Some time ago, while performing a literature search on a now forgotten topic, I came across a title of a review article "Uterus Transplantation."1 Fascinated, I opened the link and began avidly reading. I had no idea that the procedure was in the realm of clinical possibility today! It does not feel that long ago when the world was stunned by the strides reproductive medicine made that resulted in the live birth of Louise Brown in the late 1970s, the first baby born as a result of in vitro fertilization. Attitudes toward transplantation began to shift from lifesaving to enhancing quality-of-life transplantations with the advent of the first hand transplantation and first larynx transplantation, both of which occurred in 1998.2

The journey Dr Brannstrom and his team took in the pursuit of the suggestion that he transplant a patient's mother's uterus in her can be read in the second reference. The interest in performing the operation began when a young woman undergoing a hysterectomy said that he could place her mother's uterus inside her so that she could have children. Approximately 3% to 5% of women globally who have absolute uterine factor infertility would benefit from the transplant.3 In addition, there is a subset of women for whom adoption or surrogacy is not a viable option because of personal, religious, or societal reasons. This unique operation combines assisted reproductive technology and transplant medicine to provide a "transient" transplant to improve the quality of life as opposed to the extension of life a typical transplant operation provides.4 After a year of follow-up, 7 women who received a uterus transplant have demonstrated long-term viability of the organ and continue to demonstrate menstruation and healthy uterine blood flow.5 Because the operation is still considered experimental, there are several ethical and legal issues that need to be considered.

What if a relative or close family friend wanted to donate her uterus to the woman she cares for? The donor's uterus should be proven to be suitable in that there has already been a successful pregnancy from that uterus. One problem is that a person in the close family network may feel extreme pressure to help her sister or friend. It also must be kept in mind that the surgery is very invasive, complicated, and carries many risks. Paying for an organ donation is illegal; however, there may be legal implications if there was a "gift" given to the donor in return for the uterus.6

A live, unrelated donor may, for altruistic reasons, donate her uterus to an unidentified woman who wishes to bear a child. Willingness to undergo the dangers of a nontherapeutic procedure for a stranger can call into question the motivations of the donor. Does there need to be an assessment of the donor's medical, psychological, and social status? Who will perform the assessment and who will approve or disapprove of the transplant? The donor will likely be able to be compensated for the surgery and costs of care, but according to the current regulations surrounding organ transplantation, the donor should not be able to make a profit from donating the uterus.6

A uterus obtained from a cadaver would obviously have greatly reduced risks; however, there are problems such as age, vasculature of the uterus, and the lack of a diagnostic workup to verify that there are no problems that may interfere with fertility.6 It has been noted that a donation from the deceased has previously been successful and may be morally preferable.7 This situation brings concerns of the definitions of death and what criteria for declaring a person brain-dead should be used.

And finally, what about the recipient of a donated uterus? She would need to consent to several procedures including the ovum recovery for in vitro fertilization and embryo transfer (to ensure fertility), removal of the nonfunctioning uterus, placement of the donor uterus, cesarean deliveries for birth of the neonate, and a hysterectomy to remove the donated uterus. The transplant is intended for a short period in that after the woman has 1 or 2 pregnancies, the uterus would be removed. The situation here begs the question of who legally owns the property of that uterus. It can be argued that the woman who first donated the organ does not have any legal rights, but when it is removed from the recipient, does it then become the property of that recipient? Can she then request that the uterus be used again in a friend, relative, or stranger? Could the donated uterus be considered as an implanted medical device, and if so, then would the surgeon or surgeon's hospital/university have control over the uterus? Would the transplant be covered by health insurance? Could single women and same-sex couples be allowed to have access to uterine transplantation?6

Lots of ethical and legal questions and issues to be considered as uterine transplantation becomes more a more common practice. Who knows what next is on the horizon!

-M. Terese Verklan, PhD, CCNS, RNC, FAAN

Professor and Neonatal Clinical Nurse Specialist

University of Texas Medical Branch

School of Nursing Galveston

Graduate School of Biological Sciences

Galveston, Texas

References