could-they-help-50342">womb transplants</a> are due to take place in 2016. The experimental programme could allow 10 women with damaged or missing uteruses to give birth. If successful, the procedure is likely to be made available to more women who suffer from this particular type of infertility. But should such operations be made available freely on the NHS?</p>
<p>There are a number of arguments that people who feel uneasy about this prospect might make. One seemingly obvious objection that can be applied to publicly funding any fertility treatments is that they don’t save lives. But this argument simply doesn’t work. Some of the most important things the NHS does are quality-of-life interventions such as cataract operations, hip replacements and general pain relief. So the fact that fertility treatments are designed to improve rather than extend lives doesn’t make them different from widely accepted NHS procedures and isn’t a reason not to fund.</p>
<p>Another argument is that the NHS shouldn’t spend money on treating infertility because it isn’t a disease. This view is out of line with <a href="http://www.who.int/reproductivehealth/publications/infertility/art_terminology2.pdf">most official classification systems</a> – but some people remain sceptical. One reason for this is that infertility only harms people who want children. People sometimes think of alleviating infertility as being more a way of satisfying a desire for a <a href="http://www.theguardian.com/commentisfree/2015/sep/30/womb-transplants-medical-necessity-lifestyle-choice">certain lifestyle</a> than of treating a disease.</p>
<p>But while infertility is only directly harmful to those people who want children, that doesn’t mean that it can’t be a disease. Whether something is a disease is partly a matter of whether the person’s body is functioning as it normally would at any given stage of their life. So we expect a 25-year-old woman’s body to be capable of conception and pregnancy – if it is not, this is a pathological state, regardless of whether she wants children. Unwanted infertility can also have very <a href="http://www.health.harvard.edu/newsletter_article/The-psychological-impact-of-infertility-and-its-treatment">serious psychological side-effects</a> such as anxiety, depression and stress.</p>
<h2>Overpopulation</h2>
<p>Another approach is to argue infertility treatment shouldn’t be provided because of overpopulation. World population grew from <a href="http://www.scientificamerican.com/article/population-growth-climate-change/">1.6 to 6.1 billion</a> during the 20th century and, as well as pressures on food and water supplies, increasing global population makes it ever <a href="http://www.scientificamerican.com/article/population-growth-climate-change/">harder to tackle climate change</a>. Therefore (so the argument goes) it would be incoherent for governments to expend resources tackling climate change while at the same time spending public money on what is, in effect, creating extra people.</p>
<p>But restricting infertility services is unlikely to be a fair or effective means of achieving environmental goals. Treating infertile couples makes a comparatively small contribution to population size. In the UK in 2012, just <a href="http://www.hfea.gov.uk/docs/HFEA_Fertility_Trends_and_Figures_2013.pdf">2% of births resulted from IVF</a> and the figure for womb transplants would only ever be a tiny fraction of this.</p>
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<img alt="" src="https://images.theconversation.com/files/104135/original/image-20151202-22439-12pga3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/104135/original/image-20151202-22439-12pga3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/104135/original/image-20151202-22439-12pga3b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/104135/original/image-20151202-22439-12pga3b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/104135/original/image-20151202-22439-12pga3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/104135/original/image-20151202-22439-12pga3b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/104135/original/image-20151202-22439-12pga3b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Is giving birth really a ‘lifestyle choice’?</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>Then there are questions of fairness. People who are biologically infertile are suffering from a medical condition that our health system has the technical ability to treat. Given this, denying them such treatment on environmental grounds seems ethically problematic. It would arbitrarily single out people with a particular disability (infertility) and require them to bear costs others don’t face. They would then either have to fund treatment themselves or, if they can’t afford it, be deprived of the opportunity to be a parent. Whereas if everyone paid evenly spread environmental taxes instead, no single person would need to bear such a high cost.</p>
<h2>Adoption and surrogacy</h2>
<p>Another suggestion is that, just as paying for everyone to have gold fillings rather than cheaper alternatives would be a waste of NHS resources, womb transplants are a wasteful solution to infertility when adoption and surrogacy arrangements are possible alternatives. But are these really adequate alternatives? Certainly not for those women who attach great value to the experience and process of pregnancy and childbirth.</p>
<p>In any case, adoption and surrogacy can be problematic. Potential adopters must often be willing and able to parent older children, missing out on the early months and years of development and precluding the chance to have their own “genetic child”. Surrogacy arrangements, meanwhile, are not legally enforceable in the UK – the surrogate mother can choose <a href="http://www.hfea.gov.uk/1424.html">to keep the baby</a> even if they are not genetically related. The ban on payments also makes it harder to find willing surrogates.</p>
<p>As with any medical treatment, womb transplants must first be shown to be cost-effective and safe. But if this can be done, there is no good reason to rule out NHS funding.</p><img src="https://counter.theconversation.com/content/51682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Wilkinson receives funding from the Wellcome Trust.</span></em></p><p class="fine-print"><em><span>Nicola J. Williams does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Fertility treatments might be designed to improve rather than save lives but that doesn’t mean they shouldn’t be publicly funded.Stephen Wilkinson, Professor of Bioethics, Lancaster UniversityNicola J. Williams, Post-Doctoral Researcher in Applied Ethics, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/486932015-12-03T15:17:16Z2015-12-03T15:17:16ZWould you donate your womb when you die?<figure><img src="https://images.theconversation.com/files/104138/original/image-20151202-22461-1yvp3cx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The year 2018 could well see the <a href="http://www.theguardian.com/lifeandstyle/2015/sep/29/10-women-receive-go-ahead-for-first-ever-womb-transplants-in-uk">UK’s first babies</a> born to women who have received <a href="https://theconversation.com/explainer-what-are-womb-transplants-and-who-could-they-help-50342">womb transplants</a> because their own uteruses didn’t work properly or were missing. While such transplants have <a href="http://www.theguardian.com/society/2014/jan/13/womb-transplants-success-swedish-project">successfully taken place elsewhere</a> in the world, and have <a href="http://www.theguardian.com/science/2014/oct/04/woman-gives-birth-womb-transplant-medical-first">resulted in the birth</a> of apparently healthy children, the UK births will differ in one important – and ethically interesting – respect.</p>
<p>Previous transplanted wombs have been donated by living women, and often to individuals to whom they are related. In the UK, they will be donated post-mortem. This means that no operations will be needed to remove the wombs of any living women thus avoiding the risks that attend such procedures. However, it is debatable if this is the <a href="http://www.bionews.org.uk/page_567572.asp">morally preferable approach</a>.</p>
<p>The main issue is consent. Will women be happy for their wombs to be taken and used for childbirth by someone else after they die? It might be logical to think that if a woman was willing to donate her vital organs, she would also be willing to donate her womb. But this might not necessarily be the case. Donating organs might save a life. Yet while the desire to become pregnant and carry a child <a href="http://www.theguardian.com/lifeandstyle/2015/sep/30/meet-sophie-lewis-the-30-year-old-hoping-to-have-a-womb-transplant">is deeply felt</a>, womb transplantation is not a life-saving procedure. Will all women be happy to donate their wombs for what some might consider <a href="http://www.theguardian.com/commentisfree/2015/sep/30/womb-transplants-medical-necessity-lifestyle-choice">a “lifestyle choice”</a>?</p>
<h2>Organ donor pool</h2>
<p>In cases of live donation, the issue of consent is complicated but there is no question that it is given. This consent is called into question in the case of post-mortem donation. It appears the ten wombs intended for transplant will be taken from women who have signed the <a href="https://www.organdonation.nhs.uk/register-to-donate/">UK’s Organ Donor Register</a> (ODR). However, no information about womb transplant is provided to those who sign the ODR. While this is not surprising – it is a very new procedure – it is not clear how individual women might feel about their wombs being made available for transplant. </p>
<p>The ODR does provide registrants with some degree of control over the specific organs they wish to donate. And if womb transplants become more common, we would expect them to be added to the list of potential organs. But for the purposes of these ten experimental procedures, it would seem that the wombs of all currently registered women will be considered for donation alongside their other organs, if the worst were to happen.</p>
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<img alt="" src="https://images.theconversation.com/files/104137/original/image-20151202-22476-1p4pcrv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/104137/original/image-20151202-22476-1p4pcrv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/104137/original/image-20151202-22476-1p4pcrv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/104137/original/image-20151202-22476-1p4pcrv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/104137/original/image-20151202-22476-1p4pcrv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/104137/original/image-20151202-22476-1p4pcrv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/104137/original/image-20151202-22476-1p4pcrv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Tick box exercise.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/magnus_d/4047845656">Magnus D/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>The NHS Blood and Transfusion service has confirmed it <a href="http://www.bbc.co.uk/news/health-34401940">will be working with the womb transplant team</a> and, no doubt, with others to consider how best to approach this issue. At present, the suggestion is that the transfusion service will seek consent from the families of those who are candidates for donation.</p>
<p>But Wales has <a href="http://www.bbc.co.uk/news/uk-wales-34964382">just become</a> the first part of the UK and the latest country to introduce a system of presumed consent where people have to opt out of becoming an organ donor rather than opt in. It’s reasonable to ask whether this will also apply to womb donation and, if so, whether this is legitimate? </p>
<h2>Impact on other donations</h2>
<p>As someone who does not have a womb I am not sure if these questions are ones that I should seek to answer, at least not in the first instance. But how we respond to them will likely inform our subsequent accommodation of <a href="https://en.wikipedia.org/wiki/Face_transplant">face and</a> <a href="https://en.wikipedia.org/wiki/Hand_transplantation">hand transplants</a> if and when these procedures become more common occurrences.</p>
<p>Even if most women feel no differently about their wombs than they do about any of their other transplantable organs there is, as yet, no evidence for this. Furthermore, regardless of what the majority think it is almost certain that some women will not wish to donate their wombs whilst being happy to donate other organs.</p>
<p>If we want these individuals to remain on the ODR – and thereby continue to be among the pool of potential life-saving organ donors –- we should give serious consideration to including “womb” (and “face” and “hands”) on the list of organs people can choose not to offer.</p>
<p><em>Now read this: <a href="https://theconversation.com/explainer-what-are-womb-transplants-and-who-could-they-help-50342">what are womb transplants and who could they help?</a></em></p><img src="https://counter.theconversation.com/content/48693/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nathan Emmerich does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The advent of womb transplants raises serious issues of consent for organ donors.Nathan Emmerich, Visting Research Fellow, Queen's University BelfastLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/503422015-12-03T14:18:48Z2015-12-03T14:18:48ZExplainer: what are womb transplants and who could they help?<figure><img src="https://images.theconversation.com/files/104132/original/image-20151202-22473-e8bs61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>In October 2014, a Swedish woman <a href="http://www.bbc.co.uk/news/health-29485996">became the first</a> person born without a womb to give birth. This was a major milestone for the 1.5 million women worldwide <a href="http://www.ncbi.nlm.nih.gov/pubmed/26536423">thought to be infertile</a> because they have abnormal or damaged uteruses – or lack one entirely. Often this is caused by a genetic condition or cancer treatment, which can sometimes include surgically removing the womb. </p>
<p>Previously, the only motherhood possibilities for women facing “absolute uterine factor infertility” (AUFI) were adoption or the use of a surrogate carrier. But both these options may be unavailable to some women for religious, ethical or legal reasons, and neither allow them to undergo a pregnancy and give birth to their own genetic offspring.</p>
<p>But work by our team in Gothenburg and others has created a new option that for the first time could allow these women to experience genetic, gestational and legal motherhood. We’ve already helped four patients to give birth to healthy babies, while another has an ongoing pregnancy.</p>
<h2>How do womb transplants work?</h2>
<p>Before any transplant could take place, we needed to know that the couples trying to conceive were fertile. This involved creating and preserving at least ten embryos per couple in the lab using in vitro fertilisation, just as would happen if a woman with a healthy womb wanted to undergo the IVF process. </p>
<p>We then needed donor wombs. <a href="http://www.ncbi.nlm.nih.gov/pubmed/25301505">In our work</a>, the donors were the patients’ mothers (five cases), close relatives (three cases) or, in one case, a family friend, all of whom were between 37 and 62 years of age. In each instance, the entire uterus including its arteries and veins was removed in a complicated procedure that took over ten hours by expert gynaecological surgeons, vascular surgeons and urologists.</p>
<p>Next, the recipients underwent a transplantation procedure that lasted four to five hours and included the creation of vascular and vaginal connections as well as fixation of the womb. Our donors and recipients then spent around a week in hospital recovering. But the recipients also needed to take drugs to suppress their immune systems so that they didn’t reject the new wombs. The dose of drugs was reduced after several months if no problems occurred, but extra medication was needed if the body did try to reject the uterus.</p>
<p>After six months, seven of our nine patients still had transplanted wombs in good condition and these women experienced regular menstrual periods from one to two months after transplantation. Sadly, the other two wombs had to be surgically removed because of complications.</p>
<p>One year after transplantation, we were able to start transferring the embryos to the wombs. Two patients got pregnant at their first embryo attempt, the first of which led to a birth by cesarean section several weeks early after the monther experienced the pregnancy condition preeclampsia. The baby had normal weight for the gestation period (1.8 kg) and is today a healthy one-year-old boy.</p>
<p>After successfully giving birth, the mothers should be able to become pregnant again after another IVF cycle. But the wombs will eventually be removed so that they can stop taking the immunosuppression drugs. </p>
<h2>What are the downsides?</h2>
<p>Womb transplantation does carry surgical risks for the donor and recipient because of the long, complicated nature of the procedures, which are also expensive. But the risk could be minimised using robotic assisted laparoscopic (keyhole) surgery. The need for immunosuppression can also have adverse effects on the mother and foetus because it reduces the ability of the immune system to ward off infections, although this process is constantly being refined and developed.</p>
<p>The risk of rejection means the patients need to be carefully monitored through repeated cervical biopsies. And we need to take repeated culture samples from the patient’s vagina to detect any infections in the early stage and provide prompt antibiotic treatment.</p>
<p>Because of the small number of successful operations that have taken place so far, all in one centre, we only have limited information about the risks and possibilities of womb transplant. We will have a better estimate of the true results of the process when it is introduced in more locations and the collective results are published. </p>
<p>One thing that may make the procedure more widely available is the use of wombs taken from people when they die rather than living donors. However, we don’t yet know if this is possible.</p><img src="https://counter.theconversation.com/content/50342/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Uterus transplants could make giving birth a possibility for thousands of infertile women.Henrik Hagberg, Research chair in fetal medicine, King's College LondonMats Brännström, Professor, Department of Obstetrics and Gynecology, University of GothenburgLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/38642012-10-14T19:20:21Z2012-10-14T19:20:21ZA womb of her own: risking uterus transplant for pregnancy<figure><img src="https://images.theconversation.com/files/16462/original/c65mz4pv-1350013808.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many women believe that experiencing pregnancy is a key component of motherhood.</span> <span class="attribution"><span class="source">Dhini van Heeren</span></span></figcaption></figure><p>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.</p>
<p>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.</p>
<p>The two recipients must now wait for 12 months before doctors will implant embryos previously produced using their own eggs and their partners’ sperm. </p>
<p>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.</p>
<h2>Uncertain success</h2>
<p>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. </p>
<p>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. </p>
<p>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. </p>
<p>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. </p>
<p>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.</p>
<h2>Ethical debates</h2>
<p>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. </p>
<p>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. </p>
<p>These risks have to be weighed against the likely benefits.</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<h2>Controversial transplants</h2>
<p>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. </p>
<p>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. </p>
<p>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.</p>
<p>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.</p>
<p>So there’s another side to the uterus transplant story.</p>
<h2>Assisted reproduction</h2>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<p>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.</p>
<p><em>This is the one part of our short series on motherhood. Click on the links below for other articles in the series:</em></p>
<p><strong>Part two:</strong> <a href="https://theconversation.com/hes-my-mother-motherhood-across-gender-boundaries-9623">He’s my mother: motherhood across gender boundaries</a></p>
<p><strong>Part three:</strong> <a href="https://theconversation.com/ivf-treatment-for-older-women-is-age-the-greatest-concern-4141">IVF treatment for older women: is age the greatest concern?</a></p>
<p><strong>Part four:</strong> <a href="https://theconversation.com/hilarious-or-horrifying-foetuses-photoshopped-onto-bellies-9600">Hilarious or horrifying? Foetuses Photoshopped onto bellies</a></p>
<p><strong>Part five:</strong> <a href="https://theconversation.com/origins-of-love-the-reality-and-ethics-of-reproductive-tourism-9815">Origins of Love: the reality and ethics of reproductive tourism</a></p><img src="https://counter.theconversation.com/content/3864/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ruby Catsanos does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.</span></em></p>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…Ruby Catsanos, Doctoral student in Bioethics, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.