An adolescent gynaecologist, and she really drove the first uterine transplant and works at the Sydney Children's Hospital as well as the University of New South Wales and Genea IVF unit. I'm gonna ask her to introduce a very special guest of ours called Prue Craven. Yeah, thank you.
So Prue is a patient of mine. She was our second recipient of a uterus transplant, but she's become involved in this debate because she had a very long surrogacy journey prior to embarking on the transplant. Thank you.
Thank you. Welcome, Prue. To the right of Rebecca is Professor Jason Abbott, and he's one of Australia's leading gynaecological surgeons, and he's a professor at the University of New South Wales.
He works at the Royal Hospital for Women in Sydney and also in the Prince of Wales Private Hospital. He was one of the surgeons involved, so he can tell us about the difficulties of the surgery and the aspects of the surgery we need to know, and I'd like to thank you so much for coming today, Jason, and taking time this morning. Right on the end is Tamara Hunter, and again, she's a CREI certified fertility specialist, but she works at Monash IVF in Western Australia in Perth.
We wanted her to come today because she does a lot of pediatric and adolescent gynecology in Western Australia, and she just provides a really unique view about what it's like working outside the big cities and how uterine transplantation may impact people who are more rural and more remote, and I thank you so much for coming today. Now, to my left, Alison Gee is a very renowned CREI certified fertility specialist, and she's the Deputy President of the ANZRI Conference today. She's been involved in surrogacy in Australia for a long time, and she works at Sydney IVF, sorry, Genaea IVF in Sydney, and she has a lot of experience about surrogacy over the years and can tell us a lot about aspects of it that are important in Australia.
To her left is Dr. Shadi Keshaba, and he is, again, a CREI certified fertility specialist who works at IVF Australia in Sydney, but however, he does a lot of surrogacy, and he's on the board of Surrogacy Australia and on Rainbow Families, but is also at the moment on a working party for the ACT government looking at changing some of the surrogacy laws in Australia, so he's a very informed person about surrogacy today. And finally, to the very left is Dr. Phil McChesney, and he, again, is a CREI certified fertility specialist and the incoming chair of the CREI Education Committee at the Royal College of O and G. He works at Fertility Associates in Auckland, New Zealand, and he's able to comment on the New Zealand surrogacy program which is different to Australia and some of the impacts that are different in New Zealand. I'd like to welcome him, too.
Thank you. Excellent, so we're gonna get started. I'm first gonna ask the pro side for uterine transplant to go through some of the reasons why you believe uterine transplant should be superior to surrogacy.
Thank you very much, Eve. So for me and my journey going through the development of uterine transplant really did start as a patient-based thing. So I, as you mentioned, I'm a pediatric adolescent gynecologist and a fertility specialist.
Ever since I started working with MRKH patients, they've always asked why can't you do a uterus transplant from the minute they're diagnosed. And certainly when the development of it occurred in Sweden and Mats Brownstrom actually received ethics approval and it was published on the lay press, the floods of requests just came through. So for me, that journey has come from the patients.
I think that's the most important thing is we are trying to give autonomy to our patients. I think that these days we do a lot of procedures that enhance life. They're not all just life-saving.
And I think that uterus transplant gives reproductive autonomy another choice for women and enhances their quality of life. Do you want to comment? All I can say is that I completely agree. I think that for someone who was born without a uterus, I never envisioned that this might be an option for someone like me.
And I have spent a long time investigating surrogacy and going through surrogacy process as well. So this was really my last option. It wasn't the first option.
It's the most extreme, obviously, but I think it's wonderful that finally in this day and age that this is an option that is available to women. Can you talk a little bit just about the surgical aspects of what's required for uterine transplantation? Sure, I think that this is one of the things that everyone really gets very hung up on because it's not an easy surgery. It's by far and away the most complicated surgery that I've ever been involved with.
And it's more complicated, I suppose, than what we would see in oncology because, of course, with oncology, what you're doing is you're pretty much sticking in the center and you're taking everything out and you're not worrying about it. Here, what you are is you're taking everything out very laterally and you have to keep everything intact because those vessels become the most important thing because graft survival is paramount. We're doing a transplant here, so it's no different to taking a kidney, taking out a liver, taking pancreas.
We need that graft to survive. So it's complicated surgery. And so we've only been doing this effectively for the last 10 years, so since Mats Brandström and the team in Sweden really pioneered this work, and although there were two cases before that, one wasn't successful, the second finally was successful after a very, very long break, nine years.
But that graft is by far and away the most paramount thing. So we know that you have to take out all of the veins and it really comes down to the venous circulation of the uterus. You've got to have good venous outflow.
And so currently, the top part is actually relatively straightforward and most people can do that. It's when you get down to the distal part and you're looking at distal ureter, taking out the veins and then getting out laterally to the internal iliac veins, and then taking a patch of that internal iliac vein, and then that all has to come out on block. All of the veins, the arteries, none of them can leak.
So every single tributary to the uterus has to be either accounted for or closed. So this is a pretty major undertaking and certainly seeing it for the first time is quite different to doing the online video and the training and the animals and stuff like that. When you see it in a person, it blows your mind.
But it is the most terrifying slash exciting slash extraordinary thing that I've been involved with from a surgical perspective. And it makes you completely rethink the way that the pelvis works and the way that we think about things from a gynecological perspective as well. And so, I mean, I'm gonna have to take hats off to Mats Brandström and the Swedish team who just spent decades perfecting this technique and understanding that anatomy.
It's truly, truly extraordinary. And whilst we know that donor surgery takes on average about nine hours, recipient surgery is certainly less than that. And it's now between four and six hours, I have no doubt that we'll get that down to a shorter time.
There are fewer than 100 procedures overall. And if you think about all types of surgical procedures, when you've done fewer than 100, we're nowhere near mastery of the technique. And this is all over the world.
The Swedes have done 30, 35 now, I think. Is that right? 35, 32, between 32 and 35 there. The United States, 30 amongst the three centers there.
So if you talk about the international understanding of this particular procedure, it's still in its very, very early stages. We absolutely need regulation of this. There is no doubt.
We absolutely need concentration of skills to understand it. And we absolutely need to know the long-term issues and implications. I think for donor surgery, everyone talks about, well, yes, the risks.
And the risks are that distal ureter. It's the ureter in that bladder because that's where all of the vessels get unbelievably tricky. So you've really got to be very cautious and very careful in that distal area.
And then, of course, as soon as you go lateral and inferior, you're into venous territory that no one, we would never in a squilling years go there. And you wouldn't go there in oncology either. But of course, you want to take all of that out and that patch of internal iliac to give you the greatest venous outflow.
And so by doing that, then you optimize the chance of the graft. And I think the second thing, of course, is that the graft goes on to the vagina, but the vagina is not sterile. And so here, if you were transplanting a kidney and you're putting it back in the pelvis, yes, it's got a venous outflow and arterial inflow, but it's in a sterile environment at least.
So you don't have to worry about the infection. And what we need to make sure is that not only is it attached and it's got good venous outflow, but you're decreasing that risk of infection. But the fact that it can be done at all is truly extraordinary.
So what are the alternatives? I suppose in terms of the donor situation where you do have that increase in risk, and at the moment worldwide, about a 17% complication rate, which can be fairly substantive. We're talking about Claviendindo 3 or above. So these are not insubstantial complications.
So you need to be aware of that. What else could we do? Well, we could do a deceased donor model, and certainly that's been done around the world. We're certainly thinking about it in Australia and have ethics approval to do that.
And that means that you don't have any of the issues with the donor surgery. So you take the uterus out at the end of an organ retrieval of a young person, and we can then strip the veins up quite high, and you've got hopefully big, fat venous outflow tracts. And that may help to decrease the time and give you a decent outflow at the venous end.
But also then we don't have to worry about that distal ureter from the deceased donor, which is really advantageous. And then that means we're gonna reduce the time down probably to the order of three to four hours. Three hours I think probably is a good donor surgery, and maybe a recipient surgery, and maybe even a little bit less in time.
We also know that things like robotics may change the space for the future. Of course, robotics means that you get that absolutely extraordinary 3D visualisation of those distal tracts. You can take out and see those tiny, tiny little vessels, much more than we would with an open approach, or even a laparoscopic approach necessarily.
And of course that means we've got a minimally invasive approach if we are gonna do it in a live donor situation. So that's another area for us. And I guess finally, in this picture where we are talking about surgery and the impact that surgery can have, it takes me back to sort of my early days when I was thinking about becoming a surgeon, because I was thinking about doing laparoscopic surgery, and everyone said, don't worry about that laparoscopic hysterectomy thing.
It's never gonna take off. And of course the first laparoscopic hysterectomy was nine hours. We saw huge complication rates in the early days.
We saw a lot of negativity, and now it's considered gold standard. I don't think that we're gonna see this as gold standard in terms of delivery. We don't want to be doing millions of these cases, but I do think that it's an absolutely fantastic option, and Prue is definitely living proof of that.
Do you want to add something, Tamara? Oh, I was just going to add that the surgical aspect of this is incredibly complex, and we certainly will be having centers of excellence to do that, and you're probably all thinking about the negatives about doing the morbidity and potential mortality associated with this. But the other part of this that we really have to think about is the psychosocial issues surrounding our recipients and how important this is to them. A lot of the worldwide survey data, predominantly of your MRKH population, overwhelmingly shows that they are in support and advocate for this.
So this is something that gives them reproductive autonomy, it gives them choice. And I think that's the big thing that patients with uterine factor infertility want is to have that choice. Something else that is really important to populations, uterine factor infertility populations is that sense of empowerment over the pregnancy.
It's often very challenging for those who are sort of going, their only choice is to go through gestational surrogacy, is not having that option to really manage that pregnancy, how they would want to manage it. So there's a great deal of disempowerment and uncertainty that goes with that journey, no matter how many legal and social things that we put in place. I do agree that it is a procedure that is going to be limited to single centers with lots of expertise, but there are ways that, for example, where we are in Western Australia, probably the most isolated capital city in the world and certainly the furthest away from where the center of excellence is, there are ways that we can collaborate.
There are certainly transplant physicians that can help manage the cases. There are gynecologists who can be trained to do the cervical biopsies to look for ejection. We have maternal fetal medicine specialists who can manage these pregnancies as well.
So having a cross-continental team approach to these patients is certainly possible. And so it doesn't really discriminate that equity of access at all in the sort of remote and regional areas. It just has to be really well managed.
Excellent. Well, I think that our pro-transplant side has made an incredibly strong argument for why transplantation should be considered. I'm gonna turn this over to the pro-surrogacy side to give the pro side of why gestational surrogacy is so important.
Thank you, Eve. And I thought just for the wider audience, I would just give a little bit of background to surrogacy in Australia. So unlike some other countries in Australia, surrogacy is required to be altruistic.
So commissioning parents cannot pay a surrogate to carry a pregnancy, but you can reimburse for reasonable medical expenses. We have five states and two territories in Australia, and each of those states and territories unfortunately do have different regulations surrounding surrogacy. But in all states and territories, then it does need to be an altruistic donation.
Generally, with the surrogacy arrangement in Australia, the surrogacy is undertaken for, if parents or an individual can't carry a child, generally for medical reasons, and generally each state will have its own guidelines surrounding indications for surrogacy. Counseling is required for surrogates. We require both counseling and legal advice for surrogacy.
And a written agreement is required as well. And in most states, this is legally binding. When a child is born through surrogacy arrangements, the parenting order is then applied to by the commissioning parents, and that unfortunately can take about three to nine months, and then a new birth certificate is issued thereafter.
So our laws and regulations do differ quite from the United States. And for Australians, that can make surrogacy a very difficult option, and you can see why we are looking at options like uterine transplant. So in terms of why surrogacy, I might hand over first to Phil and then Shadi, and we're gonna talk to you about some of the aspects which we think are very important to take into consideration in this debate.
Thanks, Alison. Well, certainly, starting off the pro-surrogacy side, clearly it's a well-established procedure. It's been happening.
Not sure exactly when the first one was, but it was clearly before 1999, so well over two decades now. The data in New Zealand suggests that about 50 babies are born annually from surrogacy arrangements. The most up-to-date data I could find from the United States was from back in 2013, when there were 3,500 cycles of surrogacy annually, which had increased significantly over that previous decade.
And so another 10 years on, I'm sure it's well above that. And I guess next, obviously gestational surrogacy has significantly lower medical risk for all parties involved compared to uterine transplantation. While I couldn't find any data on the maternal mortality rate from gestational surrogacy, the mortality rate in general pregnancies is hundreds of times lower than that of a radical hysterectomy, which has to be the nearest surgical procedure to removing a uterus for a donation.
The paper suggests a 23% grade three surgical complication, and this is clearly just not present in a gestational surrogate. In terms of intending parents, a surrogacy, there is no medical risk to the intending parents of a surrogacy arrangement, compared to the recipient of a transplant who obviously has the donation surgery, a requirement for cesarean section, hysterectomy at the end, along with immunosuppressant treatment throughout the time that they have their transplanted uterus. And then it's also likely that gestational surrogacy has a much lower risk to the child compared to a transplanted uterus with no exposure to immunosuppressants and lower risks of IUGR and preterm birth.
So that's where I stand currently on gestational surrogacy, and I'll hand over to Shadi for a little bit more. Thank you. Well, as Alison alluded and Phil, surrogacy in Australia is well regulated, and there is a lot of prerequisites before going through a surrogacy journey.
It's quite an established practice, and we do have around 400 to 500 cases of surrogacy happening in Australia locally and internationally. Now, surrogacy has been established and is safe for both parties, the intended parents and the child born through that process. Having the uterine transplant is quite experimental surgery, and you put a lot of risk onto the donor and the recipient of that uterus, and also the child born for that.
We don't know the implications of having the rejection medications on the children born through that. Now, there is also the expenses. I mean, yesterday it was quoted in Australia it costs around $100,000 for a single uterine transplant, which is grossly underestimated.
I mean, having all those specialist hospital expenses, medications to the uterine transplant, that costs at least 10 times that amount with uncertain outcome. I mean, we know that one out of five uterine transplant fails before even having any embryo transfer following that. So that's a great lower risk or success rates.
We know with surrogacy, they have very high success rates of transfer, almost reach 70% per embryo transfer of a live birth. So surrogacy is well-established, very low risk. This is quite experimental and never reached to a status that has becomes the standard of treatment.
And also we have to focus on the reproductive justice. This is an expensive, exclusive procedure. Only one center or two center in the country can provide that, while surrogacy can be done in any location.
So that's my point in regards to surrogacy and I think it's the way to go so far. Thank you. And I just wanted to raise two other issues just surrounding sort of surrogacy and the ethics in terms of considerations.
So in terms of the surrogate and acting as a surrogate, many surrogates have been through pregnancy themselves and therefore they are very aware of the risks and side effects and complications of the agreement that they're entering into. For innovative procedures like uterine transplant, it may actually, in a way, compromise valid and informed voluntary consent because we don't know a lot of the long-term outcomes of the procedures, both to the donor, to the recipient, and quite importantly, to the children conceived. So the long-term outcomes of children conceived by choice by parents could be different to the choice of the parents themselves.
And are we considering that in terms of the offspring through all arrangements that we undertake to enhance the families worldwide? The other point I guess to raise is in terms of surrogacy, there is always the notion that we're exploiting surrogates by entering into these arrangements. And I think to address the potential exploitations, there's been a lot of work in many countries and jurisdictions in frameworks and regulations surrounding surrogacy, sort of aiming to protect the rights and wellbeing of both the intended parents and the recipients, and I think in Australia we do that very well, and I think in the United States they've got some excellent national framework that also provides for that. So I think what we need to be advocating for is for those type of frameworks to be more sort of a very worldwide standard framework, and I think that will only enhance the surrogacy arrangements that we are able to enable our patients to partake in.
Thank you very much both sides there. I just wanted to ask Prue, Prue's actually experienced surrogacy as well, so we might just ask you a little bit about your experiences, if you're happy to talk about them, and some of the thoughts you have around surrogacy. So my husband and I started our surrogacy journey back in 2013.
At the time, there was no other option for us to have children. We explored adoption in Australia, but we were deemed ineligible because we had frozen embryos in storage. And we were quite a young couple, we were only 27 years old, so immediately you're already discriminated against based on the fact that you might not have your life well set up and you don't own a house and things like that.
So we investigated surrogacy. Unfortunately, we didn't have the option of a surrogate in Australia. Most of our friends and family were too young and were still having their own families, which is a major disadvantage in surrogacy.
Your target audience for a surrogate is usually a middle-aged woman, whether it's a friend or family member. And that carries its own complications, I guess. So we had no other option but to explore surrogacy overseas.
This was a process that, for a lot of people, they say it's quite unethical, but we were desperate, we had no other option. So we did go through treatment in Thailand over the course of two years, shipping embryos over there, and basically going through a private clinic and having surrogates chosen for us. Unfortunately, we tried with three surrogates and it didn't work out.
And that process was extremely difficult because you have no control. You're not there. You get a say, but everything is sort of guided by the experts and you're just sort of relying on other people to make all these decisions for you.
And also, we were very young and naive. So we just sort of had to roll with the process. And as you know, surrogacy is extremely expensive.
And then of course, when you're doing it overseas, you've got the added cost of that process that that's involved. My husband and I didn't actually explore surrogacy in Australia until in the middle of COVID. We started the transplant screening actually through RPA, and then the trial was on hold for a number of years.
So in between, I had a nurse that was a close friend that offered to be a surrogate. She was middle aged, she was about mid to late 40s, and she offered to carry a baby for us. Obviously, she lived in a different state to us at the time.
So there was the complication of managing that process from two different states, but we managed to work it out. The process of getting from when you start the process to when you can have a embryo transfer is long and complex and extremely costly. We had to get our surrogacy order and go through quite extensive counselling and psychological assessments for both us and our surrogate.
And our surrogate, obviously, because she was in her mid to late 40s, she was treated as a geriatric pregnancy. So she had to have like additional screening and reviews from a specialist obstetrics. And then about eight months down the line, when we finally were ready to start, we actually found out that her lining was never gonna be thick enough to even attempt a transfer.
So there were lots of flaws in that process. And it was incredibly difficult mentally on us because you do relinquish a lot of your control and faith in the medical experts, but also someone else who's willing to carry a baby for you. And I think that I'd much rather assume the risks of pregnancy than putting that risk on someone who's in their mid 40s who hasn't carried a child for 10 years.
And the impacts that that might have on them and their family if something were to go wrong. So if uterus transplantation had have been an option for me 10 years ago, I would have absolutely gone down that route first. And it's not just to be able to experience the pregnancy.
It's just because if I had the choice, I would want to take the risk over someone else. And in terms of donor versus someone offering to be a surrogate, these people volunteer for this process. They go in knowing what the risks are.
And these are obviously the most extraordinary people that you will ever meet that will offer to do something like this. So it's their choice as much as it is the recipient or intended parents. Thank you so much.
That was great. I was just gonna say, I think that's a really valuable perspective that I think sometimes some of the criticism of transplantation is that pregnancy is not an experience, right? And I think when you frame it in that sense of everything that you've been through, I think it really sheds light on some of the patient driven motivation in order to like this is a viable way that you can actually have a child in the setting of many other things that have failed. So I think that's just a really interesting and a perspective that I think is not often thought of.
I think a lot of the criticism of transplant comes in that pregnancy is not an experience, it's a means to an end. And I think that really highlights that point. So thank you.
I'm gonna let the uterine transplant side address some of the other cons that were discussed by the surrogacy side. And then we will flip and we will have the surrogacy side talk about some of the cons that you bring up with the transplant side. Okay, thanks Eve.
I totally agree with Prue and her journey. I think probably most of you in the room have treated patients who have gone through surrogacy. It sounds like an easy journey, it's really not.
Most of the issues are around the fact that you have to choose a woman who's finished their family typically. And otherwise, as Prue said, they're in a different age bracket to you. That's not a procedure without risk.
We're all very aware of the risks of the geriatric or the older woman carrying a pregnancy, risks of cardiac issues, risks of RUGR, GDM, and of course, cesarean section, which is a very high risk in the older woman carrying a pregnancy. In terms of the risks to the baby, I think that they're actually quite well known. It's not that we don't know the risks of the immunosuppression.
We've had many studies looking at the immunosuppression protocol that we use typically for uterus transplant, which is just like a low-risk kidney transplant, depending on the immunogenic profile between the patients. So those risks to the baby are not zero, but they're certainly not high, as the other team stated. So slightly increased risk, as you said, of preeclampsia, growth restriction.
We have wonderful maternal-fetal medicine now that can monitor things like that with uterine artery, Doppler flows. We can watch the baby, and we can deliver. And we, in the first world, have wonderful NICU facilities that can also watch the baby and deliver a very healthy child, of which there have been many, many delivered, over 35 delivered, around the world.
In terms of the autonomy, the parenting order is complicated in Australia. So obviously, there have certainly been cases where surrogates didn't want to relinquish that child. And imagine going through that nine months of pregnancy, watching that woman like a hawk.
What is she eating? Is she smoking? Is she being in a room with smoking women? And you can't actually control that in any way at all. And then at the end of the line, they've gotta give that baby up to you. And knowing couples that have been through it, or different couples, the relationship changes.
They might be your best friend in the world. At the end of the process, you've lost a friend. So I think the altruistic surrogacy reduces the chance of exploitation, but it's not without its own complications.
I'm just gonna raise two further points, I think, Ken. The first one is around cost, because cost is certainly one of the huge things that people talk about. But to any cost discussion, there has to be the benefit discussion as well.
So if we're talking about costs, we have to talk about efficacy. We have to talk about outcome. We're talking in uterus transplantation about putting an organ into a relatively young, healthy person.
And that's part of the criteria that we have so far. And graft survival is very high. And the take-home baby rate is also very, very high.
You have the added advantage, I think, in uterus transplantation of not just one pregnancy, but multiple pregnancies too, and possibly even three. But at this current time in most research protocols, it's two, and that means that that single uterus transplantation is going to give the option for multiple babies without all of the issues and the impact that we've heard about here from surrogacy and going through surrogacy multiple times where you're gonna have double the cost. We absolutely don't have that with uterus transplantation.
So for all of the cost discussions, it's not just about how much you put in, it's how much you get out. And that has to include quality of life, and it has to include the psychological benefit. And Prue has been very, very clear about the psychological advantages of that, and the locus of the control is back on the patient.
I think the second thing that I just wanted to counter with regards to surrogacy is this idea of exclusivity. Prue's from Melbourne, we're in Sydney. Kirsty, our first recipient, is in Coffs Harbour, six hours north of Sydney.
We're not running an exclusive service at all. We are open for anyone, anywhere. And that federated model is exactly what we should be doing, a centre where you can focus the attention of the very, very acute issues of surgery and understanding that.
And then as Tamara has said, you work with a team, and that team has got experience in a wide variety of areas, including transplantation, including fetal maternal medicine. And that's exactly what we would want. It's also the model that's run in the United States at the moment, and the model that's been run out of Sweden, where they're starting to work within the rest of Scandinavia.
So this is not an exclusive model, and we would never want it to be so. We would always want it to be for everyone, so that there is access. Not everyone is gonna want a uterus transplantation, there's no doubt about it.
But for those who do, it should be available, and it should be available where they can get the very best of care. And we need to be aware of the costs, of course, but front and centre must be the patient and what they want. Our opposition talked about the fact that surrogacy has no medical risk, and I certainly think Rebecca has spoken to a couple of the situations where there could be an increased medical risk.
But I also want to address the other side of this, in that there is a huge psychosocial risk associated with surrogacy. Prue has alluded to that sense of helplessness and that sense of loss of control. And in the literature, there are many cases where recipient families have found the process actually quite traumatic.
And to face that option versus a life of childlessness or a life of pursuing very difficult adoption when they could potentially have the choice of uterine transplant, I certainly think things open up for our patients. We've also got to be reminded that surrogacy is state-based law. In fact, in WA surrogacy, the Surrogacy Act went through in 2008, so before that time, there wasn't even access to surrogacy in Western Australia.
And the laws are quite archaic, and so to be sourcing surrogates is quite difficult locally. And then when you start to do cross-border surrogacy, it becomes even more difficult. So we have a long way to go to make that a truly national process.
It is a very difficult process, as Prue has alluded to. And I think it's really important to table that issue of exploitation in locations where surrogacy is difficult. People are still forced to go overseas, and I think we are all not too young to remember the Baby Gami case, which happened not too long ago where a couple were forced to go overseas.
They had a child born with Down syndrome and then decided to not take that child. So they're the sort of psychosocial implications that surrogacy can put on the table, which uterine transplant simply takes away. I'm gonna turn it back over to the surrogacy side to address some of the cons that were addressed by the transplant side.
I guess I'd just like to make a correction. I didn't say there was no medical risk to surrogacy, but there's no surgical risk to surrogacy. Yes, surrogacy can be a difficult process, but imagine that transplanting a uterus and to get to here has been an extremely difficult process.
And so just because something's a difficult process doesn't mean we can get there and make it better. And I guess it's up to people like us to champion the lawmakers to make surrogacy an easier process. In New Zealand, where I'm from, it's a highly regulated process.
It is altruistic, and essentially, you have to make an application for surrogacy to a national ethics committee. You have to have the surrogate and the intending parents need to have independent medical, psychological and legal reports. And once it's approved, it can go ahead.
At the moment, we do have a problematic law like a lot of places, but in fact, there's a new law about to be approved, which will arrange a surrogacy order so that immediately on the delivery of the baby, the intending parents will have legal guardianship of the child. And it also means that they will have, they'll be responsible for any costs and things immediately as well. So I think that that will make it better from a legal point of view and make sure that surrogates will give up the child.
The other team mentioned a loss of a friend in a surrogate situation. I don't think that that can be exclusive to surrogacy. I think if you have your donor who has some terrible urinary complications for the rest of their life, you may well lose that friend as well.
Thank you, Phil. And I'll go for you through a few points that you mentioned and also the legal issues that happen through surrogacy. I mean, surrogacy is a common practice and as I said, we have around 500 cases.
And if you canvas through the court cases, that happen through surrogacy, there are around 0.2% or one per 500 cases of surrogacy. So it's very well regulated practice and the kind of disharmony that happens afterwards, it's very, very minimal. And studies, although they're very small, they suggest good psychological wellbeing for the intended parents.
And there's no concerns for child bonding happens with the children born through surrogacy process. The second point that you mentioned, I think Jason, about the success rates. I mean, very well success rates, that's very relative.
If we got one in five transplanted uterus will fail and being accepted. And then the success rates per embryo transfer is around 30% or I'm not sure how many embryos you transfer to reach to that number. And the live birth rates for that is even less.
While with surrogacy, it's almost 70% per embryo transfer. And also the cost is usually in the initial cost with surrogacy. It's like when you do the counseling, when you go with the legal advice, and when you create the embryos.
But when you do an embryo transfer, that is very low cost, very minimal invasive procedure. And you can start and complete a family through one process of legal requirements. The other point that you mentioned was, what was it? Being exclusive.
I mean, you had to canvas the whole land of Australia to find one or two cases that are suitable for that. And even the donor to be available to donate their uterus and be a suitable donor. So it's very limited scope, even makes it more exclusive than finding a surrogate.
And surrogates, they don't have to be advanced maternal age or geriatric pregnancy. A lot of surrogates are young women that are willing to carry the pregnancy. And they're all consenting adults and they know the risk of going through a pregnancy and giving birth.
It was very low risk in comparison with a uterine transplant. So these are my points that I'm trying to. Thank you.
And I just have one last point. I think what I want to raise is, are we really focusing on a successful outcome in uterine transplant rather than the complex process and the side effects? We had a lovely talk by Rebecca yesterday, but one of the things that I took home from that on uterine transplant was that for the donor, there was a 17.2 complication rate and for the recipient, there was a 19% failure rate before the embryo transfer. So these are not insignificant complications and side effects from complex surgery.
I think what we also have to look at is into the future, are we going to be, will transplantation, if we're looking at sort of reproductive outcomes in the wider community, will this be offered to transgender females, cisgender males? And is that going to pose an extra layer of complexity and complication on a surgical procedure for which we are looking towards normalization of? And I think that's a very important point to consider. Okay, so we're going to open it up to questions from the audience. Matt Bowman.
Yeah, and for our live stream audience, we do have that, we do have that chat box open for the live stream audience if anyone watching live wants to put some questions in the chat. Hi, my name's Mark Bowman. I'm from Sydney.
Just firstly, just one point. Tamara, the actual, the WA family court, I think actually got to the truth of the baby gammy case, which was largely difficulties around the surrogate who was also acting as an agent. Not that the primary issue lay with the parents, but that's another story.
I think the, as someone who's lived through both the initial challenges of surrogacy and back in the late 90s, and now the initial challenges around transplantation, I would suggest the majority of the audience probably aren't binary towards one argument or the other, but, and nor would, I think, probably the speakers. We're probably trying to balance the indications, really. My only other comment is, I don't think it's necessarily an argument around costs.
I think the argument is gonna be around resourcing, because it's the resourcing of a public institution to give up quite a lot of operative time, and I think that's where your biggest battles are going to lie. You're talking about two theatres, each running for several hours, because cost involves both personal cost and state cost, whereas it's the resourcing around the theatres, I think, is where the biggest arguments are going to sort of be made, and, to be honest, probably your biggest challenges for those who are on the surgical side. I might just actually ask Prue about costs, and then maybe the transplant team, and then maybe the surrogates a team could respond to.
Thanks for your comments, Mark. As a taxpayer for the last 20 years while I've been working, I've otherwise been fit and well and haven't overly utilised too much of healthcare services, so I think that the cost of a transplant being funded by either the government or hospital raising money through research is justified, and as someone who has been through a huge amount of surrogacy treatment as well, my husband and I, including IVF, have spent in excess of $120,000. That is money that we didn't really have when we were 27, 28 years old, and that's money that could have set us up for life in a house.
It's a huge amount of pressure for couples to find quite a huge expense, and there's some other complications that go along with that as well. For someone like me, or anyone with MIKH, as soon as you go to an IVF clinic and you mention that you're doing surrogacy, your IVF treatment is not funded by Medicare at all, has to be done private. I didn't disclose to my IVF clinic that I was doing surrogacy in Thailand.
It's because it wasn't technically allowed, but I didn't have any other choice, so thankfully I got funding, which I should be completely entitled to. It's not a choice to be born without a uterus, and I should be entitled to that Medicare funding as much as the next woman who's got the same condition as me or just for some reason has lost their womb. So that is one of the other major disadvantages, so it's really the patients that are absorbing all those costs, both financially and physically, emotionally, mentally, et cetera.
I can just quickly add to that. So in terms of costs, so obviously Prue's spent over $120,000 in the surrogacy journey. She hasn't spent any money, obviously, because it's all been research-funded.
So probably at least equivalent, and that's with a donor, a live donor surgery. I think a lot of the costs may come down with deceased donation. We know that when you talk about access and availability, paper just published in Angiog last week by our team over the last five years looking at multi-organ donors, somewhere between 20 and 30 per year are available who would meet criteria for uterus transplantation.
So that takes away a lot of the ethical considerations of deceased donation, and we do have access to these uteri, which would be exceptional to help people like Prue, born without a uterus. In terms of other expressions of interest that we've received through the research project, obviously over 80 in the last 12 months for patients like MRKH who wouldn't want to have a uterus, only less than 10 have an available donor, and it would be the same sort of consideration for surrogacy. Prue luckily did have a donor, but a lot of women do not.
We also received, interestingly, 57 people who want to donate their uterus as a living individual, to just altruistically be a living donor, which is enormous compared to altruistic kidney donation, which occurs. So there are problems with, obviously there's surgical risks with uterus donation, but in terms of risk profiling compared to losing a kidney, it's much lower. So that's something that may be considered the non-directed donor pathway, so where you don't know the donor, and that's something that we are definitely looking into as well.
Neil Johnson. Is it on? Yes. Team, thank you very much to all of you.
That's just been absolutely superb. As a father of a surrogacy baby, I can feel it, what you're expressing, Prue. So I think my wife and I found ourself in a situation of needing a uterus, and of course that uterus is always attached to a human being.
So I think it's a good opportunity for us to acknowledge all of those who have been involved in both surrogacy and uterine transplantation, and all of the women who've given that most remarkable gift, including the gift of our son Noah, to us as a couple. When I went to the first presentation, I think in the States, from Max Branstrom a few years ago, and listened to his presentation of the first cohort and the first live birth, it was interesting that the round of applause was robust. It was the ASRM in Hawaii.
It was a robust round of applause that died away, and then suddenly it gathered pace again, and everybody in the room stood up and gave a standing ovation. So my wife and I took this back to New Zealand, and we both said, oh well, uterine transplantation won't be a thing in New Zealand or Australia for 20, 30 years, so we can forget that. So I think good on you guys, amazing pioneering work.
Pru, this is a very special thing for us to sit here, and to, you've given us all a great privilege here today that you, as the first person to undergo this in Australia. So really wish you well, and thanks guys. It's been an amazing debate, all of you.
Neil, just before you finish, we've heard a lot about surrogacy when it didn't work. Where are you with your relationships with your surrogate? What was that relationship like, and how did that pan out? Because there have been some very positive experiences as well. Yeah, look, I can, all of the things, all of the challenges actually ring true with the surrogacy experience.
You know, I'm happy to say that ultimately we've ended up with a lovely relationship with Noah's tummy mummy, as he calls her. So, you know, it can work very well as well, guys. Mummy, mummy, I love you.
As you well know. So we have a comment from the live stream. This is from Bob Stillman, who is actually one of the authors of the original paper.
And Dr. Stillman's at Shady Grove Fertility in Washington, D.C., and he said, I have the privilege of writing the consign for the fertility and sterility battle. Nine hours, think about nine hours in a volunteer donor that has the best transplant surgeons in the world, uniformly say the most complicated surgery they have ever done. Volunteer, try counting nine hours for those of you who have been surgeons.
And that's just one of the ethical issues involved. So first, do no harm. So that was his perspective on the piece as well, which I think we can all appreciate, the complexity of the argument.
In the final minute, do we have any other comments or questions from the audience? We have time for one more. Jeff Pearson. Jeffrey Pearson, Sydney.
I've just got a couple of genetic questions. I've been involved with surrogacy for a quarter of a century now, and my more recent case is I've been advising PGTA. Do you think we should be offering that? It makes, I think, questions of non-progressive pregnancy complications, because that's one of the things you have to deal with in surrogacy.
How are you going to deal with an abnormal pregnancy, especially one that may be genetic? And shouldn't that be some sort of gold standard to, I think, both of these groups that we're talking about? And the other question I have is, with MRKH, and it's presumed to be, I think in many cases, autosomal dominant, is there any genetic workup done with things like whole exome screening so you can offer potentially PGT? Yeah, so Jeff, just in terms of in relation to surrogacy and PGTA, I also am involved quite a bit with surrogacy. I generally do recommend the PGTA, and I have been in the situation, possibly like yourself, where we did transfer an embryo, and it didn't look like it was going to be, we weren't sure if it was a progressive pregnancy or not, and there was a lot of difficulty surrounding counselling, and also counselling a surrogate in terms of requiring a dean's, either medical or surgical management, if there is a pregnancy loss, and the psychological impact that can have both on the surrogate and also on the commission couple. So I am an advocate where possible if you are able to do PGTA, but again, that also does increase the cost of the process for some patients undertaking surrogacy, and particularly in younger patients, it might not be, as we discussed yesterday, so valid, particularly for when a female is less than 35 years of age, and the risk of aneuploidy is indeed very low.
Now, that might be a different perspective from those doing the uterine transplant. It may be thought to be a little bit more of a, sort of a different situation, and I wouldn't mind their comments because we did hear yesterday that the fair first pregnancy didn't have the PGTA screening undertaken. Yeah, I was just wondering how complicated management of a non-progressive pregnancy would be in cases of a uterine transplant.
Rebekah, I might just add. Okay, so firstly, just to address the genetic predisposition of MRKH, it's not autosomal dominance, usually de novo, and it's sort of, we're still investigating. There may be some target genes, but there's gene in environments.
There's nothing to test for MRKH particularly. In terms of PGTA, yes, absolutely good idea, but in our trial, we didn't make it a mandatory thing necessarily because a lot of the women were young, so the chance of aneuploidy is low, but, and it does add the cost, obviously, and that's the issue. So certainly, if it was something that the patients were willing to, a cost that they would bear, then we would encourage it.
Hassan, you've got a question. Thank you. That's an amazing debate, and I still remember the moment that Neil alluded to.
It was amazing to be on the SRM revealing the first pregnancy after uterine transplantation. I think this is a real breakthrough that happened recently in our field. I think that at the moment, uterine transplantation versus surrogacy is not comparable because we don't have enough data to compare both of them, but I think it is an excellent option, maybe the last option for the patient, and my question is that from the case series that has been done on uterine transplantation, what was the time to pregnancy? So mostly, it's quite quick because they only have five or six embryos in Saatchi.
There was one case in Sweden where they did IVF again with uterus transplanted, and that was for a second child, which was also successful. So it's usually within a year. Initially, the embryo transfers were delayed by 12 months, but now we often transfer within the first three to six months, and then you do one per month.
Thank you. I just want to thank all of you. It is a superb debate, and I think it's important that where we are at this time, we should all talk about surrogacy and uterine transplant as options.
I just wanted to just raise another aspect of uterine transplant. There, I recently referred a patient to Rebecca Deans with MRKH, and there are certain women who don't have the option of surrogacy because of their religious beliefs, and for them, it is the only option if, as a 16-year-old, you're diagnosed with MRKH. That just changes your life, and throw hats off to you to sit here and talk about all that.
Best of luck to you, and I think there is no comparison because they are not allowed third-party reproduction, so as Muslims, they cannot take donor embryos, they cannot take donor sperm, and they have got no choice, so for them, uterine transplant is a big innovation. Thank you. Yeah, and I think I just want to end on this note of reproductive choice, and especially coming from the American vantage point of ongoing restrictions and reproductive choice.
I think probably at the forefront is giving individuals and couples to do what makes the most sense for them, right? So for those couples that choose surrogacy, I think surrogacy is an amazing and a powerful option for those individuals where uterine transplant maybe is the only option. Having a choice in that situation, I think, is really paramount. So I'm just going to conclude by saying there is no winner.
But that I want to thank our entire audience and both on the live stream as well as here in Sydney for participating in this debate, and Pru, we're all rooting for you. So thank you all.
