Number performed: 1 reported in literature
Date:
The operation was performed on April 6, 2000. No other transplants have
been reported in literature, but it is possible that others have taken
place in the three years since.
Background:
The idea of uterine transplant was first explored in the 1950s. However,
most of the experiments that were performed on dogs and baboons failed
because of the complex blood vessels that must be connected. There was
also concern that anti-rejection drugs necessary after surgery could harm
a fetus.
The surgeons at the King Fahad Hospital had done 18 trial transplants on animals before attempting the operation on a human. Autologous orthotopic uterine reimplantation was performed on 18 virgin female animals (16 baboons and two goats). After 6–12 weeks, the abdomen of each animal was explored to determine pelvic infection, viability of the fallopian tubes and uterus and of the organ vasculature. Due to the success of the animal experiments, the team prepared a protocol for a human trial.
Location:
The operation was performed at King Fahad Hospital and Research Centre
in Jeddah, Saudi Arabia. The team of doctors was led by Dr. Wafa Fageeh,
a professor at Abdulaziz University. The Islamic religious position on
uterine transplantation was clarified in March 1990, before initiation
of this project, when the Islamic Jurisprudence Council approved the transplantation
of reproductive organs that do not transfer genetic coding.
(photo from King Fahad National Guard Hospital website:http://www.kfnghosp.8k.com/)
Procedure:
The transplant was performed on a 26-year-old Saudi woman who had lost
her uterus because of excessive bleeding after a caesarian section at
the age of 20. The donor organ came from a 46-year-old post-menopausal
woman who had been advised to have a hysterectomy she found out she had
ovarian cysts. ABO compatibility, HLA tissue matching, and negative cytotoxic
antibodies in the recipient were confirmed.
First, the patient was placed under general anesthesia. The donor uterus
was connected to the recipient's vaginal and the uterine arteries and
veins were extended using reversed segments of the great saphenous vein.
They were then connected to the external iliac arteries and veins, respectively.
Human uterus, ovaries, and fallopian tubes
(photo from http://medlib.med.utah.edu/WebPath/FEMHTML/FEM082.html)
Follow-up:
Immunosuppression was maintained by oral cyclosporine, azathioprine, and
prednisolone. Allograft rejection was monitored by ultrasound and MRI..
White blood count, cyclosporine level, and creatinine phosphokinase enzyme
levels were checked twice a week. Nine days after the operation the patient
complained of low abdominal and back pain, general fatigue, malaise, and
body ache. She had a low-grade fever, and tachycardia, indicating acute
rejection.. However, doctors were able to control it with a drug called
anti-thymocytic globulin (ATG).
The woman was given estrogen and progesterone hormones to thicken the womb's lining so that menstruation could occur. The lining grew to 18 millimeters thick, which meant that hormones were getting through and that blood supply was good. The hormone treatment was given for 21 days, then stopped for a week so a menstrual period could occur, then restarted.
On the 99th day, the patient experienced a sudden feeling of heaviness, with a foul-smelling vaginal discharge on straining. Immediate ultrasound revealed a blockage in one of the grafted vessels which cut off blood supply to the uterus. The organ had to be removed as a result of the acute vascular thrombosis, but the clot did not endanger the woman's life. Tissue analysis suggested that the blood vessels had become kinked or twisted most likely as a result of the new uterus lacking proper support in the body.
Future:
The team of doctors who performed the surgery are optimistic that transplanting
uteruses could help young women who have had a hysterectomy or who have
a congenitally malformed uterus with normally functioning ovaries.
In an editorial, the Chicago-based journal said that the operation had had a promising outcome. The clotting "is not the equivalent of a clinical failure," as the uterus had already shown it could respond to the hormone treatment, it argued.
Some scientists say it will not be an acceptable form of infertility treatment until less toxic anti-rejection drugs become available.
Ethical issues:
For transplant
One argument presented in the editorial accompanying the journal article
was, "To some individuals, childbearing is the greatest event of
a lifetime. To such persons, transplantation of organs of reproduction
would not be considered frivolous or unnecessary, even though these organs
do not sustain life."
“Further clinical experience and additional development of the surgical techniques could make uterine transplantation useful in the treatment of infertility, especially in communities where the surrogate mother concept is unacceptable from a religious or ethical point of view”, noted the team of doctors who performed the surgery. Surrogacy is not acceptable on religious grounds to Muslims.
Against transplant:
"It is technically feasible, theoretically desirable, but presently
unsafe," Roger Gosden, a fertility pioneer at Eastern Virginia Medical
School in Norfolk, Virginia, told the Associated Press. "Their results
reveal the risks and this procedure awaits the development of safe immunosuppression.
A transplant to save life is an acceptable risk, but not one for fertility,
when there are alternatives," he said. "This is why we would
never be given ethical clearance to try this in the United States for
the foreseeable future.”
"The uterus is a very dynamic and complex organ, and it is hugely
blood-flow dependent. It is supplied by four blood vessels, which are
very small by transplant standards, giving more scope for blood clotting,"
said David Barlow, director of the assisted reproduction unit at the John
Radcliffe Hospital in Oxford, Britain. He felt that blood connections
"are major hurdles to overcome." In addition, pregnancy would
cause a huge increase in blood flow to the vessels connected to a transplanted
uterus.
Robert Winston, a leading British fertility expert also voiced concern
about the same issue. “Blood clotting is exactly what you would
expect and is what happened in all the experiments previously carried
out in every experimental animal in which this has been done. It is a
great pity that women’s hopes have been raised in this way,”
Links:
http://health.iafrica.com/healthnews/907102.html
http://www.tribuneindia.com/2002/20020308/world.htm#2
Journal Article:
Transplanation of the Human Uterus
W. Fageeh, H. Raffa, H. Jabbad and A. Marzouki
International Journal of Gynecology and Obstetrics
Volume 76, Issue 3, March 2002 , Pages 245-251
http://www.sciencedirect.com/science?_ob=IssueURL&_tockey=%23TOC%235062%232002%23999239996%23287797%23FLA%23Volume_76,_Issue_3,_Pages_243-354_(March_2002)&_auth=y&view=c&_acct=C000022678&_version=1&_urlVersion=0&_userid=489286&md5=111043144c22272e1d7091cc0e7b06c1
