Source: http://www.medscape.com/viewarticle/...0112PN&spon=17

I'm Art Caplan and I'm at the Division of Medical Ethics at the New York University (NYU) Langone Medical Center in New York City. Some fascinating news recently broke in the field of reproductive technology. It got a little bit lost amid all the headlines concerning Ebola, but a team in Sweden announced the first baby born from the transplant of a uterus. That is a fascinating approach to helping people who are either born without a uterus or perhaps have had it surgically removed. People wondered whether it would be possible to conceive and carry to term a baby in a transplanted uterus. So far, one child has been born, and at this time, two more pregnancies in women with uterine transplants have occurred but births have not yet been announced.

How does it work? A woman might have had her uterus removed because she had cancer that required the removal of the uterus. She might have been born without a uterus. Thousands of women worldwide are without a uterus and unable to have a child.

The idea behind the transplant is to take a uterus from a living donor—and that is all that has been used so far—maybe a mother or a sister. You might be able to use the uterus of a stranger or from a cadaver, but no one has gone that far yet.

They perform the surgery to transplant the uterus and then administer immunosuppression to the recipient so that she doesn't reject the foreign tissue. She becomes pregnant using in vitro fertilization, by putting embryos into the transplanted womb, and then the baby is born by C-section because the physical force of a birth would be too much for the transplanted uterus to sustain.

The goal is to let a woman who wants to carry her own child do so, and to have the experience of pregnancy. What are the options? A couple might decide not to have a child at all. They could use a surrogate to carry the pregnancy. They could adopt. This is not a situation where you are allowing someone to have a child who can't have one. You are allowing them the experience of pregnancy.

That raises a couple of very interesting ethical questions. Is it worth it from the point of view of economics to go through all of this? You have a donor who is put at risk to supply the uterus. That person has to undergo surgery, and there are costs involved there. The immunosuppressant drugs cost a lot. You have to give them at least throughout the pregnancy. It is not cheap to do all of this. You are talking tens of thousands of dollars. In a world of scarce resources, does this make sense?

Part of the answer to that is a question: Can women find options? In some parts of the world they can, because they can hire a surrogate, and perhaps it makes more sense to do that and have a child delivered vaginally rather than by C-section, which poses more risks. We don't know whether the children born this way are going to be premature or have health issues because of exposure to immunosuppression, or perhaps fetuses in a transplanted uterus might be born earlier. A case could be made that it is a little bit safer to use a surrogate mother.

The problem is that in many parts of the world and in many states in the United States, surrogacy is illegal. We can debate the rights and wrongs of that another time, but the reality is that access to surrogates is not available to a lot of women around the world. That is particularly true in the Middle East, where surrogacy is banned. This procedure may fulfill a need in some parts of the world where there is no access to a surrogate and where a woman would experience shame or stigma if she didn't deliver her own child. It would not be culturally acceptable to use someone else, so I suspect that there is a demand for this procedure, although small, in some parts of the world.

Another issue in uterine transplantation is determining whether a donor can donate a uterus. A mother who is asked by a daughter, "Can I have your uterus because I don't have one and you want a grandchild?" is probably not giving a free consent. She is going to feel somewhat coerced. Are there enough living donors out there to help women who might want to take advantage of this procedure? I suspect not, and if successful, we will see the push to cadaver donation. When they sign a donor card, most people are thinking about their livers and hearts, not about their uteruses. That raises its own emotional and psychosocial issues about whether women would feel comfortable donating their uterus upon their death.

Undoubtedly some would, but perhaps some wouldn't, and that might reduce the willingness of people to be organ donors overall.

It is nice that we had a birth, and that is a wonderful thing to celebrate—the first child born of a uterine transplant—but there are a whole host of tough, ethical issues that have to be addressed before this technology moves forward.
I'm Art Caplan at the NYU Langone Medical Center.