Put on someone else’s uterus, give birth to your own child, and then remove it

This article was written by carollero

Transplanting a woman’s uterus into another woman’s body for normal fertility–sounds like a sci-fi plot, but is being used in reality gradually realized.

February 17th, a French hospital announced that it had given birth to the first patient in France to conceive from a transplanted uterus. Birth of a baby. [1]

Two years ago, this man was born withMüllerian hypoplasia (Mayer-Rokitansky-Küster-Hauser syndrome, MRKH), who received a uterus transplant from his mother.

Last July, when the epidemic in France eased and the city lifted the lockdown, the hospital implemented medically assisted reproduction for her. Successfully had a baby through my own body.

Get someone else

This is not the first transplant in the world The uterine birth case, the earlier story happened 7 years ago.

In October 2014, the Swedish Central Radio 4 announced that the University of Gothenburg, Sweden, successfully completed the delivery of a transplanted uterus , aroused a burst of attention in the medical field.

Just a year ago, this 35-year-old woman with congenital uterine loss received a Uterine transplantation in aged women.

hysterectomy animation

Source: Cleveland Clinic YouTube account

On the 43rd day after the transplant, the recipient had her first menstrual period, and this menstrual period lasted between 26 and 26 The regular cycle of 36 lasted for one year. Then the doctors made a bold attempt —they decided to perform the first single embryo transfer for the 35-year-old woman, allowing her to become pregnant .

After embryo transfer, the patient received three immunosuppressive treatments, including tacrolimus. , azathioprine and corticosteroids, good anti-rejection effect. Throughout pregnancy, fetal growth parameters, as well as uterine arterial and umbilical cord blood flow, were at normal levels.

At 31+5 weeks of gestation, this patient was diagnosed with “preeclampsia”. The next day, the fetal cardiogram was abnormal and the patient underwent an emergency caesarean section. Fortunately, a healthy baby of 1775g was delivered successfully with an APGAR score of 9, 9, 10. [2] This delivery, successfully demonstrated the effectiveness of this technology in the treatment of complete uterine factors Infertility (Absolute Uterine Factor Infertility, AUFI)This matter has considerable prospects. However, we all know that even after uterine transplantation is proven effective, six years later, the technology is still unknown to most people. In China, there is no specialized institution for such transplants, and there are even fewer cases of surgery. What is ‘holding back’ a uterus transplant? Before we discuss uterine transplantation, let’s take a look at the history of this technology. In the 1960s, some researchers used 18 non-pregnant bitches to perform a combined “uterus + ovary” transplantation, and then through vaginal smears and other tests, confirmed the The two transplanted organs can still maintain their original functions. Since then, 3 female dogs have successfully conceived, and 2 have successfully delivered pups. [3] Under the experiment of scientists, mice, rabbits, sheep, pigs, and non-human primates have all completed the uterus. Transplanted pregnancy and childbirth. Since then, human uterine transplants have been put on the agenda. In 2000, the first human uterus transplant was performed in Saudi Arabia. The recipient had a hysterectomy following a postpartum hemorrhage 6 years earlier, and the donor was a 46-year-old woman with Polycystic Ovarian Syndrome (PCOS). During the procedure, the doctor places the new uterus in the place of the recipient’s original uterus, which is attached to the vaginal fornix and additionally secured by shortening the uterosacral ligament.The uterine artery and vein use the reverse segmental extension of the great saphenous vein, and then connect to the external arteries and veins, respectively. Postoperatively, the patient received oral immunosuppressant for anti-rejection, and combined estrogen and progesterone therapy at the same time, and the treatment response was good. Postoperative Doppler ultrasound image of recipient uterine arterySource: Reference 4However , After surgery, doctors found that the donor’s left ureter was damaged. The doctor judged that the ureter was very close to the uterine artery, so improper operation during hysterectomy caused damage to the ureter. Two misfortunes, 99 days after the transplant, the recipient also had problems. An acute thrombosis developed in the blood vessels of the recipient’s new uterine body, which caused the embolism, necrosis of the entire uterus, and the doctor had to perform a hysterectomy for her. [4] Obviously, at that time, whether it was for the donor or the recipient, and whether it was the separation/stapling operation, postoperative Anti-rejection and other technologies themselves, or the level of doctors’ operation, seem to be immature. In terms of “high difficulty, high risk, and low success rate”, all organ transplants are the same. Only the operation of uterine transplantation itself, including preoperative and intraoperative immunosuppressive drugs, donor uterus acquisition, donor uterus – A series of extremely complex and challenging procedures such as graft vascular anastomosis between recipients and graft fixation in situ. [5] First of all, the separation and removal of the uterus is related to the normal life of the living donor after surgery and the The functionality of the transplanted uterus requires extremely high precision, and the operation is cumbersome. Detailed surgical procedures include the separation of the uterus and its vascular pedicles (bilateral uterine arteries, veins, and part of the iliac vessels), partial circular Preservation of ligaments, uterosacral ligaments, and extensive vesicoperitoneum, resection of bilateral fallopian tubes, and separation of the pelvic sidewall (analysis of ureters and their connecting tissue), preservation and resection, etc. [5] patients with uterine transplantation Source: Reference 6Secondly, according to relevant studies, the contractile activity of transplanted uterus is related to the concentration of cryoprotectant. Therefore, lavage and preservation of isolated uterus Important factors affecting the success of uterine transplantation. The most commonly used method for preserving uterus in clinical practice is low temperature and preservation solution. There is no consensus on the lavage height of the isolated uterus and the most suitable preservation solution for the isolated uterus, which needs to be further studied, which increases the uncertainty and risk of transplantation. [5] In addition, like other transplants, the operative process of uterine transplantation is generally more than 8-10 hours. Prolonged general anesthesia also greatly increases the risk of organ damage, infection, bleeding and other risks. [5] For this reason, every step in the technological development of uterine transplantation can be called “in the wind and rain.” Forge ahead.” Image source: Graphworm CreativeHowever, if the uterus transplant surgery is only attributable to the slow development The technical difficulty seems to be unreliable. Because in the following 20 years of medical development, liver transplantation, kidney transplantation, lung transplantation, bone marrow transplantation, etc., are all transplant operations with high technical difficulty.< strong>However, the volume of these operations is increasing year by year, which is far greater than that of uterine transplantation: why is the development of uterine transplantation so slow? Among them, there is another reason to be concerned: other transplants are life-saving organ transplants, while uterine transplants are for patients to achieve pregnancy and pregnancy. Purpose of Pregnancy – Ethically speaking, their starting point is different. Today, Lilac Garden invited Associate Professor Ma Jun, School of Public Health and Management, Chongqing Medical University< span>. Hopefully, an ethical perspective can be provided.

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• Secondly, it isthe conflict between patient rights and donor rights strong>: In the process of realizing their reproductive rights, the patient is actually harming the (living) donor’s right to life and health to some extent;

• Furthermore, there will bethe conflict between the rights of patients and the rights of children:Whether the use of anti-rejection drugs will adversely affect the physical health of the offspring, and whether the patient’s psychological rejection of the transplanted uterus will affect the acceptance of the offspring;

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• increasing the problem of illegal organ trade : Taking the illegal trade of organs as an example, because the uterus is not a necessity for survival, will it bring individuals without reproductive needs to be forced by some The reason is the donor of the uterus. On the other hand, the illegal transplant market may be larger, which may lead to some disguised exploitation, women’s rights, social and public security and other issues.

4. Some other transplant operations in China have been relatively mature, and uterine transplants are rare. What do you think are holding back the development of this technology? In other words, what do you think are the reasons that hinder the promotion of this type of surgery? Currently, uterine transplantation in China is really not mainstream, and technical difficulties are one of the reasons, but for this part, it is only a matter of time to overcome. If you want to say what is “impeding” the popularization of this surgery, on the one hand, uterine transplantation is still a “non-life-saving” organ transplantation, There are other ways to raise children and enjoy family happiness, in other words, not All AFUI patients have an urgent need for uterine transplantation; On the other hand, as mentioned earlier, the Multiple rights conflicts and ethical disputesmake medical staff take a cautious attitude when developing this technology. 5. In your opinion, what other issues should we pay attention to in the development of uterine transplantation? The progress of medical science and technology is a double-edged sword, which can bring about some problems while benefiting mankind strong>. We need to predict the ethical issues that may be faced by uterine transplantation in addition to technical difficulties, so as to prevent them from happening, and avoid these ethical issues. For example, we need to think about:< ul class="list-paddingleft-1">

• Provide the rights of women in uterus and ensure the health of offspring and equity?

• Criteria for determination and exclusion of recipients? recipient’s rights?

• How to maintain social justice and order?

All of these should be paid attention to in the development of uterine transplantation, not just technology. (Content review: gyouza)Acknowledgments: This article was approved by Zhong Zixing, an attending physician in the Department of Obstetrics and Gynecology, Zhejiang Provincial People’s Hospital Review

[Note]

Zhong Zixing, Attending Physician, Department of Obstetrics and Gynecology, Zhejiang Provincial People’s Hospital Review comments:

First of all, although the vast majority (75%) of uterine donors are from living donors, mainly relatives of recipients, especially mothers. A quarter of uterine donors are still brain dead. Because brain-dead patients who agree to donate often donate not only uterus, but also other vital organs that sustain life, such as heart, liver, etc. If the uterus is removed before these organs, it may affect the quality of the latter and, more importantly, post-transplant outcomes (heart, liver). [7]

Secondly, compared to other transplanted organs, there are international Accepted priorities for transplantation, butthere are currently no appropriate access, allocation criteria for uterine transplantation—even though uterine transplantation is technically possible to Uterine transplantation to post-transgender women, Whether it is ethically open to genotype XY (male) uterine transplantation(no such attempt is currently made) ? For another example,What age is suitable for entering the waiting list and how many years are removed from the waiting list? Or, 20 years old, uterine dysplasia, 35 years old, previous childbirth and death, and hysterectomy due to postpartum hemorrhage, Who should get the uterus first ? These all need to be addressed in the future.

Finally, there is another special feature of uterine transplantation, which is that after the completion of the transplantation time, it is currently recommended to cut again. So, this is the only transplant with a “shelf life”. [8]

Therefore, in the process of re-excision, this postoperative risk and the resulting ethical issues , and should be fully informed before the initial transplant.

Title image source: YouTube

References:[1].https://www. francetvinfo.fr/sante/hopital/bebe-miracle-une-femme-met-au-monde-un-enfant-apres-une-greffe-duterus_4300895.html[2]Brännström M,Johannesson L , Bokström H, Kvarnström N, Mölne J, Dahm-Kähler P, Enskog A, Milenkovic M, Ekberg J, Diaz-Garcia C, Gäbel M, Hanafy A, Hagberg H, Olausson M, Nilsson L. Livebirth after uterus transplantation. Lancet .2015 Feb 14;385(9968):607-616.doi:10.1016/S0140-6736(14)61728-1.Epub 2014 Oct 6.PMID:25301505.[3].EraslanS, HamernikRJ, HardyJD.Replantation of uterus and ovaries in dogs,with successfulpregnancy[J].ArchSurg,1966,92(1):9-12. DOI: 10.1001/archsurg.1966.01320190011002.[4]. Fageeh W, Raffa H, Jabbad H, Marzouki A. Transplantation of the human uterus. Int J Gynaecol Obstet. 2002 Mar;76(3):245-51. doi: 10.1016/s0020-7292(01)00597-5. PMID : 11880127.[5]. Wang Lijun, Ma Jun. Ethical dilemma and countermeasures faced by human uterine allotransplantation [J]. Medical Contentiousness 2019(02)[6]. Luis Arturo Ruvalcaba Castell ón, Martha Isolina García Amador, Roberto Enrique Díaz González, Montoya Sarmiento Jorge Eduardo, César Díaz-García, Niclas Kvarnström, Mats Bränström JBRA Assist Reprod. 2017 Apr-Jun; 21(2): 126–134.doi: 10.5935/1518 -0557.20170028 PMCID: PMC5473706[7].Heidi Mertes, Kristof Van Assche. UTx With Deceased Donors Also Places Risks and Burdens on Third Parties[J].Am J Bioeth,2018,18(7):22-24.[8].Laura O’Donovan, Nicola Jane Williams, Stephen Wilkinson.Ethical and policy issues raised by uterus transplants[J].British Medical Bulletin,2019,131:19-28.