Cleveland Clinic surgeons performed the nation’s first uterus transplant last week; nine more are planned as part of a clinical trial. The goal is to make it possible for a woman with a damaged or missing uterus to become pregnant. This is innovative, skilled surgery. But it does not represent real progress for infertile women.
Transplant medicine can save and improve lives — one of us (Eric) has had a kidney transplant. As a couple, we know firsthand the suffering that infertility can cause and how technology can help. Without in vitro fertilization, we would not have our daughter. We believe that people deserve access to interventions that can help them build families.
Yet the wholly understandable desire to bear a child does not justify the significant risks to mother and fetus posed by uterine transplants, not to mention the enormous financial cost. Safer, less costly, and more certain ways to have children already exist. When it comes to uterine factor infertility, we must ask ourselves: What is more important, the experience of pregnancy or the health of a woman and her future child?
The risks include infection, rejection of the uterus, and miscarriage or stillbirth due to failure of the uterus. A woman would need to have at least three surgeries — the transplant, a cesarean section to deliver the baby, and the eventual removal of the donated uterus. In Sweden, where nine uterus transplants have already been done, the donated uterus was removed in two cases before pregnancy could be attempted because of infection or the development of serious blood clots.
There are also risks to the baby. The child the prospective mother attempts to create will dwell in a temporary womb from a dead donor in an immunosuppressed body. Of the four babies born in the Swedish trial, all were premature. Since none of the babies are more than 1 year old, we don’t yet know whether the procedure carries any long-term risks for them.
There are ethical issues to consider as well. The woman isn’t the only subject of these experiments — the embryo and fetus are, too. We must determine what protections each of them is owed.
The concept of clinical equipoise says that genuine doubt must exist about whether a new treatment is safe and effective when compared to existing alternatives before enrolling individuals in a clinical trial. For women with uterine factor infertility, these alternatives include foster care, adoption, and gestational surrogacy. Since rearing genetic offspring is imperative for many parents, we’ll consider only surrogacy here.
Surrogacy can be legally, ethically, and emotionally complex. But it is clearly safer for both mother and child than pregnancy following a uterine transplant. Surrogates are generally healthy women who have successfully given birth already. The risks to the surrogate and the child are those usually associated with normal pregnancy and birth.
Dr. Andreas Tzakis, the surgeon leading the Cleveland Clinic uterine transplant trial, told the New York Times that uterus transplants are ethically superior to surrogacy because surrogacy “possibly exploits poor women.” Although the possibility of exploitation exists, it is inaccurate and unfair to suggest that surrogacy in the United States often leads to exploitation. Research shows that American women willingly and happily act as gestational surrogates. These surrogates are often paid for their services — like the Cleveland Clinic transplant team — but that doesn’t make the arrangement unethical.
In some countries, legal barriers prevent couples from turning to surrogates. Why wield a scalpel to surmount those barriers? A woman should not have to risk her life or the life of her fetus when surrogacy has proven to be an effective way to have genetically related children. Instead, it would be prudent to repeal such laws and put in place common-sense protections for surrogates, intended parents, and prospective children, as several US states have done.
If a uterus transplant could save a woman’s life, or if it really were her only way to have a child, then the risk and the cost — possibly as much as $300,000 — might be worth it. But uterine transplantation is not done to save a life, and it is far riskier and costlier than gestational surrogacy, a fact that insurers will surely recognize should they be asked to cover the transplants.
Uterine transplantation may be the newest and most experimental way to become a mother, but it is not the best way. A woman contemplating uterine transplantation must ask herself whether her wish to carry a child is more important than what comes after — being a parent.
Eric Trump teaches bioethics at Vassar College and is writing a book about transplantation. Josephine Johnston is director of research and a research scholar at The Hastings Center, a bioethics research institute in Garrison, N.Y., where she works on ethical, legal, and policy issues in genetics and reproductive medicine.