The ethical issues surrounding uterus transplantation touch upon fundamental questions about views on fertility and parenthood as well as on medical progress. These conceptions are not the same the world over and the diversity of moral, religious and philosophical values in different groups will probably mean that uterus transplantation in human beings is accepted in some societies/cultures but rejected in others.
The research project at the Sahlengrenska Academy and the Sahlgrenska University Hospital has had the aim of shedding light on all aspects of the transplantation procedure. In addition to comprehensive research, the ethical perspectives have been carefully debated and evaluated, among other things by the Regional ethics board in Gothenburg, whose approval is a precondition for the entire project.
The ethics board, which is composed of both researchers and representatives of the public, gave its go-ahead to the study on May 7, 2012.
One prerequisite for transplantation in human beings is successful results in several animal species, including human-like species, in order to replicate the operation on humans as closely as possible. This is also recommended in the ethical guidelines for uterus transplantation which have been made public by FIGO (the International Federation of Gynecology and Obstetrics).
Several different occupational groups should be involved in the transplantation process, which places considerable demands on the hospital performing the transplantation. Before the transplantation, experienced psychologists and counselors participate in the examination of potential recipients and donors.
Specialists in reproductive medicine evaluate the patient/recipient and her partner before the transplantation to ensure that the conditions have been adequately fulfilled for a future pregnancy. The surgical operation itself is performed by gynecologists who are specially trained in pelvic surgery as well as by transplantation surgeons.
After the operation, specially trained pathologists and transplantation surgeons assess how the uterus is being accepted by the recipient’s body and thereby assist the transplantation physician in properly adjusting the medication which the patient takes to prevent the uterus from being rejected by the body’s immune defense. The obstetricians, both within the maternity ward and in the delivery ward, are experienced in pregnancies among transplant patients and high-risk deliveries.
The members of the team surrounding the patient have worked together for a long time to ensure that there are sufficient resources and commitment on hand for taking care of the donor, the recipient, her partner and their future child for many years to come.
It is important that the risks associated with a uterus transplantation be identified and clearly defined before the first human transplantations are performed. Established strategies for reassessing the risks that have been identified should be included in the research protocol for human uterus transplantation.
The benefits of a uterus transplantation should outweigh the risks associated with the surgical intervention. As far as the transplantation of a uterus is concerned, four people are involved: the donor, the recipient, the partner of the recipient, who is also a parent-to-be, and the future child.
The donors of a uterus ought to have given birth to children of their own, which demonstrates that the donor uterus can sustain a normal pregnancy. She should also have reached an age where she has no further desire for children and no further possibility of a pregnancy exists. This means that the living donor of a uterus is in most cases older than 40 years of age. The advantage of having a close relative (mother, maternal or paternal aunt) as a donor is that the probability of organ rejection is thereby reduced.
The surgeons who perform the intervention are very well trained and have many years of experience. It is nonetheless important that the donor be informed of the risks that such an operation may entail, and that her grasp of the potential risks be assessed during repeated conversations before the donation occurs.
Doctor’s visits before and after the donation should be offered and carried out by physicians/psychologists having previous experience with transplantations. These doctors/psychologists should be kept apart from those who take care of the donor. The most common organ donations from living persons are kidneys, with excellent results being achieved after donations from close relatives.
Before the operation, in most cases the recipient receives psychological counseling. The recipient and her partner must understand the procedure, the associated risks and the need for monitoring in order to prevent organ rejection. The risk that the recipient might fail to follow the prescription of medication she receives must be assessed in each individual case.
The recipient should also be informed about the risks associated with the use of immunosuppressant medications in general, with the increased risks of certain virus infections and malignancies after many years of treatment. Risks are associated with the particular type of immunosuppressant medication that is used and with how long it is used.
With uterus transplantation we expect that the transplanted organ will be surgically removed within three years and that as a result these risks will be drastically reduced.
The risks for the fetus/the potential child needed to be carefully assessed. Previous studies indicate no increased risk for the fetus during pregnancy when the mother takes immunosuppressant medication. Among mainly women who have undergone a kidney transplant it has been observed that the children are born somewhat earlier than is normal and that the risks of pre-eclampsia (pregnancy poisoning) have been elevated. But in pregnancies among these women before transplantation and medication with immunosuppressants, there was a similar increase in the number of these complications, which could result from the woman’s underlying illness and not from the immunosuppressant medication’s having caused this elevated risk. The long-term effects of the fetus’s exposure to immunosuppressant medication have not yet been fully clarified. Many planned pregnancies today are associated with the increased risk of fetal injuries and complications. As examples one can cite congenital malformations and complications during delivery in connection with pregnancies among diabetics.
The risks are always weighed against the parents’ desire for children. In situations where unforeseen problems arise during a pregnancy following a uterus transplantation, the health of the mother should be given priority.