In recent decades, physicians have made huge strides in helping women formerly considered infertile become pregnant with new drugs and procedures, like in vitro fertilization.
But for those with a condition called absolute uterine factor infertility, even the most cutting-edge technology could fall short if they wanted to carry their own child.
An estimated 1 in 500 women of reproductive age experience absolute uterine factor infertility (AUFI), which means they can’t get pregnant because they don’t have a functional uterus.
Until very recently, the only way women with AUFI could have children was through adoption or gestational surrogacy.
But thanks to breakthroughs in transplant medicine, that’s starting to change.
For the first time in history, a woman has given birth after receiving a uterus transplant from a deceased donor, report authors of a case study published this month in The Lancet.
The woman was a 32-year-old resident of Brazil who was born without a uterus due to a congenital condition known as Mayer-Rokitansky-Küster-Hauser syndrome.
She received a uterus transplant from a 45-year-old donor who had died following a stroke.
She became pregnant seven months later, using embryos produced through in vitro fertilization. She gave birth through caesarean section at 35 weeks and three days to a baby weighing about 6 pounds.
This wasn’t the first time a woman has given birth after receiving a uterus transplant.
But in all previous cases, the transplanted uterus came from a donor who was alive, rather than someone who had died.
“There have been many births now from uterus transplants, but this is the first birth from a deceased donor,” Dr. Rebecca Flyckt, FACOG, a board-certified obstetrician and gynecologist who’s helped perform uterus transplants at the Cleveland Clinic, told Healthline.
“For those of us that are interested in the deceased donor model,” she said, “this is really a landmark that proves to us that this approach can have the final outcome that we’re interested in, which is a healthy baby.”
The ability to get a uterus transplant could be a huge help for many women who want to get pregnant.
Women can develop AUFI as a result of congenital conditions, after sustaining irreparable damage to their uterus, or after undergoing hysterectomy following injury, infection, uterine cancer, or other health problems.
Infertility can also result in feelings of stigmatization, especially in cultural contexts where many people consider motherhood and the ability to bear children to be core aspects of being a woman.
Adoption, gestational surrogacy, or choosing to remain child-free offer alternatives to bearing children to some women with AUFI.
But those options might be inaccessible or unacceptable to others, due to restrictive adoption or surrogacy laws, cultural norms, personal values, or other reasons.
“When we think ahead to what our future can be, the prospect of being able to be a gestational mother seems to be a priority for many women,” Flyckt told Healthline.
For those women who have AUFI, uterine transplants may not be life-saving, but they’re potentially life-enhancing, she says.
To remove a uterus for donation, surgeons use a lengthy and invasive form of hysterectomy.
When the donor is alive, this procedure poses physical and psychological risks to them.
“The majority of these [living donor] transplants are from friends or family members of women who have been born without a uterus, so these are people who are close to the recipient and have significant emotional investment in what they’ve been going through,” Flyckt said.
“Their loved ones are motivated to go through a long and potentially risky surgery to help try to alleviate their suffering,” she continued, “but every living donor surgery poses risk to the donor, and you’re always weighing whether those risks are acceptable.”
When the donor of the uterus is someone who’s died rather than someone who’s living, those ethical concerns are alleviated.
But the recipient of the transplant still faces physical and psychological risks associated with surgery and the aftermath.
“There are the risks of any major surgery, from bleeding to infection to allergic reaction to medications that the recipient has never been exposed to — the entire array of complications that any surgeon will explain to a patient,” Dr. Giuliano Testa, FACS, MBA, a transplant surgeon at Baylor University Medical Center who helped perform the first successful uterus transplant in the United States, told Healthline.
“On top of this, there are the risks of immunosuppression,” he added.
Recipients of uterus transplants must take immunosuppressive drugs to stop their bodies from rejecting the organ.
Those drugs haven’t been linked to birth defects, but some of them can raise the transplant recipient’s risk for kidney disease or other health problems.
Before they undergo any type of organ transplant, prospective recipients are typically screened and counseled to help ensure they’re physically and mentally prepared for the potential risks and side effects of the procedure.
Although recent successes have been reported in the field of uterus transplant, it remains an experimental procedure. More research is needed before it becomes widely available.
Researchers at the Cleveland Clinic, Baylor University Medical Center, and other sites continue to perfect the surgical techniques used to perform uterus transplants from living and deceased donors.
Investigators are also studying the criteria used to select uterus donors.
“What does it mean to choose the right uterus?” Testa asked. “Is there an age issue? Is it the time that has gone from the last pregnancy of the donor to the moment we take the uterus? Does it have to do with the obstetrical history of the specific donor? Those are things that we still have to figure out.”
When it comes to the recipients of uterus transplants, some commentators have suggested they might one day include transgender women as well as cis women with AUFI.
In theory, uterus transplants might allow some trans women to get pregnant and give birth.
But for now, that possibility remains largely unstudied.
In addition to these areas of ongoing research, policymakers in different countries will need to decide if uterus transplants should be covered by health insurance.
In the United States, insurance providers often cover non-life-saving corrections of congenital anomalies. But many insurers don’t cover the costs of fertility treatments.
If health insurance doesn’t cover a uterus transplant, it’ll be prohibitively expensive for many people.
“If we don’t find a way of financing the procedure,” Testa said, “very few would be able to afford it.”