How did surgeons carry out the UK’s first womb transplant?

Its success was down to meticulous research, years of sharing knowledge between experts around the globe, and the hard work and dedication of doctors Professor Richard Smith, from Imperial College Healthcare NHS Trust and Imperial College London, and Isabel Quiroga, from the Oxford Transplant Centre at Oxford University Hospitals NHS Foundation Trust.

Around 50 babies have been born worldwide as a result of womb transplants, which give women missing a functioning womb (also called a uterus) a chance to have a baby.

In the first UK case, the operation to remove the womb from the 40-year-old sister lasted eight hours and 12 minutes, with surgeons leaving her ovaries behind to prevent pushing her into early menopause.

One hour before her womb was removed, surgeons began operating on her 34-year-old sister, preparing her body to receive the donated organ.

This operation lasted nine hours and 20 minutes, with the surgical team experiencing some difficulties including a higher-than-expected blood loss of two litres.

However, after just 10 days, the recipient was well enough to leave hospital and has continued to have a good recovery.

She is also having regular periods, which shows the womb is working well.

Her sister was discharged five days after her donor operation and has also made a good recovery.

Removing a womb is a similar operation to a radical hysterectomy, according to Prof Smith, who as well as being a gynaecological surgeon is the clinical lead at the charity Womb Transplant UK.

He and Miss Quiroga led the team of more than 30 staff who worked on the transplant one Sunday in February.

Prof Smith and Miss Quiroga removed the older sister’s womb, cervix and fallopian tubes, plus crucial blood vessels around the organ.

The main vessels are the uterine arteries running into the womb, but the surgeons also aimed to collect some of the larger internal vessels that lead into the smaller branch of the womb.

Prof Smith said surgeons doing these operations have to retrieve veins involved in the drainage of the womb.

Speaking to the PA news agency, he said: “One of the amazing things is that my surgical skill-mix as a cancer surgeon is to remove organs with a margin of normal tissue, while sealing the vessels as I go.

“Transplant surgical skills are different – that is to remove a normal organ with the best number of non-sealed vessels as you can.

“Isabel and I operate together with no ego – it just flows backwards and forwards across the table.”

He added: “The day itself was truly humbling. We turned up at 7am at the Churchill transplant centre with the donor and the recipient families, then we went into a pre-op huddle.”

Those in the huddle included surgeons, nurses, anaesthetists and technicians.

Prof Smith and Miss Quiroga worked to remove the womb, before the organ was prepared for transplantation by a “back table” team.

“This was an organ which had a very, very unusual blood supply,” Prof Smith said.

“In fact, it had a set of blood vessels which I’ve never seen in my entire career.

“They made my dissection a bit harder than it might have been, but we got there.”

In the theatre next door, one hour before the retrieval of the womb was completed, surgeons began to operate on the donor’s younger sister to enable her to receive the womb.

Prof Smith and Miss Quiroga switched from donor to recipient and Prof Smith removed the vestiges of the underdeveloped womb the recipient was born with.

Meanwhile, the organ was packed and transported between the two theatres under sterile conditions to prevent contamination.

A sterile bag with a cold perfusion solution contained the womb, which was then placed into a container with ice.

During surgery, ligaments attached to the womb were attached to the recipient to help the womb stay in a relatively fixed place so it does not move around the pelvis.

The most important part of the transplant operation was the joining of the very small vessels that give the blood supply to the womb.

This was the most delicate and difficult part of the operation and was led by Miss Quiroga.

For this operation, two arteries and three veins were joined in total to achieve the best blood supply and drainage of the womb.

Once all the vessels were connected, the donor’s vaginal cuff – around a 1cm part – was stitched into her sister’s vagina.

If and when the recipient is able to complete her family, the womb will be removed six months later to prevent her from needing immunosuppressants for the rest of her life.

Prof Smith said he had been “very” confident the transplant would work, adding: “You couldn’t do this if you thought there was a prospect of failure.

“Did we think we could do it? Of course, but we know that the chance of failure at the point where the uterus goes in – if you look at the world literature – is 20% to 25%.

“And that failure is usually on the basis on sepsis and thrombosis.

“So technically, we are up to the job, but what happens thereafter can be scary.

“Once you get to three or four days later, the chance of failure drops to probably less than 10%.

“Once you get to two weeks – and at the point where the woman has a period – the chance of her having a baby at that point is very high and the chance of failure has dropped to low.

“But those first two weeks – it’s very scary as a surgeon to watch and wait.”

Biopsies to check the womb was functioning were read in London but then also confirmed by an expert team in the US at Baylor University Medical Centre in Dallas, where other womb transplants have been performed.

Prof Smith said the procedure gives new hope to women born with devastating conditions.

He said: “You’ve got girls, maybe 14, who have not had periods, they go to the GP and a scan shows there is no uterus. Absolute catastrophe.

“Up until now there’s been no solution for that, other than adoption or surrogacy… That’s not the case now. It’s really exciting.”

On whether transgender women may also benefit from the operation, Prof Smith said that was still a long way off.

He said the pelvic anatomy, vascular anatomy and shape of the pelvis are different, and there are microbiome issues to overcome.

“My own sense is if there are transgender transplants that are going to take place, they are many years off. There are an awful lot of steps to go through.

“My suspicion is a minimum of 10 to 20 years.”

Miss Quiroga said the living donor programme to date in the UK has focused on women with relatives who are willing to give their wombs.

“It will come to a point where we will have friends or altruistic donors, like we have with many other transplants, but at the moment we’re only focused on people who have come forward with relatives,” she said.

Part of the reason for using family donations at present is because of the psychological impact on patients, plus the rigorous process involved in getting regulatory approval.