Uterus transplantation in Lebanon: Could it make women more vulnerable?

The first successful uterine transplant in the Middle East and North Africa was announced by Lebanon’s health minister Ghassan Hasbani last month at the Bellevue Medical Centre in Beirut (see BioNews 960). The transplant, performed in June in collaboration with the Swedish team at the University of Gothenberg, was part of Lebanon's first uterus transplantation trial which started in 2016 following its approval by the hospital's institutional review board.

Currently there are no specific legal guidelines in Lebanon for the regulation of uterine transplantation. However, it is considered as a part of clinical trials regulated under the Article 30 of the law on medical ethics and therefore research participants will not be paying for the procedure. Furthermore, Article 30 states that artificial insemination or pregnancy through IVF shall not be carried out except between a married couple with their written consent, leaving therefore a legal void around the use of other forms of assisted reproductive technologies (ARTs) such as the use of PGD (preimplantation genetic diagnosis) for non-medical sex selection, and the fate of supernumerary embryos.

This situation stems from the fact that Lebanon is a country with 18 different communities in which religion plays a key role. In that perspective, health policy is influenced by religious leaders and any drafted ethical code in medicine must be approved by Muslim and Christian religious figures or it will not be ratified.

What makes uterine transplantation an appealing reproductive procedure for the Lebanese setting and Middle Eastern and North African countries generally, is that it constitutes a way out for those women with infertility due to uterine problems such as Uterine Factor Infertility (UFI): a congenitally absent or damaged uterus. Other alternatives may not be an option: surrogacy is legally prohibited in Lebanon, while adoption is an option for Christian communities only, since it is prohibited by Islamic law.

The dominant cultural and religious backgrounds place a crucial value on genetic kinship and, therefore, on genetically-related children, which might be achieved through uterine transplantation – but not adoption or some forms of surrogacy. Hence, this might explain the acceptance and integration of the procedure in the Lebanese context.

Uterine transplantation carries with it risks and ethical, social and legal challenges for the three parties involved: the donor, the recipient and the intended child. Although the discussion and assessment of all of the issues is out of the scope of this piece, it is worthwhile noting among others, the medical and psychological risks of the surgery for both the recipient and the donor.

Uterine transplantation involves medical risks for the recipient because of the multiple surgeries she might undergo as well as the potential negative effect of immunosuppressive medication that might increase her risk of malignancy over time. In addition, the very nature of the Lebanese sociocultural context brings up its own ethical and social complications. This piece focuses on one element: the exacerbation of the vulnerability of those already-vulnerable women with UFI unable to become pregnant.

In fact, given the fundamental importance placed on motherhood in Lebanon, the impact of infertility on the couple, the extended family and particularly on the woman can be substantial. Compared with Western societies, the implications of involuntary childlessness for women in developing countries are much more dramatic and can lead to wider and more severe societal consequences. For instance, women are usually blamed for infertility and can be ostracised, disinherited and neglected by their families. This may result in psychological and physical trauma and marital instability leading sometimes to the threat of divorce.

The fear of such negative consequences creates a setting in which women become vulnerable by not fulfilling their perceived biological role in reproducing, and experience further pressure to do whatever it takes to have a biological child.

In turn, such a sociocultural context sets the ground not only for the introduction of the uterine transplantation trial into the Lebanese setting, but also, for its wide acceptance, especially by women with UFI. In order to avoid the social stigma caused by involuntary childlessness, those women are ready to take whatever risks this procedure entails.

Thus, the very availability of uterine transplantation will contribute to increasing the pressure on these women to accept such a procedure, regardless whether it is still in its trial phase or if it is potentially adopted as a safe option.

This pressure might even be exacerbated if uterine transplantation is offered as an option without the costs of the procedure being covered by the healthcare system. Such a situation would mean that access to uterine transplantation would be determined by the socioeconomic status of each woman and hence, only well-off women may be able to access it.

This inequality of access could further create an increasing pressure and vulnerability on those less well-off women with uterine problems. A pressure stemming from the lack of financial resources associated with the very existence of a procedure that they are not taking advantage of in order to give birth to a genetically-related child.

Uterine transplantation is a promising advancement that may give 'new hope' to women with UFI to 'fulfill their dreams to become mothers through pregnancy'; however, it carries with it significant risks for the parties involved. Of those risks, the greatest is perhaps the emotional burden, from which a woman might suffer if she feels more pressure to undertake such a risky procedure.

Women should be well-informed about the procedure, its risks and probability of failure and should also be supported emotionally and psychologically.

Finally, in a country where there is a lack of regulation surrounding ARTs there are other crucial considerations to be taken into account. Lebanon has an illegal organ trafficking problem that has been increasing with the Syrian refugee crisis. Might the advance of uterine transplantation lead to a black market for selling uteruses?