new frontier

Uterus transplants are experimental and risky but Indian women are already lining up for them

A hospital in Pune will perform the first uterine transplant in India this week, a procedure that has been done fewer than 20 times globally.

On May 18, Sangeeta Parikh*, a 26-year-old woman from Gujarat, will undergo a uterine transplant. A team of doctors at Galaxy Care Hospital in Pune will harvest the uterus from a donor and immediately transplant it into Parikh’s body. This will be the first such surgery to be performed in India and doctors and health authorities are watching closely.

Parikh suffers from Asherman’s syndrome, a condition characterised by scar tissue forming on the walls of the uterus. Such scar tissue might affect a small part of the organ or might occur extensively. These intrauterine adhesions often form after a dilation and curettage performed because of a miscarriage or elective abortion. Parikh has had two miscarriages that led to adhesions. Like most women with Asherman’s syndrome she is now unable to have a viable pregnancy.

Parikh has already undergone a hysterectomy – removal of her uterus. Her 46-year-old mother is the donor of the new uterus, which Parikh hopes will help her get pregnant again.

In a procedure that could take up to 12 hours, the doctors will first harvest the uterus from the donor. Doctors have checked that Parikh’s mother has a uterus free of fibroids and tumours. Donors also should have given birth at least once and be younger than 55. After removing the uterus from the donor, doctors will then surgically anastamose – sew or staple – four major blood vessels of the organ to the corresponding blood vessels in Parikh’s abdomen. This part of the procedure could take between six and seven hours. Although the vascular connections to keep the new uterus viable and healthy are made during the surgery, the fallopian tubes – the channels that normally carry the eggs from the ovaries to the uterus – cannot be connected. Uterus recipients, therefore, have to rely on in vitro fertilisation to get pregnant.

Like with most organ transplants, Parikh will be put on immunosuppressant drugs to allow her body to accept the transplanted uterus. A major sign that the transplant has been successful is when the uterus recipient starts menstruating. However, doctors still do not know the rate of success of the transplant since so few have been conducted.

Once the organ has been accepted by Parikh’s body, doctors will implant embryos prepared from her own eggs in the uterus. If she does get pregnant and bear a child, Parikh can then choose to keep the transplanted uterus or have it removed.

Even though uterus transplants are still considered experimental and have never been done before in India, Parikh wants the uterus transplant so that she can give birth to her own child.

“We were not ready for adoption,” she said. “We wanted our own child.”

Neither does she want to consider having a child through surrogacy,

“Society does not understand surrogacy,” she argued. “They will still think we got someone else’s child. It is my child and I want it in my womb.”

An experimental surgery

Fewer than 20 uterus transplants have been attempted around the world. In April 2000, doctors in Saudi Arabia attempted the first uterus transplant on a 26-year-old woman. However, the uterus infarcted – that is, a part of the tissue went dead because of an obstruction in blood supply – and the uterus had to be removed. Almost a decade later, doctors in Turkey was managed to successfully transplant a uterus harvested from a cadaver into a patient. However, despite several embryo transfers after the uterus transplant, the woman was unable to conceive a child.

In 2013, a team of doctors headed by Dr Mats Brannstrom in Sweden conducted the first successful uterus transplant that led to a viable pregnancy. On September 4, 2014, the recipient of the uterus gave birth to a healthy child. Brannstrom and his team have performed nine uterine transplants of which two were not successful.

“In two cases, we had to remove the uterus because of infection and blood clots,” said Brannstrom.

Of the remaining successful transplants, two women are scheduled to give birth to babies in June.

Brannstrom still classifies “experimental and not a therapeutic procedure”.

Uterine transplants are not necessary surgeries to cure a patient or alleviate symptoms of a disease or disorder. Brannstrom’s team is now working on reducing the time spent on these procedures since the longer a patient is on the operating table the more she is at risk of contracting infection, bleeding and complications from being under anaesthesia. In most of their surgeries, it took the team at least 10 to 12 hours to harvest the uterus. “In the next phase of our research, we are going to perform a robotic surgery to harvest the uterus,” said Brannstrom. “This will help us to reduce the time in harvesting the uterus to eight hours.”

Dr Shailesh Puntambekar, who is the lead surgeon on Parikh’s case, says he will harvest the donor uterus in between eight and nine hours. Puntambekar is the medical director of Galaxy Care Hospital and a cancer surgeon. This will be his first attempt at a uterus transplant. He plans to do 90% of the surgery laproscopically to reduce operation time.

“My expertise as a cervical cancer surgeon will help me to achieve this,” he said. “It is criminal to put the donors under such a long surgery.”

Dr Shailesh Puntambekar, medical director of Galaxy Care Hospital in Pune.
Dr Shailesh Puntambekar, medical director of Galaxy Care Hospital in Pune.

Puntambekar has a gynaecologist on his surgical team for Parikh. However, the president of the Federation of Obstetric and Gynaecological Society of India’s President Dr Rishma Pai said: “If a doctor performs a surgery beyond his expertise, he or she is liable especially if there is a complication.”

Many takers but ambiguous regulations

Parikh was referred to Galaxy Care Hospital a few months ago by her doctor in Gujarat. The Pune hospital was looking for suitable candidates for uterus transplants and Parikh was elated for having made the cut.

Along with Parikh, 22-year-old Disha Gokhle* will also undergo a uterus transplant and she will also get her new uterus from her mother. Gokhle was born without a uterus, a condition known as Mayer-Rokitansky-Küster-Hauser or MRKH syndrome and affects one in about 4,500 women.

Eleven other women are waiting to get uterus transplants at the Pune hospital. But another team of doctors in Bengaluru is also trying the procedure. Dr Kamini Rao, infertility specialist, at Milann Clinic, says that she has 31 patients with uterine factor infertility ready to have uterus transplants. Rao has been consulting with Brannstrom and is preparing to undertake a uterus transplant surgery in June.

Rao and Puntambekar differ on what permissions they need before they carry out this experimental surgery. Puntambekar has got permission from Maharashtra health department to perform the transplant.

Rao has sought and got permission from the Indian Council of Medical Research to perform a clinical trial with two patients. “It is an experimental procedure and we cannot offer it as established procedure or market it like that,” she said.

Dr Soumya Swaminathan, head of the Indian Council of Medical Research, said that uterus transplant surgeries fall in a grey regulatory area at the moment. “We don’t have a committee to look into this specific form of transplants,” she said.

Meanwhile Puntambekar’s team prepares to break new ground with Parikh’s surgery. They have already made two embryos in their laboratory, which they will implant in Parikh’s uterus after they are sure that the organ has been accepted by her body. If everything goes as per plan she may soon be pregnant.

*Names changed

In the next part of this two-part series on uterus transplants, we find out what the medical community thinks of the need for such a procedure and the ethical dilemmas of it.

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