Journal of Medical Evidence

JOURNAL SCAN
Year
: 2022  |  Volume : 3  |  Issue : 2  |  Page : 195--196

The birth of a healthy baby 9 years after a surgically successful deceased donor uterus transplant


Tanvi Jain, Samiran Nundy 
 Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India

Correspondence Address:
Dr. Tanvi Jain
Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi
India




How to cite this article:
Jain T, Nundy S. The birth of a healthy baby 9 years after a surgically successful deceased donor uterus transplant.J Med Evid 2022;3:195-196


How to cite this URL:
Jain T, Nundy S. The birth of a healthy baby 9 years after a surgically successful deceased donor uterus transplant. J Med Evid [serial online] 2022 [cited 2022 Nov 30 ];3:195-196
Available from: http://www.journaljme.org/text.asp?2022/3/2/195/354989


Full Text



 Article Information



Ozkan O, Ozkan O, Dogan NU, Bahceci M, Mendilcioglu I, Boynukalin K, et al. Birth of a healthy baby 9 years after a surgically successful deceased donor uterus transplant. Ann Surg 2022;275:825-32.

 Background



A uterus transplant can provide women who are affected by absolute uterine factor infertility a chance to conceive naturally. Some successful cases have been previously reported with live childbirths after uterus transplants from living donors. The present report is of a successful childbirth 9 years after a deceased donor uterus transplant.

A uterine transplant was performed in Germany for a transwoman as early as 1931, in conjunction with a vaginoplasty. However, she developed a post-surgical infection and died from cardiac arrest just 3 months later.[1] The first modern-day attempt at a uterine transplant occurred in 2000, in Saudi Arabia, however, the uterus had to be removed in 99 days because of necrosis.[2] Following this, many more attempts at living-donor uterine transplants have also been made worldwide including in Sweden,[3] the USA[4] as well as India[5] resulting in successes. After the baby's birth, the transplanted uterus is usually removed to avoid the side effects of the immunosuppression used to prevent it from being rejected. This presently reported procedure by Ozkan et al. in 2011, was the first from a deceased donor that culminated in a successful live birth. However, it involved a latency period of 9 years with 14 failed embryo transfers (5 miscarriages and 1 chemical pregnancy) before achieving success. Interestingly, the initial failures were reportedly attributed to allograft congestion which was tackled with a vascular venous revision to overcome the obstructed, misperfused area. The final pregnancy, though successful, was still a turbulent one with premature rupture of the membranes in the 19th week, pre-eclampsia and premature birth at the 28th week with growth restriction of the baby. The child reportedly had normal mental and motor development for his age at 16 months and the mother was also reportedly healthy on follow-up after 16 months.

 Commentary



As highlighted in the article, it is the birth of a live child rather than the outcome of the graft per se that would count as a successful transplant as opposed to other solid organ transplants. While one needs to congratulate Ozkan et al. for the success in terms of the final outcome, one cannot overlook the fact that there are many ethical considerations involved. These include the administration of long-term immunosuppression for 10 years to prevent the rejection of the transplanted organ and its effects on renal function. Furthermore, the mental trauma of the multiple previously failed attempts cannot be overlooked while lauding the technical outcome. We need to balance the desire of the mother to conceive naturally against the effects of the process on the recipient's long-term health and renal function.

The ethical principles of informed consent, non-maleficence and autonomy need to be reiterated when considering an experimental treatment that has not been studied for its long-term side effects.

We also need to consider the alternatives available for a couple for childbearing including surrogacy and adoption when counselling a patient for a uterus transplant. Although the team has reported normal long-term renal function in terms of serum creatinine, this is not an accurate or absolute indicator of renal function. The recipient of the transplant is an otherwise healthy and young female with a long-life expectancy, hence, it is of paramount importance that the procedure does not lead to any potential long-term side effects. These long-term effects remain to be studied.

Many more cases of uterine transplants will be needed to address these questions about the risks to maternal health on long-term follow-up. More studies are also required to find ways of assessing graft function in an advanced pregnancy as cervical biopsies cannot be safely undertaken in late pregnancy. Whether the recipient's desire to conceive naturally can justify all the risks involved remains an ethical concern till we find ways of achieving successful childbirth post-transplant in a short period of time, minimising the exposure of the mother to long-term immunosuppressants.

The recipient's desire to conceive naturally is the primary driving force for undertaking the procedure. The main question here is whether the recipient's desire can lead to therapeutic misconception. This raises ethical concerns and the questions of violating the principles of autonomy and non-maleficence.

When considering the possibility of bearing a child naturally, it is also important to consider alternative options such as surrogacy and adoption. Uterine transplant is not a life-saving procedure, it rather is socially driven by the recipient's emotional desires. Hence, long-term side effects should be strongly considered and discussed before committing to the procedure.

The need for long-term follow-up for the recipient and continued assessment of her renal function, development of malignancies and infections related to long-term immunosuppression should be the basis of future research in the field.

This success story is one of the technical prowess and long-term commitment of the entire team towards a positive outcome. It has paved the way for more such attempts including ones from living donors.

References

1Wikipedia: The Free Encyclopedia. Uterus Transplantation. Available from: https://en.wikipedia.org/wiki/Uterus_transplantation#. [Last accessed on 2022 May 03].
2Fageeh W, Raffa H, Jabbad H, Marzouki A. Transplantation of the human uterus. Int J Gynaecol Obstet 2002;76:245-51.
3Brannstorm M, Johannesson L, Bokstrom H, Kvarnström N, Mölne J, Dahm-Kähler P, et al. Livebirth after uterus transplantation. Lancet 2015;385:607-16.
4Flyckt R, Falcone T, Quintini C, Perni U, Eghtesad B, Richards EG, et al. First birth from a deceased donor uterus in the United States: From severe graft rejection to successful cesarean delivery. Am J Obstet Gynecol 2020;223:143-51.
5Mascarenhas A. Pune: Woman to Get Her Mother's Womb in India's first Uterine Transplant. The Indian Express; May 12, 2017. Available from: http://indianexpress.com/article/india/pune-woman-to-get-her -mothers-womb-in-indias-first-uterine-transplant-4651839/. [Last accessed on 2017 May 12].