Vidal Balielo Jr.
The first baby of a woman with a uterine transplant in Spain shakes up yet again the debate surrounding the fertility industry around the desire to be a mother.
One in 5,000 women are born without a uterus due to Rokitansky syndrome. The resultant infertility is a source of suffering for those who aspire to motherhood and know that, biologically, it is not possible for them.
This was the case for Tamara Franco, the woman who has made headlines since her successful delivery in Spain after receiving a uterus transplant. Franco received the organ from her sister, who did not wish to have any more children herself.
The transplant operation was carried out at the Hospital Clínic in Barcelona, which heralded the intervention as a pioneering medical feat for Spain. And it certainly is. But the milestone has also fueled a debate about how far one can go in the name of progress, what means are justifiable for achieving the “right” to motherhood, and how far the limits of science can be pushed. The discussion hits a thorny issue at a time when the assisted reproductive industry is in the spotlight as it grapples with a big question: Does it help women or exploit their desire to have children?
In total, worldwide there have already been some 50 births of babies thanks to this intervention (almost always within the framework of experimental studies), and it is becoming increasingly clear that, behind what at face value seems like a happy medical advance, there are many accompanying hard questions.
Risks for all three parties involved
One of the main critiques of the procedure points to the complexity of the entire process and the risk for the three parties involved: donor, transplant recipient and baby.
First of all, uterine extraction can last, as it did in Franco’s case, about eleven hours, followed by a four-hour implantation procedure. During the interventions, vascularization of important organs is jeopardized, in addition to the immunosuppression the patient is then subjected to and the risk that the transplant will fail.
Is it ethical to assume the risk the procedure entails for the three parties involved when the organ in question isn’t a vital one?
If the pregnancy reaches term, there are usually more associated complications for both the mother – for example, preeclampsia – and the baby. In fact, the boy born in Barcelona came into the world prematurely via Caesarean section at 30 weeks gestation.
Lastly, the transplant is temporary. To prevent the patient from spending the rest of their life on immunosuppressive treatments, the uterus is removed again once she has had one or two children.
Reasons against the practice
All these issues were reasons why the Hospital Clínic’s intervention went ahead without the approval of the National Transplant Organization (NTO). For the NTO, there were several factors that tipped the ethical balance towards its decision not to give the green light on the procedure.
In the first place, the potential consequences of subjecting two healthy women to a risky surgical intervention which doesn’t involve a vital organ were greater than the potential benefits of a successful intervention. As early as 2018, the director of the NTO, Beatriz Domínguez Gil, expressed her position on the subject in statements to Spanish national newspaper El País: “The risks assumed by the mother and the impact on the fetus do not compensate for the ultimate goal of conceiving a baby, and there are also viable alternatives, such as adoption.”
Comparisons between surrogacy, embryo freezing and possibilities for trans people… For critics, there are many open-ended questions at hand…
Furthermore, the fact that the donor was alive and still of childbearing age increased the ethical complexity of the intervention, since the possibility of using a deceased donor’s uterus exists, which would have avoided terminating someone else’s fertility, according to the NTO.
Lastly, the pregnancy involves in-vitro fertilization of several eggs, and the resultant embryos are then frozen. A procedure surrounded by ethical questions of its own, it has since returned to the discussion table after some research raises concerns about the fate of those embryos that are never used.
The deep-rooted, timeless debate between ethics and technical feasibility has come to head once more: should everything that can be done be done?
At the time, UNESCO offered its official view on uterine transplantations; in its 2019 report, the organization deemed them non-favorable given the risk for the people involved failing to outweigh the possible benefit.
Fanning the fire of surrogacy
There is a clear parallelism between uterine transplants and surrogacy, on both sides of the debate. Both sides agree there is an inconsistency in allowing a woman to donate her uterus (which is legal in Spain) while surrogacy remains illegal in the country.
However, those in favor of legalizing surrogacy celebrate the recent medical milestone as another way to remedy infertility, and maintain surrogacy should also be an option to treat infertility, because they don’t see any difference between a woman offering her body to bring an embryo to term and donating her uterus.
Precisely because they do not see the difference, critics of both processes see both possibilities as a form of exploitation of a woman’s reproductive capacity. “We are facing the biotechnological and experimental fragmentation of the reproductive capacity of women to submit it to the assisted reproductive market, turning women into a source of disposable parts to satisfy the reproductive desires of others,” one feminist organization in Catalonia criticized.
“This practice entails objectifying women, both the recipient and the donor,” the Bioethics Observatory of the Institute of Life Sciences of the Catholic University of Valencia, points out.
A door opens for trans women…and even men
With this intervention, “the possibility of using this type of transplantation for transgender women and even for men opens up, which would undoubtedly raise another slew of ethical questions,” the report from the Bioethics Observatory states.
“Another issue that could significantly affect our society is the possibility that a man who receives a uterus may become pregnant,” Dr. Carmona, the same doctor who carried out the intervention at the Hospital Clínic, and who reported that the transplant had been carried out successfully, acknowledged in 2020.
It might seem like something out of a science fiction novel, but it’s not that far off. Wellington Andraus, transplant coordinator at the Hospital Clínico de São Paulo, who oversaw the first birth after a uterine transplant from a deceased donor in 2018, alluded to its feasibility years back to Spanish national newspaper El Español: “If the uterus is implanted and the patient is given hormonal treatment, gestation is possible. From an anatomical, hormonal and medical point of view, it is possible. It will also give rise to an ethical debate that has not yet been addressed.”
There are two, big underlying questions: Is everything that is scientifically feasible ethical? Is the desire to experience parenthood a right?
In 2022, an Indian surgeon claimed to be preparing to carry out the first surgery of its kind for a transgender woman. “Every trans woman wants to be as female as possible. And that includes being a mother. The way towards this is with a uterine transplant, the same as a kidney or any other transplant,” Dr. Narendra Kaushik affirmed.
The nature of this operation would add more fuel to the fire on the controversy of transsexuality, biological manipulation and the body at the service of how we self-identity and the mutilation of the body of cis women to fulfill the wishes of trans women.
Are desires a question of rights?
At the root of the question, there is an underlying, perhaps more philosophical, issue. Should everything we want automatically be deemed our right? Is the mere will of an individual sufficient grounds for carrying out irreversible procedures that imply a high risk and a high level of medicalization of the human body?
The fertility industry, built around the desire of millions to experience motherhood and fatherhood, is a good example of how technology can advance, but it is not always synonymous with progress if it fails to respond to questions that are fundamental to giving meaning to our human existence.
Translated from Spanish by Lucia K. Maher