Over eight days in September, Baylor University Medical Center performed the first four living-donor uterine transplants ever done in North America. Three of those had to be taken out, but the East Dallas hospital remains “cautiously optimistic” that the fourth patient will be the nation’s first to achieve uterine functionality after a transplant. She has shown no signs of rejection and the surgeons are happy with the blood flow.
The procedures are part of a 10-person clinical trial that was announced in February after a two-year research initiative. The surgical team included four surgeons from Baylor and two from Sweden’s Sahlgrenska University Hospital, a relationship forged through Baylor’s transplant chief Dr. Goran Klintmalm and his connection to the University of Gothenburg. That was the location of the world’s first successful birth via transplanted uterus in October of 2014.
“The success here is not the transplant,” Klintmalm, the chief and chairman of Baylor’s Annette C. And Harold C. Simmons Transplant Institute, said when the initiative was announced. “The success here is the birth of a healthy baby.”
It took about five hours to remove the donor’s uterus and another five hours to transplant it in the recipient. The women receiving the donated uteri all had the congenital condition known as Mayer-Rokitansky-Kuster-Hauser syndrome and were born without a uterus. They have normally functioning ovaries. They’re all between 20- and 35-years-old, and the donors are between 35 and 60 and have successfully delivered a baby. Surgeons removed three of the uteruses after determining there was not “viable blood flow.” The fourth woman, however, is doing well—no signs of infection, no signs of rejection, and doctors are happy with the blood flow.
But there’s still a long road ahead. Once the transplant is successful, the women will begin taking immunosuppressive drugs. Their eggs have already been frozen. In three months, the women will return to regular activity. The doctors will then wait between six months and one year to implant the embryos and the baby will be carried until it’s close to term. It will be delivered by C-section, and the uterus will be removed after either one or two births.
Dr. Giuliano Testa, the principal investigator and Baylor’s surgical chief of abdominal transplantation, was in surgery Wednesday morning and unavailable for comment. He did, however, talk to TIME magazine and The Dallas Morning News, telling the former that the research potential here is huge. In announcing the transplants, Baylor says it has already learned about other ways to approach transplanting a uterus, particularly by applying “specific attention to thickness of the uterine veins.”
“This is the way we advance,” Testa told TIME. “I am not ashamed of being the one who will be remembered as the guy who did four [transplants] in the beginning and three failed. I am going to make this work. I believe from an ethical and clinical and research point of view, we have our heart in the right place.”
Back in February, Klintmalm echoed that trailblazing mentality: “This is what we did in kidney transplantation 60 years ago, and what we did in liver transplantation 50 years ago, 40 years ago. We have to figure out how to do it safely before we can start expanding upon it.”
Baylor hopes to perform another six before the year’s end. The Cleveland Clinic was the nation’s first hospital to transplant a uterus. But it was from a deceased donor, and had to be removed after the patient developed an infection. In addition to Baylor, Boston’s Brigham and Women’s Hospital and the Nebraska Medical Center are also pursuing uterine transplants. Surgeons at Sweden’s University of Gothenburg have delivered five babies from nine uterine transplants.
The procedure has generated its fair share of concern among bioethicists and in news articles. This piece, in STAT, explores the risk versus reward: Namely, is it ethical to offer an invasive, potentially risky procedure to women when there are other means to produce a child that is genetically their own? Particularly by finding a surrogate who would carry the embryo via in vitro fertilization. And there’s the money: While costs are uncertain, nobody pegs it at less than $100,000, and it’s currently only provided through clinical trials. Earlier this year, Testa reflected on all this. He said that the ethics of the procedure were his first concern, and he received no opposition from the hospital’s ethics committee, its review board, or the hospital’s leadership.
“We know what the risks of immunosuppresion are, we know what the risks of surgery are,” Testa said. “So as long as the risks are known and the person can make an autonomous decision regarding undergoing the procedure we are respecting the ethical principal that is driving medicine today, which is autonomy and respect for human beings.”