Uterus Transplant Trial Ushers In The Future Of Fertility Amid Concerns Over Ethics, Cost

By Sarah Sarder
The Dallas Morning News

WWR Article Summary (tl;dr) A Uterus transplant allows infertile women — previously limited to adoption or surrogacy — to give birth.

The Dallas Morning News

Doctors at Baylor University Medical Center at Dallas have begun the second phase in the trial of a feat once considered impossible: transplanting a womb.

With transplant candidates chosen and funding secured, a massive team of doctors and surgeons is honing the complex procedure that can allow infertile women — previously limited to adoption or surrogacy — to give birth.

Their first success with the procedure came in 2017, when Baylor doctors delivered the nation’s first baby born from a transplanted uterus. Now 1 year old, that infant is on Time magazine’s January cover about the future of babies.

Dr. Giuliano Testa, chief of abdominal transplantation at Baylor and principal investigator for the trial, said the procedure is potentially more ethical than surrogacy, in which someone other than the mother assumes the risk of pregnancy.

“Some of us think this is the most natural option if you want really to have your own genetic self given to your kids,” he said.

Despite the procedure’s success and the surrounding publicity, the response hasn’t all been positive.

Dr. Liza Johannesson, medical director for the Baylor trial, was part of the team that delivered the world’s first baby from a transplanted uterus in 2014 in Sweden — something she said critics didn’t believe could be done. Once the Swedish team succeeded, she said, the criticism shifted to ethical concerns.

Louise P. King, director of reproductive bioethics at Harvard Medical School’s Center for Bioethics, said significant work remains to be done before professionals can arrive at any ethical judgment on uterus transplants, as just 13 babies have born worldwide from the procedure.

Chief among her concerns are the creation of standards to determine which medical facilities can perform the procedure and how the process would be financed.

A new possibility
One in 500 women experiences absolute uterine infertility, a requirement for getting the transplant.

The preparation for the procedure begins with in vitro fertilization, which manually combines a sperm and egg to create an embryo. With a frozen embryo at the ready, patients receive a uterus transplant.

Then, they wait.

Women with transplanted uteruses must stay on immunosuppressants to avoid organ rejection, but the medication leaves them more vulnerable to disease. After three to six months, when the woman is at the right level of immunosuppression, the embryo can be transferred into the uterus.

When Taylor Siler, 37, saw a post from Baylor seeking donors for uterus transplants, she was incredulous — as a nurse, she knew the procedure was unheard of. Siler, a mother of two young boys, had considered surrogacy in the past but decided it would be too disruptive to her family. With a simpler process on the table, she contacted Baylor for screening.

After a months-long process involving lab work, radiology tests, psychological evaluations and extensive paperwork, trial officials asked Siler to donate.

It wasn’t until December 2017, more than a year after she underwent a hysterectomy, that Siler met the recipient — and her newborn infant, the first born as part of the program.

“It was really awkward, like going on a first date,” Siler said. “But seeing her and holding him, it was only second to holding my own kids for the first time.”

The parents of that child spoke with The Dallas Morning News about their experience but wished to remain anonymous to protect the family’s privacy.

“I’m happy and lucky to be having sleepless nights with the baby,” the mother said, choking up. “He’s a miracle.”

‘It’s science fiction’
Siler’s husband, Clint Siler, said that he’s “immeasurably proud” of his wife.

“It was beyond selfless of her to go under the knife and to do something that wasn’t needed to save a life,” he said.

But Benjamin Berkman, a bioethicist at the National Institutes of Health, said the use of live donors brings up ethical concerns because the procedure isn’t life-saving, mandating a different kind of analysis than other transplants.

“This new technology is amazing, it’s science fiction in some ways,” Berkman said. “But we’re a long way off from it actually becoming common procedure.”

Johannesson, however, believes uterine transplants are becoming a more viable option with each day of the trial.

“In five, 10 years down the road we are ready to offer this for sure as a standard procedure,” she said.

The biggest issue, Johannesson said, lies in finding the funding for transplants. Baylor is footing the bill for everything but IVF for trial patients, and all of the core team members are working pro bono, so there is no overall cost estimate for the transplant and pregnancy.

Baylor Scott & White spokeswoman Julie Smith said the transplant costs about the same as a kidney transplant — around $200,000 — but that can vary, depending on the institution and patient. Because a uterus transplant is an elective procedure, insurance policies are unlikely to cover the cost.

Charles Burton, an Association for Medical Ethics board member, said the danger exists that the transplants could be performed excessively once they’re more commonplace.

“The ethical issues are pretty straightforward,” Burton said. “It’s the economic issues that will be the real challenge.”

Looking ahead
Doctors and researchers at Baylor began work on the first phase of the trial in 2016. To date, more than 1000 potential recipients and 400 potential donors have contacted Baylor, Smith said. Medical professionals chose 20 women, 10 in each phase of the trial, to receive transplants.

The uteruses are removed after women have one to two children in order to avoid keeping them on immunosuppressants any longer than necessary. Because the trial’s recipients have hormone-producing ovaries, transplanting and later removing a uterus has no major negative effects on their bodies, doctors say.

The success of uterine transplants has ignited hope that the procedure could help transgender women carry children as well, but ovaries are just one of the factors that complicate that possibility. Testa and Johannesson would not rule out the possibility of an equivalent procedure eventually being developed for trans women — after all, a few years ago many considered uterus transplants impossible.

The transplant was life-changing for the family of the first baby born in the trial, and his parents said they’re optimistic that it will offer hope to others.

The doctors said they want to share what they’ve learned with other medical institutions and make the procedure more common and accessible. In May, they will attempt to do so at a uterus transplant summit at Baylor.

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