After conducting India’s first two successful uterine transplants in 2017 and then another seven before the pandemic, Pune’s expert team at Galaxy Care Hospital was invited by the Gujarat government to carry out the procedure for two women on September 25. The West Bengal government has also invited the team to conduct the surgery. Dr Shailesh Puntambekar, medical director of Galaxy Care Hospital, who has specialised in laparoscopic and robotic cancer surgeries, talks about the complicated womb transplant surgery and efforts to reduce risks
What is a uterine transplant? How many procedures are carried out in the world?
A uterine transplant, or womb transplant, provides a potential treatment for women who cannot become pregnant or carry a baby to full term because they lack a uterus (either they were born without it or lost it at a young age due to a benign or malignant condition) or have a totally non-functional uterus. This is estimated to affect one in 500 women according to the British Journal of Obstetrics and Gynaecology. A new uterus is obtained from a live or cadaveric donor and fitted into the recipient. This is done only for the patients who are married and wish to have children. This cannot be done in unmarried women. Also, the women have to be genetically female and should be between 21 and 35 years of age. So far, cadaveric transplants have been unsuccessful and hence live donor transplants are done. The donor is usually the patient’s mother, who is clinically verified.
More than 100 uterine transplants have been done worldwide. The first was done in Turkey in 2009. The second was done in 2011. The first live birth of a baby after a uterine transplant was in 2014. India is the fourth country to do the uterine transplant after Turkey, Sweden and the US. Our baby was the 12th baby in the world to have been born after a uterine transplant. Although the number of transplants to date is still relatively small, the number being performed globally is growing, say authors in the April 2021 issue of the British Journal of Obstetrics and Gynaecology. Uterine transplantation is a potential therapeutic intervention for women with absolute uterine factor infertility (AUFI). This condition is widely considered to affect 1 in 500 women of child-bearing age, and has been estimated to impact 2,00,000 women in Europe, 85,000 in the US and up to 1.5 million women worldwide. AUFI refers to women with infertility secondary to the absence of a uterus or the presence of one that is anatomically or physiologically dysfunctional. According to the journal, more than 70 procedures and 23 live births had taken place till 2021.
This surgery is considered risky and there aren’t many votaries for it. Why then did you take up uterine transplants in the first place?
First of all, let me be very clear that this procedure is only confined to women whose uterus is totally non-functional. Second, being an expert in laparoscopic cervical cancer surgery, I thought we could do the same procedure laparoscopically, thereby decreasing the time and also the morbidity of the donor. We were the first in the world to do laparoscopic donor retrieval for the transplant.
What about options like adoption and surrogacy?
Couples wishing to start a family are thoroughly counselled about these options. However, due to various aspects, some families do not find it an alternative. Women born with AUFI can never experience menstruation and according to the study paper in the journal, the birthing experience has been the primary motivator in 63 per cent of women with AUFI. Of the 45 reported cases, 40 (89 per cent) were performed in women with the Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome (uterus absent or under-formed). Four (nine per cent) cases were undertaken following hysterectomy (one for postpartum haemorrhage, one after cervical cancer, two following failed myomectomy. One case was undertaken in a woman with Asherman syndrome who underwent preparatory hysterectomy at the time of uterine transplantation.
In India, women without uterus or small uterus have a huge problem in getting married because surrogacy is the only option for them. These women are essentially normal but suffer a huge psychological setback due to the absence of uterus. There are huge issues of infertility in India like late age of pregnancy, multiple abortions and others. The majority of women, who are opting for uterine transplants, are those born without uterus, small uterus or those whose uterus was removed due to cancer or any emergency procedure.
You have performed nine procedures in Maharashtra and two in Gujarat. What are the challenges? What could be the complications of a surgery gone wrong?
The donor could be any family member who has children apart from the mother. We have a big team of doctors. One team is involved in laparoscopic uterine retrieval from the donor while another team is involved in preparation of the recipient’s uterus for transplant. There is a separate team of doctors for the recipient of the uterus. Additionally we need obstetricians, gynaecologists and intensivists. The financial cost is a challenge as it takes around Rs 15-17 lakh for a uterine transplant. We have done all nine transplants free of cost. Another challenge is getting permission from appropriate authorities as ours is the only team who is performing these surgeries. Unless we do many, we cannot train the next team. There has been no mortality following a uterine transplant anywhere in the world. The only complication is the rejection of the uterus like any other transplant organ.
Why are governments inviting you and your team? What is your special technique and how do you plan to reduce hours taken for surgery?
Governments like Gujarat and West Bengal are inviting us because it requires intense understanding of the anatomy of the uterus to harvest the organs. Since the number of transplants is less, training doctors is a major issue. The governments of respective states are playing it safe and would rather have the team which has successfully done the transplants, can repeat the procedure and reinvent the wheel. The special technique which we have developed is the laparoscopic donor retrieval, which has reduced the surgery time to three hours.
Do you see a rise in uterine transplants? Are you training surgeons?
We definitely see a rise in uterine transplants as a new surrogacy law prevents commercial surrogacy. So this is an option to have a genetic child. We have trained people from Brazil and Spain who have repeated the same technique. We now plan to train Indian surgeons.