From the history of the issue
Over the past hundred years, medicine has not only stepped forward, it has literally soared to previously unimaginable heights.
Just think - the first human-to-human organ transplant was performed less than 100 years ago, in 1933. The first kidney successfully changed hands in 1954 when, thanks to J. Murray, one twin brother shared his kidney with the other. 2 years later, in 1956, Thomas Starzl successfully transplanted a liver, and 10 years later, Christian Barnard performed the first successful heart transplant. In 1983, doctors learned how to transplant lungs.
Why did research into the possibility of uterus transplantation begin only at the end of the twentieth century?
It’s simple: if a person cannot live without a heart, liver, lungs, at least one kidney, then without a uterus this is quite possible; it is not a vital organ. And it is located in such a way that it is difficult to carry out the operation. And the functions of this organ are very complex: not only does the uterus need to take root, it is necessary that a human embryo can develop normally in it.
Therefore, when in 1998, in one of the Gothenburg hospitals, a patient with a uterus removed due to cancer asked doctors about the possibility of transplanting a new uterus to her, doctors perceived her idea as completely crazy. But after a year, research was very active. And last year, 2020, the first child born in a transplanted uterus was born in Sweden.
9 women were selected for the first operations. All donor organs were obtained from living donors, 5 of whom were mothers of recipients, the rest were relatives or friends. 2 uteruses had to be removed soon, as complications began. The first mother was a Swedish woman who received a uterus transplant from her close friend. The baby was born at 31 weeks via caesarean section. The baby weighed only 1800 g, but immediately screamed and was quite viable. After 10 days, the happy mother and baby were discharged home; the child is developing normally.
By the end of 2020, Swedish doctors expect several more children to be born. Another woman with a transplanted uterus underwent an IVF procedure in Turkey, and the pregnancy has so far proceeded without any particular complications. UK doctors have received permission to perform a uterus transplant, and preparations are underway for similar operations in the USA. They even say that in a few years the uterus will be able to be transplanted not only into women, but also into men.
The main difficulty lies in the peculiarities of the blood supply to the uterus, and the fact that during pregnancy it should increase significantly in size. The transplant operation can last from 6 to 12 hours.
Uterus transplantation in Russia and in the world
Among the countries where uterus transplants have ever been performed, Sweden today leads the way. To date, eight organ transplants have been performed in this country with successful pregnancy and birth of a child. Following the Swedes, successful uterine transplantation operations were carried out by Turkish specialists. American doctors and scientists from Saudi Arabia subsequently joined research in this direction.
In addition to these countries, the UK also currently has a license for uterine transplant operations.
Uterus transplantation is not currently performed in Russia. There are no clinical sites or specialists who could perform this procedure.
In Russia, not a single uterine transplant has been performed yet. Russian doctors approach this issue cautiously and believe that it is initially necessary to study all the possibilities of dangerous complications of such a complex and risky procedure. Nevertheless, the beginning of research into the problems of uterus transplantation is included in the immediate plans of Russian scientists, since the number of women in need of such an operation is quite large.
More than 30 uterus transplants have been successfully completed worldwide, including in Brazil, China, the Czech Republic, Germany, Sweden, India, Saudi Arabia, Turkey, and two clinics in the United States.
Who may need a uterus transplant?
According to statistics, more than 15% of married couples suffer from the inability to give birth to a child. The opportunity to realize themselves as parents is very limited for them: only through surrogacy or adoption. But surrogacy is prohibited in many countries, and where it is allowed, many moral, ethical and legal difficulties still remain. Adoption is also not for everyone. Thus, a uterus transplant can give the happy opportunity of motherhood and fatherhood to hundreds of people, including:
- women with congenital underdevelopment or absence of the uterus (Rokitansky-Klostner syndrome);
- women whose uterus was removed due to the development of cancer or complicated childbirth;
- transgender people who want to gain not only the external characteristics of a woman, but also her functional capabilities for procreation.
Notifications
— Can health complications arise in connection with the transplant itself?
- Certainly. Since the recipient's immune system should not reject the donor organ, the woman must constantly take immunosuppressants, and this is fraught with many problems. Immunosuppressive therapy makes it difficult to conceive. For the same reason, the donor uterus is removed when it has completed its function. And, of course, uterus transplantation is inseparable from the IVF program - a woman will not be able to get pregnant naturally.
- What is the alternative?
“You can take a less dangerous path, that’s what surrogacy is for.” And here we see completely different results: over 10 years of work, about 8,000 IVF cycles with surrogacy were carried out, this is data from the Russian Association of Human Reproduction (RAHR), 3,023 pregnancies occurred, 2,386 of which ended in successful births. If we take statistics only for the Chelyabinsk region, 49 children were born under the surrogacy program in 2020.
— Why then are some countries fighting so hard for transplantation? Maybe we shouldn’t “reinvent the wheel”?
- It's all about legislation. Today, in 15 countries around the world, including Sweden and the UK, where these programs were first implemented, surrogacy is either prohibited or is only possible on a non-commercial basis using the services of relatives. It is not surprising that in those countries where there is a legal ban, doctors are trying to find workarounds. More knowledgeable patients, of course, go to Eastern Europe, where surrogacy is legal: Russia, Kazakhstan, Belarus and Ukraine.
— But many women have many myths and fears associated with surrogacy, how objective are they?
— All these myths mostly came to us from television series. There is bound to be someone blackmailing someone, the surrogate mother is burning with love for the child, and the genetic parents are afraid that the baby will have someone else’s genes. By the way, the latter is absolutely impossible. The child inherits the material of two cells of genetic parents; the blood of the mother and fetus does not mix during pregnancy. Therefore, the influence of the surrogate mother on the child’s genes is absolutely excluded. Of course, this does not exclude the fact that she should eat right and lead a healthy lifestyle.
As for fears associated with ethical and organizational issues, in Russia since 2011 there has been Article 55, which obliges the conclusion of a bilateral agreement between the genetic parents and the surrogate mother, which must be signed by a lawyer. Based on this document, the surrogate mother provides services for bearing a child, that is, this is her work, for which she receives a decent remuneration. A child’s birth certificate is issued by a lawyer in the name of the genetic parents directly in the maternity hospital. In my practice, there has not been a single case where a surrogate mother somehow offended the genetic parents. Therefore, all fears are nothing more than the director’s intention in the movie.
Who can be an organ donor?
In Sweden, as already mentioned, relatives of female recipients became donors. According to doctors, this reduces the risk of developing a rejection reaction. Age is not important, the donor can be a woman in menopause - if only the uterus is healthy.
In the United States, it is believed that an operation to remove the uterus for subsequent transplantation poses an excessive danger for a living donor, so they consider it more justified to use dead donors - women who are brain dead, but whose heart continues to function. True, so far only one uterus transplant has been successful in the United States, and it was from a living donor. And wombs transplanted from deceased donors had to be removed due to the development of infection.
In Saudi Arabia, transplanting organs from dead bodies is prohibited by religion, so only living women can be donors there - as a rule, they are older relatives.
In Turkey, a successful transplant was performed using the uterus of a deceased woman.
Contraindications to uterus transplantation
A woman who has become a uterus recipient is then forced to take special medications for life, namely immunosuppressive drugs, to suppress the immune system in order to avoid rejection of the donor organ. Often, after a successful transplant has been carried out, and then the woman has carried and given birth to a child, the donor uterus is removed, precisely in order not to take immunosuppressive drugs in the future.
There can be many contraindications to uterine transplantation, ranging from age to serious chronic pathologies.
In general, contraindications to organ transplantation include:
- hemophilia;
- inability to undergo general anesthesia for one reason or another;
- various blood-borne diseases such as hepatitis viruses, AIDS, etc.;
- some parasitic diseases such as leishmaniasis, toxoplasmosis, etc.;
- certain somatic diseases (diseases of the blood, cardiovascular system, formations of a malignant nature, mental disorders, etc.);
- and much more, which will be determined during the examination by the attending physician and other specialists who intend to take part in the transplantation.
How does conception occur after uterus transplantation?
There is no talk of conception immediately after the operation. The transplanted organ is monitored for a year, or even longer, and optimal doses of immunosuppressants and immunosuppressants are selected to reduce the risk of rejection. If the organ has taken root, after a few months menstruation may begin and a menstrual cycle may be established.
But eggs still cannot enter the uterine cavity, since the fallopian tubes do not connect to it. This means that conception can only occur artificially - using in vitro fertilization methods.
Eggs are taken from the woman before transplantation, and the embryos are stored frozen.
Evidence shows that embryos do not take well to a transplanted uterus compared to their own, so several attempts may be required.
How does pregnancy proceed with a transplanted uterus and how does childbirth occur?
It is very likely that pregnancy will be terminated at 6-8 weeks: this is exactly what happened to Turkish women who were the first to try to carry a child with a transplanted organ. In addition, the risk of developing preeclampsia, a severe pregnancy complication that develops against the background of a significant increase in blood pressure, increases. This is likely due to taking medications that suppress the immune system, although this connection has not been proven and is only being studied. However, immunosuppressants must be taken all the time, otherwise organ rejection may occur.
The baby is born by caesarean section. At least for now. Although in the future, it may be possible not only to give birth naturally, but also to conceive naturally. To this end, research is being conducted into the possibility of transplanting not only the uterus, but also the entire complex of reproductive organs - the uterus along with the fallopian tubes and ovaries.
After childbirth, it is better to remove the transplanted uterus so that you can stop taking immunosuppressants, which are not at all indifferent to the body.
