Ten Years of Womb Transplants: What Have We Learned? What Does the Future Hold?

This online PET event marked ten years since the first live birth following a human uterus transplant (see BioNews 775). It gathered together a range of speakers to celebrate and reflect on the history and progress of this research.

Several pioneers of uterus transplants spoke at the event, including Professor Mats Brännström (the leader of the team responsible for the first live birth following a uterus transplant) and Professor J Richard Smith and Isabel Quiroga (joint leaders of the surgical team responsible for the first uterus transplant in the UK). Wider perspectives were provided by speakers Eleanor Findlater (who shared her personal experience of having a hysterectomy) and Dr Natasha Hammond-Browning (an expert on the law and ethics surrounding uterus transplants). The event was chaired by Sarah Norcross, director of PET.

A continuous theme throughout the event was how uterus transplants can transform patients' lives. As the name suggests, this procedure involves transplanting a uterus into the body of someone who does not have one. Unlike most organ transplants – such as of the heart or kidney – a uterus transplant does not directly treat a life-threatening physical disease. Instead, it is performed to give someone the chance to experience pregnancy.

In the UK, around 15,000 women of childbearing age do not have this opportunity. One in every 5000 women are born without uteruses. Others have a uterus abnormality, or have their uteruses removed via hysterectomy as part of treatment for a disease, like Findlater.

Findlater was diagnosed with adenosarcoma of the uterus, which was treated by hysterectomy. She gave a powerful personal account of the devastation she felt when she discovered that this meant she would be unable to bear children. She felt she was being denied a fundamental human experience that occurs naturally for many women.

Similar stories are shared by many patients seeking uterus transplants. While opportunities to have children exist via adoption or surrogacy, these will not always be available or attractive options. After her cancer diagnosis, Findlater was told that she could not pursue adoption until she had been in remission for five years. She, like many others, started a family through surrogacy, but difficulties can sometimes arise from these arrangements (see BioNews 1256). Uterus transplants provide another route to parenthood. Crucially, they are also the only opportunity for these patients to experience gestation. As Quiroga explained, it gives hope to patients who long to carry their own baby.

The heartfelt stories of patients like Findlater inspire and continue to drive research teams. Professor Brännström shared that the idea of uterus transplants was first suggested to him by a patient. Quiroga was convinced to pursue this research after talking with a patient, and said that a successful transplant is a joyous moment for the whole team. The relief of suffering that uterus transplants can provide is in the forefront of the minds of these researchers. As Professor Smith put it, it is about 'compassion, compassion, compassion'.

The dedication of these research teams has led to significant progress. The first live birth following a uterus transplant was a monumental achievement, and the culmination of many years of work by Professor Brännström and his team. The groundwork was laid by over a decade of animal research and two years of human clinical trials. The first UK uterus transplant was performed by a team led by Professor Smith and Quiroga in February 2023 (see BioNews 1248). As a treatment, uterus transplants are still undergoing clinical trials in the UK, but uterus transplants are developing on a global scale, with at least 78 procedures carried out worldwide and at least 40 babies born.

When compared to alternative routes to parenthood – adoption and surrogacy – uterus transplants carry greater health risk. Although Professor Brännström said surgical success has been very high, Professor Smith pointed out that this success is partly attributed to uterus transplants being performed on healthy patients. Risks may increase if the selection criteria for patients are widened.

Uterus transplants are incredibly complex procedures involving several surgeries for the recipient: the initial uterus transplant, birth by c-section, and the eventual removal of the uterus to allow the patient to discontinue immunotherapy. Living donors of uteruses also face health risks. Research into ways to optimise the treatment is continuing. The collaborative work of the International Society of Uterus Transplantation Registry, which monitors and shares global uterus transplants research, is invaluable in this.

The ethical and legal questions surrounding uterus transplants are just as challenging. Several of these were highlighted in a presentation by Dr Hammond-Browning. She noted that the same issues identified a decade ago are still being debated today, and will likely continue to be debated in the future. These include questions about the allocation of treatment. Uterus transplants are expensive – if funding is limited, how do we decide who receives them?

The answers to such questions, she said, will depend on personal values. Some believe that there is a right to gestate, which would create a corresponding right to access. In terms of access to uterus transplants for transgender people, she explained that this partly depends on how the purpose of uterus transplants is conceptualised. Is it part of gender reassignment? Or is it about the experience of gestation and parenthood?

She also noted that access to uterus transplants for transgender people faces potential legal barriers in the UK. It is currently unclear whether the Human Fertilisation and Embryology Act 1990 would permit embryo transfer into a transgender woman. Professor Smith explained that uterus transplant research has mostly been carried out on cisgender women, and this work will not easily translate into other bodies.

Overall, this event provided an informative and fascinating review of the advancements in uterus transplants. The speakers presented a detailed understanding of this newly developing treatment, which sits at the intersection of many legal and ethical questions. As Norcross noted, the whole evening was brought together by Findlater's presentation. It underscored the reason behind all this research. It is for these women. It is for their reproductive choice.

PET is grateful to Create Health Foundation and Merck for supporting this event.

The next PET event will be the charity's Annual Conference – 40 Years after the Warnock Report: What Is the Embryo's Special Status? – taking place in central London next week, on Wednesday 4 December 2024.

Find out more and register here.