Essential baby, 2/5/14

The quest for the first womb transplant babies

Kristen Male: "I feel like it's my chance to have my own baby. And the way my mum feels about it is that she's giving a uterus to get a grandchild."Kristen Male: “I feel like it’s my chance to have my own baby. And the way my mum feels about it is that she’s giving a uterus to get a grandchild.” Photo: David Mariuz

Dr Mats Brannstrom’s phone begins to buzz and the words ”Donor 9” flash up on the screen. He apologises, picks up, then starts answering the caller’s questions.

It’s now more than a year since Brannstrom and his team carried out nine pioneering womb transplants, five of them mother-to-daughter, in Sweden. But Brannstrom and his colleagues are still on call for both donors and recipients 24 hours a day.

Part of the reason for this 24-hour aftercare is that the surgery was unexpectedly difficult: the operation to remove the womb, which studies had indicated would take three to four hours, ended up taking between 10 and 13 hours in the theatre at Sahlgrenska Hospital.

Brannstrom’s team transplanted not just the womb but also long veins and arteries, which were then attached directly to the large blood vessels deep in the recipient’s pelvis. This will hopefully give a much better flow of blood to the foetus if the women succeed in getting pregnant, but it greatly complicated the surgery.

One of the recipients later suffered from a uterine infection, which meant the subsequent removal of the donated womb. Another woman’s womb was removed after she suffered thrombosis.

But five women have already had their first embryos transplanted by IVF. This puts Brannstrom and Sahlgrenksa Institute in the lead in the race for the first healthy baby from a transplanted womb – and women without wombs around the world are watching every development.

”When I found out [about the transplants] I was so excited,” says Kristen Male, a 23-year-old tax worker from Adelaide.

Male has MRKH, a congenital disorder that affects one in 5000 women and prevents the womb from developing. Her mother Debbie has agreed to donate her womb if the operation becomes available in Australia.

”To me it doesn’t feel like getting somebody else’s body part – I feel like it’s my chance to have my own baby,” says Male. ”And the way my mum feels about it is that she’s giving a uterus to get a grandchild.”

A member of Brannstrom’s team, Queensland gynacologist Dr Ash Hanafy, says he has a database with the names of about 500 Australian women who have expressed preliminary interest in the procedure.

Hanafy says that if a healthy baby is born to one of the Swedish recipients, he hopes to begin the procedure in Australia in 2016.

While advocates for womb transplantation say it will enable women without wombs to have the actual experience of bearing a child, Ruby Catsanos, a medical ethicist at Macquarie University, questions what kind of experience this will be.

”It will be a highly, highly medicalised birth, nothing like the highly romanticised idea of pregnancy that many young women have,” she argues. ”They can’t attach the nerves, so the womb itself will be numb. The women will have … IVF, a caesarean birth, and even between all that, there will be constant monitoring.”

The Australian connection 

The idea of trying to make womb transplants a reality actually came from one of Brannstrom and Hanafy’s former patients in Adelaide, a 26-year-old businesswoman they refer to as Angela, who lost her womb, and later her life, to cancer.

”While Mats was talking to her about the need for a hysterectomy and the fact that she wouldn’t be able to be a mother or to carry her own children, she came up with the idea,” Hanafy recalls.

”She said to Mats, ‘Well, why can’t you transplant a uterus? Surgeons do transplants all the time. Why can’t gynaecologists do uterus transplants?’

”The initial thought was, ‘What? This is crazy’,” Hanafy says. But when the two discussed the case later, they realised they had no idea why the operation was off the agenda.

They discovered there had been research programs with animals throughout the 1960s and ’70s, but these had stopped with the birth of the first test-tube baby in 1978.

”I think what happened basically is that IVF came in the late ’70s, and that’s how all gynaecologists basically dropped pursuing uterus transplantation because IVF sorted out 95 per cent or more of the problems of infertility,” Hanafy says.

Ethical and medical issues 

It’s not just the emergence of IVF that put womb transplant out of the picture for nearly 30 years, however: the ethics are unusually problematic.

”This isn’t a life-saving transplant. It isn’t the same as a heart, lung, liver or kidney transplant,” argues Neil Huband, a spokesman for the Uterine Transplant UK, which is trying to raise money to carry out a similar trial in Britain.

Both the UK womb transplantation team and Turkish plastic surgeon Dr Omer Ozkan – who performed a transplant in 2011 on a woman whose foetus later miscarried – favour using deceased donors to minimise surgical risks. As deceased donors aren’t related to the recipients, this usually means heavier doses of immunosuppressant drugs, which are associated with lower birth weights and premature delivery.

But Huband points out that by putting the woman donating a womb through a major operation (as well as the woman receiving one), Brannstrom effectively doubles the risk.

”If we can find matched recently deceased donors, that is a big risk that we can remove,” he argues.

Live donors are also usually much older. As well as the five mothers, Brannstrom took one womb from a recipients’ older sister, another from an aunt, one from a mother-in-law and one from a family friend.

Brannstrom’s youngest donor, the sister, was 37. But the rest were all over 50, and the oldest was 62.

This has a less serious impact on the viability of the womb than you might think; all seven remaining wombs are now menstruating normally. But it does make the donor less able to withstand such a serious operation.

One 58-year-old donor developed a fistula between her ureter and her vagina, meaning she had to have a second round of surgery.

Looking towards the future

Dr Rebecca Deans, who works with MRKH patients at Sydney’s Royal Hospital for Women, doubts whether Kristen Male will be able to receive the operation as early as 2016, as she and Hanafy hope.

”I still think we’re a long way from this as a standard care for women,” she says. ”It’s not an operation we would take lightly, and it’s not an operation without risks. I think it’s very early days.”

She argues that even if one or more of the Swedish recipients manages to produce a healthy baby, it will take years before doctors will know if the blood flow to the foetus through the transplanted womb was good enough to ensure normal development, or what the long-term impacts of the immunosuppressant regime will be.

Hanafy says while the old immunosuppressant drugs given to transplant recipients could cause other health problems, the drugs being used now are so safe they are ”almost side-effect free”.

However, he acknowledges that women having babies after a womb transplant may experience more complications during their pregnancies than other women, and their babies may be smaller.

Studies of European women who have had babies after receiving organ transplants, such as kidney and liver transplants, show that they have a slightly increased risk of complications, including pre-eclampsia, premature birth and their babies being small for gestational age.

Still, Deans does not think any of these issues will deter any of the MRKH patients she treats from volunteering for the operation.

”They’re young, and they’re desperate and they want to have a baby,” she says. ”Young women who want to have a baby will do almost anything.”

Male wants to experience carrying a child in her own body, to feel it grow inside her. ”Giving a child life is one of the most amazing things that the female body is meant to do,” she says.

Indeed, Brannstrom argues that for the women who successfully received new wombs, the experience has already been life-changing. ”Some of them are 30 or 32 and they’ve never had a period before, and they think it’s so fantastic,” he says. ”They say, ‘Now I feel like a real woman’.”