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Uterine transplant: How it’s done, risks and debate

It is now one year since India’s first baby was born to a mother with a transplanted uterus. Such cases are rare across the world — Radha, whose parents have just celebrated her first birthday, is the 12th such baby worldwide. Now demand has risen, especially at Pune’s Galaxy Care Hospital, where the transplant had been done on Radha’s mother Meenakshi Valan of Gujarat on May 19, 2017. Since them the hospital has got over 1,000 applications.

What is the need of uterine transplant?
Approximately 1 in 500 women are estimated to have uterine factor infertility according to the September issue of the British Medical Bulletin. In India, about 17% of all women face issues relating to infertility, and the reason is related to the uterus in 20% of these. For women whose uterus is not healthy, or who do not have one, a transplant is the newest form of infertility treatment.

Dr Shailesh Puntambekar, laparoscopic surgeon and Director of Galaxy Care Hospital, said worldwide there have been 30 uterine transplants and 15 babies born. Among the babies, one was born after a cadaveric uterus was transplanted. The transplanted uterus is generally intended to be removed after the woman has undergone one or two childbirths.

Normal reproduction is not possible with a transplanted uterus — a transplant makes sense only with in vitro fertilisation (outside the body). The first successful transplant was performed in Saudi Arabia in 2002 but did not result in pregnancy. In Turkey, pregnancy following a 2011 transplant lasted only eight weeks. The first birth after a transplant, in 2014, happened in Sweden.

Why uterine was transplanted in present case?
Valan had a scarred uterus due to multiple abortions and cases of stillbirth. Her mother donated the uterus. Usually, women related to the recipient are potential donors. The donor may be either living or deceased, and is chosen from among women up to the age of 50 years.

Is it the future?
Uterine transplants are still extremely rare, complicated and expensive. In the case of Meenakshi — and Shivamma, a woman who had undergone a transplant the day before Valan underwent hers — the entire process (up to the birth of Valan’s child) was made free because these were the first two such cases in India.

In the earliest cases, doctors took almost 13 hours to retrieve the uterus, because they performed open surgery. With laparoscopic intervention, the time has now come down to about six hours, Dr Puntambekar said. While the donor should ideally be a cadaver, it is difficult in practice — the donor has to be less than age 50, her uterus should have produced children, and the risk of organ rejection is higher when it is from a dead person. Minimally invasive surgery (robotic surgery) has become the standard procedure and in the future, it is likely that the recipient of the uterine transplant has to undergo only one surgery as vessels can also be sutured laparoscopically, Dr Puntambekar said.

A uterine transplant, like that for other organs, requires clearances at several levels. Now the cost is going down as patients are being discharged on the 14th day following the transplant.

Ethical considerations
There has been debate whether uterus transplants are ethically justified. There is vast literature on this debate, covering psychological and physical risks as well as complications arising out of immunosuppressive therapy. According to the British Medical Bulletin’s September issue, concerns have been raised about the welfare of living donors who may end up regretting their choice to donate. Experts suggest that a living donation is justified only after informed consent by the donor, and this after counselling by physicians and psychologists.

Dr Puntambekar said that in the last two years, they have done eight transplants and kept several on hold as they wanted the couples and family members to be extremely sure and committed about a transplant.

Source: The Indian Express

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