By Rob Stein
Washington Post Staff Writer
Monday, January 15, 2007
First came kidney, liver and heart transplants. Then a few doctors started transplanting hands. French surgeons even did a face.
Now, doctors are planning the first womb transplant in the United States.
A team based in Manhattan has begun screening women left barren by cancer, injuries or other problems who want a chance to bear their own children.
"The desire to have a child is a tremendous driving force for many women," said Giuseppe Del Priore of the New York Downtown Hospital, who is leading the team. "We think we could help many women fulfill this very basic desire."
But the planned operation, which Del Priore and his colleagues could attempt later this year, is stirring objections among some transplant experts, fertility specialists and medical ethicists. They question whether the procedure has been tested sufficiently on animals and whether the benefit of being able to carry a pregnancy outweighs the risks for the woman and fetus.
"This raises a set of very difficult medical and ethical questions," said Thomas H. Murray, who heads the Hastings Center, a bioethics think tank in Garrison, N.Y. "I think it's very questionable. This would be very hard to justify."
The operation marks a confluence of two medical specialties -- transplant surgery and reproductive medicine -- that frequently spark controversy.
"It is the convergence of two fields that are already embedded in large ethical disputes," said Lori B. Andrews, a bioethicist at the Chicago-Kent College of Law. "This represents the worst of both worlds."
Several experts said the plans highlight the unique status that childbearing holds in the United States and elsewhere, and the lengths to which some women will go to experience it, even with the availability of such options as adoption and surrogacy.
"I'm not convinced that science and medicine and society as a whole should be putting so much emphasis on having this particular nine-month experience," said Adrienne Asch, who studies family life at Yeshiva University. "Why is that the sine qua non of being a parent? The real work of parenting is in the time after a child is born and is in someone's home."
But Del Priore and others defend the effort, saying the procedure will be attempted only after careful vetting by independent experts.
They note that thousands of women cannot bear children because they were born with a malfunctioning uterus or their wombs were damaged by cancer, accidents, pregnancy complications or other problems. Women who want the operation are being screened exhaustively to make sure they fully understand the risks and have seriously considered alternatives.
"I don't think it's really a doctor's role to tell a patient that their values are not important. It's up to us as doctors to advise our patients and safely escort them to the best life that they can have," Del Priore said. Many women who lack a functioning womb suffer terribly, he said.
"It can be just heartbreaking," said Del Priore, a gynecological oncologist. He described a pregnant woman who started hemorrhaging after a car accident. "She was a newlywed, about to deliver a baby. Suddenly her husband is dead, her baby is dead and her uterus is gone. It's terrible suffering. I think she deserves every possibility."
Some ethicists and other experts, while expressing reservations, agreed, as long as doctors are reasonably confident of success and prospective patients fully recognize the risks.
"I think patients deserve autonomy," said Alan DeCherney, a fertility expert speaking on behalf of the American Society for Reproductive Medicine. "As long as they know all the facts, it should be their choice."
After practicing in baboons and goats, doctors in Saudi Arabia reported in 2002 that they had performed the first human uterus transplant on a 26-year-old woman whose womb had been removed six years earlier because of hemorrhaging after the birth of her first child. The donor was a 46-year-old woman with an ovarian condition that required removal of her ovaries and uterus. Although blood clots forced surgeons to remove the organ after 99 days, doctors called the procedure a technical success.
Del Priore and his colleagues repeated the transplant in rats, pigs, rabbits and a rhesus monkey, in which they plan to try a pregnancy. They also showed that human wombs could be removed from deceased organ donors in the United States. The problem that occurred with the Saudi Arabian patient can be avoided, Del Priore's team thinks, by transplanting larger arteries with the uterus.
"I think we're ready," Del Priore said. "There is always more you could do. But knowing what my colleagues in the field have done and what we have done, we think it's absolutely doable."
Some noted that society assigns emotional value to many parts of the body, and transplanting a uterus may make many people uncomfortable.
"Organs can have tremendous symbolic meaning to people. It can vary from individual to individual and culture to culture," said Stuart J. Youngner, a bioethicist at Case Western Reserve University. "The uterus is one of those that has a lot of symbolic meaning."
But Del Priore and his colleagues said that at least some families of people who sign up as organ donors are willing to donate their uterus at death. And hundreds of women have inquired about undergoing the procedure, including between 40 and 50 who are currently being screened, Del Priore and his colleagues said.
After performing the complex surgery, doctors would wait probably about three months to make sure the organ is functioning and has been stabilized with anti-rejection drugs.
"We'd want to make sure it was ready to provide a safe environment for the child," said Jeanetta Stega, who is working with Del Priore.
An embryo created through in vitro fertilization would then be placed in the womb. If the pregnancy goes well, the baby would be delivered by Caesarean section to minimize risks from labor and to allow doctors to simultaneously remove the uterus, so the woman could discontinue the anti-rejection drugs.
"We are calling it a temporary transplant," Del Priore said. "This minimizes the time patients have to be on the medications and makes it a much more reasonable risk to take to have a baby."
If it works, in subsequent cases women with functioning ovaries who got a uterine transplant might eventually be able to get pregnant without IVF, Stega said.
But other experts called for further work on animals first, including showing that a primate could bear offspring with a transplanted uterus.
"I think we should do more animal research before we do it in a human," said Mats Braennstroem of Goeteborg University in Sweden, who has been trying the procedure on mice, pigs and sheep. "We have to be sure it's a safe procedure and that we know exactly how we would do it in humans. We haven't done all those experiments yet."
But even if animal work showed the procedure could succeed, some questioned whether it is ethical to subject a woman to the risks of major surgery -- and both mother and baby to powerful anti-rejection drugs -- for a condition that is not life-threatening.
"This is not like a kidney transplant -- it's not medically necessary to the woman's life," Andrews said. "Without it, the woman can live a healthy life. She still has options. She can adopt. She can even still have her own biologic child with a surrogate."
And while women who have undergone other types of transplants have given birth to healthy babies, it is risky to subject developing fetuses to anti-rejection drugs and to a possibly inhospitable uterus.
"This is a very complex surgery with a lot of risks, both known and unknown, to both the women and the child," said Tommaso Falcone, a fertility specialist studying ovarian tissue transplants at the Cleveland Clinic. "I'd want to see a good core of animal data before risking it."
"You might have a viable fetus, but as it outgrows the blood supply you might end up with a compromised fetus," said John Fung, a Cleveland Clinic transplant surgeon.
Del Priore acknowledged the possible risks, but he and others said women should have the choice.
"For many women, it is an essential part of their life to be able to carry their own child. They are willing to do many brave things to do it. Natural childbirth can be very risky, but women choose that in many parts of the world. I do not think this is in any sense reckless when you compare this to that," Del Priore said. "I wish everyone could be happy with an adoption. But there are many people who don't think that is the right choice for them."
Although it may seem like the stuff of science fiction, and many obstacles remain, some even wonder whether the procedure, if successful, could theoretically lead to men being able to bear children.
"If they perfect this procedure, trust me, somebody else will think it's a good idea," Murray said. "If gay marriage gets some people upset, this is going to tip a lot of people over the edge."