Recent news on uterus transplant in India takes the infertility industry to a new level. The overarching rationale behind uterus transplant is that infertile women can ‘benefit’ from this and bear their own biological children.

The first such scientifically reported successful transplant was conducted in Sweden in 2013 where a 36-year-old, who was born without a uterus, received a donated womb from her mother. She gave birth to a baby boy using a transplanted womb in 2014. According to recent media reports, a private fertility clinic in Bengaluru has received permission from the Indian Council for Medical Research (ICMR) for uterus transplants for two women and the procedure will be undertaken as a research project. The minimum experience necessary for a clinical team to carry out this procedure, as per the Human Organ Transplant Act, is not available in India and hence the involvement of Swedish doctors, who pioneered the procedure, is being sought. The clinic has also claimed that they have obtained permission from the Medical Council of India (MCI) for the participation of Swedish doctors in the procedure.

Additionally, another hospital based in Pune is also gearing up for a set of uterine transplants, attempting to transplant the wombs of their respective mothers in three women. The nodal officer of the hospital is quoted in the media as saying that “the donor is someone who has completed a family and is donating with an altruistic motive”. However, the donor cannot be an unqualified ‘someone’ since the Transplantation of Human Organs Act 1994 lays down that it has to be a “near-relative”. At the very outset when this advanced procedure is being performed, it is crucial that this is fore grounded. There have been reports of illegal hysterectomies, most notably from Karnataka, where health activists successfully pushed for the private hospitals and the doctors involved to be brought in line. Therefore, if left unregulated, it is only a matter of time that there emerges a black market in uteri – from illegal hysterectomies to uterus transplants. These can arguably bear similarities to black markets in kidney that continue to thrive (despite a ban on organ sale).

What do the law and guidelines say?

It is interesting that the two sites where the procedure will be conducted have taken the necessary clearances from different authorities. While the Pune clinic has obtained permissions from the Maharashtra directorate of health services (as a transplant procedure), the Bengaluru clinic has got the clearance from the ICMR (as clinical trial).

It is important to weigh the merits of uterus transplant under the prevailing Transplantation of Human Organs and Tissues Act, 1994. The Act categorically mentions that transplant procedures are to be “for therapeutic purposes”. The term “therapeutic purposes” has been defined in the Act as “a systematic treatment of any disease or the measures to improve health according to any particular method or modality.” Medical science has succeeded in transplanting organs like heart, lung, kidneys, liver, pancreas and tissues like corneas, skin, heart valves, tendons, ear, ear bones and bones. Where the donor and the recipient are not related, permission needs to be sought from the Authorisation Committee under THOA.

In THOA, one of the most important provisions is Section 11 on “Prohibition of removal or transplantation of human organs or tissue or both for any purpose other than therapeutic purposes”. It states, “No donor and no person empowered to give authority for the removal of any human organ or tissue or both shall authorise the removal of any human organ or tissue or both for any purpose other than therapeutic purposes.”

Reading together, the definition of therapeutic purpose and the section 11 on prohibition from THOA, the following are clear: bearing children is not a therapeutic purpose; clinical trials are not included in the definition of therapeutic purpose; clinical trials can be deemed as not allowed under THOA, as removal and transplantation of organs can take place only for therapeutic purposes. Moreover, any authority giving permission for the same (like the ICMR and MCI, in this case) may also be doing so in contravention of these provisions. Under their own guidelines, ICMR and MCI cannot give permissions for transplants and even the authority established under THOA cannot give permission for such a ‘non- therapeutic’ transplantation to take place. Similarly, the ICMR guidelines on biomedical research on human participants (2006), in its chapter VII on “statement of specific principles for research in transplantation “, has a subsection “Guidelines on Live Donor Transplants”, clause 9, says clearly that “The experiment should be such as to yield fruitful results for the overall good of the donee without any risk to the life of the donor. The experiment should be undertaken only if there is no other method available of finding the answer to the question raised.”

Risk to women’s health- ethical and medical concerns

Uterus transplant as an emerging biomedical technology raises ethical concerns and health risks. Many experts from across the world have expressed apprehensions about a procedure that is still in its nascent stage. There has not been any conclusive findings on the long-term effects of the procedure on health of the woman undergoing the transplant or the children she gives birth to.

The news items on this procedure, on the contrary, show that it is being posited as a means to an end – that of giving a woman legal, biological and gestational motherhood.” Can this be construed as therapeutic purpose? More so, with regard to uterus transplant, some doctors specify that it is recommended that the recipient again undergoes a hysterectomy, presumably after outliving its utility of reproduction. It implies that women will be subjected to additional invasive procedures for removing the transplanted uterus. From scientific point of view long term risks seem to be automatically eliminated. One of the concerns often raised is that a uterus transplant, unlike a more established liver or kidney transplant, is not a life-saving measure. It is not developed to treat any life threatening medical conditions. Like any other medical surgery, here too the recipient undergoes the risks of surgery such as risk of hemorrhage and infections during or after the procedure. Moreover, like other transplant procedures, uterus transplant too entails the risk of rejection of the donor organ in the recipient’s body thereby necessitating immunosuppressive drugs to guard against it. The fact that uterus transplant would require the recipient to be on immunosuppressants for a very long duration, is not highlighted as much as the celebration around the technology itself.

Market for reproductive technologies

With questionable ‘therapeutic’ credentials, uterus transplant is more suitably located on a spectrum of reproductive technologies. Flourishing largely in the private sector, these technologies boost the health industry, which is heavily corporatised already and would only be increasingly strengthened in the coming times with newer innovations like these. Health activists have raised the concern whether investing in a developing technology like that of uterus transplant should be a priority in India, given lack of health care for many people, particularly the poor in the country. From a public health perspective, in a country like India with all the poor health indicators, high out-of-pocket expenditure on health, flourishing and unregulated private sector and collapsing public health system, it is bothersome to imagine such advanced technologies taking assuming priority in the milieu of health care.

The ‘promise’ of the technology tends to outshine the potential risks for individuals, who may take note only with adverse cases. A parallel can be drawn here with the increasing push for commercial oocyte donation which came under the radar only with unfortunate deaths of women like Yuma Sherpa in Delhi after acting as oocyte donor. Notwithstanding such cases, acceptance and ‘normalisation’ of such technologies can often create undue pressure on women, or even coercion to opt for these, since motherhood is deemed to be the core of femininity in a patriarchal context. First reproductive medicine develops its expertise in using in vitro fertilization (IVF) and wombs of surrogates and now this move towards uterine transplant. This obsession with skills and one’s own flesh and blood marginalises other ways of parenting.

Is motherhood the only essence of womanhood?

This entire debate on uterus transplant, brings us to the fundamental point about the patriarchal glorification of ‘biological’ motherhood for women and the imperative of creating a ‘family’ based on blood ties. Whenever ‘biological’ reproduction is hindered, these technologies are deemed to be the panacea. Feminist scholar Marsha Darling has insightfully observed that, “The concept of women’s bodily integrity is threatened by the extent to which women’s biological and reproductive organs, tissues, cells, including ovum and genes, are quickly becoming ‘spare parts’ in a medical industrial complex. At the very same time that reproduction is imagined as an industrial process by the biotech industry, women are sought after as consumers of the very technologies that will weaken women’s right to bodily integrity.”

There is a need to question the premium that is placed on biological parenthood and the assumption that motherhood can only be linked to genes and gestation. Such orthodoxy seeks to delegitimise social parenthood through adoption and impinges on women’s right to decide whether or not they want to be ‘mothers’. Motherhood must not be restricted to the biology of a woman, and a woman’s being must not be intrinsically linked only to their inability to reproduce and be mothers.

Sneha Banerjee and Sarojini Nadimpally work with Sama Resource Group for Women and Health, New Delhi