Absolute uterine factor infertility was previously an untreatable condition and affected 1 in 500 fertile-age women. These women can only achieve parenthood via a gestational surrogate or adoption. Adoption has its legal and social complications, and altruistic surrogacy, whilst it offers a couple the prospect of a genetic child, also has its ethical considerations and is even banned in some countries due to legal or religious complications.

Womb transplants offer a third alternative route to parenthood. The UK has recently penned a new chapter in its medical accomplishments, its first womb transplant. The procedure, originally pioneered in Sweden, whilst groundbreaking, is not without its challenges.

Ethical considerations of such a procedure must be taken fully into account in order to assess the effect of such a procedure on those involved and compared to the alternative options. In surrogacy and womb transplantation, the womb is donated for the conception of a child. One procedure requires the complete removal of the womb by a hysterectomy procedure. The other, though, requires the surrogate to carry the child for the couple seeking treatment in their womb for the gestation period after undergoing embryo transfer. Whilst hysterectomies are a major surgical procedure, they are considered routine procedures due to their regularity, and the risks of any resultant damage to organs are low. But who would donate their wombs? Older donors would make sense, but then the risk of complications with anaesthesia and surgery increases. Using younger donors for such a procedure would decrease these risks, but it would be difficult to find younger women willing to donate their wombs indefinitely. Surrogates, on the other hand, must meet medical and logistical criteria.

There is the risk of transferring pregnancy-related morbidity and mortality to the surrogate of course, but that risk is no higher in a regular pregnancy, and surrogates are well-informed and counselled about those risks. The effects of the process on the surrogate’s family have been in question in the past but were found to be negligible. A risk assessment would indicate surrogacy as safer, albeit time-consuming, than surgical womb donation.

For the ‘recipients’ of the womb, whether via transplant or via a surrogate, the initial procedure is similar. The patients must undergo IVF first to acquire the necessary embryo(s) for utilisation. The patients are exposed to the risk of Ovarian Hyperstimulation Syndrome (OHSS), the main risk factor of IVF, and the other risks associated with IVF such as low fertilisation rate, utilisation rate and poor embryo survival post cryopreservation. There are no further risks on the physical health of a commissioning couple using a surrogate. The same cannot be said about the womb transplant patient.

After appropriate HLA matching, the recipient undergoes the transplant procedure, which has a substantial risk of failure due to possible infection, bleeding, thrombosis, graft rejection and insufficient womb vascularisation. Any of which may require removal of the transplanted womb. The recipient is then exposed to a course of immunosuppressants to counter possible graft rejection. The dosage of immunosuppressant drugs is dependent on the occurrence of rejection episodes and an increase in dosage may expose the recipient to higher risks of immunosuppression complications such as anaemia, leucopenia, nephrotoxicity, bone marrow toxicity and malignancy. At least one year of immunosuppression is recommended to ensure stabilisation before the patient can utilise her cryopreserved embryo(s). The risks of immunosuppression are alleviated by the fact that the transplanted wombs are removed after two successful pregnancies, but with womb transplant being a life-propagating procedure, exposing a donor to these risks requires an individual risk assessment and thorough counselling.

Regular monitoring of pregnant recipients is essential due to the elevated risks of immunosuppression on pregnancy, childbirth (pre-eclampsia and pre-term delivery) and on the foetus. The timing of embryo transfer is vital in order to avoid pregnancy at a time of increased immunosuppression. This strict monitoring with conception and pregnancy, which is already a stressful period in a woman’s life becomes even more stressful. In addition, Caesarean section is the only method of delivery due to the inability of the transplanted womb to withstand a natural delivery, exposing the recipient to another procedure.

The foetus is exposed to potential risks in a transplanted womb. A higher chance of decreased vascular plasticity, placentation defects and decreased birth weight is hypothesised, but cannot be quantified. A foetus gestated in a surrogate will only encounter the regular risks associated with IVF and pregnancy. The ‘tried and tested’ surrogacy offers a more natural environment to the foetus than a transplanted womb.

There are hazards associated with surrogacy of course. These are mostly associated with social, psychological and logistical factors. Contrasting definitions of motherhood are present in different parts of the world, and in the UK, the gestational mother is recognised as the legal mother. A breach in the surrogacy contract can happen, where either the surrogate refuses to hand over the baby to the commissioning couple, or the commissioning couple refuses to take the baby. This, as well as other restrictions, can lead a couple to go overseas for surrogacy arrangements where they may encounter issues establishing the nationality of the child.

In conclusion, despite its ethical and legal ramifications, surrogacy seems to be a safer and even more cost-effective method to womb transplantation, at least for now. Womb transplantation is not a life-saving procedure and the risks associated with it seem to be considerable. It can, however, offer an avenue of conception in countries where surrogacy is not an option. It is promising that more than 15,000 babies have been born to transplanted and immunosuppressed mothers with no evident increase in foetal malformation. It may seem only a matter of time before fine-tuning of the process revolutionises fertility treatment, similar to the way IVF did.

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