Uterus Transplant Faces Technical, Ethical Hurdles

For some, it might seem like a dream come true. For others, it is simply another step toward an ethically disquieting "brave new world."

Little surprise, then, that one Manhattan hospital's move to perform a uterus transplant has reignited the controversy over this prospective procedure.

A team of doctors, led by Dr. Giuseppe Del Priore of New York Downtown Hospital, has begun screening candidates for the first uterus transplant in the United States.

Such an operation would conceivably offer hope to women who desire to have children but cannot because of past disease or injury. Concerns over risks of the procedure to both mother and fetus, however, outweigh these potential benefits, some say.

But while the public finds itself once again caught up in the ethical dilemma of whether such surgeries should be allowed, transplant experts say that developing the surgery into a reliable technique could take years -- if ever.

"I would certainly say that this is not in the next 10 years," says Dr. Sherman Silber, director of the St. Luke's Hospital's Infertility Clinic of St. Louis.

Another factor that could limit the likelihood that such a procedure will be adopted in the future is that a relatively simple alternative already exists -- surrogacy.

"Gestational surrogacy is a fairly accepted procedure," says Dr. Richard Paulson Director of USC Fertility in Los Angeles, Calif. "The approach of uterine transplant seems doubtful, as this would be technically difficult. It's just not that plausible.

"I am skeptical that this would have a wide application."

The procedure, however, has been attempted -- and arguably completed -- in the past.

In 2002, doctors in Saudi Arabia's King Fahad Hospital and Research Center performed the first human uterus transplant operation.

Doctors transplanted the uterus of a 46-year old woman into a 26-year-old Saudi woman whose uterus had been removed six years earlier.

The woman receiving the uterus took powerful drugs in order to prevent rejection -- a treatment that compromised her immune system. She also received hormone injections to allow the transplanted uterus to develop normally.

After 99 days, blood flow to the transplanted uterus stopped, and the organ was removed. No pregnancy had occurred while the uterus was inside the recipient. Still, surgeons counted the experience as a success.

The procedure has also been carried out in animals, including a Rhesus monkey.

Risks to Mother, Fetus, Could Heighten Controversy

Considering the nature of the procedure, it is no surprise that many find the prospect of a uterus transplant controversial or even objectionable.

However, while the public at large may object to the operation on gut principle, Silber and Paulson note other reasons for concern.

"Something shouldn't be considered unethical just because it is new and shocking," says Silber. He says he is not opposed to the transplant of reproductive organs; he has performed testicular and ovarian transplants in the past.

"But there is no real danger associated with these procedures," he says, adding that the potential risks of uterus transplant procedures render them "dead in the water, as a concept."

"Let's say that this could be done," Silber says. "If you have a rejection anytime during pregnancy, that's an intra-abdominal disaster. The uterus could be rejected while the fetus is still alive."

The course of anti-rejection drugs that a mother would have to take may also pose a risk to a developing fetus.

"After the transplant, the recipient would have to take immunosuppressive drugs," Paulson says.

"Nobody would really want to have a uterus transplant unless they wanted to have a baby. And if the drugs involved prohibit a pregnancy or are dangerous to a baby, it seems to me that the baby would be better off in a surrogate womb."

It is because of these risks to mother and child that many bioethicists suggest that such operations cannot be considered feasible.

"If you intend to bring a baby into existence, you do have the responsibility to think about the circumstances under which it will be born," says Jonathan Moreno, director of the Center for Biomedical Ethics at the University of Virginia.

"Will there be any unanticipated consequences of being raised in a fetal environment of immunosuppressive drugs?" asks Dr. Jeffrey Spike, a professor of bioethics at the Florida State University College of Medicine.

"Might they end up as adults with problems with their own immune systems? Could this leave them prone to cancer, immune deficiencies or autoimmune diseases?"

When the answers to questions about safety and benefit are not yet known, Spike says, "we are in the realm of experimental research, and the ethical concerns become much more explicit."

The Donor Problem

But the controversy could be a moot point -- particularly considering that hypothetically, for every woman who wants a uterus, another woman would have to give hers up.

"Here is the crazy part -- you have to find a donor," Silber says.

And even if a woman can be found who is willing to part with her uterus, he says, the donor must also be genetically compatible.

"In most situations, you can't get an identical twin," he says. "Also, you're unlikely to get a sister who is willing to donate her uterus. She would have to be willing to get a hysterectomy in order to give her uterus to her sister.

"But then the question becomes, why would she give up her uterus?"

As for the 2002 operation in Saudi Arabia, surgeons used the uterus of a woman who had to have her reporoductive organs removed, but whose uterus was still healthy. The New York surgeons say that they would use organs harvested from dead donors for their operations.

But continued problems with compatibility, as well as an unclear picture on risk, could give many surgeons and ethicists alike pause before lending their approval to such operations.

"It is too early for this procedure to be allowed," Spike says. "There is too much that we don't know about its long-term consequences. Hence, it should not be approved."

And as technology adapts over time, it is unlikely that the controversy surrounding this procedure will fade away.

"Every organ has its own cultural symbolism," Moreno says. "For all of us, the uterus is our original home. And there's no place like home."