First uterus transplant in India

First uterus transplant in India Dr KK Aggarwal National President IMA & HCFI The Milann Fertility Centre in Bangalore has received permission for uterus transplant from ICMR in two female patients and the procedure will be undertaken as a research project as per the ICMR guidelines. The minimum requisite of experience to carry out this procedure, as per the Human Organ Transplant Act, by a Clinical team is not available in any group outside the Swedish group. Milann has obtained permission from Medical council of India (MCI) for the participation of Swedish doctors for the procedure which is yet another mandatory requirement. In 2012, the world’s first successful uterus transplant with a live donor was conducted by a team led by Dr Mats Brannstrom, Professor of Obstetrics and Gynaecology at the University of Gothenburg in Sweden. In October 2014, a woman who had received a uterine transplant gave birth to a healthy baby boy. About uterus transplant • Uterus transplantation is a complex, multi-step procedure for the treatment of absolute uterine factor infertility (AUFI). • AUFI refers to infertility that is fully attributable to the uterus because of absence (congenital or surgical) or abnormalities (anatomic or functional) that prevent embryo implantation or completion of a pregnancy to term. • About 1 in 500 women of childbearing age are affected by AUFI, defined as an absent or non-functional uterus • Uterus transplantation is a highly experimental procedure to treat absolute uterine factor infertility. o Once the intended uterus recipient and organ donor have been identified, the process begins with in vitro fertilization (IVF) to create and freeze embryos for the intended recipient. o Next the organ donor undergoes a radical-type hysterectomy followed by implantation of the donor organ into the recipient. o After at least 12 months of immunosuppressive treatment, the recipient undergoes embryo transfer, pregnancy, and, if the pregnancy is successful, delivery via cesarean delivery. o At the conclusion of childbearing, the transplanted organ is removed to avoid the need for lifelong immunosuppression. • Since initial attempts at Saudi Arabia and Turkey, uterus transplantation has been successfully performed in Sweden and attempted in the United States, the Czech Republic, China, Brazil and Germany. • Keys ethical points in considering uterus transplantation include the non-life-saving nature of the procedure; existence of proven alternatives; the experimental nature of uterus transplantation; and the risks and benefits to the donor, recipient, and developing fetus. • Gestational surrogacy and adoption both exist as alternative paths to parenthood • The uterus donor may be alive or deceased. o Advantages of living donors include larger potential supply of organs and ample time for preoperative testing, screening, and assembly of a multi-specialty surgical team. The main disadvantage is the extensive pelvic surgery for organ removal. o Use of deceased donors avoids the donor's surgical risk and allows for a more extensive graft harvest. Disadvantages of a deceased-donor organ include the limited availability of organs, unpredictable timing of organ procurement, potential that the donor uterus has not yet produced a term pregnancy, and potential ethical uncertainties regarding consent. • As human uterus transplantation is in the beginning stages, the optimal inclusion and exclusion criteria for both donors and recipients are not yet known. • Living donors and recipients undergo extensive testing to ensure medical and psychological appropriateness. • Protocol includes consultation by the following services: gynecology, transplantation surgery, psychology, clinical immunology, anesthesiology, internal medicine, and radiology. • Prior to removal, the donor uterus is evaluated with ultrasound and magnetic resonance imaging (if technically possible) to estimate the uterus size, rule out uterine pathology, exclude Müllerian anomalies and evaluate the vasculature. • The goals for the evaluation of the future genetic father are to exclude male-factor causes of infertility, exclude infectious diseases that could be transmitted to the immunosuppressed mother, and to identify relationship challenges that could negatively impact the outcome of uterus transplantation. • As part of the informed consent process, the uterus donor must be free from coercion; be fully informed of the risks, benefits, and alternatives for both the donor and the recipient; have access to an independent donor advocate; and be informed of the early and late surgical risks. The uterus recipient must be educated to the risks and benefits of uterus transplantation and then consented for the multiple steps of the process that will ultimately result in a live-born child, including gonadotropin stimulation, egg retrieval for the creation of embryos, uterus transplantation, immunosuppression, embryo transfer, pregnancy, cesarean delivery, and uterus removal. The consent for the genetic father mainly pertains to the in vitro fertilization treatments that he must undergo to create embryos prior to uterus transplantation. (Source: Uptodate)

The division between private and public must go: Dr Subhash Gupta

The division between private and public must go: Dr Subhash Gupta Dr KK Aggarwal, Editor in Chief eMedinewS and IMA News in conversation with Dr Subhash Gupta, Founder and Chief of Centre for Liver and Biliary Sciences (CLBS) at Indraprastha Apollo Hospitals in New Delhi About Dr Subhash Gupta Dr Subash Gupta is the Founder and Chief of Centre for Liver and Biliary Sciences (CLBS) at Indraprastha Apollo Hospital in New Delhi, India. The CLBS group is actively engaged in Liver Transplant and complex HPB surgery. His centre conducts over 300 transplants every year. He is one of the pioneers of living donor liver transplantation in India. Dr. Gupta graduated as a national talent scholar from AIIMS, New Delhi. After spending 6 years in the UK at Queen Elizabeth Hospital in Birmingham and later at St James’s University Hospital in Leeds, he joined Sir Ganga Ram Hospital in New Delhi as a Consultant in Liver Transplant and Gastrointestinal Surgery in 1998. As cadaveric donations were rare, Dr. Gupta introduced right lobe adult-to-adult liver transplantation to the hospital. The CLBS group has introduced many innovations such as MHV and right hepatic artery clamp test, new techniques in transplants for small children, methods to avoid dual lobe transplant in obese recipients, sequential liver kidney transplant as compared to combined liver kidney transplant and techniques for splitting cadaveric liver in to two adults. He has been credited for performing liver transplants in patients with unusual and difficult conditions, such as portal biliopathy, co-existing HIV infections, and donors/recipients with situs inversus. In 2009, his team introduced the posterior sector graft for increased donor safety in India, and was instrumental in pioneering hepatic transplantation in babies under 6 months of age in India. His team has also developed guidelines on liver transplantation and the treatment of liver diseases in India. CLBS has trained many teams and surgeons from around the world in liver transplantation. Their group has helped start liver transplant in Institute of Liver and Biliary Sciences, New Delhi, Sheikh Zayyad Hospital, Lahore, Seventh Hospital, Almaty, Kazakhstan and Dow Medical College, Karachi. Since 2010, he is a Visiting Professor of Liver Transplantation at the Institute of Postgraduate Education and Medical Research in Kolkata, India. In 2012, he was honoured by the Rotary Association of India for excellence in clinical medicine, and in the same year, he was the recipient of the Vishist Chikitsak Rattan (distinguished clinician) awarded by Delhi Medical Association. In 2016, He was awarded the prestigious “YASH BHARTI” by the Uttar Pradesh government. Dr Gupta has published over 30 papers in surgery and transplantation, and his research focuses on improving post operative management of sick recipients. Dr KK: How important is the role of your family in your journey? My family has been very supportive all through my life. In 1998, when I was a Consultant in St. James’s University Hospital, Leeds, I chose to return to India and join Sir Ganga Ram Hospital to start liver transplantation in India. At that time it did not seem like a good idea and for years had to struggle to get recognized as a talented surgeon in India. All through this period, my family stood by me and supported me on all my decisions. Dr KK: What are your feelings on receiving the award? Receiving this award is a great honor and I feel that I must do more to improve medical education in our country so that we end up having universal health coverage for every Indian citizen. Dr KK: What is your message to the community? My message to the community is that each one of us should direct efforts to improve the island that one is working in and the efforts of everyone will multiply to bring about a major change in our society. Dr KK: What changes do you suggest with regard to health policies? I feel major changes in health policies are needed. The division between private and public must go. Fresh graduates are not willing to work at low salaries in the government sector and patients are not willing to see new doctors in the private sector. Nowhere in the world does this dichotomy exist. It is time that this should be changed. Those who work in the government sector must be allowed private practice. A time will come when it will be difficult to get teachers in medical colleges.