The keynote address was given by Dr. Robert Wah, the current President of the American Medical Association. A special note pride: Dr. Wah is the first board-certified Reproductive Endocrinologist to be President of the AMA. He is a teacher and continues to see patients at the NIH and Walter Reed National Medical Center.
His talk was quite enlightening for me. He did a quite a lot to dispel my misperception that the AMA is led by a group of stodgy old white men. The board of the AMA is almost half female and there are several members of color as well. The goals of the AMA are clearly patient-centered, not doctor-centered, if Dr. Wah is to be believed. And he did seem quite credible, as well as humble and of course, very intelligent. I will be watching closely the actions of the AMA in months and years to come and hopefully, their actions will align well with the goals of ASRM and womens health.
Every few years at ASRM, there is an announcement of a breakthrough procedure or technique that makes the headlines. This year, it was announced shortly before the meeting that the first baby in the world was born after uterine transplantation.
One of the highlighted speakers at the meeting was Dr. Mats Brannstrom from the University of Gothenberg and Stockholm, Sweden, the physician scientist that performed this uterine transplantation that resulted in the first live birth. He gave a thoughtful lecture, detailing his research that started in 1995, working with mice, rats, then baboons and finally, was cleared by regulatory authorities in Sweden to start work with humans. It should be noted that gestational surrogacy is not legal in Sweden, as is the case in many countries in the world. Therefore, if a woman does not have a uterus or otherwise cannot carry a baby, she must travel to a foreign country for surrogacy or adopt.
Dr. Brannstrom provided details of the particular case that led to this first live birth. The woman receiving the uterus was born without one, a condition called Mullerian agenesis, but she was born with both ovaries. The donor was a 61 year old family friend. The surgery to perform the hysterectomy on the donor took 10 hours, mainly because they had to try to preserve all of the blood vessels leading to and away from the uterus, which required laborious dissection. The surgery on the recipient took about 4 hours to complete. The recipient had previously undergone IVF and had frozen embryos available for transfer to her engrafted uterus. She had to take immunosuppressing medications after the transplant surgery and also a couple of times after she conceived in order that she not undergo rejection of the transplanted uterus.
At 31 weeks gestation, she developed severe pregnancy-induced hypertension (pre-eclampsia) and had to be delivered by C-section. It is unknown if the pre-eclampsia was in any way related to the graft and/or medications. Baby and mother (and donor) are all doing well. Dr. B also indicated that they have done 7 other transplants and 2 other patients are pregnant and near term.
It should be noted that this is a highly controversial procedure. The ethics of having a donor undergo a 10 hour procedure to provide a uterus is in question, although, with experience, that duration of surgery will likely drop. The costs of the two procedures, medications and monitoring for rejection are also likely to be substantial.
Certainly, as long as gestational surrogacy is legal, as it is in most of the United States, we doubt seriously that uterine transplantation will ever supplant surrogacy. But, this is a breakthrough of sorts, and it will be interesting to see if it spreads to other countries where surrogacy is illegal.
Next Generation Sequencing
The other major topic of this meeting was the ongoing and ever-expanding body of knowledge concerning genetic screening of embryos prior to IVF embryo transfer. When the first human genome was sequenced completely 15 or so years ago, it took many laboratories working collaboratively and billions of dollars to accomplish this. Today, through technological improvements and automated sequencing, it can take one reference lab about 10 days and $2000.00 to sequence an individuals entire set of DNA. This is what is called Next Generation Sequencing or NGS.
What this means for human embryos is that the day is coming soon when we will be doing this on embryonic DNA, instead of current techniques that give us diagnosis of single-gene mutations and/or simply chromosome copy number. The implications of this, though, are enormous. As with the rest of the medical field, out of the billions of base pairs in our DNA, we will have to figure out what the 30,000 or so genes that get made into proteins do.
We will also have to have a much better understanding of what regulates the expression of these genes such that some people will get diabetes or be at greater risk of cancer in their lifetimes, much less what genes control with regards to everyday physical characteristics or behaviors. In other words, what sequences are important? And, if there is a change in the usual sequence, is that change important? Is this really a mutation or just a benign variation? Does it mean something negative for that individual? How are we going to manage all that information? Who is going to interpret all the information? How do clinicians explain all the knowns and unknowns to our patients to try to make sense of it? It is almost mind-boggling that we can obtain this information but wont really know how to handle it.
As I said, this will not just be an issue for IVF clinicians and their patients, but potentially for all of medicine. But, it may happen here first, as we are already screening embryonic DNA and this is simply the next technological step. Stay tuned, this ought to be fascinating.
- Carolyn Givens, M.D.