August 17, 2022

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Give birth to your own child after putting on someone else’s uterus and then remove it

Give birth to your own child after putting on someone else’s uterus and then remove it



 

Give birth to your own child after putting on someone else’s uterus and then remove it

 

Transplanting a woman’s uterus into another woman’s body so that it has normal fertility -sounds like a sci-fi plot, is gradually being realized in reality.

 

On February 17, a French hospital announced that it had given birth to the first baby in France to be conceived and delivered from a transplanted womb. [1]

 

Source: franceinfo: screenshot

 

Two years ago, the patient, who was born with Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) , received a uterus transplant from his mother.

 

In July last year, when the French epidemic eased and the city lifted the lockdown, the hospital implemented medically assisted reproduction for her, and she successfully had a baby through her own body.

 

 

Get someone else’s womb and give birth to your own child

 

This is not the first case of a transplanted uterus giving birth in the world, the earlier story happened 7 years ago.

 

In October 2014, the Swedish Central Radio 4 announced that the University of Gothenburg, Sweden, successfully completed the delivery of a transplanted uterus, which attracted a burst of attention in the medical field.

 

Just a year ago, this 35-year-old woman with a congenital uterine loss received a uterus transplant from a 61-year-old woman.

 

Give birth to your own child after putting on someone else's uterus and then remove it

hysterectomy animation

Source: Cleveland Clinic YouTube account

 

On the 43rd day after transplantation, the recipient had the first menstrual period, and this period lasted for a year with a regular cycle of 26 to 36.

Then, the doctors made a bold attempt – they decided to carry out the first single embryo transfer for the 35-year-old woman to get her pregnant .

 

After embryo transfer, the patient received three immunosuppressive treatments, during which tacrolimus, azathioprine and corticosteroids were used, and the anti-rejection effect was good.

Throughout pregnancy, fetal growth parameters, as well as uterine arterial and umbilical cord blood flow, were at normal levels.


At 31+5 weeks of gestation, this patient was diagnosed with “preeclampsia”. The next day, the fetal cardiogram was abnormal and the patient underwent an emergency caesarean section. Fortunately, a healthy baby of 1775g was delivered successfully with an APGAR score of 9,9,10. [2]

This delivery has successfully demonstrated that this technology has considerable promise in the treatment of Absolute Uterine Factor Infertility (AUFI) .

However, we all know that even after uterine transplantation is proven effective, six years later, the technology is still unknown to most people. 

 



What’s “Hindering” a Uterine Transplant?


Before discussing uterine transplantation, let’s take a look at the history of this technology.

In the 1960s, some researchers performed a combined “uterus + ovary” transplant in 18 non-pregnant female dogs, and then through vaginal smears and other tests, it was confirmed that these two organs can still maintain their original functions after transplantation .

 

Since then, 3 female dogs have successfully conceived, and 2 have successfully delivered pups. [3]


Under the experiment of scientists, rats, rabbits, sheep, pigs, and non-human primates have all completed the pregnancy and childbirth of uterus transplantation. Since then, human uterine transplants have been put on the agenda.


In 2000, the first human uterus transplant was performed in Saudi Arabia. The recipient had a hysterectomy following a postpartum hemorrhage 6 years earlier, and the donor was a 46-year-old woman with Polycystic Ovarian Syndrome (PCOS).

 

During the procedure, the doctor places the new uterus in the place of the recipient’s original uterus, attaches to the vaginal fornix, and provides additional immobilization by shortening the uterosacral ligament.

The uterine artery and vein use the reverse segmental extension of the great saphenous vein, and then connect to the external arteries and veins, respectively.

Postoperatively, the patient received oral immunosuppressant for anti-rejection, and combined estrogen and progesterone therapy at the same time, and the treatment response was good.

 

Give birth to your own child after putting on someone else's uterus and then remove it
Postoperative Doppler ultrasound image of recipient uterine artery
Source: Reference 4

 

However, after surgery, doctors found that the donor’s left ureter was damaged. The doctor judged that because the ureter was very close to the uterine artery, the improper operation during the hysterectomy caused the damage to the ureter.

Misfortunes didn’t come singly, and 99 days after the transplant, the recipient also had problems.

An acute thrombosis developed in the blood vessels of the recipient’s new uterine body, which caused the embolism, necrosis of the entire uterus, and the doctor had to perform a hysterectomy for her. [4]

Obviously, at that time, whether it was for the donor or the recipient, and whether it was the separation/anastomosis operation, the postoperative anti-rejection technology itself, or the doctor’s operation level, it seemed that it was not mature enough.

In terms of “high difficulty, high risk, and low success rate”, all organ transplants are the same.

Only the operation of uterine transplantation itself includes a series of extremely complex and complex procedures, including preoperative and intraoperative immunosuppressive drugs for recipients, donor uterus acquisition, graft vascular anastomosis between donors and recipients, and in situ fixation of grafts. challenging process. [5]

First, the separation and extraction of the uterus is related to the normal life of the living donor after surgery and the functionality of the transplanted uterus. It requires extremely precise and cumbersome operations.

Detailed surgical procedures include separation of the uterus and its vascular pedicles (bilateral uterine arteries, veins, and some intrailiac vessels), partial teres, uterosacral ligaments, and extensive vesicoperitoneal retention, bilateral tubal resection, and pelvic side Wall separation (analysis of ureter and its connecting tissue) preservation and resection, etc. [5]

 

 

Give birth to your own child after putting on someone else's uterus and then remove it Give birth to your own child after putting on someone else's uterus and then remove itUterine Transplantation in MRKH Patients
Source: Reference 6

 

 

Secondly, according to relevant studies, the contractile activity of the transplanted uterus is related to the concentration of cryoprotectant.

Therefore, the lavage and preservation of the isolated uterus are important factors affecting the success of uterine transplantation.

At present, the most commonly used method for preserving the transplanted uterus in clinical practice is the method of cryopreservation plus preservation solution.

However, there is no consensus on the preservation time limit of the isolated uterus, the lavage height of the isolated uterus, and the most suitable preservation solution for the isolated uterus. Further research is needed to clarify, which increases the uncertainty and risk of transplant surgery. [5]

In addition, like other transplants, the operation process of uterine transplantation is generally more than 8 to 10 hours, and a longer period of general anesthesia also greatly increases the occurrence of organ damage, infection, bleeding and other risks. [5]

Therefore, every step in the technological development of uterine transplantation can be called “moving forward in the wind and rain”.

However, it does not seem credible to attribute the slow development of uterine transplantation to technical difficulties alone.

 

Because in the following 20 years of medical development, liver transplantation, kidney transplantation, lung transplantation, bone marrow transplantation, etc., are all highly technically difficult transplantation operations, but the volume of these operations has increased year by year, much larger than the uterus. Transplantation: Why is uterine transplantation developing slowly?

Among them, there is another reason to be concerned: other transplants are life-saving organ transplants, while uterus transplants serve the purpose of achieving pregnancy and pregnancy for the patient–ethically speaking, their starting points are different.

Today, Lilac Garden invited Associate Professor Ma Jun from the School of Public Health and Management of Chongqing Medical University . Hopefully, an ethical perspective can be provided.

 


1. Ethically, do we view uterus transplantation and other organ transplantation differently?


Like other organ transplants (heart, liver, kidney, lung, etc.), uterine transplantation is an organ transplantation, so they have some commonalities, such as some ethical issues they face, such as illegal organ trade, the rights and interests of both donors and recipients, etc. .

But at the same time, there are differences between them. Other organ transplants are more for the realization of the patient’s right to life and health, while uterus transplantation is more for the realization of the patient’s right to reproduction .

Therefore, in addition to the ethical issues of organ transplantation, there are also issues related to reproductive ethics— offspring rights, parent-child relationship, family ethics, social ecological balance, etc.

 


2. What groups are the existing uterine transplants mainly aimed at? What do you think about the needs of these groups for this surgery?

First of all, any surgery must have corresponding surgical indications, and allogeneic uterine transplantation is no exception.

As a promising technology for the treatment of AUFI, it carries the endless expectations of countless patients. For these patients, this is the realization of individual reproductive rights, which is one of the basic human rights and should be protected by morality and law , which is understandable in itself.

But at the same time, no right exists absolutely and in isolation .

When realizing reproductive rights, it is likely to conflict with other rights and interests , such as basic human rights (such as the right to life and health), other individual rights (such as donor rights, offspring rights, etc.), and even the rights of society as a whole.

 


3. You mentioned that “no rights exist absolutely and in isolation”. Compared with other organ transplants, does uterus transplantation face a more special ethical dilemma because it involves offspring?

Indeed, uterine transplantation faces dual ethical issues of organ transplantation ethics and reproductive ethics .


First of all, it will encounter the contradiction of the patient’s own rights and interests: carrying out a uterus transplant operation, the operation risk is high, and the patient himself will face the contradiction between the right to life and health and the right to reproduction ;

 

Secondly, it is the contradiction between the rights and interests of patients and the rights of donors : in the process of realizing their reproductive rights, patients actually damage the (living) donor’s right to life and health to some extent;

 

Furthermore, there will be a conflict between the rights of the patient and the rights of the offspring : will the use of anti-rejection drugs be detrimental to the physical health of the offspring, and will the patient’s psychological rejection of the transplanted uterus affect the acceptance of the offspring? sex;

 

Exacerbating the problem of illegal organ trade : Take the illegal trade of organs as an example, because the uterus is not a necessity for survival, will it bring individuals who have no reproductive needs to become uterus donors for some reason ? The transplant market may be larger, which may lead to some disguised exploitation, women’s rights, social and public security and other issues.

 

 

4. Some other transplant operations in China are relatively mature, but uterine transplants are rare. What do you think are holding back the development of this technology? In other words, what do you think are the reasons that hinder the promotion of this type of surgery?

At present, domestic uterine transplant surgery is indeed not mainstream, and technical difficulties are one of the reasons, but in this part, it is only a matter of time to overcome.

If you want to say what is “impeding” the popularization of this operation, on the one hand, uterine transplantation is still a “non-life-saving” organ transplantation. There are other ways to raise children and enjoy family happiness . In other words In other words, not all AFUI patients have an urgent need for uterine transplantation ;

On the other hand, as I said before, the multiple conflicts of rights and ethics faced in this process make medical staff take a cautious attitude when developing this technology.

 

5. What do you think should we pay attention to in the development of uterine transplantation?

The progress of medical science and technology is a double-edged sword, which will bring some problems while benefiting mankind .

In addition to technical difficulties, we need to predict the ethical issues that may be faced by uterine transplantation, prevent them from happening, and avoid the occurrence of these ethical issues. For example, we need to think about:

  • The status of the uterus, is the uterus a “thing”? Is it the same as the status of general organs?
  • Provide the rights of women in the womb, can the health and rights of the offspring be guaranteed?
  • Recipient identification and exclusion criteria? recipient’s rights?
  • How to maintain social justice and good order?


All of these should be paid attention to in the development of uterine transplantation, not just technology. 



 


 

Experts reviewed comments:

 

First, while the vast majority (75%) of uterine donors are from living donors, they are mainly relatives of recipients, especially mothers.

A quarter of uterine donors are still brain-dead. Because brain-dead patients who agree to donate often donate not only the uterus, but may also include other vital organs that sustain life, such as the heart and liver.

If the uterus is removed before these organs, it may affect the quality of the latter and, more importantly, post-transplant outcomes (heart, liver). [7]

 

Secondly, compared with other transplant organs, there are internationally recognized transplant priorities, but there is currently no suitable access and allocation criteria for uterine transplantation – even if uterus transplantation is technically possible to transplant uterus to post-transgender women, ethical Is it possible to open up uterus transplantation for genotype XY (male) (there is no such attempt currently)?

For another example, what age is suitable for entering the waiting sequence, and how many years are removed from the waiting sequence ? Or, at the age of 20, the uterus is dysplastic, and at the age of 35, the previous child died and the uterus was removed because of postpartum hemorrhage.

Who should have the priority to get the uterus ? These all need to be addressed in the future.

 

Finally, there is another special feature of uterine transplantation, that is , it is recommended to remove it again after a period of time after the transplantation is completed . So, this is the only transplant with a “shelf life”. [8]

 

Therefore, in the process of re-excision, the postoperative risks and the resulting ethical issues should also be fully informed before the initial transplantation.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Title image source: YouTube

References:
[1].https://www.francetvinfo.fr/sante/hopital/bebe-miracle-une-femme-met-au-monde-un-enfant-apres-une-greffe-duterus_4300895.html
[2] Brännström M, Johannesson L, Bokström H, Kvarnström N, Mölne J, Dahm-Kähler P, Enskog A, Milenkovic M, Ekberg J, Diaz-Garcia C, Gäbel M, Hanafy A, Hagberg H, Olausson M, Nilsson L. Livebirth after uterus transplantation. Lancet. 2015 Feb 14;385(9968):607-616.doi:10.1016/S0140-6736(14)61728-1.Epub 2014 Oct 6.PMID:25301505.
[3]. EraslanS, HamernikRJ, HardyJD.Replantation of uterus and ovaries in dogs,with successfulpregnancy[J].ArchSurg,1966,92(1):9-12. DOI: 10.1001/archsurg.1966.01320190011002.
[4]. Fageeh W, Raffa H, Jabbad H, Marzouki A. Transplantation of the human uterus. Int J Gynaecol Obstet. 2002 Mar;76(3):245-51. doi: 10.1016/s0020-7292(01)00597 -5. PMID: 11880127.
[5]. Wang Lijun, Ma Jun. Ethical dilemma and countermeasures faced by human uterine allotransplantation [J]. Medical Contention 2019(02)
[6].Luis Arturo Ruvalcaba Castellón, Martha Isolina García Amador, Roberto Enrique Díaz González, Montoya Sarmiento Jorge Eduardo, César Díaz-García, Niclas Kvarnström, Mats Bränström JBRA Assist Reprod. 2017 Apr-Jun; 21(2): 126– 134.doi: 10.5935/1518-0557.20170028 PMCID: PMC5473706
[7]. Heidi Mertes, Kristof Van Assche. UTx With Deceased Donors Also Places Risks and Burdens on Third Parties[J].Am J Bioeth,2018,18(7):22-24.
[8].Laura O’Donovan, Nicola Jane Williams, Stephen Wilkinson.Ethical and policy issues raised by uterus transplants[J].British Medical Bulletin,2019,131:19-28.

Give birth to your own child after putting on someone else’s uterus and then remove it

(source:internet, reference only)


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