Womb transplants, one of the newer trends in a field that has advanced many frontiers in recent years, have now been shown to be possible. This could have implications for the types of fertility treatments available in the future.

Successful womb transplants for women without wombs

Surgeons at Baylor University Medical Center in Texas have granted four women born without uteruses the ability to bear children, when they each received one in operations last month as part of a clinical trial aiming to enroll ten women born without functional uteruses. Although three had to be removed as a consequence of poor blood flow, the fourth still has hers. Promisingly, she is showing no signs of rejection.

There have been at least 16 recorded uterus transplants worldwide, with at least five of these from Sweden, done by Swedish doctor Mats Brannstrom, who is currently working with doctors at Harvard Medical School and the Mayo Clinic to help women outside Sweden get access to the procedure. Two of his former team members are working in the Baylor trial. Womb donors can be alive or deceased.

Women first go through in-vitro fertilisation (IVF) to retrieve embryos that may be frozen for later use, up to a year after the transplant. Babies resulting from uterine transplants are delivered through caesarean section.

Long-term use of the transplanted wombs is not viable; to prevent rejection of the womb, the woman must take potent drugs, and these pose long-term health risks. Hence, the uterus is removed after one to two successful pregnancies.

The pioneering doctor who made it possible

The idea of womb transplants began with an audacious question from an Australian patient to Brannstrom; she had asked if she could have a womb transplant, so she could one day carry her own baby despite having to have her own uterus removed due to cervical cancer.

"I thought she was a bit crazy," Brannstrom said.

Still, he explored her suggestion in a series of painstaking research projects upon his return to Sweden, despite criticism that the procedure was life-threatening, medically unnecessary and impossible.

Brannstrom eventually became the first medical professional to deliver babies from women with transplanted wombs, banishing doubts as to the feasibility of the procedure. However, none other has succeeded, despite attempts in the U.S., Saudi Arabia and Turkey, and ongoing efforts in China, Britain, France, and the Czech Republic, to name but a few.

Brannstrom has come a long way from womb transplants in mice in 1999. The surgery was so complex that four custom-made tools were needed to perform the microscopic operations. After nearly two years, irrevocable evidence of womb transplants being possible in mice was obtained. "If it hadn't worked in mice, we would have quit," he said.

Over the next decade, Brannstrom and his team progressed from mice to other animals and were finally ready to try the surgery on nine Swedish women in 2012. Two experienced complications, leading to a need to remove their wombs. Five had healthy babies and the last two are trying to get pregnant.

A miracle of nature

Scientists now believe Brannstrom's work could help them extend the use of organs for those who need transplants and learn how embryos implant in the uterus after conception, a poorly understood but critical stage in pregnancy.

Certainly, it is a marvel of nature that babies have been born from organs once flushed with a cold solution — rendering them technically dead — before being placed into the recipient.

"Miscarriages are happening all over the place but here you have these dead uteruses that can carry a baby," Dr. Tommaso Falcone of the Cleveland Clinic said.

It is equally remarkable that the wombs of some post-menopausal women were able to grow healthy babies after being transplanted. Younger organs are expected to work better, but in the case of womb transplantation, organs from older women appeared "rejuvenated" after being dosed with hormones.

According to Dr. Stefan Tullius, chair of transplant surgery at Harvard Medical School, this could lead to insights into extending the use of other organs.

In Singapore, fertility treatments like IVF are already gaining in popularity. According to preliminary figures from the Ministry of Health (MOH), 6,059 Assisted Reproduction cycles were carried out in 2014, 549 more than in 2013 and 1,099 more than the year before. In fact, the Singapore government actively encourages it as part of its pro-birth policy.

The burgeoning acceptance and demand for fertility treatments extends beyond Singapore to the entire Asia Pacific region, as infertility rates are spiralling – with the IVF services market forecast to reach $3.5 billion by 2020. MIMS

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