She was 16 when medical tests, performed because she had not begun menstruating, found that she had ovaries but no uterus — a syndrome that affects about one in 4,500 newborn girls. She comes from a large family, she said, and always assumed that she would have children. The test results were devastating.

Dr. Andreas G. Tzakis, the driving force behind the project, said, “There are women who won’t adopt or have surrogates, for reasons that are personal, cultural or religious.” Dr. Tzakis is the director of solid organ transplant surgery at a Cleveland Clinic hospital in Weston, Fla. “These women know exactly what this is about,” he said. “They’re informed of the risks and benefits. They have a lot of time to think about it, and think about it again. Our job is to make it as safe and successful as possible.”

 

Laying the Groundwork

The hospital plans to perform the procedure 10 times, as an experiment, and then decide whether to continue. Dr. Tzakis said he hoped to eventually make the operation readily available in the United States.

Sweden is the only country where uterine transplants have been completed successfully — all at the University of Gothenburg with a uterus from a live donor. Nine women have had them, and four have given birth, the first in September 2014. Another is due in January. Their babies were born healthy, though premature. Two transplants failed and had to be removed, one because of a blood clot and the other because of infection.

 

Two earlier attempts — one in Saudi Arabia, and one in Turkey — failed. Other hospitals, in the United States and in Britain, are also preparing to try the surgery, but are not as close as the team in Cleveland is.

Dr. Tzakis said the anti-rejection drugs were safe, noting that thousands of women with donor kidneys or livers, who must continue taking anti-rejection drugs during pregnancy, had given birth to healthy babies. Those women are more likely than others to have pre-eclampsia, a complication of pregnancy involving high blood pressure, and their babies tend to be smaller. But it is not known whether those problems are caused by the drugs, or by the underlying illnesses that led to the transplants. Because the women receiving uterine transplants would be healthy, Dr. Tzakis said, he was optimistic that complication rates would be very low.

 

A medical ethicist not connected with the research, Jeffrey Kahn, of Johns Hopkins University, said the procedure did not set off any alarms with him.

“We’re doing lots of things to help people have babies in ways that were never done before,” Dr. Kahn said. “It falls into that spectrum.”

 

Dr. Eric Kodish, the director of the clinic’s ethics center, said that when organ transplantation started more than 50 years ago, the goal was purely to save lives, but has broadened to include improving quality of life, with for example, face and hand transplants.

 

Dr. Tzakis, 65, said he had performed 4,000 to 5,000 transplants of kidneys, livers and other abdominal organs. To prepare for the uterine surgery, he spent time with the Swedish team, practicing in miniature swine and baboons and observing all nine of the human transplants in the operating room.

He described transplantation as ethically superior to surrogacy. “You create a class of people who rent their uterus, rent their body, for reproduction,” he said of surrogacy. “It has some gravity. It possibly exploits poor women.”

 

A Complicated Process

The Swedish team used live donors, and showed that a uterus from a woman past menopause, transplanted into a young recipient, can still carry a pregnancy. In five cases, the donor was the recipient’s mother, which raised the dizzying possibility of a woman giving birth from the same womb that produced her.

 

The Cleveland doctors will use deceased donors, to avoid putting healthy women at risk. For a live donor, the operation is far more complicated than a standardhysterectomy and takes much longer, seven to 11 hours, Dr. Tzakis said, adding, “You have to work near vital organs.”

The surgeons have to remove part of the donor’s vagina and other tissue needed to attach the uterus to the recipient. And they must tease away tiny blood vessels without harming the donor.

The uterine vessels are wound around the ureters, which carry urine from the kidneys to the bladder. “They’re like worms wrapped around a tube,” Dr. Tzakis said. “It’s very tedious to separate them.”

With deceased donors, there is no need to worry about injuries. The organ can be removed faster and can survive outside the body for at least six to eight hours if kept cold.

For a prospective recipient of a uterus, the process is long and complicated. To be eligible, candidates must be in a stable relationship, because they will need help and support. They must also have ovaries. The initial phase includes screening for psychological disorders or relationship problems that could interfere with a candidate’s ability to cope with a transplant and be part of a study. Candidates are also interviewed to make sure that they are not being pressured to have the transplant. Doctors use similar criteria for people receiving other types of organ transplants because the process is arduous, and patients with a strong social support system seem to fare better.

Finances matter, too, because during parts of the study, recipients will have to live in Cleveland, and those from out of town will have to pay for their food and lodging.

Because the fallopian tubes will not be connected to the transplanted uterus, a natural pregnancy will be impossible

 

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