Like a Virgin

by Prasad, Aarathi

  What would it mean if a foetus could be gestated entirely outside of a woman’s body? Ectogenesis is clearly not an ethically easy path for starting or expanding a family. Hand in hand with the creation of a viable artificial womb, doctors and counsellors would have to create something to analyse a number of genetic defects carried by a fertilized egg or early-stage embryo that may not yet be recognized through pre-implantation genetic diagnosis. During in vitro fertilization, some embryos may fail to implant in the natural womb because of random or inherited genetic mutations or those that accumulate with age. With an artificial womb, that process would not work in the same way; the embryos would likely be attached by doctors to the synthetic placenta (or other filtration system that might provide nutrition) meaning that implantation would succeed where it would fail in a natural womb. And the embryo with potential abnormalities might then be able to develop to term in such a highly regulated environment. Would ‘pulling the plug’ on that foetus in an artificial womb be seen as an early-term abortion or euthanasia?

  There is a flip side to that dilemma, of course: it just might be easier to make genetic corrections and modifications to a foetus in a plastic box, which is what an artificial womb is likely to be, less its sophisticated controls. Not only would it be easier to reach the foetus, it would avoid the need to operate on the mother in order to get into the womb. For both mother and child, this would make pregnancy a much safer prospect.

  Another point to consider is whether the only role of a mother’s womb is to house the developing embryo and provide what it needs to grow. We now know that a woman shapes the genetics of her child through what is known as epigenetics, which refers to changes written over DNA that are environmental and potentially reversible. Epigenetics is the force involved in genetic imprinting, when a chemical group sits on a stretch of DNA and influences whether and when the genes there work – or don’t. These influences can be good, neutral, or bad for a child; epigenetics is agnostic when it comes to development.

  The inheritance of characteristics through epigenetics is something that scientists have only quite recently started getting to grips with. But it seems that even from very early in life – including when we are in our mother’s wombs – we can be influenced by things that we previously thought had no impact, things like how much a woman eats and how stressed she is. There are, for example, very clear epigenetic signatures that mark those whose mothers have lived through famine and poor socio-economic circumstances. One study of a small town in Sweden found that having plenty of food had an interesting effect: the grandsons of men who ate well had a greater risk of diabetes than the granddaughters of women who did – meaning that the sex chromosomes could be involved. A 2008 study of women who were diagnosed with depression in the third trimester found that their infant children reacted to stressful situations by releasing more of the hormone cortisol, which increases blood sugar and helps with metabolism – getting a person ready for the quintessential fight-or-flight response. And it did not matter if the women were receiving treatment for depression; the stress-response trait passed to the infant regardless. Epigenetic signatures have also been associated with being abused as a child, changing both that person’s DNA – and possibly also her offspring’s.

  There are sure to be other traits passed to a baby through the simple fact of being in one woman’s womb rather than another’s. And since epigenetics is about shaping genetics, sharing genes with the child in your womb may not make a difference when it comes to these effects. It is possible, for instance, that through epigenetics surrogate mothers are influencing the way a child’s genetics play out, including elements of the child’s personality – that is to say, how the child adapts to its outside environment. Of course, by the same token, an artificial womb may throw no epigenetic influence on to the foetus growing within it. Whether that would be good, neutral or bad, it is far too early to know. Our knowledge of epigenetic influences is too new for us to begin to contemplate what would happen if they were removed from the process.

  What would undoubtedly be good for the foetus would be gestating removed from exposure to undesirable chemicals such as nicotine, alcohol, and other drugs that can be absorbed via the placenta when a mother imbibes. During pregnancy, up to fifteen percent of women are believed to use alcohol, and about five percent use illegal drugs. The proportion of women taking these substances decreases as they enter the later stages of pregnancy, but the effects on the foetus are often worse in the early stages of growth. And drug misuse, illegal or not, is known to have potentially disastrous consequences for an unborn child. Heroin, or more specifically withdrawal between heroin use, can lead to spasm of the placental blood vessels, which reduces blood flow to the placenta and lowers birth weight. Benzodiazapines, which are used to treat anxiety and insomnia among other things, but which are also often abused, slightly increase the risk that a baby will be born with a cleft palate; they are also associated with low birth weight as well as premature birth, and can trigger withdrawal symptoms in the newborn. Cocaine is a powerful constrictor of blood vessels; heavy use increases the risk of several serious conditions, including the placenta detaching from the womb, stunted brain growth, underdevelopment of organs and limbs, and even foetal death. Tobacco causes a reduction in birth weight greater than that caused by heroin, and is a major factor in increasing the risk of Sudden Infant Death Syndrome (SIDS), or cot death. Cannabis use does not seem to have a direct effect on pregnancy, but because the drug is frequently mixed with tobacco, the results can be the same as smoking during pregnancy.

  Finally, there is humanity’s most accepted drug: alcohol. When consumed in large amounts, alcohol results in reduced birth weight. In the most extreme cases, a baby will suffer the effects of so-called foetal alcohol syndrome (FAS): low birth weight, with general growth throughout life being stunted, including the circumference of the head – and consequently the size of the brain. Children with FAS will also exhibit dysfunctions in the central nervous system, including learning disabilities and certain, characteristic facial abnormalities, known as the FAS face. Children with FAS are likely to have smaller head size and eye openings, an underdeveloped jaw, flattened mid-faces and nasal bridges, smooth philtrums (the slight groove between the nose and upper lip will be absent), thin upper lips, and ear abnormalities.

  Substance misuse is often associated with poverty and other social problems, with far-reaching effects on health. And a majority of drug-using women are in their childbearing years. It follows that drug-using women may well be in poor general health before they become pregnant, making their wombs less conducive to a healthy pregnancy, even before ongoing drug use and other issues are factored in. The alternative – a womb outside of your own body – may just be a more salubrious place in which to start life.

  One alternative that is already making headlines is transplantation of a new womb, whether a donated organ or an artificially created womb-like structure, into a woman whose own uterus is damaged or missing. While a womb transplant wouldn’t get around the inherent dangers to the mother of pregnancy and childbirth, or the dangers to the foetus from a mother ingesting alcohol or other drugs, it would probably provide a healthier environment – especially given the limits that would be put on a woman’s behaviour after having undergone transplant surgery to begin with. But although ovaries have successfully been transplanted in humans, womb transplants have only recently been tried in humans, and early operations with dogs in the 1970s proved unsuccessful.

  In April 2000, Dr Wafa Fageeh, leading a medical team in Jeddah, Saudi Arabia (where surrogacy is illegal), became the first surgeon to attempt a womb transplant in a human. The recipient was a twenty-six-year-old who had lost her womb six years earlier, after haemorrhaging during childbirth, and the donor was a forty-six-year-old who had been told she must have a hysterectomy because of ovarian cysts. Fageeh’s work was innovative, and the transplant was not rejected by the recipient patient – in fact, she went on to have two natural men
strual cycles. This meant that the graft had been properly done, and had been given a sufficient blood supply. But the transplanted womb had to be removed after ninety-nine days, when a clot developed in a blood vessel that was surgically attached to it. Ultimately, the operation could only be regarded as unsuccessful, since it did not result in a pregnancy.

  Within three years, however, scientists began to mark their first triumphs transplanting wombs in mammals. First, mice with donated wombs carried to term and gave birth to normal babies. In 2006, Giuseppe Del Priore, at New York Downtown Hospital, performed a womb transplant on a rhesus monkey; though he was able to establish blood flow between the donor organ and the monkey, the animal was given an incorrect dose of anticoagulants and the experiment had to be terminated within a day. Then, in 2009, a team led by Richard Smith, a consultant gynaecologist at London’s Hammersmith Hospital, managed to transplant not just the womb, but also major blood vessels including the aorta, in rabbits. Once the transplant surgeries were completed, the rabbits were placed on immunosuppressant drugs, which helped to prevent the donated womb from being rejected. Alas, despite being mated, none of the rabbits became pregnant. On this occasion, it seemed that the trouble lay with the Fallopian tube, which became blocked and could not carry the fertilized egg to the womb.

  These early successes have led to some speculation about the possibility of implanting an embryo into a man. One possibility, in the near term, would be to insert the embryo in the abdomen, the equivalent of an ectopic pregnancy – when an embryo attaches to tissue outside the womb, yet continues to develop. Ectopic pregnancies are dangerous – they can lead to haemorrhaging and death – but a handful of cases in women have been taken to a healthy, live delivery via laparotomy, a form of Caesarean section. In 2008, for instance, a British woman, Jayne Jones, gave birth to a son at twenty-eight weeks gestation; the pregnancy had not terminated earlier because the embryo had attached to a fatty portion of the mother’s large bowel, ensuring a good source of nutrition, and the foetus was removed as soon as it was discovered to be outside the womb. This was the first successful delivery in the UK of its sort – and thirty-six medical staff attended.

  The eminent fertility expert Lord Robert Winston has commented that ‘male pregnancy would certainly be possible, and would be the same as when a woman has an ectopic pregnancy... although to sustain it, you’d have to give the man lots of female hormones’. In such a case, the foetus would be implanted inside a hormone-packed man’s abdomen, with an artificial placenta attached to an internal organ – such as the bowel. But apart from all the hormones the procedure would necessitate, the problems associated with ectopic pregnancy would not make it an attractive prospect to anyone. To prevent haemorrhaging at birth, for instance, the placenta would probably have to stay intact, attached to his insides, after delivery. This would be risky for his health – the tissue would either grow, almost like a tumour, or detach or rupture and become lethal when it haemorrhages. If men were to carry embryos to term in this manner, they would, by definition, be experiencing an ectopic pregnancy – which is known to be dangerous to women, and tends to be terminated as soon as it is discovered.

  Womb transplantation would be a different prospect entirely – particularly in women. The womb, of course, is a defined space provided for the foetus; as we’ve seen, it is where the placenta embeds itself, offering a line of communication between the mother and the foetus, not just resource management. And while there are several major hurdles to overcome before the procedure could be considered ready for regular trials in humans, optimism reigns. In 2011, for example, Eva Ottosson, a fifty-six-year old mother of two from Nottingham, England began proceedings to have her womb transplanted into her twenty-five-year-old daughter, Sara. Sara was born lacking a uterus and some parts of the vagina, yet wanted to experience pregnancy and childbirth. In an interview with the Telegraph newspaper, Sara expressed no uneasiness about receiving the womb that had carried her to term. ‘I’m a biology teacher, and it’s just an organ like any other organ,’ she said. Eva had asked, ‘Isn’t it weird?’ – but her daughter had answered with an unequivocal no. On the other hand, many people undergoing organ transplants later report feeling as though something about them has changed – not just that a physical bit has been grafted into them, or that they have recovered their health, but that they have acquired new tastes, behaviours, or personality traits, which they usually link to the donor. It might be that the womb, because it has been viewed historically as a vessel for another life, doesn’t trigger the same feelings in transplant recipients. But if it does, there may be some odd feelings after the procedure, despite Sara’s sure answer.

  In any case, the surgery, scheduled for 2012, is not something that the mother and daughter take lightly. Sara noted that she was ‘more worried that my mum is going to have a big operation.’ Indeed, Mats Brännström, the surgeon planning the groundbreaking transplant, has been working on the procedure for years. He is convinced that it will be more technically demanding than a kidney, liver, or heart transplant. He is especially focused on the complicated connections between the womb and the blood supply and between the womb and the vagina. Will these surgically created connections be strong enough to survive the strain of pregnancy?

  Brännström has had successes with some early operations, conducted in sheep. He and his team were able to remove the wombs of five ewes, keep the tissues alive outside of the body for a couple of hours, and then replace the wombs in the original animals, reconnecting the blood supply and the vagina successfully. And four of the five ewes subsequently became pregnant. Brännström and his colleagues have also performed the procedure on mice, rats, and baboons, with two out of five baboons that underwent the surgery resuming regular menstruation afterwards. These are small, incremental steps, but transplantation in humans is the end goal.

  Of course, even if Brännström succeeds, womb transplants may not be a viable option for everyone – think of a woman who has already had an invasive hysterectomy in order to remove cancer then choosing to undertake a series of transplant operations, with all of the medical risks that would entail. A safer, more desirable course of action might be to turn to a womb outside of your own body. Though today the technology is quite limited, researchers in the field are right to believe that a fully functional artificial womb will come to exist in the next decade or so.

  There is obviously a complicated relationship between an embryo in the womb and its mother, in terms of how a developing baby develops an immune system and takes on board a range of environmental cues while in a mother’s body. Indeed, there are many issues that are still not understood, about epigenetics and more. Yet, much has been learned about the underpinnings of disease in the last couple of decades, and that knowledge is breaking open the last remaining barriers to an artificial womb for humans. An artificial womb, after all, will primarily be used to bridge the gap between the fertilization of an egg in a test tube and the movement of the developing embryo into an incubator – since Amillia Taylor’s birth a period approaching a brief twenty weeks. And it could help to save pregnancies, whether their origins are in vitro or in vivo, in which the embryo is not yet able to survive with current incubator technology – including many ectopic pregnancies that could endanger the life of the carrying parent.

  But an artificial womb could also offer solutions, much as IVF did, both for those with clinical need (which would include gay men if you consider that neither partner will have a womb of their own, and will clinically need one if they want to have a child) and for those who opt for it for various other reasons. For many women who use IVF to become pregnant, the time, pain and expense are wasted when their babies fail to implant in their own wombs. The reasons why this happens are currently not clear, but having access to another womb in a controlled environment certainly sounds like a helpful option for them. During labour, the birth canal is sometimes a treacherous place for babies and the ordeal can lead to death – a scenario that would be avoided i
f gestation were not inside the woman’s body. And because, of course, a woman would not technically have to carry her child, and as pregnancy poses a risk to the mother – in particular, it can genuinely endanger the health of an older mother – this is one advantage, and a use of the technology that becomes very tricky to argue against.

  But if you remove a foetus’s development from the context of the ‘natural’ womb, an idea that some opponents say is like putting a foetus in a box for forty weeks, will you also remove the ‘special bond’ that forms between a mother and her child? To all intents and purposes, however, this question is a red herring: carrying a baby has never been a prerequisite for loving one’s baby or being able to bond with it – otherwise the same issues would be an argument against adoptive parents, mothers who use surrogates, and even fathers. In fact, being able to watch, in plain sight, the fragile, doll-like foetus as it develops and grows may encourage a new and special bond. Over the past thirty years, sonograms and other scans have become a regular part of prenatal care, and this ability to view the foetus, as an independent being, is thought to contribute to a maternal–foetal relationship forming much earlier in development – weeks earlier than a mother is usually able to feel kicks and other movements. If it is also the case that bonding is proportionate to the degree to which a child is wanted, parents who have put themselves through any of the gruelling aspects of assisted reproduction – including the artificial womb of the future – may see their great desire to bring their child into the world translate into a great bond with their child, no matter the womb it developed in.