COVER STORY

Mother's womb, daughter's, too

Mother's womb, daughter's, too Breaking new ground: Dr Shailesh Puntambekar (extreme left) with his team at Galaxy Care Laparoscopy Institute, Pune | Janak Bhat

In India's first uterus transplantation, a mother volunteers to donate her womb to her daughter, who was born without one

  • The world's first uterus transplantation was performed in Saudi Arabia in 2000. The recipient was a 26-year-old woman who had undergone a hysterectomy owing to postpartum haemorrhage. The uterus had to be removed after three months as she had blood clots.

  • “All women who have ovaries, but no functional uterus and are capable of bearing their own child could be considered eligible for uterus transplant” - Dr Kamini Rao, Milann fertility centre, Bengaluru

  • One in every 4,000 women in India is born without a uterus. There are about 4 lakh women with congenital absence of uterus in the country.

  • In 2011, Derya Sert of Turkey became the first woman to receive a uterus from a deceased donor. Sert was born without one.

The green shoots sprouting from the soil do little to calm Varsha. Her farm and family mean the world to the 46-year-old. Even as she sees her farm come alive in myriad shades of green, she has been worried sick about her daughter, Tejaswini. Married for six years, the 22-year-old has been childless.

Until a few months ago, Varsha thought Tejaswini would never be able to conceive, for she was born without a uterus. “Unlike girls her age, she never got her periods,” she says. A sonography confirmed the absence of a uterus, a condition called Mayer-Rokitansky syndrome. But now, Tejaswini can get pregnant and have her own baby, after her mother volunteered to donate her uterus to Tejaswini.

India is gearing up for its first uterus transplantation, the next big thing in reproductive medicine after in vitro fertilisation. If everything goes as per plan, Tejaswini will be India's first uterine transplant recipient, providing her baby with a womb that was once home to her for nine months. “I am desperate to have a baby and carry it in my womb,” says Tejaswini, sitting next to her husband, Santosh, a Solapur resident.

Tejaswini will undergo the womb transplantation on May 18 at Galaxy Care Laparoscopy Institute, Pune. “We are all set for the surgery,” says Dr Shailesh Puntambekar, medical director of the institute. “What makes the surgery all the more unique is that we will be retrieving the uterus from the donor laparoscopically.”

Puntambekar, a surgeon known for his breakthrough keyhole surgery in cervical cancer, is confident that his vast experience in hysterectomy and laparoscopic surgeries will come in handy for the uterus transplantation. Laparoscopy can revolutionise the procedure, he says. “The blood loss will be bare minimum. A uterine transplant patient undergoing open surgery to remove the uterus would require a few blood transfusions. Our donors need lesser hospital stay and reduced anaesthesia time. They can go home after 48 hours,” he says.

The world's first uterine transplant baby was born in Sweden in 2014, and the team behind the medical marvel was led by Prof Mats Brännström of the Sahlgrenska University Hospital at Gothenburg. Brännström's track record as a babymaker has been quite impressive so far—six babies with two ongoing pregnancies.

While listening to a talk by Brännström in 2014, Puntambekar realised that the uterus can be removed from the donor much faster. “Brännström initially took 14 hours to take out the uterus, which later came down to six hours. The woman would be under anaesthesia all this while. This can be done laparoscopically in just two hours. With this idea, I started doing my experiments,” says Puntambekar. He went to Tübingen University in Germany and perfected his technique by doing vessel harvest in cadavers with cervical cancer. Brännström and his colleagues, Dr Pernilla Dahm-Kähler and Dr Niclas Kvarnström, will fly to Pune next month to assist Puntambekar and his team.

Mother's womb, daughter's, too High on hope: Dr Shailesh Puntambekar with Santosh, Tejaswini and her mother | Janak Bhat

The woman who receives the donor womb has to undergo three major surgeries. First, she has to undergo the transplantation surgery that will place the retrieved uterus in her pelvis. She can only have a C-section, not a normal delivery, says Puntambekar. “The nerves cannot be transplanted along with the uterus. Without the nerves, the uterus cannot undergo spontaneous contraction and relaxation required for normal delivery,” he explains. “Here you can only transport a physical uterus, which will act as a home for the baby, but the uterus has no ability to function on its own to push the baby outside. So the baby will have to be delivered through a C-section.”

Tejaswini is planning to have only one child. Once the baby is born, she will have to undergo yet another surgery. “That is to remove the uterus, so she can stop taking immunosuppressive medicines,” says Puntambekar.

But why would a woman be willing to go under the knife again and again to have a baby? For women born without a uterus, the only option available is to have a baby through surrogacy. As commercial surrogacy could soon be banned in India, uterus transplantation becomes the next best alternative. It allows a woman to experience motherhood from pregnancy onwards and have a legal, biological and gestational baby.

One in every 4,000 women in India is born without a uterus. There are about 4 lakh women with congenital absence of uterus in the country. The number could be higher as many of them do not disclose it owing to social taboo.

The surgery benefits women with non-functional uteri, too. Valli, whose uterus transplantation at Galaxy Care is scheduled for May 15, does not menstruate and has had two intrauterine deaths and two abortions. The surgeons will replace her uterus with her mother's so that she can have a baby. “Broadly speaking, all women who have ovaries, but no functional uterus and are capable of bearing their own child could be considered eligible for uterus transplant. Those who have had hysterectomy very early but have had their ovaries intact are good candidates for the transplantation surgery,” says Dr Kamini Rao of Milann fertility centre, Bengaluru, who is planning to perform two uterine transplants in June. It offers promise to women who have had their uterus removed at a young age due to cancer or postpartum haemorrhage or in cases where the uterus is severely damaged due to genital tuberculosis or Asherman's Syndrome.

20-birth-of-the-alternative

The recipient should be in the reproductive age group, ideally less than 35 years, with a good number of oocytes (immature egg cells), for better results. However, donor oocytes can also be used in case the woman does not have healthy eggs.

The donor should be a close relative who is immunologically compatible with the recipient. An ideal uterus donor is someone who has had a successful pregnancy, a sure-shot sign that the uterus can hold a baby. Women up to the age of 55 years can be considered for uterus donation. However, younger donors who menstruate are preferred. “An active uterus sheds its uterine endometrial lining every month. Only the basal layer remains that forms into a new lining in the following menstrual cycle. The embryo burrows itself into this wall of endometrial lining. If the uterus is menopausal and completely atrophic, we will have to menstruate the recipient and get the uterus to function,” explains Rao. Combination hormones of oestrogen and progesterone are given to the woman to initiate menstruation. The recipient then goes through an IVF before the transplantation. “We collect eggs, make embryos and ensure they are good enough before moving on to the surgery,” says Rao.

Mother's womb, daughter's, too Dr Kamini Rao, Milann fertility centre, Bengaluru

What challenges do the doctors anticipate? For one, organ rejection, where the recipient's immune system attacks the uterus. Doppler scan is used to check for signs of rejection. The recipient's cervix will also be examined. Blueness or too much redness can be signs of rejection.

Even the mother of the world's first uterine transplant baby had three mild episodes of organ rejection, one during pregnancy. But Brännström and his team were able to overcome that.

A genetic donor and immunosuppressants can reduce the chances of rejection. If the rejection cannot be modulated with drugs, then the uterus will have to be surgically removed.

Infection is another concern. The first uterus recipient in the US had to get the transplant removed a few weeks after the surgery, owing to an infection. The surgery was performed at the Cleveland Clinic on February 24, 2016. The uterus belonged to a deceased donor. Immunosuppressants make a recipient vulnerable to infections. “They are prone to infections in the first three weeks. However, all these recipients are healthy, unlike liver or kidney transplant patients who have been suffering from their diseases for a long time,” says Puntambekar. “The uterus recipient is typically a young woman who doesn't have any medical problems and her tolerance to immunosuppression will be excellent. So the chances of infection are very low.”

According to Dr Milind Telang, consultant laparoscopic gynaecologist at Galaxy Care, the immunosuppressives taken by a recipient during pregnancy are less likely to have any serious detrimental effects on the baby. “Women who conceived after renal transplant have been able to deliver healthy babies without any congenital anomalies. They were on immunosuppressives throughout their pregnancy,” he says.

Though Brännström transferred the embryos into the recipients' uteri after a year, Puntambekar plans to do it in six months. “The protocol is already written, shown to Brännström and agreed by him,” he says. “There is no data that says if you implant the embryos after six months, the result will be poor or vice versa. The idea is to allow the recipient to go off immunosuppressives as early as possible.”

Also, living conditions in India are quite different from that of Sweden. “In Sweden, they don't have tuberculosis. Their houses are cleaner and better managed,” says Puntambekar. “In India, women often get infections from the toilet or unhygienic environment. So we can't wait for one year to transplant the embryo.”

The joy of experiencing pregnancy and motherhood comes at a price of the patient's own health, says Dr Sumit Sharma, chief renal transplant surgeon and consultant in the urology department, Columbia Asia Hospital, Gurgaon. But, as an afterthought, he adds, “But then what do I know? I have fathered a child, not mothered one.”

Dr Kiran Coelho, consultant, gynaecology at Hinduja Healthcare Surgical, Mumbai, is aware of the risks associated with uterus transplantation. Yet, she says, “I think it is wonderful for women who don't have a uterus. Uterine transplant could be ideal for them.”

All the women shortlisted for uterus transplantation had one thing in common, says Puntambekar—they all wanted to carry a baby in their tummy.

Some names have been changed.

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