Uterus transplantation

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The uterine transplant is the surgical procedure whereby a healthy uterus is transplanted into an organism whose uterus is absent or diseased. As part of the normal mammalian sexual reproduction process, a diseased or absent uterus does not allow for normal embryonic implantation to occur, effectively rendering a female infertile. This phenomenon is known as uterine factor infertility (UFI). The uterine transplant is currently being proposed as a potential treatment to this form of infertility. The world's first successful uterine transplant was conducted by a team of doctors from Akdeniz University Hospital in southern Turkey on the 9th of August 2011 [1][2] [3][4][5][6][7][8].

History

In 1896, Knauer published the first study of ovarian autotransplantation documenting normal function (in a rabbit) and that lead to the investigation of uterine transplantation in 1918.[9][10] Erslan, Hamernik and Hardy, in 1964 and 1966, were the first to perform an animal (dog) autotransplantation of the uterus and subsequently deliver a pregnancy from that uterus [11]. In 2011 Edwin Ramirez M.D, et al.demonstrated that a pregnancy can be carried in a sheep transplanted uterus under the influence of immunosuppressive therapy.[12] These experiments initiated in 2001 as a Ramirez family project at University of Texas, Odessa and ended in Bogota, Colombia at the La Salle University.[citation needed]

In humans: In 1931, Lili Elbe died from organ rejection three months after receiving one of the world's earliest uterine transplants.[13] With the availability of in vitro fertilization in 1978, uterine transplantation research was deferred (Confino et al. 1986). In Saudi Arabia in 2000, a uterine transplant was performed by Dr. Wafa Fagee from a 46 year old hysterectomy patient into a 26 year old recipient[14] whose own uterus had hemorrhaged after childbirth. The transplanted uterus functioned for 99 days, however it ultimately needed to be removed after its failure due to blood clotting. Within the medical community there is some debate as to whether or not the transplant can truly be considered successful.[15] Post-operatively, the patient had two spontaneous menstrual cycles, followed by amenorrhoea; exploratory laparotomy confirmed uterine necrosis. The procedure has raised some moral and ethical concerns.

Turkey

A 21-years-old Turkish woman named Derya Sert, who was born without a uterus, has become the first woman in the world to receive a womb from a deceased donor. The operation, performed on August 9, 2011 by Dr. Ömer Özkan and his team at Akdeniz University Hospital in Antalya,Turkish Riviera has been a success. Ms. Sert has had 6 menstrual periods post-surgery and it is said that the uterus is fully functioning. However, the Turkish medical team who performed the delicate surgery is still cautious about declaring the operation a complete success. "The surgery was a success. But we will be successful when she has her baby", Ozkan said. "For now, we are happy that the tissue is living".[16][17]

Procedure

Uterus transplantation starts with uterus retrieval surgery on the donor. Working techniques for this exist for animals, including primates.[18] It may need to be stored for e.g. transportation to the location of the donor. Studies on cold-ischemia/reperfusion indicate an ischemic tolerance of >24 h.[18] The following insertion procedure, with vascular anastomosis, has not been fully developed in animal models, indicated by frequent thrombosis formation.[18]

The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation

In their paper entitled "The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation" published in Transplant International[19], Ariel Lefkowitz, Marcel Edwards, and Jacques Balayla from McGill University developed a set of criteria deemed to be required for the ethical execution of the uterine transplant in humans.

Assuming that a human uterine transplant (UTx) is shown to lead to a viable gestation and is proven to be medically safe for the mother and fetus, a woman with uterine factor infertility (UFI) may be considered as a candidate for a uterine transplant if and only if all of the following criteria, as they pertain to three distinct groups, are met:


1. The recipient

a. is a genetic female of reproductive age with no medical contraindications to transplantation,
b. has documented congenital or acquired UFI which has failed all current gold standard and conservative therapy,
c. (c1) has a personal or legal contraindication to surrogacy and adoption measures, or (c2) seeks the UTx solely as a measure to experience gestation, with an understanding of the limitations provided by the UTx in this respect,
d. has not had her decision to undergo UTx deemed as irrational expert psychological evaluation,
e. does not exhibit frank unsuitability for motherhood, and
f. is responsible enough to consent, informed enough to make a responsible decision, and not under coercion.


2. The donor

g. is a female of reproductive age with no medical contraindications to donation,
h. (h1) has repeatedly attested to her conclusion of parity, or (h2) has signed an advanced directive for post-mortem organ donation,
i. has no history of uterine damage or disease, and
j. is responsible enough to consent, informed enough to make a responsible decision, and not under coercion.


3. The health care team

k. is part of an institution that meets Moore's third criteria as it pertains to institutional stability,
l. has provided adequate informed consent to both parties regarding risks, potential sequelae, and chances of success and failure,
m. has no conflict of interest independently or with either party, and
n. has the duty to preserve anonymity if the donor or recipient do not explicitly waive this right.

Application on transgendered women

It may be possible for trans women to receive uteruses in the future. Some concerns regarding genetics, anatomy and hormones addressed below:

  1. Women with Swyer syndrome have male genetics and lack ovaries, but have a uterus. Similarly to trans women, they need hormone replacement therapy to induce female puberty and maintain female secondary sex characteristics. Such women have had successful pregnancies, though obviously requiring egg donation and IVF.
  2. In the case of most trans women who began HRT past male puberty, the pelvis has failed to develop femininely and broaden as it would have before or during puberty. However, as proven by Nadya Suleman (octuplets), Lina Medina (youngest mother) and Stacey Herald (smallest mother at 71 cm [20]), a small pelvis is not an obstacle to gestation, even in extreme cases. Delivery would be via c-section.

References

  1. ^ http://www.dailymail.co.uk/health/article-2050401/Married-nurse-hopes-worlds-baby-womb-transplant-donated-MOTHER.html
  2. ^ http://www.timesofmalta.com/articles/view/20111010/health-fitness/turkish-woman-has-world-s-first-womb-transplant.388596
  3. ^ http://www.allvoices.com/contributed-news/9926041-revolutionary-womb-transplant-performed-in-turkey-worlds-first
  4. ^ http://rt.com/news/first-uterus-surgery-success-845/
  5. ^ http://www.alarabiya.net/articles/2011/10/01/169542.html
  6. ^ http://www.hurriyetdailynews.com/doctors-hopeful-for-uterus-transplant.aspx?pageID=238&nID=12614&NewsCatID=373
  7. ^ http://www.trt-world.com/trtworld/en/newsDetail.aspx?HaberKodu=0222eb41-3a81-41b9-9123-2a256f5f2b31
  8. ^ http://www.worldbulletin.net/?aType=haber&ArticleID=77268
  9. ^ Knauer, E. (1896). "Einige Versuche uber Ovarientransplantation bei Kaninchen". Zentralbl. Gynäkol. 20: 524–528.
  10. ^ D.Nugent, D.Meirow, P.F.Brook, Y.Aubard and R.G.Gosden (1997). "Transplantation in reproductive medicine: previous experience, present knowledge and future prospects". Human Reproduction Update. 3 (3): 267–280.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ Eraslan S, Hamernik RJ, Hardy JD (1966 Jan). "Replantation of uterus and ovaries in dogs, with successful pregnancy". Arch Surg. 92 (1): 9–12. PMID 5948103. {{cite journal}}: Check date values in: |date= (help)CS1 maint: multiple names: authors list (link)
  12. ^ Ramirez, ER.; Ramirez Nessetti, DK.; Nessetti, MB.; Khatamee, M.; Wolfson, MR.; Shaffer, TH.; Ramirez, VZ.; Ramirez, HA. "Pregnancy and outcome of uterine allotransplantation and assisted reproduction in sheep". J Minim Invasive Gynecol. 18 (2): 238–45. doi:10.1016/j.jmig.2010.11.006. PMID 21354071. {{cite journal}}: Cite has empty unknown parameter: |month= (help)
  13. ^ "Nicole Kidman as the world's first reported woman with surgically corrected Harry Benjamin Syndrome".
  14. ^ Nair, A.; Stega, J.; Smith, JR.; Del Priore, G. (2008). "Uterus transplant: evidence and ethics". Ann N Y Acad Sci. 1127: 83–91. doi:10.1196/annals.1434.003. PMID 18443334. {{cite journal}}: Unknown parameter |month= ignored (help)
  15. ^ Grady, Denise (March 7, 2002). "Medical First: A Transplant Of a Uterus". The New York Times.
  16. ^ "World's first successful uterus transplant performed in Turkey". Oct 2011.
  17. ^ "Nurse hopes to have world's first baby from a transplant womb donated by her own mother". Daily Mail. 18-Oct-2011. {{cite journal}}: Check date values in: |date= (help)
  18. ^ a b c Brännström M, Wranning CA, Altchek A (2010). "Experimental uterus transplantation". Hum. Reprod. Update. 16 (3): 329–45. doi:10.1093/humupd/dmp049. PMID 19897849.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Lefkowitz, A., Edwards, M. and Balayla, J. (2012), The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation. Transplant International. [1] doi:10.1111/j.1432-2277.2012.01438.x. PMID: 22356169
  20. ^ "World's smallest mother shows off baby number three". Daily Mail. 6-Jul-2010. {{cite journal}}: Check date values in: |date= (help)

External links

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