The Uterine Transplant: A Controversial Means Of Entering Motherhood

By Ethan Tackett

Women with uterine factor infertility (UFI) suffer infertility due either to irreversible uterine damage or to uterine complications that arise during embryonic development. These women are incapable or, at most, have an extremely low chance of getting pregnant because of limited treatment options.

However, last year, the Cleveland Clinic gave hope to women suffering from UFI. On February 24, 2016, Cleveland Clinic performed a historic uterine transplant on Lindsay McFarland, a then-26-year-old woman born without a uterus. After ten hours in the operating room, McFarland became the first woman in the United States to receive a uterine transplant. While this is a great medical feat, the uterine-transplant procedure brings with it many questions including whether the Affordable Care Act (ACA) will require insurance providers to cover the procedure.

McFarland was the first in a Cleveland Clinic study of ten women with UFI selected to receive a uterine transplant. The procedure begins with stimulating the woman’s ovaries to produce multiple eggs. The eggs are removed, fertilized with sperm via in vitro fertilization, and frozen for future use. The woman then starts anti-rejection medication and undergoes the transplant. Twelve months later, after the uterus fully heals, the embryos are thawed and implanted one at a time. During pregnancy, the mother continues taking anti-rejection medication and is closely monitored through delivery. After delivering one or two babies by C-section, the woman undergoes a hysterectomy to remove the transplanted uterus and stops taking anti-rejection medication.

Though McFarland’s uterine transplant was a success, her transplanted uterus was removed approximately two weeks later on March 8, 2016, due to a severe yeast infection. The Clinic voluntarily put a hold on the study to allow for consultation with infectious-disease specialists and amend the procedure to prevent this problem from happening again. Dr. Andreas Tzakis, program director of the transplant center and primary investigator of the uterus transplant clinical study, says that the Clinic’s work was not a failure, as it has shown that these transplants are possible.

Although this procedure offers a ray of hope to women incapable of carrying a child, it also raises medical, social, and legal issues that need to be assessed.

First, this procedure includes medical risks to women receiving a uterine transplant and children being born from a transplanted uterus. As with any major operation, this procedure poses serious risks of surgical and anesthetic complications. These women also face an increased risk of infection not only from the surgery, but from the anti-rejection medication. The procedure requires the woman to take large quantities of anti-rejection medications for an extended period which results in a suppressed immune system. Additionally, babies born from a transplanted uterus face risks from the prolonged exposure to the anti-rejection medication taken by the mother. By undergoing the uterine-transplant procedure, these women and their children face a great level a risk.

Second, the uterine-transplant procedure reinforces traditional social stereotypes of what it means to be a woman and a mother. The procedure underscores the idea that a uterus is required to be a “real” woman. This affects women born without a uterus, including both ciswomen who suffer from syndromes like Mayer-Rokitansky-Küster-Hauser syndrome and transwomen. The procedure also emphasizes the notion that genetic relation to and gestation of a child are required to be a “real” mother. This affects mothers who adopted or enlisted the help of a surrogate to start a family. Cleveland Clinic’s uterine-transplant procedure challenges modern social interpretations of womanhood and motherhood.

Last, this procedure raises legal questions in the area of insurance law. As this procedure either introduces a uterus into or replaces a non-functioning uterus in a woman’s body, the uterine-transplant procedure is neither a life-saving operation nor an urgent procedure. Thus, the potential availability of the procedure begs the question of whether insurance providers should be required to cover a uterine transplant. Currently, the ACA requires every health plan to cover pregnancy and childbirth. As this procedure is further developed and becomes more available to women, Congress and/or the Department of Health and Human Services, the agency responsible for implementing the ACA, will need to decide whether this procedure qualifies under the ACA requirement for pregnancy and childbirth.

Though the Cleveland Clinic’s study is a huge leap forward in reproductive and surgical medicine, the uterine-transplant procedure isn’t without its negative implications. While the procedure provides women like McFarland the otherwise impossible option of experiencing pregnancy, the successful completion of the Cleveland Clinic’s study may have greater social and legal effects than previously anticipated. Like with all great advances in medicine, the researchers, physicians, and bioethicists involved should develop the uterine-transplant procedure and assess its effects at a responsible pace.

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