Public funding of uterine transplantation

Directed and conditional uterus donation

Uterus transplantation (UTx) is highly anticipated for the benefits that it might bring to individuals wanting to carry a pregnancy in order to reproduce who do not have a functioning uterus. The surgery-now having been performed successfully in several countries around the world-remains experimental. However, UTx is at some point expected to become a routine treatment for people without a uterus and considering themselves in need of one: women with absolute uterine factor infertility; transgender women; and even cisgender men who wish to gestate. Given the unique benefits UTx offers, uteri are likely to be 'in demand', and such demand, we suggest, will feasibly outstrip supply. Therefore, allocation of those uteri available for transplant may become a pressing issue. In this paper, we consider one aspect of organ allocation-the preferences of donors in making a directed or conditional donation of their uterus. To what extent, in the context of uterus donation, would such donations be ethically permissible?

Ethical and policy issues raised by uterus transplants

INTRODUCTION

In 2014, Brännström and colleagues reported the first human live birth following uterine transplantation (UTx). Research into this treatment for absolute uterine factor infertility has since grown with clinical trials currently taking place across centers in at least thirteen countries worldwide.

SOURCES OF DATA

This review summarizes and critiques the academic literature on ethical and policy issues raised by UTx.

AREAS OF AGREEMENT

There is general agreement on the importance of risk reduction and, in principle, to the sharing and maintenance of patient data on an international registry.

AREAS OF CONTROVERSY

There are numerous areas of controversy ranging from whether it is ethically justified to carry out uterus transplants at all (considering the associated health risks) to how deceased donor organs for transplant should be allocated. This review focuses on three key issues: the choice between deceased and living donors, ensuring valid consent to the procedure and access to treatment.

GROWING POINTS

UTx is presently a novel and rare procedure but is likely to become more commonplace in the foreseeable future, given the large number of surgical teams working on it worldwide.

AREAS TIMELY FOR DEVELOPING RESEARCH

Uterus transplantation requires us to re-examine fundamental questions about the ethical and social value of gestation. If eventually extended to transgender women or even to men, it may also require us to reconceptualize what it is to be a 'father' or to be a 'mother', and the definition of these terms in law.

Provider Perceptions, Opinions, and Insights Into Uterine Transplantation in Canada

OBJECTIVE

This study sought to evaluate perceptions and insights regarding uterine transplantation among members of a women's health care national specialty organization in Canada.

METHODS

The investigators obtained permission and used an electronic survey developed by Bortoletto et al. to conduct a cross-sectional study of members of the SOGC between April and May 2018. Participants were requested to answer a total of 29 questions grouped into four different categories: personal opinions and attitudes, medical opinions, ethical opinions, and demographics. The investigators compared answers with a published survey of members of the American Society for Reproductive Medicine (ASRM) and the American Association of Gynecologic Laparoscopists (AAGL).

RESULTS

Of a total 247 responses, 230 were complete, for a completion rate of 93%. Respondents were primarily female, White, obstetrician-gynaecologists within 15 years of starting practice. Statements viewed favourably by most of respondents (strongly agree or agree) included "Women should be allowed to donate or receive a transplanted uterus" (53.5%), "Uterine transplantation should be considered a potential treatment option for infertile women with severe uterine factor infertility" (42.4%), and "Uterine transplantation is ethical" (39.9%). Statements that were viewed unfavourably by the majority of respondents (strongly disagree or disagree) included "Uterine transplantation carries an acceptable risk for recipients" (43.7%) and "Uterine transplantation for severe uterine factor infertility should be covered by health insurance" (59.1%). When compared with members of the ASRM and AAGL, the degree of agreement was similar, except with regards to "Uterine transplantation carries an acceptable risk for donors" (50.0% vs. 65.3% ASRM/67.8% AAGL; P < 0.001), and "In countries or states where gestational surrogacy is illegal, uterine transplantation is a more permissible ethical option" (42.0% vs. 65.0% ASRM/51.4% AAGL; P < 0.001).

CONCLUSION

Most respondents either felt that uterine transplantation was ethical or were neutral to the subject. However, only a small minority would currently recommend the procedure to their patients. As advances in uterine transplants are made, future studies should re-evaluate providers' perceptions towards this procedure before it is introduced into clinical practice.

Uterine transplantation: Review in human research

Uterine transplantation is the solution to treat absolute uterine fertility. In this review, we present the historical, medical, technical, psychological and ethical perspectives in human uterine transplantation research. We reviewed the PubMed database following PRISMA guidelines and added data presented by several research teams during the first international congress on uterine transplantation.