Womb transplant marks birth of new legal and ethical dilemmas
Fertility medicine made a leap forward 10 days ago when a Swedish obstetrician announced the first birth of a baby from a transplanted womb, but specialists in Boston say such operations are unlikely to become commonplace anytime soon.
Although the birth opens exciting avenues for exploration, there are complex ethical and legal considerations surrounding the transplantation of a uterus from one woman’s body to another, as well as high costs that no insurer is likely to pay, they said.
And in much of the United States, including Massachusetts, women have a safer, less expensive option.
“It’s exciting news, but I think it would be considered very developmental in its stage of experimentation,” said Dr. Thomas L. Toth, a reproductive endocrinologist who heads the in vitro fertilization unit at Massachusetts General Hospital.
“I think that we’re going to be very interested in learning more and seeing more of the results coming from this group,” Toth said of the Swedish researchers. “At the MGH, we don’t have a trial anticipated in short term, but we’re watching very carefully.”
The Swedish doctors who pioneered the transplantation technique say that the baby born prematurely but healthy last month could be the start of a new wave, with two more women who became pregnant after womb transplants due to deliver in the next few weeks.
‘‘It means a lot to me that we are able to help patients who have tried for so long to have families,’’ said Dr. Mats Brannstrom, a professor of gynecology and obstetrics at the University of Gothenburg, who led the project that brought about last month’s pioneering birth. ‘‘This is the last piece of the puzzle in finding a treatment for all women with infertility problems.’’
Brannstrom predicted there would soon be many more babies born to women who have received donated wombs in countries where doctors are studying the technique, including Australia, Britain, the United States, Japan, and China.
Toth, at MGH, was far more cautious, saying that the birth in Sweden was an exciting development but that one successful birth would not quickly popularize such a difficult and controversial procedure.
“This opens up more discussion about the possibility, although there are many hurdles that would still have to be addressed,” he said.
Dr. Antonio Gargiulo, a specialist in infertility and reproductive surgery at Brigham and Women’s Hospital, where surgeons have pioneered complex transplants of faces and arms, said he is confident that he and his colleagues could overcome the technical aspects of a womb transplant, but they still face major ethical issues.
Gargiulo said doctors must consider the safety of the donor, if a live donor is used; of the recipient; and of a potential fetus.
A live donor would have to undergo a radical hysterectomy, he said, which would remove a larger portion of the tissues surrounding the uterus than in a typical hysterectomy, so that those tissues could be connected with tissues of the recipient.
Such a surgery could cause excessive bleeding or injury to the bowel or the ureters, he said, and could lead to an infection that could develop into sepsis.
“It’s a major abdominal surgery,” he said.
There would be similar risks for the recipient, Gargiulo said, who would also require ongoing treatment with immunosuppressants to ensure that her body did not reject the transplanted organ, increasing her risk of cancer.
Finally, any fetus in the transplanted womb would be in potential danger because of the risk of rejection for the transplanted organ and the difficulty of properly connecting the complex web of blood vessels that support the uterus, which could affect the formation of the placenta.
“There are major doubts,” Gargiulo said.
He said it would be difficult for any team of surgeons in the US to convince a hospital ethical committee that the potential benefits are greater than the risks and that the hospital would be legally protected if something went wrong.
The costs of a womb transplant are also daunting, he said, and could run as high as $300,000 in the United States.
Toth and Gargiulo both said that women in much of the US who are unable to carry a child don’t require womb transplants to become mothers because they have access to surrogacy, in which a gestational carrier, or surrogate mother, is implanted with an embryo created through in vitro fertilization using the sperm and egg of the prospective parents.
Gargiulo said a womb transplant was appealing to women in Sweden in part because in that country and throughout Europe, paid surrogacy is illegal.
“The big Atlantic divide on this issue is an issue of ideology, of what people think is right to do about gestational carriers,” Gargiulo said. “Some people in Europe feel very strongly that . . . it’s something that is medically and really ethically wrong.”
Despite his reservations, Gargiulo said, the successful birth is a game-changing development that has renewed interest among his colleagues.
Since the summer of 2013, Gargiulo has met twice to discuss issues around womb transplants with Dr. Stefan G. Tullius, chief of the Division of Transplant Surgery at Brigham and Women’s, and Dr. Neil Horowitz, director of clinical research in gynecologic oncology at Dana-Farber Cancer Institute.
Now, he said, the trio plans to meet soon with doctors from the Brigham’s division of maternal fetal medicine to continue the conversation.
In Sweden, Brannstrom is continuing his pioneering work with an attempt to grow a womb in the laboratory. That involves taking a womb from a deceased donor, stripping it of its DNA, then using cells from the recipient to line the structure. He has started preliminary tests in animals and estimated it would be another five years before the technique can be tried on humans.
While that may sound like science fiction, the techniques that led to the birth announced Oct. 3 also sounded outlandish just years ago.
‘‘It makes what was formerly impossible possible,’’ said Dr. Nannette Santoro, chair of obstetrics and gynecology at the University of Colorado, who was not involved in Brannstrom’s research.
The happy couple in Sweden named their son ‘‘Vincent’’ — which means ‘‘to conquer’’ — to celebrate a victory over their difficult journey to parenthood.
Welcoming an Associated Press reporter into her home, the mother cradled her sleeping baby in a spotless, stylish kitchen where an errant pacifier on the counter was one of the only clues that a newborn was around.
She said she still could not believe she is a mother, after discovering at 15 that she had no womb and being told that she would never carry her own children. Now 36, she was one of nine women to receive a transplanted womb last year in a ground-breaking trial led by Brannstrom.
The mother spoke on condition the exact location of her home not be revealed; she would not be named because she does not want her son to become a target of publicity.
She and her husband said they haven’t quite figured out how they will tell their son that he made medical history once he’s older.
‘‘We will show him all the articles that were written and tell him everything we went through to get him,’’ she said. ‘‘Maybe he will be inspired to become a doctor.’’