“An ephemeral transplant”: analysis of scientific publications on the Brazilian case of uterine transplantAbstract
This article analyzes scientific publications that discuss or mention the uterine transplant procedure performed on humans in Brazil in 2016. Thirteen articles published between 2016 and 2023 were selected from PubMed, later subjected to a narrative review, and public statements from the doctors involved in this type of transplant were considered. From this, we sought to understand the discourses, consensus, and controversies that arise in the scientific field. We approached this analysis from the perspective of social studies of science and regarded scientific discourse as historical, provisional, and partial construction, influenced by economic, social, and political interests. The findings indicate the mobilization of moral arguments - not exclusively “technical” ones - in defense of the transplant and an (over)emphasis on favorable aspects of the procedure. There is also a noticeable strong biological essentialism that reinforces the idea that ideal motherhood requires the experience of pregnancy within one’s own body, ensuring gestational, genetic, and legal components.
Keywords:
Transplant; Uterus; Gender, Science; Reproduction
Resumo
Este artigo analisa publicações científicas que discutem ou mencionam o procedimento de transplante uterino em humanos ocorrido no Brasil em 2016. Foram selecionados 13 artigos no PubMed publicados entre 2016 e 2023, posteriormente submetidos a uma revisão narrativa. Foram consideradas falas públicas dos médicos envolvidos com esse tipo de transplante, a partir das quais buscou-ses compreender os discursos, consensos e controvérsias que surgem no campo científico. Partiu-se da perspectiva dos estudos sociais da ciência e encarou-se o discurso científico enquanto construção histórica, provisória e parcial, mobilizada por interesses econômicos, sociais e políticos. Os resultados apontam para a mobilização de argumentos morais, e não exclusivamente “técnicos” em defesa do transplante, além de uma (sobre)valorização de aspectos favoráveis do procedimento. Percebe-se, ainda, forte essencialismo biológico que corrobora a ideia de que a maternidade ideal exigiria passar pela experiência da gestação no próprio corpo, para que os componentes gestacionais, genéticos e jurídicos sejam garantidos.
Palavras-chave:
Transplante; Útero; Gênero, Ciência; Reprodução
Introduction
In September 2016, at the University of São Paulo’s Hospital das Clínicas (Brazil), a 32-year-old Brazilian woman diagnosed with a rare congenital syndrome called Rokitansky syndrome,1 characterized by the absence of a uterus, underwent an experimental procedure in which she received the uterus of a recently deceased donor. In this type of procedure, reproductive technologies prepare the body for a very specific event: the experience of pregnancy. From this, a sequence of “biologically female” events, such as menstruation, pregnancy, and childbirth, could occur. It is worth noting that the transplanted uterus is removed along with the baby at birth so that immunosuppression therapy (used to prevent the body from rejecting the transplanted organ) can be discontinued, thus minimizing short- and long-term side effects. For these reasons, uterus transplants are referred to by doctors as “ephemeral transplants”.2
In the latest registry published by the International Society for Uterine Transplantation,3 released in January 2023, 45 transplant cases were reported, 78% with living donors, 22% with deceased donors, 16 pregnancies, and 19 babies born (3 women had twins) worldwide. However, researchers estimate that, adding unpublished experiences, the number could increase to 80 cases and 40 births. The experimental procedure has already been performed with living donors in Europe (Sweden, Czech Republic, Germany, and Spain), Asia (Saudi Arabia, India, China, Lebanon), and the United States, and with deceased donors in Turkey, the Czech Republic, the United States, and Brazil (Brännström et al., 2023).
The Brazilian case stands out in this regard as a “success story” and is considered emblematic because it was the first recorded birth from a uterus transplant from a deceased donor. According to the Dimensions Analytics data platform, the Brazilian article (Ejzenber et al., 2018) reporting the event, published in 2018 in The Lancet, was cited 203 times by other publications. The platform also indicates that, compared to other publications in the same field, the article received approximately 75 times more citations than the average. At a public online event held in June 2023, physician José Maria Soares Júnior, a member of the team responsible for the transplant and currently head of the Department of Obstetrics and Gynecology at the University of São Paulo School of Medicine (FMUSP), remarked: “I think we really did something incredible for the world”.
We assume that there is a very specific relationship between scientific production and the maintenance of gender stereotypes, as already pointed in studies by Laqueur (2001), Rohden (2001), Martin (2006), Silva et al. (2019), among others, which highlight the construction of a certain medical grammar for thinking about and intervening in the female body. We will then investigate how medical discourse is disseminating the phenomenon of uterus transplantation in Brazil, based on scientific publications that mention the case, and we will analyze how conceptions of gender and sexuality emerge in these documents. More specifically, we will discuss how medical texts emphasize the embodied experience of pregnancy, the boastful perspective that celebrates scientific progress in this case, and how the articles articulate a perception of success and failure of procedures. From a critical and feminist perspective on science, we aim to build a reflection on gender and science, nature and culture.
We believe that scientific discourse is neither neutral nor impartial, and that scientific facts are scientific productions-intersected by interests, negotiations, and imbued with political and social values. This article aims to analyze scientific publications from a perspective that places them in dialogue with social studies of science and gender.
Methods and Results
To understand how medical-scientific discourse has been constructed to explain uterine transplant, we conducted a narrative review of publications addressing the Brazilian case. We aimed to analyze how these discourses are formed, both in the field of new reproductive technologies and in the field of organ transplantation, and what the more or less explicit controversies are. Unlike a systematic review, a narrative review presents a more open-ended theme, not necessarily starting from a specific, previously defined question. The lack of a rigid protocol favors the possibility of analytical choices during the data collection process itself, with the main objective of offering a description and analysis of the material that can highlight trends, themes, or perspectives. Therefore, a narrative review becomes useful when we desire a more comprehensive view of a studied topic, offering a more current panorama for deeper exploration in future studies (Cordeiro; Oliveira; Rentería, 2007).4
As of the date of the search, June 2024, PubMed, an online search engine that accesses the Medline (Medical Literature Analysis and Retrieval System Online) database, retrieved 600 articles, editorials, and postprints discussing or mentioning uterine transplantation in humans worldwide. In this survey, we noted that from 1947 to 2011, there was an average of 2.48 publications per year, while from 2011 to 2024, the average was 38.42 publications per year.
The exponential growth seen over the past 13 years seems quite significant, as it reflects an expansion of the discussion following the increase in the number of transplants performed and success stories published. According to a timeline presented by Brännström (2024) in the last webinar on uterine transplant, since 2011 there has been a significant increase in transplants performed on humans, along with an expansion of the techniques used, with deceased donors (DD), living donors (LD), the use of robots, and an apparently more uniform protocol for data collection.
In our search, we used the combination of the terms "Uterus transplant" or "Uterus transplantation" and "Brazil," selecting the species "human" in PubMed and the BVS (Virtual Health Library). From this, we obtained an N of 13 publications in PubMed and 6 in BVS, and the 6 found in BVS were also located in the PubMed search. The publications ranged from 2016 to 2023 (Chart 1).
Discussion
A “new” new reproductive technology
Science has historically been concerned with any instability of the sexes (Laqueur, 2001), with demarcating boundaries (Rohden, 2001), and with emphasizing characteristics and social roles "naturally" established for each sex (Nucci, 2010). Anatomy is not a consolidated and immutable fact - science not only investigates difference, but also constructs it. Schiebinger (2001) states that in the 18th century, there was already a movement seeking to affirm sexual differences using human physiology as a parameter. The development of anatomy provided tools to support such assertions. Oudshoorn (1994) points out that, in the 19th century, physicians’ attention began to turn almost exclusively to the female body - in particular, the organs that make up the reproductive system: the uterus and ovaries (the essence of femininity seemed to lie there). It is worth remembering that any biotechnological interventions are endowed with emotional investments, expectations, and desires based on what is expected of certain bodily experiences. Therefore, contemporary vitalism, in which the category of “life” is anchored in biological materiality, is directly linked to notions such as “happiness”, “fulfillment”, and “quality of life” (Russo, 2017; Foucault, 2017).
According to Luna (2007), new reproductive technologies are procedures in human reproductive medicine that replace the sexual act for conception - and a privileged field of research in Anthropology for understanding the relationship between nature and culture. They can occur through artificial insemination, when semen is introduced through the cervix, or through in vitro fertilization, when egg and sperm are united outside the body to form embryos and then transferred to the uterus.
For many centuries, reproduction was thought of as an entirely natural process. However, with the advent of new reproductive technologies, the dimension of naturalness has been redefined, as has the conception of nature as something independent of human intervention. New reproductive technologies also imply a new perspective on the pregnancy process, in which carrying a baby in the womb becomes highly valued as a maternal function/condition in which there is a continuous exchange of substances and affections (Luna, 2023).
Science and the creation of new technologies have expanded, through different methods, the possibilities of choice for those who want to have children. Also noteworthy here is the production of new desires, as new paths and promises of treatment are offered for previously immutable “naturally given” conditions (such as being born without a uterus). In this sense, the dimension of desire is both produced by new technologies and is a central condition for their development, capable of expanding the dimension of choices and possibilities - to have, not to have, with whom to have, how to have, and when to have (Luna, 2004).
Uterine transplant
The first uterus transplant performed in Brazil highlights the paradox of producing a nature that is expected to be innate, that is, one in which, in principle, human intervention would not be necessary. Doctors emerge in this scenario as those who will ensure or correct the body so that biological laws are fulfilled. Dreams and promises make up a certain social imaginary of what science would be capable of achieving. We believe that the dimension of the desires of countless women who do not have a uterus or who have an infertile uterus, before and after the possibility of a uterus transplant, is being and will continue to be mobilized. Although the procedure is in its experimental phase in Brazil, we believe there is a proliferation of discourses capable of generating disputes on the topic.
Furthermore, we note in this scenario the emergence of a synthetic subjectivity (Rohden, 2021), which, more than any approximation to an artificial, synthetic character, refers to the idea of synthesis, composition, or even bodily-subjective engagement. The synthesis in question occurs through the incorporation of different types of elements, initially recognized as external. Breaking with the naive opposition between natural-true and artificial-false, the concept of synthetic subjectivity proposes the emergence of precisely the synthetic quality of these subjectivities and corporalities (hybrid bodies of prostheses, substances, that is, incorporations of elements recognized as external).
Following the logic of improvement/enhancement and/or corrections of an inadequate nature - as would be the case with a reading of the biological body of a cisgender woman who lacks a uterus - the synthetic quality shows that characteristics are contingent and can be (re)adapted for various reasons. Therefore, beyond its posthuman character and its inescapable plasticity of self-transformation, uterine transplant exemplifies that contemporary processes of bodily-subjective transformation anchored in new biotechnologies can be socially and technically innovative, despite being highly conservative (Haraway, 2000; Rohden, 2021; Luna, 2023).
According to the doctors:
Indeed, uterus transplant is an option that redefines the boundaries of reproductive surgery, offering new horizons for patients without a uterus or with a dysfunctional uterus who have recently begun to dream of giving birth and becoming mothers (Silva; Carvalho, 2016, p. 477, emphasis added).
Finally, uterus transplant can be considered a therapeutic hope for women who were born without a uterus or lost one unexpectedly during their reproductive life (Ejzenberg; Soares Júnior; Baracat, 2016, p. 295, emphasis added).
The therapeutic dimension of the procedure and personal fulfillment through the fulfillment of the dream of motherhood emerge as central arguments in defense of the procedure. We see essentialism at its core when the experience of pregnancy in one’s own body is presented as justification for such a risky and costly procedure (psychologically, economically, biologically, and ethically). The shift from what would be expected as a natural phenomenon to what can now be produced seems, at the very least, like a discursive disjunction.
“Tota mulier in útero”: the experience of embodied gestation
Patients who have no uterus or a dysfunctional uterus now have the chance to dream of pregnancy and motherhood. Combining principles of solid organ transplant and human reproductive techniques, uterine transplant is the first ephemeral transplant performed to promote women's reproductive potential and can be removed after a successful pregnancy. Eleven uterine transplants have been performed on patients worldwide. Of these, seven maintained reproductive potential, with viable transplanted uteruses and regular menstrual cycles (Silva; Carvalho, 2016, p. 474, emphasis added).
The cited excerpt encapsulates the primary objective of the procedure: the experience of pregnancy through the body itself. “Hope”, “dream”, “desire”, and “fulfillment” are terms that emerge linked to the promise of reproductive empowerment. The emergence of a science marked by an essentialist character seems to invest in an expectation of the future supported by moral values - not exclusively technical, nor impartial. Could medical technology, then, be helping to complete the cycle of feminine nature?
It must be considered that the expansion of reproductive technologies has contributed to changing the profile of the social practice of motherhood - with all its contradictions, changes, and permanency. From refusal to desire, the gender perspective has allowed us to glimpse motherhood in its multiple facets. Because of this, we understand that maternity wards, in the plural, can represent an ideal of feminine fulfillment, of women's power, or even of oppression. There are countless interpretive keys to the same symbol. With reproductive technologies, we move from a circumstantial refusal of motherhood to the possibility of choice, which expresses a relationship with motherhood that is historically, socially, politically, and culturally constructed. Uterus transplant is presented as a technological solution to a human reproductive issue - female infertility - and the high value placed on this modality is anchored precisely in its biological dimension - that is, because it occurs within the woman’s own body (Scavone, 2001a; Russo; Nucci, 2020).
Through the team’s publications and public statements, we noticed that other forms of motherhood, such as adoption or surrogate motherhood, are strongly discredited or rendered invisible. Doctors suggest that these alternatives are difficult for women who wish to become mothers to accept, justified by genetic desire and/or by the difficulty of finding a family member willing to carry a pregnancy (in cases of surrogate motherhood). They also affirm that infertility is
[...] an abnormality [that] can have a major impact on the psychological sphere of many women, as the remaining options are adoption or the use of a surrogate uterus. Both alternatives present difficulties. In the first case, the slowness and bureaucracy involved, while the second includes the need for a relative or friend willing to risk a pregnancy and the emotional ties that could develop towards this baby. Furthermore, this latter option is not permitted in many countries such as Japan and Sweden. Therefore, the only option left for patients who wish to use their gametes is the possibility of a uterine transplant, albeit experimental (Ejzenberg, Soares Júnior; Baracat, 2016, p. 295, emphasis added).
It is worth noting that the legal prohibition of surrogate uteruses does not apply in Brazil. Just as it is common sense to say that the legal adoption process in Brazil is too slow and/or bureaucratic, this statement only discourages the practice of legal adoption. There’s no set timeframe for the entire adoption process to be completed, as the duration of the entire process takes into account the family’s desired profile (age, gender, with or without siblings, etc.).
UTx [uterus transplantation] has its peculiarities. It is a temporary procedure that does not necessarily save a life in danger but rather improves quality of life and offers women anatomically or functionally incapable of bearing children the possibility of becoming mothers and giving birth to healthy babies (Castellón et al., 2017, p. 126, emphasis added).
Although the articles acknowledge that uterus transplant has peculiarities compared to other transplants and that it is a temporary procedure (not necessarily lifesaving), they still emphasize the improvement in quality of life and the possibility of pregnancy through one’s own body. “UTx [uterus transplantation] emulates a normal situation with the primary components of motherhood: genetic, gestational, and legal” (Castellón et al., 2017, p. 126, emphasis added). There is an emphasis on the idea that the transplanted uterus simulates a more “natural” situation of motherhood, in which the genetic, gestational, and legal components converge. Explicitly, we can note a scientific discourse grounded in moral enunciations and the valorization of what constitutes ideal motherhood.
In this sense, we see both a reinforcement of the social nature of motherhood and a strong biological determination. The face of an ideal motherhood, presented as unique, rich, and irreplaceable, is reaffirmed as a primordial element of feminine identity that would clarify the connection between body and nature (Russo; Nucci, 2020). We know that the reasons for choosing motherhood can be linked to numerous factors that, individually or in combination, intersect biological, subjective, and social dimensions. However, motherhood, as a social phenomenon and producer of multiple experiences, does not affect all women equally. What reproductive technologies have come to provide is the possibility of contraception or conception mediated by personal choices - which take into account social, economic, cultural, and other factors (Scavone, 2001b).
At an event6 organized by the Brazilian team that performed the transplant from a deceased donor, it was mentioned that “women defend this procedure with nails and claws7 [...]”. In articles produced by the same team, we noted a strategy of disqualifying one measure (adoption or surrogate uterus) to qualify the other (transplant), besides emphasizing fundamental aspects such as the fulfillment of women's desires.
In Brazil, surrogacy is permitted, but it is difficult for most women to find such a volunteer. The option of uterine transplant can, therefore, expand the realization of women's desire to become pregnant on their own. [...] We anticipate that the deceased donor uterus transplant modality will prove quite viable and successful, not only so that women with volunteer donors in their families, but all women with uterine factor infertility, can have a real option for a healthy pregnancy (Ejzenberg et al., 2018, p. 7, emphasis added).
In the discourse of these doctors, we frequently find an emphasis on a truer, more real, and healthier motherhood resulting from the transplant and the possible success of carrying a pregnancy to term. There is a game of valorization of the convergence between social aspects and biological markers. Swedish Mats Brännström is the coordinator of the research group that performed the world's first uterine transplant (in 2000) and the first case that resulted in a live birth (in 2014). He is considered by other research groups around the world as a pioneer of this type of transplant and is currently one of the founding members of The International Society of Uterus Transplantation.
According to the doctor, uterine transplant
[...] is a procedure for women with AUFI [absolute uterine factor infertility] to become not only genetic mothers, but also gestational mothers. Uterine transplantation (UTx) also provides a bond between mother and child during pregnancy and childbirth, eliminating specific issues related to surrogacy regarding legal motherhood (Brännström, 2018, p. 592, emphasis added).
The romanticization of motherhood and the generalization that it is a desire of all women are common in most articles. Furthermore, the idea that transplant creates the possibility of “gestational mothers” is particularly interesting because it points to the valorization of an embodied experience of menstruation and pregnancy, which in turn would strengthen the bond between mother and child, in contrast to what is suggested as problematic in the surrogacy experience.
Scientific boastfulness
For Brazilian researchers involved in uterine transplant, the event is seen as “a surprising scientific advance that will mark the history of human reproduction” and that would “mark the beginning of a new era” (Silva; Carvalho, 2016, p. 474). We call a certain scientific boastfulness a discourse that points to new milestones in science, that speaks of revolutions and remarkable transformations, or even the prospect that great transformations are on the near horizon (Azize, 2010; 2011).
This was a scientific breakthrough that will be remembered in the history of human reproduction and will transform the lives of many women who dream of becoming mothers. Medically speaking, this would be impossible for patients born without a uterus or who had one surgically removed. But now there is hope (Silva; Carvalho, 2016, p. 474, emphasis added).
There is intense emphasis on the brilliance of the technique, but also on those who conduct it, as the researchers writing about the phenomenon are the very doctors who are developing uterine transplants. Technician and technique are conflated. While they emphasize the difficulty of performing this type of transplant, they also value their expertise, highlighting the unprecedented nature of the phenomenon and the competence of their own work. The very construction of the texts expresses superlatives and hyperboles, portraying the phenomenon as an extraordinary scientific milestone.
Even when some apparent adversity arises during or after the procedure, they employ euphemisms to soften the situation and emphasize that the situation was controlled by the doctors. “The transplanted uterus had only one episode of mild rejection, reversed with corticosteroids” (Silva; Carvalho, 2016, p. 476) or “it was a considerable challenge, but it was done!” (Soares Júnior et al., 2016, p. 627, emphasis added). Furthermore, they often trigger a positive promise of what's to come in terms of research - always something even better and more refined.
The idea of scientific progress goes hand in hand with the proposal to solve the problem of “absolute uterine factor infertility” (a medical term), which was previously incurable, and offer pregnancy to bodies that could not otherwise experience it. Unanimously, all articles consider uterine transplant a technique capable of providing hope for infertile women.
We all know that there are still major challenges in improving the technique, selecting potential donors, and preserving the organ to be transplanted. Another highlight of this therapeutic modality will be curbing expectations of success within the community, given the learning curve required to implement any procedure. Finally, uterus transplant can be considered a therapeutic hope for women who were born without a uterus or lost it unexpectedly during their reproductive life (Ejzenberg; Soares Júnior; Baracat, 2016, p. 295, emphasis added).
The articles often emphasize the idea that motherhood and pregnancy are a dream for many women and that there is a high social demand for this type of procedure. They point out that infertility, caused by hysterectomy or congenital infertility due to Rokitansky syndrome, affects 3 to 5% of the global population (Soares Júnior et al., 2016). Even so, we cannot say that this percentage would fully desire a uterine transplant.
The transgender population is also included in the discussion as a potential target for this type of procedure. In an article titled “What are the Possibilities of Uterine Transplantation in Transgender Patients?” (Lerner et al., 2017), the Brazilian team uses resolutions from the Federal Council of Medicine (CFM) and the principles of universality and comprehensiveness of the Unified Health System (SUS) to argue that uterine transplant should be a possible option in the future, aiming for a “complete” sex reassignment process, that is, including the ability to conceive.
Transgender individuals have a gender identity that is inconsistent with their biological sex. This discrepancy can cause intense psychological distress and is unrelated to preferences or objects of sexual desire. The individual feels dissatisfied with their own body, and this feeling is independent of the romantic relationship models they have experienced. In this scenario, there is a desire for complete transformation, including the possibility of procreation, which is one of the main dilemmas with existing technology (Baracat et al., 2017, p. 521, emphasis added).
Another vision of the future present in the articles is the proposal that uterine transplant surgeries be performed robotically, with the justification that they would be less traumatic surgeries, with less blood loss and shorter operating time.
The potential advantages of laparoscopy, and especially robotic-assisted procedures, include less surgical trauma, less blood loss, shorter hospital stays, and shorter sick leave. In the future, we envision that living donor UTx [uterine transplantation] could be performed with robotic-assisted laparoscopy on both the donor and recipient, with the uterus retrieved and inserted through the vagina of the donor and recipient, respectively (Brännström, 2018, p. 596-597).
What appeared to be a promise in 2018 was fulfilled in 2023, when the first birth occurred via a robotic-assisted uterus transplant. However, the article was not a “premonition” of what was to come, as the author himself, Mats Brännström, was already studying this type of technique, which he himself would perform a few years later.
"The milestone in reproductive medicine" (Castro et al., 2021, p. 2570) is also fraught with controversies, technical variations, disagreements among different research groups, and ethical concerns from other healthcare professionals. Even so, it is argued that refinement of the technique will be a sine qua non for increasing the number of transplant recipients, and that the safety of the procedure can only be determined after a complete cohort study.
In 2021, the [International Uterine Transplantation] Society was incorporated as a section within The Transplantation Society. The missions within the ISUTx [International Society for Uterine Transplantation] statute aim to facilitate networking among UTx [uterine transplantation] teams, promoting multidisciplinary and collaborative research, and, most importantly, aim to establish and maintain an international registry of uterus transplants by collecting and analyzing data on procedure characteristics and outcomes, confirming best practices for this rapidly expanding field (Brännström et al., 2023, p. 11, emphasis added).
Success versus failure and extension versus quality of life
The technical impasses, contradictions, and fragility of a more standardized procedural protocol among different research groups receive little attention in all the publications analyzed. There is an intense technical explanation of the procedure through images, duration, medications - in other words, a set of information that almost sounds like a step-by-step guide. The images are often similar, whether through schematic illustrations or photographs of the procedure.
Despite reporting on unsuccessful procedures, little is discussed about the bioethical challenges involved. Even in experiments that resulted in complications and required early removal of the uterus, doctors optimistically state that the complications were managed. For example, of the nine cases performed in 2012 in Sweden with living donors, one had uterine artery thrombosis and one had a severe uterine infarction - both of whom underwent hysterectomy. The remaining four cases had rejections considered “mild” by doctors, and only one resulted in a birth, in 2014 (Silva; Carvalho, 2016, p. 476).
The rejections are classified as “mild,” and there is a sense of straightforward management; risks, failures, rejections, and the very idea of failure are minimized. After all, if the primary goal of transplant is to produce a live birth and the uterus must be removed before that, then shouldn't we classify such episodes as failures? For doctors, not necessarily. Based on the publications, we understand that performing the transplant and securing the uterus in the transplant recipient's body, even for a few days, can already be considered a successful experience to some extent.
Furthermore, we noted an internal debate within the field about whether the procedure should be performed with a living or deceased donor. Some groups will point out that the main obstacles to donation from a deceased donor are related to “costs, religious concerns, tissue viability, organ preservation, trained professionals, and family consent” (Soares Júnior et al., 2016, p. 627). However, the same groups that emphasize this difficulty are the groups that successfully performed transplants with a deceased donor.
The use of statistical data is a widely used argument. “It is estimated that the uterine factor accounts for 3 to 5% of infertility cases” (Ejzenberg; Soares Júnior; Baracat, 2016, p. 627) or “1 in 500 women worldwide are affected by uterine factors of infertility” (Castellón et al., 2017, p. 126) - these data are repeated in different articles analyzed. We believe that they are used, in addition to the large number of articles cited, to corroborate the idea that female infertility is a public health issue and that it needs to be addressed socially. At the same time, completely decontextualized and poorly explanatory data are also mentioned, such as “100,000 hysterectomies are performed per year in Brazil” (Silva; Carvalho, 2016, p. 474). It is not possible to extrapolate the data and assert that the reported N would indicate the real demand for uterine transplants if they were offered.
One of the main ethical questions posed to physicians by the non-medical community and some professionals who also work with reproductive technologies concerns the concrete need for uterine transplants. This is based on the argument that the primary objective of a uterine transplant is not to “save” a life at risk. After all, it must be remembered that, unlike all other organ transplants, the uterus is not a vital organ, and this type of transplant is temporary rather than definitive. However, the physicians involved often counter this type of tension by stating that this transplant does not offer an extension of life, but rather an improvement in “quality of life” - a value that is, to say the least, imprecise and circumstantial.
Furthermore, performed with the aim of promoting fertility and thus improving the patient's quality of life, and not necessarily to extend it, this is the first ephemeral transplant, that is, the transplanted organ can be removed after the treatment objectives are achieved (Silva; Carvalho, 2016, p. 474, our emphasis).
According to Minayo, Hartz, and Buss (2000), the concept of quality of life is, above all, a social representation created from subjective parameters such as well-being, happiness, personal satisfaction, and goals, whose reference is the fulfillment of basic needs. The term encompasses many meanings that reflect both individual and collective experiences and values. Therefore, it is a social construct marked by cultural relativity and that changes throughout history. The notion of quality of life is polysemic, related to ways and styles of life, and, in the health field, expresses how a given society establishes parameters for itself (Azize, 2002; 2006; 2008). We emphasize here that this nonspecificity and generalism of the concept itself is adopted by medical discourse to justify something that falls outside the conditions of comorbidity or disease - given that the absence of a uterus does not represent either of these situations. In this sense, the term “quality of life” is commonly used in the healthcare field to justify something that isn't necessarily measurable but has the potential to produce some kind of personal fulfillment.
The experience of pregnancy and motherhood, although limited by very specific conditions (such as immunosuppression therapy and cesarean section followed by hysterectomy), constitutes the main justification for uterine transplant, even if in its experimental phase. We found only one article explicitly mentioning the risks the procedure may entail:
Unlike individuals who opt for surrogacy, women who receive uteruses assume health risks associated with the transplant, pregnancy complications, and immunosuppression therapy. The duration of the allograft will be essentially determined by the recipient's pregnancy potential and satisfactory parity. Once [pregnancy] is achieved, the uterus is surgically removed to allow for the discontinuation of immunosuppressants, thus minimizing long-term side effects (Castellón et al., 2017, p. 126, emphasis added).
Marisol Marini (2018), working with heart transplants and, more specifically, the relationship between biological bodies and technological artifacts, highlights that these biological technologies are co-produced from distinct natures, supported by specific materialities, practices, and moralities. The author also points out that these artificial organs (or, in our case, an ephemeral transplant) are in a field that is still very experimental and therefore unstable, which would explain the reason why medical protocols are not so standardized. If the different technologies and their corporeality emerge in this panorama as more or less natural, the question of “success” and “failure” for doctors does not necessarily imply positive outcomes for the patient.
Thus, we understand that corporeality can be seen not as fixed or immanent, but as an emergent process, the result of dialogical and relational practices and processes. Such processes involve biology; technical artifacts; medical and scientific knowledge; and the experience of patients who carry such [artificial] hearts (Marini; Monteiro; Slatman, 2022, p. 4).
Final considerations
When analyzing the articles, we found the recurring use of the term “quality of life”, as frequently used as it is poorly defined, to justify or present the benefits of uterine transplant. Azize (2002) points out that the discourse of quality of life, in the health field, functions as an axis that permeates the vocabulary of both users and medical discourse. A sort of culture of quality of life has developed, especially among the contemporary urban middle class, even without a clear definition of what it ultimately entails. In the case of the articles on uterine transplant analyzed here, the dimension of “quality of life” dialogues with the valorization of “gestational motherhood”, a certain type of bond that could not, theoretically, be generated otherwise.
Examining the articles individually, we have the impression that with each new study conducted, the same rhetorical model is replicated. That is, we note a certain standardization of the articles, which tend to present a more technical and objective description of the method used - adding some new technical aspect adopted by that team. The same articles are frequently cited, and because of this, the Swedish group’s work receives high recognition. However, this isn’t necessarily due to their pioneering efforts, as other groups had made previous attempts. We believe they became the leading authority in this type of procedure because they performed the first successful transplant and continued to consistently achieve positive results.
More than 40 references cited in a 10-page article is,8 above all, a common discursive strategy to reinforce a given argument by highlighting other work already performed - a very common feature in biomedical scientific publications. We found this argumentative structure in almost all the articles analyzed, except for editorials. We noted that in the editorials, the main objective seems to be to quickly communicate relevant scientific development. The catchy titles reveal this, with expressions such as “First Latin uterine transplantation: we can do it”, “Uterus transplant: are we close to this reality?”, and “What are the possibilities of uterine transplantation in transgender patients?”. It is worth remembering that the appellative/conative function of language is widely used in advertisements, publicity, and news sources in general. The use of imperative verbs and vocatives indicate that the objective is the recipient of the message and, primarily, their persuasion.
In a more individualized analysis of each publication, we note competition within the field in terms of innovation and techniques. A satisfactory result is not enough: to gain recognition from other groups and scientific notoriety, innovation is necessary. Just as Latour (2000, p. 39) proposes progressing from “final products to production, from stable and cold objects to unstable and warmer objects”, Brazilian doctors use thermal measurement to discuss the dissection (warm phase) and excision (cold phase) phases of the uterus - also drawing an analogy to the level of instability and stability of the process.
The publications analyzed use common-sense gender stereotypes in their arguments. We see a strong call for the demarcation of boundaries between the feminine and the masculine, based on the body, anatomy, and the laws of nature. However, the construction of facts, guided by a regime of truth and neutrality, can easily be destabilized by any questions that consider the ethical dimension of scientific endeavor.
The material presented and analyzed here is part of a broader effort to map the values, subjects, and discourses surrounding the phenomenon of uterine transplant. In this space, we focus on interpreting how the successful Brazilian case of transplant from a deceased donor appears in scientific articles, analyzing this material from a perspective that considers science and its terms imbued with values, concepts, and prejudices that can only be social. Here, we recall something already pointed out by Scavone (2001a, p. 150), that it is necessary to continually “exercise non-passivity in the face of technological conveniences and doubt about the magical possibilities of solving reproductive problems”.
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1
Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, better known as Rokitansky syndrome, is a congenital disorder that affects the female reproductive system, characterized by the absence or malformation of the genital organs - mainly the uterus and vaginal canal.
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2
All statements that appear throughout the text between quotation marks and in italics indicate expressions used by the team of Brazilian doctors, found in the articles analyzed or in public speeches (interviews, lectures, classes).
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3
More information about meetings, events and members can be found on the Society's website: <https://tts.org/isutx-home>. Access on: 19 Sept. 2023.
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4
All research data are available in this text.
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5
This is the first article the Brazilian team published after performing a uterine transplant in 2016, with successful results in Brazil. The work remains one of the most cited in the field and a benchmark for “success stories”.
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6
The open online event, titled "Uterus Transplantation - State of the Art," took place on June 20, 2023, on the Zoom platform. It was organized by the USP Uterus Transplant Commission, and the attending physicians are Dani Ejzenberg, José Maria Soares Júnior, Wellington Andraus, and Luiz Augusto D'Albuquerque. It was impossible to determine how many or who were in attendance; this information was kept private.
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7
The most common expression is "tooth and nail." Here, we recall the study of metaphors analyzed by Emily Martin (2006) and believe that “claws” does not appear in this discourse by chance. It is a characteristic anatomical quality of animals such as birds and felines. When we consider that mothers are constantly invoked as figures of nature who protect their “young”, just like felines, we understand that replacing “teeth” with “claws” reinforces this idea of a wild nature.
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8
See: BRÄNNSTRÖM, M.; BELFORT, M.; AYOUBI, J. Uterus transplantation worldwide: clinical activities and outcomes. Current opinion in organ transplantation, v. 26, n. 6, p. 616-626, 2021.
All research data are available in this text.
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