P-390 Uterus transplantation, is it ethical to authorize living donor programs when no other alternative to this type of donation is possible?
Authors: Carton I , Dion L , Hofmann B , Lavoué V 
Published: June 2023

Abstract

Study question
Can we guarantee a freely taken decision for a living donor when she represents the only possibility for a loved one to have a uterus-transplantation?

Summary answer
The autonomy and freedom of the donor may be reduced by the awareness that they are the only possibility for the relative to achieve parenthood.

What is known already
The subject is unknown unlike to the many studies that compare surrogacy to uterus transplantation. The closest study is Lisa Guntram's 2021 paper "May I have your uterus? The contribution of considering complexities preceding live uterus transplantation" which looks at the difficulty of simply having to ask this question. She highlights that the answer, including a refusal, can have both short-and long-term consequences.
However, it does not specifically address the constraint that this represents, or rather adds to the already complex problem of not offering any alternative to the living donor. As a reminder, this is a complex and risky surgery

Study design, size, duration
This is a qualitative study based on semi-structured interviews. The study protocol was submitted to an independent ethics committee for approval. The study was carried out during the year 2022. Communication was made through patient associations and participants volunteered to take part in the study.

Participants/materials, setting, methods
We interviewed 9 health professionals involved in uterus transplantation programmes in France and Sweden and 9 women with Rokitansky syndrome. The health professionals were gynaecologists or psychologists. The interviews were recorded, manually transcribed and analyzed using a thematic content analysis method. The analysis of the interviews was carried out in double reading.

Main results and the role of chance
Many centres that offer the possibility for women with Rokitansky syndrome to be transplanted do not offer a deceased donor uterus transplant programme or surrogacy.
According to some of the professionals interviewed, mothers, the main potential donors identified, already feel guilty about their daughters' disease (Rokitansky syndrome). They cannot therefore consider, despite the risks involved, refusing to donate their uterus. But how can an agreement based on guilt be considered? Furthermore if there is no other solution if they refuse to allow their daughter to become both a legal and biological mother.
In the case of uterus transplantation, is the institution that has legalized such a procedure putting them in this difficult position bears some responsibility?
A total ban, however, would remove the hopes of these women.
According to some professionals and women, the constraint is reduced if women know that in the event of the absence of an identified donor in their entourage, the possibility of resorting to a deceased donor is possible.
Thus, freedom is possible at all levels: asking or not for a uterus transplant and having the possibility to accept or not to donate

Limitations, reasons for caution
This study is based on 18 interviews, which is a small number. Furthermore, all the interviews are in Europe, and only in 2 countries, which may make extrapolation to a larger scale difficult. It has the merit of opening the discussion

Wider implications of the findings
Even if it seems difficult to legislate on a global scale, it is necessary to reflect on the prerequisites before endorsing a transplant programme, including the notion of an alternative to be offered to donor/recipient couples by encouraging the development of a deceased-donor programme, altruistic donors, or by legalizing surrogacy.

Trial registration number
not applicable