COVER STORY

Labour gains

A woman gives birth using her mom's womb, thanks to India's first uterine transplant

20-Minaxi-Walan Wish come true: Minaxi Walan with daughter, Radha | Anirudha Karmarkar

Minaxi Walan, 28, ran a beauty parlour out of her home in Vadodara. She would shape eyebrows, making them look like seagull wings. Occasionally, she would get brides.

Minaxi Walan had a series of stillbirths and miscarriages. She also developed Asherman's Syndrome, a disorder that affects fertility.
It took three years for us to prepare for the transplant. We went to Germany and Turkey, and started working on cadavers to understand the anatomy of the uterus. - Dr Shailesh Puntambekar, medical director of Galaxy Care Hospital, Pune
I want to devote all my attention to my baby until she grows up. I might start working again once she starts preschool. - Minaxi Walan, who ran a beauty parlour from her Vadodara home

Her world was small and quiet. But she was troubled. For, Walan desperately wanted to be a mother. She had a series of stillbirths and miscarriages. “My first baby had growth problems during pregnancy. The second time around, the baby lost its heartbeat while in the womb,” said Walan. “During my third pregnancy, I underwent an ultrasound. The doctor told me that there was some bone (foetal part) left in my uterus, which had to be removed. While removing the foetal bone, my uterus got injured.”

Walan was advised either to get the wound sutured or undergo a hysterectomy (surgical removal of the uterus). But she wanted to conceive. So, she opted for the suture. “My periods stopped after that,” she said. “Then, I got a hysteroscopy done. The doctor told me that the inner walls of my uterus were like white cement, and that I wouldn't be able to conceive.”

Walan developed Asherman's Syndrome, a disorder that affects fertility. She almost gave up on her dream of motherhood. But a team of doctors at Galaxy Care Hospital in Pune made the impossible possible for her through a uterine transplant. Walan received the uterus from her 48-year-old mother. She is now a proud mother of a two-month-old girl—Radha.

Radha is the first baby to be born after a uterine transplant in the Asia-Pacific region. She is the 12th uterine transplant baby in the world. The world's first womb transplant baby was born in Sweden in 2014. In a first, a woman in Brazil received a uterus from a deceased donor and gave birth to a girl in December 2017.

Clad in a pink singlet, Radha was taking a nap when I first saw her. She was oblivious to the extraordinariness of her journey. A preemie, Radha was kept on a baby warmer. “She is doing well,” said Walan. Radha weighs 2.5kg now.

Minaxi Walan | Mini P. Thomas Minaxi Walan | Mini P. Thomas

Dr Shailesh Puntambekar, medical director of Galaxy Care Hospital, called Radha a miracle. “She was born from a 48-year-old uterus that had long forgotten to produce babies,” he said. Radha's arrival was a birthday gift for Puntambekar. She was born at 12.12pm on October 18, sharing her birthday with Puntambekar, 55. “She made my last birthday the most memorable one till date. We always celebrate my birthday with a bash, but this year we celebrated the whole night,” he said, smiling.

Radha's birth offers hope to thousands of women who do not have a uterus. One in 4,000 women in India is born with congenital absence of the uterus. “A woman born with an absent or tiny uterus can now have a biological child and carry it in her womb, thanks to uterine transplant,” said Puntambekar. “It is a boon for young women who have had a hysterectomy due to cancer or fibroids, and those with a non-functional uterus.”

The uterus has four arteries and four veins. Keeping all these vessels intact and rejoining them can be a surgical challenge. Until now, uterine transplant surgeons would implant the uterus along with the arteries and veins. The Galaxy Care Hospital team has proven that only one uterine artery and one ovarian vein are sufficient for the entire transplant. Also, they took out the uterus from the donor laparoscopically, which meant a smaller incision and shorter surgical time. “The Swedish doctors initially took 15 hours to take out the uterus,” said Puntambekar. “Now they take ten hours, whereas we can do it laparoscopically in 5 hours 20 minutes. This reduces the donor's exposure to anaesthesia by half.” These innovations have created a buzz in the uterine transplant community worldwide.

For Puntambekar and his team though, it has been a tough journey against all odds. “It took three years for us to prepare for the transplant. We went to Germany and Turkey, and started working on cadavers to understand the anatomy of the uterus,” said Puntambekar, renowned for developing the laparoscopic radical hysterectomy known as the 'Pune technique'. “In India, there are no cadaveric labs, except at Ramaiah Memorial Hospital in Bengaluru, which is only for orthopaedics. Meanwhile, we used to do live surgeries for cancer, which also helped us perfect the surgical technique.”

Helping hand: Dr Shailesh Puntambekar with Minaxi Walan and Radha | Mahesh Chaudhari Helping hand: Dr Shailesh Puntambekar with Minaxi Walan and Radha | Mahesh Chaudhari

The team faced a significant challenge early on. “As we approached the government of Maharashtra for permission to carry out the transplant, the Indian Council of Medical Research got in the way,” said Puntambekar. “It was trying to increase its own importance by saying we should seek its permission for the transplant.”

Finally, the government formed a six-member expert committee to have a look at the facility. “They visited the hospital and inspected every operation theatre, every blood bank and everything that was in-house. Then only they gave us a go-ahead,” said Puntambekar. “Also, the ministers turned out to be better than the bureaucrats. When the entire bureaucracy was opposing us tooth and nail, Chief Minister Devendra Fadnavis and [cabinet] minister Girish Mahajan stood by us.”

Then came a series of setbacks as the team went ahead. Prof Mats Brännström, the Swedish doctor whose patient delivered the first uterine transplant baby in the world, had promised to come to Pune to help the team with its first transplant recipient—Shivamma Chalgeri, 22, from Solapur. Brännström, however, did not turn up and later even called the team “surgical cowboys trying to gain fame”. What followed was even worse—Chalgeri had two miscarriages.

Walan underwent the transplant in May 2017, and got her period 48 days post transplant. That the transplanted uterus was functioning gave a much-needed boost to the team. “A transplanted heart, liver or kidney normally functions within 24 hours,” said Puntambekar. “In the case of the uterus, you have to wait till the recipient gets her first period to make sure that the organ is functioning well.”

Small wonder: Radha is the first baby to be born after a uterine transplant in the Asia-Pacific region | Anirudha Karmarkar Small wonder: Radha is the first baby to be born after a uterine transplant in the Asia-Pacific region | Anirudha Karmarkar

The embryo was then transferred into Walan's womb in January 2018. What appeared to be a dream run, however, was thwarted by a miscarriage 48 days after the embryo transfer. “That was one of the toughest phases in this journey,” recalled Puntambekar. “People started questioning us, and as a team leader, I had a hard time keeping up the morale of everyone.”

Walan underwent an embryo transfer again in April. She got pregnant, and the first and second trimesters went off uneventfully. An anomaly scan was done in the second trimester—the baby looked normal.

Theoretically, uterine transplant babies have an increased risk of developing congenital abnormalities as their mothers are put on immunosuppressants. However, 14,000 kidney transplant recipients in the world have had healthy babies, says Dr Milind Telang, consultant laparoscopic gynaecologist at Galaxy Care Hospital. “We took our cue from them,” he said. “We brought Walan's dose to a particular level before doing the embryo transplant to avoid adverse effects on the foetus.”

One of Puntambekar's worst fears was Walan having a stillbirth, owing to her history. “In retrospect, I can say we were worried for nothing. Because the uterus that led to the death of her babies was no longer there. This was a new uterus,” he said.

The baby came earlier than planned. On October 17, when Walan had completed just 32 weeks, her blood pressure started rising, and her amniotic fluid levels went down from 1l to 200ml. So, it was decided to perform a C-section. A neonatal ICU was created in 24 hours. Paediatricians and doctors were hired. A phototherapy equipment and ventilator were brought in. And, the baby was born.

Today, Galaxy Care Hospital has 600 patients waiting for uterine transplant from India and countries like Bangladesh, Pakistan, England, Kenya and Oman. Lower costs have made the hospital a popular destination for women wanting to get womb transplant done. The entire transplant costs Rs15 lakh to Rs18 lakh at the hospital.

Puntambekar has now been invited to Baylor University Medical Center, Dallas, where the world's second uterine transplant baby was born, for a talk on laparoscopy in transplantation. Easy availability of grants is one of the reasons a majority of innovations happen in the west, he said. “The Baylor transplant team got a grant of around $1 million; the Swedish doctors got €1.2 million for the transplant project. We did not get a single rupee from anybody,” he said. “The first three transplants cost us Rs2 crore. We could still take the project forward because of our sheer willpower. I wanted to prove to the world that we are second to none when it comes to surgical skills, technical mastery and patient care.”

Looking back, Puntambekar said it had been a remarkable journey. “At times, my team members broke down. My wife broke down,” he said. “But I did not. If I had also fallen apart, the transplant would not have happened.” It would have been like a captain abandoning his ship.

And, Walan is grateful that the team did not lose hope. “Doctors and staff at Galaxy Care took good care of me,” said Walan, who has been in the hospital since the embryo transfer. “Dr Puntambekar's wife has been very kind to me. She would make khichdi and dal for me.” Walan, for now, has shut her beauty parlour. “I want to devote all my attention to my baby until she grows up,” she said. “I might start working again once she starts preschool.”

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