First thing’s first: Beloved rapper and Instagram sensation Cardi B does in fact have a uterus and appears to be using it. After all, she’s just given birth to a baby girl. Both Cardi B and Dr. Giuliano Testa — the surgeon who performed the first successful uterus transplant resulting in a live birth in the United States — made Time’s 100 Most Influential People List for 2018. The woman Dr. Testa operated on was a patient in one of the country’s first clinical trials for uterus transplants — a procedure in which a donor (who is done using their uterus or doesn’t need it — the organ’s primary function is for childbearing purposes) allows it to be surgically removed and transplanted into a recipient’s body, so they can carry and birth a child.
If your jaw just hit the floor, we’re right there with you. We picked ours up off the floor and looked into this astounding breakthrough in reproductive science to learn how it works and how it can make pregnancy and birth an option for those who want to carry and deliver a child.
My jaw’s still on the floor — give me some context
Right now, uterus transplants are an option for those who do not have a uterus or whose uterus is not viable for carrying a baby. This might include those who had a hysterectomy or cancer survivors whose uterus was damaged from chemotherapy or radiation.
Keep in mind, the surgery is still experimental and only being conducted as a part of small clinical experiments in the United States at The Cleveland Clinic, University of Pennsylvania, and Dr. Testa’s trial at Baylor University. Each of these trials has enrolled fewer than 20 people who meet very specific inclusion criteria, like absolute uterine factor infertility (AUI). Meaning, their uterus is non-functioning or nonexistent — an estimated 3 to 5 percent of women of childbearing age worldwide are estimated to have AUI.
The majority of the women enrolled in the experimental trials have a condition called Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, which contributes to AUI. Those with MRKH were born without a uterus, but with intact and functioning ovaries. The trials only include women assigned female at birth, with functioning ovaries, and who are interested in having biological children.
With us so far? Let’s breaks down how this beyond cool, complex procedure actually works.
Step 1: Finding a donor
Any healthy woman could be a viable donor, but since having the removal surgery comes with serious risks and side effects (more on this in a bit), the donor is typically a close relative or BFF. (Get this: We know Mother’s Day was last month, but a team of doctors and researchers in Sweden witnessed a single uterus bridge three generations — seriously. A mom donated to her daughter, who then delivered a healthy baby boy. Talk about a multi-generational medical miracle.) Age, however, is a factor: Those older than 60 may have diminished uterine blood vessels that are needed to keep the transplanted organ nourished in its new home. Donors must be free of certain STDs, have no history of diabetes or hypertension, have a BMI of less than 30, have had at least one full-term delivery, and be cancer-free for at least five years.
The donor who gave her uterus to the new mother in Dr. Testa’s study is Taylor Siler, a 36-year-old registered nurse from Dallas who heard about the trial (the new mother chose to remain anonymous). Siler and her husband have two boys and are finished growing their family. She told TIME, “I have family members who struggled to have babies, and it’s not fair. I just think that if we can give more people that option, that’s an awesome thing.” So, if you’re the kind of gal who checks the organ donor box at the DMV, it’s possible that at some point down the road, perhaps your uterus could help a person with AUI.
Step 2: Prepping for pregnancy
You’d think this step would come later, but it actually happens before anything surgical occurs. There’s no spontaneous or natural conception following a uterus transplant. According to the previously cited TIME article, all uterus recipients must go through in vitro fertilization (IVF), often months in advance of transplant surgery. This means they have eggs inside their ovaries extracted and mixed with sperm (perhaps from a partner or donor) to create frozen embryos. Later, once the transplant surgery is complete, the embryos will get transferred to and hopefully implant in the individual’s brand new (err...borrowed) uterus.
Step 3: The surgeries
As you probably guessed, the first surgical procedure is retrieving the donor’s uterus. We checked out this NPR interview with Dr. Testa and his colleague Dr. Johannesson to give you some of the deets:
Dr. Johannesson: “Well it's a transplant, and it's a completely new transplant. .... I think we can compare it to a hysterectomy. When it comes to the donor surgery, probably a little bit more complicated than a simple hysterectomy. It takes about five hours. For the recipient, the transplant itself takes about five hours too. ... Then after you have the transplant, you don't have an immediate success. First you have to know the uterus is staying with the recipient, then you have the periods coming, showing it's viable, then you have to implant the embryo, and then finally you have a pregnancy and then you have to wait the nine months before you have a baby. So the actual success is one and a half years down the line. That's very rare in transplants.”
Step 4: Pregnancy and birth
As Dr. Johannesson notes, recipients have to wait awhile after surgery to make sure everything is functioning properly before they take the new uterus for a conception test run. Ideally, those born without a uterus have their periods for the first time (minus the middle school angst). But again, natural conception isn’t possible. Here’s why: During ovulation, the ovaries can’t release an egg into the new uterus since the fallopian tubes are not connected to it — the surgery doesn’t address this. But IVF can be an effective workaround: If the transplant appears successful, the frozen embryos are transferred hopefully result in a conception.
Assuming all goes to plan (pregnancy is achieved and the recipient carries the baby to full-term), delivery must happen via Cesarean section (c-section). (Of course, this is yet another surgery with additional risks.) Since a transplanted uterus does not have any nerve connections, the labor sensations and processes necessary for vaginal delivery (like uterine contractions and pushing) can’t be physically achieved.
What are the risks and concerns?
In Dr. Johannesson’s quote above, she mentions something important — success. In fact, she indicates that it’s rare. Right now, only two babies have been born after uterine transplants in the United States. Both were part of the trial at Baylor. Because this procedure is so very new, it remains unclear what all the long-term risks are to the babies and mothers, if any.
Like all organ transplant surgeries, how the recipient’s body will react to foreign tissue is unpredictable. Complications like infection, failed blood supply, or immune system rejection are common. In fact, almost half of the women enrolled in the ten-person trial at Baylor had to have their donated uterus surgically removed afterwards because of an issue. Uterus transplant recipients also require immunosuppressive therapy (medication that weakens the body’s immune system, in hopes of it not rejecting the foreign uterus), which can be life-threatening.
Some medical ethics groups have raised concerns about these unnecessary risks. After all, adoption and surrogacy are options for those wishing to become a parent. Here’s what Dr. Testa has to say about this: “I don’t have a very intelligent answer...I just understood through this process that I myself had completely underestimated the wish of any woman that I’ve met thus far to have their own child. I don't know whether there is a price for it. I have no philosophical discussion to add. I just have to say that it was a humbling discovery and I’m still profoundly touched by it.” Dr. Johannesson added that uterine transplants don’t exclude adoption or surrogacy — it’s just a complement treatment.
Of course, costs are a major factor: The ballpark price tag, according to Dr. Testa, is $200,000 to $250,000 — no joke.
The future of uterus transplants
So, what if uterus transplants were to become more routine? Intersex and transgender women have already expressed interest in uterus transplant trials. Individuals in the transgender community have reacted with understandable excitement to possibilities opened up by successful uterus transplant surgeries. At the 2014 World Professional Association of Transgender Health conference in Bangkok, there was a keynote lecture devoted to uterine transplant as a new frontier in reproductive healthcare for trans women.
Although uterus transplants will likely only be available to a few women meeting strict inclusion criteria for the near future, it adds one more option for those experiencing infertility and hoping to carry and birth a child, which can be a deeply felt, personal desire. At Modern Fertility, we love nothing more than nerding out on the latest and greatest reproductive health technologies. But most of all, we’re excited to witness the hope and possibility this procedure will bring to those desiring a biological family.