Infertility, or the inability to reproduce, has major social and psychological consequences for couples who want children. As many as 25 percent of couples experience childlessness following one year of contraceptive-free intercourse. In the majority of cases, factors from both the man and woman contribute to infertility of the pair, but in 30-50 percent of couples, a determining factor from either partner can be identified1. While various acquired causes—including smoking and higher maternal age—have been identified, a small number of women are infertile as the result of a uterus not compatible with childbearing, or the complete absence of the uterus from birth.
In February of this year, a transplant team at the Cleveland Clinic performed the first uterus transplantation in the United States, aiming to help this group of women. The nine-hour surgery was performed on a 26-year old woman who was unable to conceive because she was born without a uterus. This condition, known as Mayer-Rokitansky-Küster-Hauser syndrome, affects an estimated 1:4,500 newborn girls and results in absolute infertility.
The procedure, as performed by the Cleveland team, follows the death of a consenting and eligible donor. The donor uterus is cooled to preserve function and removed from the donor. After a few hours outside the body, the uterus is transplanted, restoring blood flow through the organ. Immunosuppression is required to prevent rejection of the transplanted uterus. Unlike other transplants (kidney, liver, heart and lung), the uterus can be temporarily transplanted and removed when the woman has successfully delivered her children. After removal, immunosuppression can be stopped.
In this first Cleveland Clinic case, the procedure proved unsuccessful, leading to the forced removal of the transplanted uterus. The patient is said to be in good health, though obviously disappointed by the loss. The medical team reported on April 8th that they believe the complication was infection-related. This first transplant marked the initiation of a clinical trial set to include 10 women with uterine factor infertility.
The Cleveland Clinic transplant was not the world’s first. Sahlgrenska Hospital at the University of Gothenberg in Sweden reported the first successful birth following a uterus transplant in 2013. To date, this center has reportedly performed nine uterus transplants that have resulted in five healthy live births. Contrary to the Cleveland Clinic’s first transplant, the Swedish group makes use of live donors, which offers the benefit of being able to plan the transplant procedure instead of having to rush to transplant when a deceased donor becomes available. Saudi Arabian (2000) and Turkish (2011) teams have also attempted the procedure, but both were unsuccessful in achieving live birth.
Dr. Andreas Tzakis, the lead transplant surgeon at the Cleveland Clinic, says that his team “won’t be celebrating until a transplant results in the birth of a healthy baby to a healthy mother.”3 While this new technique presents a new frontier in reproductive health and transplant surgery, it is not uncontrPrgeoversial. The technique brings significant risk and costs for a non-life-threatening condition, where alternatives like adoption are available. It does, however, offer the only option for pregnancy and childbearing in women with uterine factor infertility.
1 U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), Assisted Reproduction Technology Success Rates (2011), National Summary and Fertility Clinic Reports, December 2013 at http://www.cdc.gov/art/ART2011
2 Brännström M, Johannesson L, Bokström H, Kvarnström N, Mölne J, Dahm-Kähler P. Livebirth after uterus transplantation. Lancet. 2015 Feb 14;385(9968):607-16.doi: 10.1016/S0140-6736(14)61728-1
Image courtesy of http://www.kidspot.com.au/