Current status of surrogacy in Japan and uterine transplantation research

Uterus transplantation: from research, through human trials and into the future

Women suffering from absolute uterine factor infertility (AUFI) had no hope of childbearing until clinical feasibility of uterus transplantation (UTx) was documented in 2014 with the birth of a healthy baby. This landmark accomplishment followed extensive foundational work with a wide range of animal species including higher primates. In the present review, we provide a summary of the animal research and describe the results of cases and clinical trials on UTx. Surgical advances for graft removal from live donors and transplantation to recipients are improving, with a recent trend away from laparotomy to robotic approaches, although challenges persist regarding optimum immunosuppressive therapies and tests for graft rejection. Because UTx does not involve transplantation of the Fallopian tubes, IVF is required as part of the UTx process. We provide a unique focus on the intersection between these two processes, with consideration of when oocyte retrieval should be performed, whether, and for whom, preimplantation genetic testing for aneuploidy should be used, whether oocytes or embryos should be frozen and when the first embryo transfer should be performed post-UTx. We also address the utility of an international society UTx (ISUTx) registry for assessing overall UTx success rates, complications, and live births. The long-term health outcomes of all parties involved-the uterus donor (if live donor), the recipient, her partner and any children born from the transplanted graft-are also reviewed. Unlike traditional solid organ transplantation procedures, UTx is not lifesaving, but is life-giving, although as with traditional types of transplantation, costs, and ethical considerations are inevitable. We discuss the likelihood that costs will decrease as efficiency and efficacy improve, and that ethical complexities for and against acceptability of the procedure sharpen the distinctions between genetic, gestational, and social parenthood. As more programs wish to offer the procedure, we suggest a scheme for setting up a UTx program as well as future directions of this rapidly evolving field. In our 2010 review, we described the future of clinical UTx based on development of the procedure in animal models. This Grand Theme Review offers a closing loop to this previous review of more than a decade ago. The clinical feasibility of UTx has now been proved. Advancements include widening the criteria for acceptance of donors and recipients, improving surgery, shortening time to pregnancy, and improving post-UTx management. Together, these improvements catalyze the transition of UTx from experimental into mainstream clinical practice. The procedure will then represent a realistic and accessible alternative to gestational surrogacy for the treatment of AUFI and should become part of the armamentarium of reproductive specialists worldwide.

Commercial Surrogacy: An Overview

OBJECTIVE

 Surrogacy is the process in which a woman carries and delivers a baby to other person or couple, known as intended parents. When carriers are paid for surrogacy, this is known as commercial surrogacy. The objective of the present work is to review the legal, ethical, social, and cultural aspects of commercial surrogacy, as well as the current panorama worldwide.

METHODS

 This is a review of the literature published in the 21st century on commercial surrogacy.

RESULTS

 A total of 248 articles were included as the core of the present review. The demand for surrogate treatments by women without uterus or with important uterine disorders, single men and same-sex male couples is constantly increasing worldwide. This reproductive treatment has important ethical dilemmas. In addition, legislation defers widely worldwide and is in constant change. Therefore, patients look more and more for treatments abroad, which can lead to important legal problems between countries with different laws. Commercial surrogacy is practiced in several countries, in most of which there is no specific legislation. Some countries have taken restrictive measures against this technique because of reports of exploitation of carriers.

CONCLUSION

 Commercial surrogacy is a common practice, despite important ethical and legal dilemmas. As a consequence of diverse national legislations, patients frequently resort to international commercial surrogacy programs. As of today, there is no standard international legal context, and this practice remains largely unregulated.

A comparison of assisted human reproduction (AHR) regulation in Ireland with other developed countries

BACKGROUND

Assisted human reproduction (AHR) treatment is not regulated in Ireland although it has been practiced since 1987. Thus, Ireland is one of the only European countries without any form of AHR specific regulation. This literature review research aimed to provide a comprehensive and comparative overview of AHR regulation and any associated literature to compare Ireland and other developed countries.

METHODS

Systematic searches were conducted in several databases (Google Scholar, Web of Science, MEDLINE, SCOPUS and official government websites) utilising search strings in relation to AHR legislation for each country under review. A final review of 155 research articles were eligible after screening related to legislation in each country for inclusion. The findings were synthesised and summarised by legislation in each country.

RESULTS

Different countries offer different levels of ART and IVF provision and services in terms of the type of services allowed, financial support, age, sex and eligibility of recipients. The UK's oversight legislation combined with the Netherlands financial legislation section provides as being most effective hybrid model of best practice for adoption in Ireland.

CONCLUSIONS

This research concluded that there is no AHR legislation in any country that can be described as all-encompassing in terms of the services allowed, financial support and age of recipients. It was concluded that significant changes need to be made to the Irish draft legislation which is in limbo with the government for the last 3 years in order to meet Irish patient needs.

Keio Uterus Transplantation Research: From Basic Research toward Future Clinical Application

Uterus transplantation (UTx) is now a potential option to allow women with uterine factor infertility to give birth. However, UTx is still at an experimental stage, and basic animal studies, including in non-human primates, are needed for the accumulation of data prior to clinical application. Considering that UTx may provide new hope to Japanese women, we launched UTx research in 2009 and have since accumulated a large archive of results in the UTx research field. Furthermore, we have carried out various activities aimed at the implementation of clinical applications of UTx in Japan while clarifying the ethical and social issues involved. Currently, the clinical application of UTx in Japan is just around the corner, and it is expected that UTx research will develop further in the future. Herein, we summarize our basic experiences using non-human primates and our activities with the goal of future clinical applications.

Concerns Associated with Uterus Transplantation in Japan

Uterus transplantation (UTx) has seen increasing global adoption as an alternative for women with uterine factor infertility to achieve pregnancy. However, several medical, ethical, and social issues need to be addressed before UTx can be applied clinically. Since 2009, Japan has amassed a large database of basic research on UTx in non-human primates, but clinical application has not been realized because of conservative attitudes and prudent concerns. Nonetheless, UTx may be viable in Japan after comprehensive resolution of the concerns associated with this medical technology.

Uterine transplant: an ethical framework analysis from a Middle Eastern perspective

BACKGROUND

Significant advances in infertility treatment have been achieved over the past several decades, but women with uterine dysfunction, anomaly, or agenesis still need support to carry a pregnancy to term. Recently, advancements in surgical, anesthetic and immunosuppressive therapy have brought the idea of successful uterine transplant closer to reality, but many challenges must be overcome before uterine transplant can become more common, including ethical challenges related to the study and the conduct of this procedure.

METHODS

This was an updated ethical analysis of uterine transplant from a Middle Eastern perspective, using an established ethical framework that has been adapted for the analysis of research in non-Western cultures and developing countries.

RESULTS

Using the ethical framework, this analysis explored research developments in uterine transplant to date, using the following categories: collaborative partnership, social value, scientific validity, a fair selection of study population, favorable risk-benefit ratio, independent review, informed consent, and respect for recruited participants. The analysis revealed a significant need for region- and religion-specific ethical guidelines for uterine transplant procedures.

CONCLUSIONS

The horizons of research need to expand by addressing and researching the ethical issues related to uterine transplant trials and clinical procedures.

LIMITATIONS

Limitations included the challenges related to applying ethical analyses to work in developing countries, and the fact that this analysis was based on the views and interpretations of a single researcher.

Surrogacy and "Procreative Tourism". What Does the Future Hold from the Ethical and Legal Perspectives?

Background and objectives: To explore the ethical and legal complexities arising from the controversial issue of surrogacy, particularly in terms of how they affect fundamental rights of children and parents. Surrogacy is a form of medically-assisted procreation (MAP) in which a woman "lends" her uterus to carry out a pregnancy on behalf of a third party. There are pathological conditions, such as uterine agenesis or hysterectomy outcomes, that may prevent prospective mothers from becoming pregnant or carry a pregnancy to term; such patients may consider finding a surrogate mother. Many issues relating to surrogacy remain unresolved, with significant disagreements and controversy within the scientific community and public opinion. There are several factors called into play and multiple parties and stakeholders whose objectives and interests need to somehow be reconciled. First and foremost, the authors contend, it is essential to prioritize and uphold the rights of children born through surrogacy and heterologous MAP. Materials and methods: To draw a parallel between Italy and the rest of the world, the legislation in force in twelve European countries was analyzed, eleven of which are part of the European Union (France, Germany, Italy, Spain, Greece, Netherlands, Belgium, Denmark, Lithuania, Czech Republic and Portugal) and three non-members of the same (United Kingdom, Ukraine and Russia), as well as that of twelve non-European countries considered exemplary (United States, Canada, Australia, India, China, Thailand, Israel, Nigeria and South Africa); in particular, legislative sources and legal databases were drawn upon, in order to draw a comparison with the Italian legislation currently in force and map out the evolution of the Italian case law on the basis of the judgments issued by Italian courts, including the Constitutional and Supreme Courts and the European Court of Human Rights (ECHR); search engines such as PubMed and Google Scholar were also used, by entering the keywords "surrogacy" and "surrogate motherhood", to find scientific articles concerning assisted reproduction techniques with a close focus on surrogacy. Results: SM is a prohibited and sanctioned practice in Italy; on the other hand, it is allowed in other countries of the world, which leads Italian couples, or couples from other countries where it is banned, to often contact foreign centers in order to undertake a MAP pathway which includes surrogacy; in addition, challenges may arise from the legal status of children born through surrogacy abroad: to date, in most countries, there is no specific legislation aimed at regulating their legal registration and parental status. Conclusion: With reference to the Italian context, despite the scientific and legal evolution on the subject, a legislative intervention aimed at filling the regulatory gaps in terms of heterologous MAP and surrogacy has not yet come to fruition. Considering the possibility of "fertility tourism", i.e., traveling to countries where the practice is legal, as indeed already happens in a relatively significant number of cases, the current legislation, although integrated by the legal interpretation, does not appear to be effective in avoiding the phenomenon of procreative tourism. Moreover, to overcome some contradictions currently present between law 40 and law 194, it would be appropriate to outline an organic and exhaustive framework of rules, which should take into account the multiplicity of interests at stake, in keeping with a fair and sustainable balance when regulating such practices.

Experimental techniques for the development of a uterus transplantation model in cynomolgus macaques

Uterus transplantation (UTx) is now a treatment for women with uterine factor infertility to have a child. However, UTx is still largely at the experimental stage, and many medical issues remain unsolved. Therefore, adequate studies in large animals including non-human primates are required for validation of these issues. UTx research, especially in non-human primates, can provide important information for its full establishment in humans due to the anatomical and physiological similarities between the two. We accumulated data from UTx studies using cynomolgus macaques since 2009 and established autologous and allogeneic UTx models which led to deliveries after performing the procedure. In this paper, we summarized key points to develop UTx models in cynomolgus macaques based on our experience. UTx models in non-human primates can surely contribute new and beneficial knowledge in this field and can be useful for the further development of UTx in humans.

A survey of public attitudes toward uterus transplantation, surrogacy, and adoption in Japan

This study aimed to evaluate the attitudes of male and female members of the public toward uterus transplantation (UTx), surrogacy, and adoption in Japan via a web-based survey. One thousand six hundred participants were recruited with equal segregation of age (20s, 30s, 40s, and 50s) and gender. We assessed the association between ethical view and gender, age, infertility, and the knowledge level of UTx, using a questionnaire. The findings were as follows. First, 36.5% and 31.0% of respondents agreed that UTx and gestational surrogacy should be approved, respectively. Second, the respondents would potentially choose to receive UTx (34.4%), gestational surrogacy (31.9%), and adoption (40.3%), if they or their partners experienced absolute uterine factor infertility. Third, 10.1%, 5.8%, and 14.3% of the respondents chose UTx, gestational surrogacy, and adoption as the most favorable option, respectively. Fourth, if their daughters suffered from absolute uterine factor infertility, 32.3% of female respondents might want to be donors, and 36.7% of male respondents might ask their wives to be donors. These data were affected by age, gender, infertility, or the knowledge level of UTx. UTx was a more acceptable option than gestational surrogacy and adoption. The effects of gender, age, infertility, and the level of knowledge of UTx are important in understanding the attitude toward UTx. On the other hand, there were concerns about the safety of UTx for recipients, donors, and babies. It is important to continue to understand public attitudes to inform the development and safety of UTx, which will enhance the discussion on the ethical consensus on UTx.

Current Progress in Uterus Transplantation Research in Asia

Uterus transplantation (UTx) is now a possible approach for women with absolute uterine factor infertility to deliver a child, following the first successful delivery by Brännström et al. in Sweden in September 2014. This remarkable achievement attracted major attention worldwide and caused many countries to prepare for UTx, including countries in Asia. To date, three groups have performed UTx in humans in Asia, and many others are aiming for the clinical application of UTx with accumulation of basic experimental data. Therefore, it is likely that UTx will expand rapidly in Asia in the near future, although this will depend on ethical, social and religious views in each country. With this background, herein we summarize the current progress of UTx in East, Southeast and South Asia, with the purpose of increasing understanding of the current status of basic and clinical UTx research in each country and sharing progress and knowledge to ensure future development of UTx research in Asia.

A survey of public attitudes towards third-party reproduction in Japan in 2014

Objective

The objective of this study was to examine public attitudes towards third-party reproduction and the disclosure of conception through third-party reproduction.

Methods

We conducted the web-based survey for the public attitude towards third-party reproduction in February 2014. Twenty-five hundred people were recruited with equal segregation of age (20s, 30s, 40s, and 50s) and gender. We analyzed the association between gender, age, infertility, and ethical view using a questionnaire regarding donor sperm, donor oocyte, donor embryo, gestational surrogacy, and disclosure to offspring.

Results

Of the respondents, 36.2% approved and 26.6% disapproved of gamete or embryo donation. The frequency of those who approved was lowest in females in the 50–59 year age group, and was significantly higher in males or females with infertility. Secondly, 40.9% approved and 21.8% disapproved of gestational surrogacy. The frequency of those who approved gestational surrogacy was higher in males or females with infertility. Thirdly, 46.3% of respondents agreed and 20.4% disagreed with “offspring have the right to know their origin”. Those who disagreed were primarily in the 50–59 year age group of both genders, and disagreement was significantly higher in the infertility group compared with non-infertility group.

Conclusion

In this study, public attitudes were affected by gender, age, and experience of infertility. These study findings are important in understanding the attitude towards third-party reproduction and disclosure to the offspring. Respondents having indecisive attitudes were >30%, which might indicate an increased requirement for information and education to enhance the discussion on the ethical consensus on third-party reproduction in Japan.

Basic research on uterus transplantation in nonhuman primates in Japan

Uterus transplantation (UTx) is now a potential option for women with uterine factor infertility to have a child. However, UTx is still in an experimental stage and basic animal studies including in nonhuman primates are needed for accumulation of data that will provide important information for establishment of UTx in humans. Herein, we summarized our experiences using cynomolgus macaques, with the goal of promoting further development of UTx studies in nonhuman primates. Our basic studies using cynomolgus macaques were summarized, including the results of other teams in nonhuman primates. Our team in Japan launched UTx research in 2009 using cynomolgus macaques and has accumulated a large archive of results in the UTx research field, including examination of uterine blood flow, surgical procedures of autologous and allogeneic UTx, organ perfusion methods in deceased donor models, immunological response and rejection and ischemia/reperfusion injury. We achieved the first delivery after autologous UTx in primates and the first periodic recovery of menstruation after allogeneic UTx in nonhuman primate models. Results from animal studies, including those in nonhuman primates, provide the basis for clinical application of UTx. Therefore, our accumulated data since 2009 and our basic experience in cynomolgus macaque are meaningful for future UTx trials in Japan. In addition, more validation in nonhuman primate models is needed for resolution of medical issues and further development of UTx in humans, despite clinical application of UTx in several countries.

Uterine transplantation: Review in human research

Uterine transplantation is the solution to treat absolute uterine fertility. In this review, we present the historical, medical, technical, psychological and ethical perspectives in human uterine transplantation research. We reviewed the PubMed database following PRISMA guidelines and added data presented by several research teams during the first international congress on uterine transplantation.

Recent advances in the molecular mechanisms of Mayer-Rokitansky-Küster-Hauser syndrome

Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) is a disease caused by congenital absence of the uterus and two-thirds of the upper vagina. The pathogenic mechanism of MRKHS may involve gene abnormalities, and there are various case reports associating MRKHS with the Wnt family member 4 (Wnt4) mutation. Analysis of genes mapped to regions in which deletion and duplication are frequently detected in patients with MRKHS has shown involvement of LIM homeobox 1 (LHX1), HNF1 homeobox B (HNF1B) and T-box 6 (TBX6). In addition, there are case reports of MRKHS caused by chromosomal translocation and epigenetic function may be involved in MRKHS onset. Overexpression of HOXA and overexposure to estrogen may contribute to the onset and regulation of expression by methylation as a pathogenic mechanism. Determination of the molecular basis of MRKHS is in progress, but current treatment only includes vaginal enlargement and vaginoplasty for improved quality of life. Clinical application of uterine transplantation to allow childbearing by MRKHS patients is under investigation and clinical trials are underway around the world.

Survey of Attitudes toward Uterus Transplantation among Japanese Women of Reproductive Age: A Cross-Sectional Study

Objective

Uterus transplantation (UTx) is a potential option for women with uterine factor infertility to have a child, but there has been no large-scale survey of the views on UTx in women of reproductive age in Japan. The present study was aimed to clarify the views of Japanese women of reproductive age on UTx for uterine factor infertility.

Methods

A questionnaire on UTx was conducted by an Internet research company in December 2014 as a cross-sectional study in 3,892 randomly chosen women aged 25 to 39 years old. Responses were analyzed from 3,098 subjects (mean age 32.1±4.2 years old), after exclusion of inappropriate respondents in screening.

Results

Of the respondents, 62.1%, 34.7% and 18.1% favored adoption, UTx and gestational surrogacy, respectively. In contrast, 7.0%, 21.9% and 63.3% opposed adoption, UTx and gestational surrogacy, respectively. In choices of candidates for UTx based on highest priority, deceased persons (33.8%) and mothers (19.0%) were favored as donors, and women with congenital absence of the uterus (54.4%) and hysterectomy due to a malignant uterine tumor (20.0%) as recipients. Regarding societal acceptance of UTx, the answer rates were 15.7% for "UTx should be permitted", 77.6% for "UTx should be permitted with discussion", and 6.7% for "UTx should not be permitted, even with discussion". Regarding personal opinions on UTx, 44.2% were in favor, 47.5% had no opinion, and 8.3% were against.

Conclusion

Our results suggest that many Japanese women of reproductive age feel that UTx is socially and individually acceptable, but that concerns requiring further discussion remain among these women. There was also a tendency for UTx to be viewed more favorably than gestational surrogacy.

Security giving in surrogacy motherhood process as a caring model for commissioning mothers: A theory synthesis

AIM

Despite the increasing use of surrogacy, there are no caring theories/models that serve as the basis for nursing care to surrogacy commissioning mothers. This study has designed a model for caring of surrogacy commissioning mothers in 2013.

METHODS

The theory synthesis of Walker and Avant's strategies of theory construction (2011) was used to design a caring model/theory. The theory synthesis includes three stages: (i) selection of focal concept (the concept of "security giving in motherhood" was selected); (ii) review of studies in order to identify factors related to focal concept relevant studies (42 articles and 13 books) were reviewed, statements and concepts related to focal concept were then extracted and classified, and their relations were specified; and (iii) organization of concepts and statements within a relevant general and effective manifestation of the phenomenon under study which led to developing of a model.

RESULTS

In this caring model/theory, entitled "security giving in surrogacy motherhood", nurses roles were conceptualized within the conceptual framework that includes three main roles: (i) coordination; (ii) participation; and (iii) security giving (physical, emotional, and legal support; empowerment; presence; relationship management between both parties and advocacy). Training surrogacy specialist nurses and establishment of surrogacy care centers are important factors for implementation of the model.

CONCLUSION

This model could help to provided better caring for surrogacy clients, especially for commissioning mothers.

The need for laparoscopic ovarian transposition in young patients with cervical cancer undergoing radiotherapy

Maintaining the quality of life by preserving ovarian function in premenopausal patients with cervical cancer undergoing radiation is crucial. This can be accomplished with a simple and safe laparoscopic ovarian transposition procedure. This procedure aims to move the ovary out of the irradiation field, protecting it from direct radiation and irreversible damage and preserving its function. However, this procedure is often forgotten and seldom offered to patients. This review aims to lay stress on and reconsider the importance of laparoscopic ovarian transposition as a simple, safe, and extremely useful procedure. The biological effects of radiation are described briefly and several studies are evaluated, which reveal that this procedure has more benefits than risks.