First uterus transplant in India

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Dr KK Aggarwal
National President IMA & HCFI

The Milann Fertility Centre in Bangalore has received permission for uterus transplant from ICMR in two female patients and the procedure will be undertaken as a research project as per the ICMR guidelines.

The minimum requisite of experience to carry out this procedure, as per the Human Organ Transplant Act, by a Clinical team is not available in any group outside the Swedish group. Milann has obtained permission from Medical council of India (MCI) for the participation of Swedish doctors for the procedure which is yet another mandatory requirement.

In 2012, the world’s first successful uterus transplant with a live donor was conducted by a team led by Dr Mats Brannstrom, Professor of Obstetrics and Gynaecology at the University of Gothenburg in Sweden. In October 2014, a woman who had received a uterine transplant gave birth to a healthy baby boy.

About uterus transplant

• Uterus transplantation is a complex, multi-step procedure for the treatment of absolute uterine factor infertility (AUFI).
• AUFI refers to infertility that is fully attributable to the uterus because of absence (congenital or surgical) or abnormalities (anatomic or functional) that prevent embryo implantation or completion of a pregnancy to term.
• About 1 in 500 women of childbearing age are affected by AUFI, defined as an absent or non-functional uterus
• Uterus transplantation is a highly experimental procedure to treat absolute uterine factor infertility.
o Once the intended uterus recipient and organ donor have been identified, the process begins with in vitro fertilization (IVF) to create and freeze embryos for the intended recipient.
o Next the organ donor undergoes a radical-type hysterectomy followed by implantation of the donor organ into the recipient.
o After at least 12 months of immunosuppressive treatment, the recipient undergoes embryo transfer, pregnancy, and, if the pregnancy is successful, delivery via cesarean delivery.
o At the conclusion of childbearing, the transplanted organ is removed to avoid the need for lifelong immunosuppression.
• Since initial attempts at Saudi Arabia and Turkey, uterus transplantation has been successfully performed in Sweden and attempted in the United States, the Czech Republic, China, Brazil and Germany.
• Keys ethical points in considering uterus transplantation include the non-life-saving nature of the procedure; existence of proven alternatives; the experimental nature of uterus transplantation; and the risks and benefits to the donor, recipient, and developing fetus.
• Gestational surrogacy and adoption both exist as alternative paths to parenthood
• The uterus donor may be alive or deceased.
o Advantages of living donors include larger potential supply of organs and ample time for preoperative testing, screening, and assembly of a multi-specialty surgical team. The main disadvantage is the extensive pelvic surgery for organ removal.
o Use of deceased donors avoids the donor’s surgical risk and allows for a more extensive graft harvest. Disadvantages of a deceased-donor organ include the limited availability of organs, unpredictable timing of organ procurement, potential that the donor uterus has not yet produced a term pregnancy, and potential ethical uncertainties regarding consent.
• As human uterus transplantation is in the beginning stages, the optimal inclusion and exclusion criteria for both donors and recipients are not yet known.
• Living donors and recipients undergo extensive testing to ensure medical and psychological appropriateness.
• Protocol includes consultation by the following services: gynecology, transplantation surgery, psychology, clinical immunology, anesthesiology, internal medicine, and radiology.
• Prior to removal, the donor uterus is evaluated with ultrasound and magnetic resonance imaging (if technically possible) to estimate the uterus size, rule out uterine pathology, exclude Müllerian anomalies and evaluate the vasculature.
• The goals for the evaluation of the future genetic father are to exclude male-factor causes of infertility, exclude infectious diseases that could be transmitted to the immunosuppressed mother, and to identify relationship challenges that could negatively impact the outcome of uterus transplantation.
• As part of the informed consent process, the uterus donor must be free from coercion; be fully informed of the risks, benefits, and alternatives for both the donor and the recipient; have access to an independent donor advocate; and be informed of the early and late surgical risks. The uterus recipient must be educated to the risks and benefits of uterus transplantation and then consented for the multiple steps of the process that will ultimately result in a live-born child, including gonadotropin stimulation, egg retrieval for the creation of embryos, uterus transplantation, immunosuppression, embryo transfer, pregnancy, cesarean delivery, and uterus removal. The consent for the genetic father mainly pertains to the in vitro fertilization treatments that he must undergo to create embryos prior to uterus transplantation.

(Source: Uptodate)