Womb transplants — is surrogacy safer?

The recent news that the Health Research Authority has given approval to a UK charity to conduct a clinical trial for womb transplants is seen as welcome news for women without wombs (1). Womb Transplant UK, led by Dr Richard Smith, a consultant gynaecologist at the Queen Charlotte's and Chelsea Hospital in London, has been given
approval to conduct a clinical trial involving ten womb transplants (2).

The donated womb will come from a brain-dead organ donor, and the health of the woman and the womb will be closely monitored for one year before an embryo will be implanted in the womb. The embryo will be created from the recipient's own egg and her partner's sperm and, if a pregnancy occurs, the fetus will be delivered at approximately eight months' gestation by caesarean section. When possible, couples will be given the option of trying for two pregnancies. The transplanted womb is to be removed six months after birth, negating the need to take immune suppressants for life (3,4).

Generally, transplants and advances in transplant procedures are to be welcomed as they can drastically improve the length and quality of life of patients. For example, kidney transplants allow people to live free of lengthy and life-consuming dialysis procedures. While organ transplants are usually carried out for life-lengthening reasons (i.e. without an organ donation, many people would die sooner
than, if they received one), womb transplants are not performed for life-lengthening purposes. However, I believe that the potential benefit of womb transplants needs to be more closely examined. The sole purpose and benefit of a womb transplant
is to provide the recipient with an opportunity to become pregnant and carry a child and, in this particular trial, any children produced will be genetically related to the woman who received the womb.

The pain and suffering of the involuntarily infertile
is not to be underestimated, and neither are the effects upon their lives and those around them. However, what makes this case study interesting is that the women who would be eligible for this clinical trial do have other options that will allow them to become parents, as they can choose to adopt a child, or utilise gestational surrogacy. Therefore, without a womb transplant, they are not denied the opportunity to be a parent but rather the opportunity to carry a child.

While adoption may not be the preferred option of the involuntarily infertile, particularly when the woman without the womb has functioning ovaries, gestational surrogacy would produce the same result as a womb transplant in this clinical trial — a genetically related child.

Of particular concern is that the potential recipients of a womb transplant will be putting themselves and their bodies through substantial risk and stress in order to achieve something that can be achieved via a far less risky route. The recipients will undergo major surgery at least twice, to receive the womb transplant and to remove it, as well as up to two planned caesarean sections, in addition to taking anti-rejection drugs (and the associated risks) throughout the period that they have the transplanted womb.

However, in both the gestational surrogacy and the womb-transplant option, the recipient will need to take drugs to stimulate her ovaries for the production of eggs for the creation of embryos for the IVF procedure. This is a process that cannot be avoided in either scenario.

I do not deny that there are problems with surrogacy^* — not least asking another woman to run the risks of pregnancy on your behalf — but when compared to the extensive surgeries required for a womb transplant, is it not the safer option? Where the gestational surrogate has freely and voluntarily consented to carry a pregnancy on behalf of another woman, surrogacy must be preferable to the multiple risky procedures to transplant a womb in order to (potentially) carry a high-risk pregnancy. Recipients of donated wombs are at risk of far greater harm by choosing to undergo a womb transplant due to the extensive, and currently experimental, surgery required.

On one hand, pregnancy is a uniquely feminine experience, and one that I can understand that women without wombs may want to experience for themselves, but is it an experience that they will deem life-changing enough to put themselves through surgery? On the other hand, if the goal of the women eligible for this transplant is to have a genetically related child, why not achieve that goal through surrogacy? And if the UK law on surrogacy is reformed to recognise genetic/intended parents as legal parents from birth, this would be another incentive to avoid needless surgery.

There is far more to consider than just the potential future children and the scientific advances that are being made — the health and well-being of the women involved must also be taken into account.

^*The problems with surrogacy are well documented and include concerns around the exploitation of women, the commodification of children, consent, financial inducements, unenforceability of contracts (in the UK context at least) and the legal status of intended parents. Examples of literature include S Wilkinson 'Bodies for Sale: Ethics and exploitation in the human body trade' (Abingdon, Routledge 2003), K Horsey 'Swept Under the Carpet: Why Surrogacy Law Needs Urgent Review' in N Priaulx and A Wrigley (Eds) 'Ethics, Law and Society Volume V' (Ashgate, Surrey, 2013), R Ber Ethical Issues in Gestational Surrogacy (2000) 21 Theoretical Medicine and Bioethics 153-169.