First ever uterus transplant in the UK
A milestone in UK medicine was reached this week when doctors announced that they had successfully completed the country’s first uterus - or womb - transplant. The organ was donated to the recipient - who lacked her own uterus - by her sister, who had completed her own family. Ellie Patterson is a junior doctor currently working in Obstetrics and Gynaecology in Wellington, New Zealand. She developed a keen interest in the science of uterine transplants from the time that she was a UK medical student and has been following the story over a number of years. She took our own Chris Smith through what the procedure involves…
Ellie - Uterus transplantation is now a proven available treatment for absolute uterine factor infertility, which means that women either don't have a womb or they have a womb which is unable to support a pregnancy. So the vast majority of cases of uterus transplant that have happened, and there's about a hundred cases that have happened across the world, are for women that have been born without a uterus. So that's a congenital reason. The process itself involves IVF as well as the transplant procedure you need to transplant embryos into the recipient. It's a very high risk pregnancy, so there's a lot of monitoring involved following successful pregnancies and live births. If that does happen, patients will need to have the graft removed to avoid having immunosuppression for the rest of their lives.
Chris - And when they actually do the surgery - I'm just thinking of the internal anatomy of the female body, you've got the vagina, the cervix, and then the uterus sits on top - what bits do they take out of the donor and how do they install that into the recipient?
Ellie - You need to take a decent amount of length with the arteries and veins that are going to supply the graft once you've transplanted it in, you need to take supporting structures. So that's mainly the ligaments that are attached to the uterus to be able to fix the uterus in place. The top third of the vagina is taken with the graft and that will be attached to the existing two thirds of the vagina. That will be within the recipient as well to allow menstruation once the transplant has started to work. And also you need that passage away for the embryo transfer after the transplant has hopefully been successful.
Chris - And the recipient, they can't conceive naturally once they've got this in place?
Ellie - They can't conceive naturally because you don't have the connection between the ovary and the uterus. So the patients will need to undergo egg stimulation and IVF prior to the transplant. They'll then have the transplant and their embryos that have been created from IVF will be inserted by embryo transfer.
Chris - And when will the obstetricians say that it's safe to do that? How will they know that the uterus they've put in has been grafted safely and it's healthy and it's capable of supporting a pregnancy in its new home?
Ellie - So in terms of the rejection that is monitored with a variety of different blood tests and also with cervical biopsies. In terms of being able to judge whether the uterus itself is functional, that's partially judged with the return of menstruation, which hopefully will occur in the first few months after the transplant.
Chris - And are there any major risks if you have a baby like this that we have to watch out for or do we think to all intents and purposes, this uterus in its new home should work the right way and it should grow a baby to term that's healthy?
Ellie - In terms of foetal outcomes, it's just really too early to say. There's been about 40 babies that have been born, but seeing as the first birth was in 2014, it's really too early to be able to comment on whether there's any foetal abnormalities as a result of the uterine transplants.
Chris - The surgery in the UK was paid for by donations. It cost about 25,000 pounds were the estimates that I've read. Some people have argued that the woman in question didn't have to have this done. She had her own eggs and her partner was able to fertilise them, producing embryos. They could have asked her sister to be a surrogate, for example. Is this a sensible thing given the risks?
Ellie - Yeah, so this is a concern that some people have raised; this idea of having gestational parenthood as opposed to surrogacy. There are some concerns about whether this is putting too much emphasis on the "perfect" nuclear family and the way that that should be produced. But with surrogacy, there's a lot of ethical concerns that also come with that process. There's a lot of countries throughout the world where surrogacy is actually not legal. So I suppose families are much more limited if they don't have that as an available option to weigh up as well. I think it really should be done on a case by case basis and taking patients' wishes into account. Obviously there's a lot of large surgery involved, which comes with a lot of risk.