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Uterus Transplants Raise Hope and Questions

The first uterus transplant in the United States was performed on February 24, raising hope that more women will be able to become pregnant and give birth but also raising questions about the risks and ethics of the procedure. “Safer, less costly, and more certain ways to have children already exist,” write Josephine Johnston, The Hastings Center’s director of research, and Eric Trump in Stat News. Johnston’s research focuses on ethical issues in reproduction and genetics.

What is it? A uterus transplant is an experimental procedure developed to enable women without a uterus, or whose uterus is malformed or badly damaged, to become pregnant. The operation involves transplanting a uterus from a living or deceased donor. A year after having the operation and taking anti-rejection drugs, a recipient can try to become pregnant using in vitro fertilization. Any resulting pregnancy will be deemed high risk and monitored very closely, with the birth by Caesarian section. Ultimately, another operation is required to remove the donated uterus. The first uterus transplants that resulted in live births were performed in Sweden. Nine women received the transplants from living donors. The New York Times reported that at least four of the recipients have given birth and that the babies were premature but healthy. With the first uterus transplant in the U.S., performed at the Cleveland Clinic, the uterus came from a deceased donor and went to an unidentified 26-year-old woman. [UPDATE: The donated uterus was removed in March because of a sudden complication.] The Times estimates that 50,000 women in the U.S. could be candidates for uterus transplants.

Why is it controversial? The controversy concerns the risks to the mothers and their fetuses and the high financial costs. “The risks include infection, rejection of the uterus, and miscarriage or stillbirth due to failure of the uterus,” write Johnston and Trump. In Sweden, where nine uterus transplants have already been done, the donated uterus was removed in two cases before pregnancy could be attempted because of infection or the development of serious blood clots.” These risks raise an ethical question: do they exceed the risks posed by the only other option available to women without a uterus who want biological children: surrogacy. “Surrogacy can be legally, ethically, and emotionally complex. But it is clearly safer for both mother and child than pregnancy following a uterine transplant,” write Johnston and Trump.

Another consideration is the cost, estimated at up to $300,000. “If a uterus transplant could save a woman’s life, or if it really were her only way to have a child, then the risk and the cost might be worth it,” they write. “But uterine transplantation is not done to save a life, and it is far riskier and costlier than gestational surrogacy, a fact that insurers will surely recognize should they be asked to cover the transplants.”

News in Context. More uterus transplants will be performed as part of the Cleveland Clinic’s clinical trial. The Cleveland Clinic’s institutional review board has approved 10 in all to determine whether the procedure is safe and effective. Looking beyond the clinical trial, Johnston sees problems integrating uterus transplants into medicine. She notes that in the U.S., IVF, surrogacy, and other assisted reproduction technologies are frequently excluded from health care coverage, leaving would-be parents to pay out of pocket. “This refusal to cover treatment for patients struggling with infertility is unjustified and leads to significant inequities in access to care.” she says. “It also introduces an incentive for patients paying out of pocket to seek to maximize their pregnancy chances at every turn, leading, for example, to high rates of multiple births following fertility treatment. The introduction of uterus transplants as a possible treatment for uterine factor infertility raises the question of whether this form of assisted reproduction would be covered by insurers and Medicaid–and if it is, why other safer, less costly interventions are not.”

Photo credit: Johan Wingborg/ AP

Published on: April 6, 2016
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