First UK birth after womb transplant is a medical breakthrough – but raises important ethical questions

A baby girl named Amy Isabel has become the first child in the UK to be born to a mother who has had a womb transplant. Amy is one of around 65 children worldwide born as a result of pioneering research into the procedure.

This breakthrough provides hope for many of the estimated 15,000 UK women with uterine factor infertility – which means they are unable to have children naturally due to problems with their womb, or because they were born without one. Previously, adoption and surrogacy were their only reproductive options. This latest success could some day make womb transplantation another option for these patients.

However, before this new treatment is offered more widely, complex questions will need to be answered about how it will be resourced, how wombs will be procured and who will get access to the treatment.

The cost of a transplant

The first birth by a mother following a womb transplant happened in Sweden in 2014. Since then, the number of womb transplant programmes being established globally has greatly increased.

The past 12 years have seen significant advances in the field. These include live births following a womb transplant from a deceased donor and the expansion of donor and recipient acceptance criteria. We’ve also seen the introduction of robotic-assisted surgery, which has made it possible to perform donor retrieval surgery in a faster, less invasive and more precise way.

While most transplant centres only offer the procedure as part of research trials, several now offer it in clinic – including in the UK.

The UK’s womb-transplant programme is currently funded by charitable donations from Womb Transplant UK, who currently only have plans to fund up to 15 living donor procedures. The procedure is expensive – costing the charity an estimated £25,000-£30,000. And it appears that this amount only covers the cost of the transplant, despite the fact that many other costs need to be factored in – such as IVF treatment, medications and follow-up care.

At present, prospective recipients normally bear the costs of the IVF treatment needed themselves. To be eligible for the transplant, women must have first produced and stored at least five embryos. IVF is necessary as the transplanted uterus will not be connected to the patient’s ovaries. This means that pregnancy through sexual intercourse is not possible. But before womb transplants can become routinely available within the NHS, commissioners will have to decide whether this treatment should be publicly funded – and under what circumstances.

On the face of it, public funding seems justified in the interests of patient autonomy and well-being. There are many psychological harms associated with infertility – such as depression, anxiety, stress and diminished quality of life. These harms must be taken seriously.

However, NHS resources are constrained – and there is already a “postcode lottery” of unequal access to IVF, with people in certain areas of England being less able to access NHS treatment. So there’s a risk that similar inequalities will arise for womb transplants if the procedure is NHS-funded.

Who gets priority?

If womb transplants are ever to become a routine procedure in the UK, difficult decisions will also need to be made about organ allocation policies.

According to the law in England, adults are considered to have agreed to become organ donors when they die unless they have opted out or are in an excluded group (such as those lacking mental capacity). However, this “deemed consent” only applies to commonly transplanted organs and tissues such as skin, hearts and lungs. It doesn’t apply to novel or rare transplants, which would include wombs. The NHS organ donor register also excludes the womb. Family members would therefore need to give explicit consent to the donation of their relative’s womb after death.

Living organ donors in the UK are able to specify a named recipient (such as a family member). Deceased donors can also request for directed allocation to a specific person. But this is only permitted so long as the offer to donate is unconditional and certain criteria are met, such as the recipient being able to receive the organ and being in need of a transplant.

More generally, since organs and tissues are scarce resources, complex policies are currently used to ensure fair and transparent allocation. Clinical need also guides allocation so that the sickest patients are prioritised for a transplant.

However, the same logic cannot apply to womb transplants. This is because absolute uterine factor infertility does not come in degrees. All women with the condition have a 0% chance of becoming pregnant.

As such, considerations that normally play no role in allocating life-saving organs could be explored in the context of womb transplantation. For instance, priority might be given to those who are childless. Age may also be relevant, especially given that the fertility treatment needed to create embryos is only funded by the NHS if a woman is below a certain age. The age limit varies by region, but can be as low as 35 in some places.

Policy decisions will also be needed about whether wombs are included in donor registers to increase their supply. Even if they are, people may prove less willing to donate reproductive organs than lifesaving organs and tissues. These decisions could also have knock-on effects on public trust in transplantation and organ-donation willingness more widely. And the inclusion of novel and rare organs could lead to more blanket opt-outs from organ donation altogether.

Next steps

Given the relative novelty and experimental nature of the procedure, there has not yet been a comprehensive roll-out of womb transplants as a mainstream fertility treatment anywhere in the world. In the UK, we’re not even at the beginning of that journey. Before that happens, womb transplants would need to be demonstrably cost-effective relative to other NHS-funded fertility treatments.

Nevertheless, there’s an opportunity here for the UK to become a world leader in creating and applying equitable access policies for womb transplants. To do this well, it will be necessary to carefully consider the clinical and health economic data, the ethical and legal issues, and the views of all those affected – especially those with uterine factor infertility.

Laura O'Donovan has previously collaborated with members of the Womb Transplant UK research team.

Nicola J. Williams currently receives funding from The Wellcome Trust (grant number: 222858_Z_21_Z) and previously held a Leverhulme ECR fellowship (grant number: ECF-2018-113). She is currently chair of the Special Interest Group: Ethics and Law for the European Society for Human Reproduction and Embryology and has previously collaborated with members of Womb Transplant UK.

Stephen Wilkinson currently receives funding from Wellcome (grant number: 222858_Z_21_Z). He has previously collaborated with members of Womb Transplant UK. He is a member of the Nuffield Council on Bioethics (NCoB) but this article is a personal view and unrelated to his NCoB role.