On the 23 August 2023, it was announced that the UK team, Womb Transplant UK, had performed their first living donor uterus transplant (see BioNews 1204). The transplant was performed in February 2023, and took place between two sisters. The recipient was a 34-year-old woman who was unable to gestate as she has Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, and her 40-year-old sister was her donor. The two overlapping surgeries took over 17 hours, involved eight surgeons, and over 30 clinicians formed a special team for the transplant. Womb Transplant UK (a registered charity) paid for the costs of the NHS and all the surgeons and specialists in the team donated their time free of charge.
The first uterus transplant in the UK is a significant achievement for the Womb Transplant UK team, who has been conducting research into uterus transplantation for more than 25 years, and who has approval to conduct uterus transplant clinical trials with deceased donors as well as live donors. For women who have absolute uterine factor infertility, that is women who are born without a uterus, have had their uterus removed, or have a non-functioning uterus due to a condition such as Asherman's syndrome, the development of uterine transplantation provides them with another reproductive option beyond surrogacy and adoption.
Uterus transplantation hit the headlines on the 3 October 2014 with the announcement of the birth of the first baby following a uterus transplant, which had occurred in 2013. Just ten years since the first uterus transplant was performed, it is now estimated that over 100 uterus transplants have taken place worldwide with over 50 babies born. Almost all uterus transplants are taking place as part of clinical trials, with the exception of one in the USA. The University of Alabama Medicine uterus transplant programme is the first to offer uterus transplantation outside of a clinical trial, and in May 2023 the first birth in that programme happened. The cost of uterus transplantation should not be underestimated, a study published in Human Reproduction of the first clinical trial in Sweden estimated the costs at approximately 75,000 euros (including preoperative investigations, IVF, and postoperative costs for two months).
Since the first birth in 2014, developments in the field of uterus transplantation have been rapid; proof of concept with deceased donors occurred in 2018 when a baby was born in Brazil following deceased donation (see BioNew 980), then robotic operated uterus transplantation was successfully used in 2021 for both the donor and recipient surgeries, and there are ongoing studies into growing and using bioengineered uteri.
Transplants have now occurred in Saudi Arabia, Turkey, Sweden, China, the USA (Dallas, Cleveland, Pennsylvania, and Alabama), Brazil, the Czech Republic, Germany, India, Serbia, Lebanon, Italy, and most recently Australia and the UK. Belgium and Spain are currently recruiting for participants, while France and the Netherlands have also expressed interest in conducting uterus transplantation clinical trials in the near future.
It is estimated that up to one in 500 women are affected by absolute uterine factor infertility, and the team behind the UK transplant assembled by Womb Transplant UK estimates that it could perform up to 30 uterus transplants per year. Nonetheless, not all women impacted by absolute uterine factor infertility will want to pursue a uterus transplant in order to reproduce, and not all will be eligible. Selection criteria for clinical trials are set by the clinical trials teams (and reviewed by the relevant research ethics committees), and understandably, there are many similarities across the teams working worldwide as they will be working to best medical practice, using criteria that are medically proven and help to ensure patient safety and successful outcomes. However, some criteria will also be influenced by the regulatory situation in which the teams are working, for example, they may only be able to include married heterosexual cisgender women, if that country only permits access to IVF by this group.
As a generalisation, current selection criteria require potential recipients to be cisgender women aged between 20-40 years of age, able to produce their own eggs, to be medically fit, and (normally) in a (heterosexual) relationship. Therefore, these criteria exclude any cis woman who is unable to produce her own eggs (despite egg donation being a permitted practice in many of the countries conducting uterus transplantation clinical trials), as well as women outside of the permitted age range, and single women or women in same-sex relationships. Where legally permissible within the countries performing uterus transplants, these criteria should be expanded, to allow women who currently fall outside of these criteria access to uterus transplantation, as I argued in an article in British Journal of Obstetrics and Gynaecology. The medical criteria, such as not having systemic disease, are more easily justified as they will be in place to ensure patient safety both during and after surgery, as well as ensuring the best possible chance for the surgery, and hopefully subsequent pregnancies, to succeed.
The debate around access to uterus transplantation by transgender women and, less prominent but equally important to debate and discuss, access by cisgender men, is one that cannot be ignored. Undoubtedly, the current selection criteria requiring potential recipients to produce their own eggs prevents transgender women from accessing uterus transplants, in the same way that it prevents cis women without ovaries or sufficient eggs to access it. However, the expansion of the criteria to allow the use of donated eggs should not be seen as opening the floodgates to allowing everyone access to uterus transplants. Rather, this is one selection criteria of several that require justification where the law would otherwise permit access. The limited number of available uteri, the high financial costs involved, and the lack of public funding will also further limit access of all interested people to uterus transplants worldwide.
Interestingly, there has been little to no debate about a transgender man accessing uterus transplantation in order to gestate their own genetically related child. It is not unfeasible for a trans man to have absolute uterine factor infertility prior to transitioning, to be able to produce eggs (where they have retained their ovaries), and to be in a relationship with a partner who produces sperm. The current barrier to access for a trans man is the fact that they do not identify as a cis woman for the purposes of the selection criteria, yet anatomically they are in the same position as cis women with absolute uterine factor infertility.
There is no doubt that the most recent announcement that uterus transplantation has been successfully performed in the UK is one that many with absolute uterine factor infertility will be following with great interest. Yet, the concerns that many have around uterus transplantation must not be ignored, there must be reasoned and informed debate, and the selection criteria of potential recipients should continue to be refined to be legally, morally, and medically justified.
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