What if you were told, at the age of 15, that you wouldn’t be able to carry a pregnancy?
Malin Sternberg was and her story is riveting and emotional, and one of the reasons that researchers are working on refining the procedure of uterine transplant (UTx).
The first uterine transplant was actually performed for a transgender woman in 1930 who tragically died from complications (Ciclosporin, the drug that prevents the rejection of transplanted organs, was not available until 1980, almost 50 years later). During the 1960-1970’s, research on transplantation of the uterus was performed on animals as a treatment option for tubal factor infertility. It was ultimately abandoned after the birth of Louis Brown in 1978 since IVF now seemed a viable option.
After years of performing extensive animal research, Dr Mats Brännström in Sweden gained approval to perform his first UTx on September 20, 2012. In Dr. Brannstrom’s initial study he performed nine UTx procedures. Each of the recipients had previously underwent IVF treatments to cryopreserve embryos. All the uterine donors were live and were either related to, or known by, the recipient. The outcomes of these procedures resulted in hysterectomy in 2 cases (one due thrombosis of uterine vessels and the other due to uterine infection). The remaining seven recipients had confirmed spontaneous and regular menstruations 1-2 months after UTx. Twelve to fourteen months after the UTx, embryo transfer was performed. Two of the women became pregnant and the first world birth (baby boy Vincent) from a UTx was on September 4, 2014 to Malin Sternberg,the woman mentioned earlier who was 15 years old when she was told she had been born without a uterus and would never carry a child of her own.
Since the birth of Vincent there are now nine healthy babies born from uterine transplant, with number nine being noted as the first United States live birth on December 4, 2017 at Baylor University Medical Center at Dallas. Currently in the United States there are four registered studies recruiting for uterine transplantation: University of Pennsylvania, Baylor University Medical Center, University of Nebraska Medical Center and Cleveland Clinic in Florida.
Institutional support and a patient’s ability to afford the procedure is an anticipated hurdle for prospective infertility patients. It can be assumed that insurance coverage for UTx will vary in the U.S. from state to state and policy to policy and that the studies will need to demonstrate success and medical need in order to be considered for coverage.
Of course, before proceeding with any experimental procedure, the risks and benefits to the patient would need to be weighed and, in the case of uterine transplant we need to actually consider the risks to three people: the recipient of the uterus, the donor, and the intended baby. Should we, as medical professionals, suggest an arguably risky procedure when there are other proven, well-studied, safer alternatives available, such as utilizing a gestational carrier (GC). In some cases, where there may be legal or religious constraints, the answer might be yes.
For example, some faiths do not permit gestational surrogacy but will permit transplant. Also, gestational surrogacy is illegal in some parts of the world and even in some states. Proceeding with a GC cycle requires profound trust between the Intended Parents and the GC that she will follow pre-pregnancy guidelines and the resulting lack of control is difficult for many Intended Parents. The Intended Mother also has to accept the fact that she will not get to experience physically carrying a pregnancy. Even though a thorough medical history and physical examination are performed on the gestational carrier prior to attempting pregnancy, there are risks inherent to pregnancy that might not be avoidable, but can be detrimental to her health. UTx allows the intended parents to assume all risks involved. Once the procedure is perfected, another valid subset of patients who would benefit from UTx would be the transgender community.
Arguably, one of the most important questions to ask is if it’s ethical and reasonable to perform a complex transplant procedure, with all of its inherent risks, for a non-vital organ. Even among the REI community, opinions are mixed (ASRM’s only formal response, at this point is linked here). After Dr. Brännström’s interesting and engaging lecture at ASRM in 2014, some members still doubted the necessity of UTx in the U.S. citing the fact that there are few legislative barriers for gestational surrogacy. Ultimately, we need more high-quality research to help us better understand the balance of risks and benefits for this procedure. For women like Malin, though, this procedure gave her opportunity to carry a pregnancy, a life event that she thought she would never get to experience.