Cautious optimism at the first live birth after womb transplant from deceased donor

The news broke on the 4 December 2018 that clinicians had achieved a successful pregnancy and live birth following a uterus transplant from a deceased donor.  

This has been heralded worldwide as groundbreaking for uterus transplantation, and gives credence to clinical trials persisting with deceased donation, despite previous attempts failing. The feasibility of the use of deceased donors for uterus transplants was looking uncertain, and so the demonstration of the proof of concept is welcomed.

The transplant procedure took place in Sao Paulo, Brazil, on 20 September 2016. After seven months, an embryo was transferred resulting in pregnancy. A female baby was born on 15 December 2017 by caesarean section. The recipient was a 32-year-old woman with congenital uterine absence (MRKH syndrome), and the donor was a 45-year-old woman who had suffered a subarachnoid haemorrhage. The donor had had three previous deliveries and was in good general health. The heart, liver and kidneys were also retrieved for donation.

A successful pregnancy and live birth from a deceased donor uterine transplant is a medical milestone and the team involved are to be congratulated for their success. The medical team took steps to minimise the risks to the recipient from immunosuppressive therapies through reducing the time from transplant to embryo transfer (in this instance it was planned for six months but was delayed to seven months due to the uterus not being in an optimum state for the embryo transfer). 

The donated uterus was removed in the same operation as the caesarean section and so the recipient was taking immunosuppressive therapies for approximately 16 months. This contrasts with the deceased donor transplant that occurred in 2011 in Turkey where, to the best of my knowledge, the recipient is still in receipt of the donated uterus and subject to continuing immunosuppressive therapies. 

Medical knowledge has undoubtedly moved on since 2011, and improvements in the uterine transplant procedure are on-going and will be evident in future procedures. The reduction in time of taking immunosuppressive drugs also helps to reduce the overall cost as well as lowering the risks of adverse side effects.

The advantages and disadvantages of deceased and living donors have been well debated (see Williams, Lavoué, Aurora). This birth demonstrates that deceased donation for uterus transplants is a realistic avenue for research. Deceased donation widens the pool of potential donors, as people are often more willing to donate organs upon death rather than during their lifetimes. In comparison, living donation relies on the willingness of family members, or altruistic anonymous donors, to undergo complex, invasive, radical hysterectomies without any benefit to themselves. The risks to living donors include general anaesthesia, bladder injuries, onset of menopause (if not already started), and possible feelings of regret, particularly if the transplant fails. Deceased donation negates the risks to living donors, as well as increasing the number of potential donors. 

The Brazilian team estimate that approximately 3500 deceased uterus donors would be available each year, although the ability to access donors would require national standardisation and a new infrastructure to support it (Ejzenberg).  It is the logistics of deceased donation that possibly pose the biggest hurdle for uterine transplantation. It is likely that retrieval of organs will occur at some distance from the recipient, as such the longer storage time of the donated organ requires further investigation with regards to the outcome of the transplant. Co-ordination between the different organ retrieval teams is also important; as a quality of life transplant, the uterus will likely be retrieved after the life-saving organs have been removed; work is ongoing in this area (for example, Gauthier). 

Caution must be exercised in welcoming this news. Deceased donation for uterus transplants will not immediately become available to all those desirous of such a transplant, nor does it overcome the substantial risks and invasive procedures that recipients go through in order to have an opportunity to gestate a biological child (see BioNews 828 and 847).  

It does, however, provide an opportunity for renewed support for research and clinical trials utilising deceased donors for uterine transplantation. If risks can be negated to living donors through pursuing alternative options, and transplant procedures improved for women with uterine infertility, then deceased donation ought to be continued and encouraged. 

There are a number of research teams worldwide conducting work with deceased donors, including Womb Transplant UK and the Cleveland Clinic in the USA, so it appears that it is only a matter of time until this success story is replicated. It is hoped that those conducting clinical research are working with other organ retrieval teams, as well as governing bodies of transplanted organs, in order to start the process of establishing procedures that will enable the use of donated uteruses from deceased donors without jeopardising other life saving organs, whilst ensuring the viability of the donated uterus through a comprehensive understanding of the logistics involved.