1998. In a patient room at the Royal Hospital in Adelaide, Australia, a 25-year-old woman has just been told she has cervical cancer – stage 1B. Angela. The prognosis for her survival is good, but doctors Mats Brännström and Ash Hanafy want to remove her uterus. Mats: “That means you can´t have children”. Angela: “But can´t you transplant a uterus the day I want children?” The question is simple and the solution to a large infertility problem should be as simple. Why can´t you transplant a uterus? Bothered by the question Mats is forced to reply: “No, that’s not possible. Maybe in the future”.

2012. The moment they all been waiting and training for, are here. In an operating room at the University Hospital in Gothenburg, a group of surgeons and nurses are gathered for a time out. Customary before an operation is to go around and present themselves. So even today. Main operator Mats Brännström says: “Today we are going to do a uterine transplant. The first.” They nod gravely. Embrace the moment. The patient on the operating table is a Swedish woman who, at age 25, lost her uterus in cervical cancer – stage 1B. Me.

***

The operation

September 15th 2012

The night before the big operation, they meet. Gynecologists, transplant surgeons, everyone who are surgically involved in the project. After 15 years, it´s about 15 people. Now they run everything through one last time – the procedures, who will do what and who will be in each operating room. The one with the donor or the one with the patient. They talk about media. So far, Sahlgrenska and the team have kept a low profile, but they can not be sure that the press has got news about Sweden’s first uterus transplant and that they will be outside the hospital the next morning. Niklas Kvarnström, one of the transplant surgeons, calls the patient and inform her their strategy. If the press is watching the main entrance, she should call one of the nurses who will let her in through the back door.

They arrive early. Some of them change clothes in a building further away and then walk to the operating rooms through the culverts, just in case. It is Saturday and the corridors are empty. Just as planned. The research should in no way interfere with ordinary activities. The staff who work in the aftercare this day have previously notified their interest in working an extra shift.

Gynecologist team one initiates the operation. Well skilled, they lay the first cut. A so-called midline cut that extends two centimeters above the navel. The woman, the patient’s mother, is a 52-year-old healthy woman who has given birth to three children vaginally without complications. An exemplary donor. X-rays and rigorous studies show that uterus and surrounding vessels are equally exemplary – whether that is true or not they won´t know for sure until they open up. Do they hold their breath?

They inspect. The uterus is of normal size and slightly backward. On the left side there is an active ovarian and inside is even an follicle. The right ovarian is somewhat atrophied. Of the relatively common muscular tumor myomy, there are thankfully no signs of.

A grueling work begins. The space in a woman’s pelvis is surgical minimal and the uterus is clamped between urethra, urinary bladder, fallopian tube, ovaries and intestines. Around these weaves a fine mesh of a variety of thin blood vessels. Just as with an archaeological excavation, all this must be carefully distinguished and separated. The longer vessels the better. Vessels that will accompany the uterus to the other body. They divide, dissect and cut.

In the operating room next door, they prepare the patient. The device they use to cut the tissue is slightly malfunction and the device is replaced. Between the bowel and ovaries, the gynecologist team two detects some adhesions, from the patient’s previous surgery. Then when the uterus was removed. The cavity after the first uterus has also caused the bladder and rectum to slightly collapse and the ureters are glued to the pelvic wall. Further down behind the bladder, more adhesions are detected. Thicker ones. They search for the ligaments that the uterus usually is attached to. Stubs that after the removal have been degenerated but is now marked with threads for the new uterus. Two on the side and two back down towards the rectum. Pelvis vessels from before are also picked up. On them they place small rubber bands for easier access later on. In wait of the transplant, the open wound is covered up.

It takes time. Much more time than they expected. The veins in the donor’s abdomen are twisted and collapse easily. A little naive, the team has assumed that the operation should be almost identical to the procedures on the baboons, perhaps even a little shorter because the anatomy of a human being is bigger. It did not. Womb transplantation is an advanced affair. But the surgeons are tough. Concentrated. They talk and laugh. And when it gets critical it becomes dead silent. Three at a time they take turns in the surgical wound, burning and holding. Outside the operating rooms, in a barren waiting room, the patient’s partner waits. Trying to make time pass he watches movies on the phone – first one, then several. He even falls asleep a couple of times.

On the arena, the transplant surgeons finally enter. They stand for a while and reflects the operating wound before they finish the releasing of the vessels. The uterus is taken out. Thoughtfully they place it on a separate table where it is flushed and iced. When it disappears from the room, the donor’s team of gynecologists remains. Closing the wound. From here it’s like any other operation. Gently they place a final hand on the woman’s body. The work of her and the gynecologists has now been completed.

They sew. Ligament. Veins. Arteries. Then the final solemn moment remains. The clamps that block the blood flow during the operation are loosened and the blood is released. The uterus gets a nice pink colour in just a few seconds. On the right side, the flowmeter measures about 15 ml per minute. On the left about 60 ml per minute. The transplant surgeons take a break and the patient’s gynecological team sews the suspension ligament and the vagina. When the transplant team attends once again, the flow reaches approximately 50 ml on the right side and 70 ml on the left side. They are pleased with that.

When the patient is rolled out of surgery, it is night time. The team of around 15 people elected to perform the world’s first womb transplant from mother to daughter has been operating for 18 hours. It’s like a relay race. Methodically and tactically, they run one lap at a time, hour after hour. Like persistent runners they are trained to endure lactic acid and mental stress. The adrenaline that pumps during the long waking hours keeps them alert. Afterwards a wave of exhaustion rinses over them.

A clear September day has passed them by entirely. In the cool autumn darkness, they now pull the jacket close to the body and slowly walk across the parking lot. At the car they stop for a short while gazing out to the horizon where the sun soon will rise. They take a deep breath and sigh satisfied. It is done.

In just a couple of hours, they will gather here again. For the next operation. Tomorrow, another woman will be given a uterus from her mother.

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