"We succeeded in helping two children to see the light of day who would otherwise never have been born," said Wallwiener of the medical success. This is also a breakthrough and a "new chapter in transplant surgery" for medical research.
Doctors from Gothenburg, Sweden, who are regarded as pioneers in the field of uterine transplantation, were also involved in the transplants in Tübingen. To date, there have been around 40 transplants of this type worldwide, with more than 10 births.
The mothers were both born with labia but without a vagina or uterus. About one in 4500 newborn females has this rare genetic defect - also known as Müllerian agenesis.
About 8000 affected people live in Germany. As a rule, the disease does not manifest itself until puberty. The women have ovaries, normal hormone production, breast development, and are otherwise "hormonally inconspicuous," explains Sara Brucker, medical director of the Research Institute for Women's Health at the same hospital, but they do not get their period.
It's especially during puberty that these patients are psychologically very vulnerable, says Brucker: "And that's exactly when we have to tell them the diagnosis during this phase. But we also can tell those affected: 'You are not alone. We can help you'."
For most of the patients concerned, it's not a question of having their own children at all in the beginning. The desire to have children can possibly be fulfilled by an adoption later.
But many patients want a sex life. So the doctors create a so-called neovagina — a surgically produced vagina. The aim is to "enable patients to change from girls to women," says Brucker. So far, 560 women have undergone such operations in Tübingen. Currently, about 40 to 50 more women are undergoing surgery each year.
The second step: uterus transplant
The uterus transplant is then "the next logical step", says the doctor. "We wanted to make it possible for them not only to go from girl to woman, but also from woman to mother." So far, doctors at the University Women's Hospital have successfully performed three such operations — for the first time in October 2016.
First, the donor (in Tübingen these were the mothers of the patients) donates the uterus. The doctors then wash the organ to remove blood components that might later lead to occlusion.
In one case, a donor's uterus had already been removed but could not be transplanted because the necessary washing procedure was not successful.
The organ is then implanted in the recipient. This has been achieved three times in Tübingen. "For the first time in their lives, women [subsequently] have had menstrual bleeding," said Brucker.
The children must in any case be conceived by artificial insemination, also called in-vitro-fertilisation. The egg is then implanted into the uterus. This is necessary because it wouldn't be medically possible to transplant the fallopian tubes undamaged and to ensure that the egg nests in the right place in the uterus.
In order to protect the uterus and the vagina, the children must also be born by caesarean section. The risk that the transplanted organ would otherwise be damaged would simply be too great.
Large team — manageable costs
The operations in Tübingen required the entire competence of the University Hospital. A total of 18 departments with over 40 experts were involved.
"The procedure is still a research project," said Wallwiener. It cannot yet be offered to the general public.
However, it's already clear that the costs will be kept within reasonable limits once the procedure has a broader application. "They lie between those of a kidney and liver transplant," estimates Wallwiener. And Brucker adds: "significantly less than 50,000 euros".
The medical director of transplant medicine at the University Hospital Alfred Königsrainer also explains, "unlike a kidney transplant, the patients are healthy". The risk of surgery is therefore much lower.
More than one pregnancy possible
In the case of the two women who had already delivered a child, the uterus could be preserved. So for medical reasons, nothing stands in the way of a second pregnancy, says Brucker.
The third transplant, which was carried out in Tübingen, didn't take place until January 2019. Since the patient is expected to wait a year after the transplant before becoming pregnant, the next child could be born in 2020 at the earliest.
During the transplant, the recipients of the organ donation receive drugs to prevent the rejection of the donor organ, known as immunosuppressants. However, these drugs have no effect on the child during pregnancy.
No ethical concerns about using live donors
Urban Wiesing, director of the Institute of Ethics at the University of Tübingen, when asked whether doctors have ethical concerns about uterine transplants, since living people are used as donors, said the law limits living donations to operations that save a patient's life or to "serious illnesses to alleviate suffering".
In the case of accident victims, it is very difficult to find out the history of the uterus. Is it possible that there is an infection with the human papillomavirus (HPV)? Is there a risk of cancer? Have the accident victim's births been successful? As long as doctors cannot rule out such risks, they prefer not to conduct a transplant.
Will transgender women soon be able to have children?
According to the current state of medical knowledge, the Tübingen physicians aren't confident this is possible. At this stage, they say, transgender patients have neither the ovaries nor the necessary hormone production to maintain a healthy uterus capable of growing a child.
Although there have already been studies on ovarian transplantation, the risks and chances of success are difficult to assess. According to Brucker, such a step wouldn't be ethically justifiable right now.