Media watch: Is Japan ready for uterus transplants?

According to an article published by Asahi Shimbun on Nov. 25, Keio University has applied to the health ministry for permission to carry out uterus transplants. If permission is granted, the ministry will start screening applicants for the procedure early next year, after which clinical trials will be launched. Last July, the Japan Medical Association studied the prospects for uterus transplants and agreed to permit clinical trials, which would be the first step toward actual transplant operations. The JMA’s summary stated that the transplants would be for women in their 20s and 30s diagnosed as being unable to bear children, women who were born without uteruses, and women who had undergone hysterectomies due to benign tumors. (Women who had had hysterectomies because of malignant tumors are not eligible.) As with donated eggs, transplanted uteruses can only be from blood relatives of the recipient, typically an older, pre-menopausal woman like a mother or an aunt. Anti-rejection medication is administered following the transplant procedure and menstruation is monitored for at least 6 months to determine the viability of the transplanted organ. The recipients retain their ovaries, from which eggs are harvested and fertilized. The resulting embryo is then implanted in the transplanted womb. Any baby that is subsequently brought to term is delivered via caesarian section. Since the mother must continue taking anti-rejection drugs, she is allowed a maximum of two babies. Eventually, the transplanted uterus is removed. The cost of the operation alone is estimated at ¥25 million, but as the article points out there are still many issues to be resolved before any transplant can be performed.

The first uterus transplant took place in Saudi Arabia in 2000 on a 26-year-old woman, but the uterus turned out to be not viable. After more testing on animals was carried out over the years, the first child born to a woman via a transplanted uterus was in Sweden in 2014. As of October, there have been 98 uterus transplants worldwide that produced 52 babies. The procedure to remove the uterus from the donor takes 8-10 hours and the implant operation takes about 5, so it is a large-scale surgical matter. According to an assistant professor at Keio who talked to Asahi, uterus transplants differ significantly from other transplant operations in that they are not performed to save or otherwise extend the lives of their recipients. The purpose is simply to provide women who are not able to conceive or deliver children with another option to give birth. Viable uteruses can be transplanted from either living donors or deceased donors, but initially in Japan only living donors will be allowed, though, according to the assistant professor, deceased donors are more appropriate due to any surgical complications when operating on a live donor. But because of existing Japanese transplant guidelines and laws, the JMA will need to discuss the related ethics first, and they plan to do so next year along with the Japan Gynecological Academy. 

Another aspect that would make uterus transplants different in Japan than in other countries where it is performed is that it is being approved in a legal environment where surrogacy is still not permitted. In most countries, women who cannot become pregnant or deliver babies themselves have the option of implanting their fertilized eggs in the womb of a third party, but in Japan this is illegal due mainly to the Civil Code, which defines the mother of a child as being the person who gives birth to that child. A number of women have opted for surrogacy, but they have had to go overseas, and even in that instance, on their family registers the child, even if it is the product of an egg from the contracting mother that has been implanted in the surrogate, is designated as being adopted. (Courts have been divided on the matter, but the law is unchanged.) For many Japanese families this is not an acceptable option and so, while being more complicated and expensive, uterus transplant may be a more desirable option. It is also notable that any woman who undergoes the procedure must be married, ostensibly because the woman would require “cooperation.” 

The Asahi article states that one of the most common problems associated with the need for uterus transplants is the congenital condition known as Mayer-Rokitansky-Kuster-Hauser Syndrome, which describes the under-development or lack of a uterus. The JMA estimates that about 3,500 women in Japan between the ages of 20 and 39 were born with this condition. But one doctor cautioned that given the criteria that the JMA requires to proceed with uterus transplants, the number of possible recipients is greatly limited because living donors would for the most part be biological mothers, and the older the donor, the less the likelihood of success. 

The article also states that the real impetus behind the move to permit uterus transplants in Japan is “medical progress,” which raises the question of how women who seek out such care will be treated, at least in the short run. Some interested parties are worried that before transplants are allowed, women who are unable to bear children due to MRKH Syndrome or other factors be eligible for medical and psychological counseling and support so that they can make a more informed decision. A report by the health ministry that came out this summer clearly pointed out that such support is lacking in Japan due to a paucity of counselors. Such support should also necessarily be extended to potential donors. As another assistant professor, this one from Waseda University, told Asahi, at the moment the main issues for the medical community with regard to uterus transplants are technical ones, but providing mental and social support is just as vital, she said. Ideally, there should be a medical and social environment where uterus transplants are just one means to an end. 

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