Proposed uterine transplant sets off ethical debate

News that a team of New York doctors is ready to perform the country's first uterine transplant to help a woman carry a child to term sparked criticism last month that the physicians are moving too fast and that the risks of the procedure -- for mother and child -- could outweigh the benefits.

The transplant was outlined in part in a January Obstetrics & Gynecology article that documented the team's successful retrieval of uteruses from eight brain-dead organ donors whose families specifically consented to the harvesting.

The team, headed by Giuseppe Del Priore, MD, MPH, an ob-gyn and gynecological oncologist at New York Downtown Hospital, would transplant the uterus and wait three months to make sure the organ is functioning properly. If so, a frozen embryo would be transferred and, if all went well, the child would be delivered via cesarean section. At the same time, physicians would remove the uterus.

A human uterus was successfully transplanted in 2002 in Saudi Arabia, but blood clots forced doctors to remove it after three months. Dr. Del Priore's team has successfully performed the transplant in rats, pigs, rabbits and a rhesus monkey. However, leading experts at the Cleveland Clinic and elsewhere have said more animal research is needed before a human uterine transplant is attempted again.

Arthur L. Caplan, PhD, director of the University of Pennsylvania's Center for Bioethics and an expert on the ethics of organ donation, said he believes more animal research is necessary to lower the potential risks to the transplant recipient and the potential child.

The transplant physicians "need to make sure they're clear about an exit strategy if someone gets pregnant but the uterus doesn't function properly," Dr. Caplan said. For example, it raises the question of what would happen if the mother's life is endangered but she insists the doctors proceed in order to save the child. "Since there is a third party involved, [doctors] have to be very clear about how the planning goes."

Carson Strong, PhD, professor of medical ethics at the University of Tennessee College of Medicine, agreed, saying that "concern about the fetus is the debate stopper at present." Fetal growth could be retarded or birth could be premature, he said, and "one could reasonably say, on behalf of such a child, that he or she was wronged by having been created by means of such a risky experimental procedure." In his view, more animal research needs to be done to ensure "the risk of serious handicaps to the child is comparable to the background risks associated with ordinary procreation."

Dr. Del Priore and New York Downtown Hospital officials were no longer granting interviews, but in earlier news reports Dr. Del Priore said that while more research could be done on uterine transplantation, "We think it's absolutely doable."

A hospital ethics committee last month approved the procedure and will re-examine the matter once physicians conclude their process of screening 40 to 50 potential recipients.

The debate brings together two of the most controversial areas of medicine, organ transplantation and reproductive technology.

Previous breakthroughs such as in vitro fertilization, embryo screening, embryonic stem cell research, and hand and face transplants have received similar scrutiny. Like the hand and face transplants, the proposed procedure puts recipients at risk without offering a lifesaving benefit.

Many physicians and ethicists argue that it should be up to patients, once they have been fully informed of the potential risks, to decide whether to proceed. Other observers question how new medical options can alter the social landscape.

Barbara Katz Rothman, PhD, is a sociologist at the City University of New York who has authored a number of books examining childbearing, including Recreating Motherhood.

"Maybe there is some woman somewhere desperate enough that she's begging for this," Dr. Katz Rothman said. "But every single woman who is now in this position has to say, 'I wanted to have a baby by my own body, but not enough to risk this.' It makes it harder for women to just say no and move on."

No shortage of volunteers

New York Downtown Hospital reportedly has already received dozens of calls from women wanting to volunteer for the procedure or even become living uterus donors. That worries Pamela Madsen, executive director of the American Fertility Assn., an advocacy group for infertile couples.

"One of the things many women identify as a central part of being female is the ability to conceive, carry a baby to term and give birth," Madsen said. "That is a biological desire and it is a social desire, and when that ability is taken away from us we will go to extreme lengths to take it back."

That said, the idea of a uterine transplant "is not available right now and is not safe," and couples' pursuit of the option could distract them from readily available and relatively well-tested options such as surrogacy.

Madsen acknowledged, however, that there was only so much outsiders will have to say about the matter.

"Ultimately, each woman and each physician is responsible for making this personal decision," she said. "If the technology and the science is available in the United States of America, we have personal choice and isn't that wonderful?"