At the end of February, a team of transplant and gynecological surgeons at the Cleveland Clinic reported that they had made history in the OR: After a nine-hour operation involving a 26-year-old patient, they had performed the first successful uterus transplant in the U.S.
A few weeks later, the patient, identified as Lindsey, appeared in a press conference with her doctors looking hopeful and upbeat. She was told at 16 that she could not bear children. The plan was that she would be monitored monthly for a year and if all looked good, she would begin trying to get pregnant.
But two days after that, Cleveland Clinic announced that a sudden complication had caused the transplant to fail and the uterus had to be removed. What went wrong? And what does it mean for the future of other uterus transplants?
A Mixed History of Success
The earliest womb transplant wasn’t to help a woman get pregnant — it was a part of a string of gender reassignment surgeries. One of the most storied cases involved Lili Elbe, a Danish transgender woman who was immortalized in the Hollywood biopic, “The Danish Girl.” In 1931, Elbe received a uterine transplant — the final of several sex-change surgeries she underwent. Roughly three months after that surgery, Elbe suffered paralysis to the heart from organ rejection and died.
Interest in the surgery waned with the development of in vitro fertilization, but around the turn of the last century, the procedures again gained traction as an option for women who were born without a uterus or had their uterus removed due to an illness like cancer.
In 2000, a uterus was transplanted from a 46-year-old patient to a 26-year-old patient in Saudi Arabia. The operation was a success for 99 days but then failed due to blood clotting.
A team of doctors in Turkey also attempted the operation in 2011 on a 21-year-old woman who became the first patient to receive a womb from a deceased donor. In 2013, the patient announced she was pregnant, but during an eight-week examination of the patient, doctors failed to detect a fetal heartbeat.
Then in 2014, the revolutionary operation succeeded in bringing its first healthy baby into the world. The little boy was born by a 36-year-old mother who received a womb from a 61-year-old family friend. Led by Dr. Mats Brannstrom, uterus transplants in Sweden have resulted in five births after a total of nine transplants.
The Surgery Comes to The U.S.
Cleveland Clinic is the first institution in the U.S. to offer a clinical trial for uterus transplant patients. The transplant team screened 250 women before identifying 10 patients who qualified for the trial. To meet the requirements, the women needed to be between 21 and 45 and be without a functioning uterus but have ovaries healthy enough to produce eggs. About one in 4,500 women in the U.S. are born without a uterus, according to the National Institutes of Health.
Cleveland Clinic said that the team opted to use uteri from deceased patients to avoid the need for an additional surgery on a live patient.
Before the transplant, the women in the study undergo in vitro fertilization to remove eggs from their ovaries. After the transplant, they are monitored for a year before they begin implanting the eggs and attempting pregnancy. If successful, they have to have a cesarean section to avoid the trauma of delivery.
After two successful pregnancies, the plan is that transplant patients will have the uterus removed so that they can stop taking rejection medications.
Speculation on What Went Wrong
Cleveland Clinic’s announcement that Lindsey’s transplant had failed provided no details about why the uterus had to be removed. When contacted for comment, Cleveland Clinic said they have no further details to share at this time.
But one of the most notable issues that the team will surely be asked to comment on is the possibility that it could have been related to the use of a deceased patient’s organ — rather than the live patients used in Sweden. For now thought, it could be too early to tell if that was a factor.
There are a host of other reasons why transplants fail, including organ rejection — when a body’s immune systems recognizes antigens on the donor organ and attacks them.
The uterus could have also become infected, had problems with blood supply, or a blood clot could have imparted blood flow to the uterus.
The learning curve involved in a new operation could have also come into play according to Dr. Alexander Maskin, an assistant professor of surgery at the University of Nebraska Medical Center.
“It’s not so much more difficult [than other transplants]; it’s just that it’s a brand-new surgery, so the learning curve is steep figuring out how to actually do it,” Maskin told LiveScience. He pointed out that kidney transplants used to take six to 10 hours, but are now done in an hour and a half.
Cleveland Clinic is continuing its trial of uterus transplants with the nine other women in the study.
Two other hospitals — Baylor University Medical Center in Dallas and Boston’s Brigham and Women’s Hospital — have also been approved for uterus transplant studies.
Even after those trials begin, many have noted that it could be decades before an operation like this becomes routine in the U.S.
Meanwhile, Dr. Brannstrom in Sweden has set his sights on a new horizon: growing uteri from scratch. In 2014, Daily Mail reported that the pioneering surgeon is working on a way to take the womb of a deceased patient, strip its cells and then coat it with the stem cells of a woman in need of a uterus. It would then be grown in a lab before being transplanted into the patient.