Womb transplants: 'Now the impossible has become real'

The world's first live birth following a womb transplant (reported in BioNews 775) represents a huge step forward in reproductive technology. The success of Mats Brannstrom and his team in Sweden received worldwide media coverage and has given hope to thousands of women around the globe.

The team's clinical trial looked at uterus transplantation in nine women with absolute uterine factor infertility. The details, published in The Lancet, report that a 36-year-old woman who was born without a uterus has given birth to a healthy boy following a transplant. The donor was a close family friend of the recipient who had completed her family and at the date of the surgery was 61 years of age.

Before the uterus was transplanted, IVF had been carried out and embryos had been cryogenically frozen, ready to be transferred. The patient became pregnant at her first transfer, and the pregnancy proceeded normally for the first 31 weeks, until the recipient developed pre-eclampsia and was admitted to hospital where a caesarean section was performed soon after.

The baby (named Vincent) emerged healthy, weighing 1.8 kg and was moved from the neonatal unit ten days after birth. The mother was in good condition the day after delivery and her blood pressure normalised spontaneously with no further treatment. She was discharged from hospital three days after the caesarean section and has been followed up in regular outpatient visits. The researchers have also reported that two more of the women in the clinical trial are also pregnant and are due to have babies by the end of the year.

The transplanted uterus can be removed after one or two babies have been born (so as to minimise the amount of time they need to take anti-rejection drugs) and they have been advised to wait no longer than six months between the birth of their first child and getting pregnant with their second. Brannstrom and his team in the Lancet claim 'our demonstration of the first live birth after uterus transplantation opens up the possibility to treat the many young women with uterine factor infertility worldwide'.

Talking to the media, the mother stated: 'I have always had this large sorrow because I never thought I would be a mother… and now the impossible has become real.'

Richard Smith, consultant gynaecological surgeon at Queen Charlotte's Hospital in London, is planning to apply for ethical approval to conduct the first five womb transplants in England in 2015 and has reported that there are 60 women on the waiting list. The British operations will also be funded through charitable donations to Womb Transplant UK. It is estimated that there are 15,000 women in the UK without a womb.

As uterine transplantation for clinical treatment now appears to be in the offing, how will this be regulated in the UK and what social, legal and ethical issues does it raise? For instance, once uterine transplantation is offered to women born without a uterus, do male-to-female transgendered individuals who have undergone gender reassignment and undergone the process in the Gender Recognition Act 2004 have a right to receive a uterus transplant so that they too can experience gestation? Once this occurs, by default, will we have discovered the science to achieve male pregnancy and the prospect of unisex gestation?

On a practical note, who will regulate this new treatment? Would such a procedure constitute fertility treatment under the remit of the Human Fertilisation and Embryology Act 1990, or should it be treated in the same manner as other organ transplants (and thus be regulated by the Human Tissue Act 2004)? As the legal framework governing organ transplantation and fertility treatment differs, could a woman could find herself in the invidious position of having successfully received a womb transplant only to be declined IVF treatment, or vice versa? The best guidance as to how this could be avoided and how this advance could or should be governed would be from the statutory authorities set up by Parliament to oversee regulation of assisted reproduction and transplantation, the Human Fertilisation and Embryology Authority (HFEA) and the Human Tissue Authority.

The HFEA Horizon Scanning Panel in the 2007/8 Annual Report considered the possibility of uterus transplantation but accorded it 'low priority' - the status ascribed to 'issues that have either been considered previously or are unlikely to impact on research and treatment in the future'. In light of this breakthrough, this procedure and the issues raised therein merit revisiting. If the UK is to maximise from this scientific advance and is to be adequately equipped to respond to the challenges it will raise, it needs to be more proactive and less reactive. The time is now to debate uterus transplantation.