In September 2014, doctors at Sahlgrenska University Hospital in Sweden had a particularly special delivery: the first baby born from a transplanted uterus. Dr. Mats Brannstrom, who once called the idea of a transplanted uterus “mad,” began clinical trials with his colleagues in 2013. Since the first birth in September 2014, the trial has resulted in five live births so far and is serving as the model for other hospitals around the world hoping to follow in their footsteps. And now, Baylor University Medical Center at Dallas is now bringing that possibility to Texas. At the end of January, Baylor announced that they would be the second hospital in the U.S. to begin a clinical trial for uterus transplants.

On February 25, surgeons at the Cleveland Clinic announced that they had performed the first successful uterus transplant in the U.S. As the first U.S. hospital to begin clinical trials, the Cleveland Clinic—like its Swedish counterpart—hopes to give women without uteruses a chance to become pregnant. Similarly, candidates for the Baylor trial are women with absolute uterine factor infertility, or AUI, meaning their uterus is “nonfunctioning or doesn’t exist.”

The Swedish doctors used live donors, preferring donated uteruses that had already been through pregnancy, which they suggested could handle the task of a transplant pregnancy. In a few cases, the donated uteruses came from the patient’s mother, meaning that some babies were born in the same womb their mothers were born in! For the Cleveland trial, they’re opting to use deceased donors because of the complicated surgery, which can take up to eleven hours. The team at Baylor plans to be the first in the world to use uteruses from both live and deceased donors in order to provide the patients with more options.

The viability of uterus transplants opens up questions about the possibility of giving the chance for transgender women and even men to give birth. After the New York Times reported on the Cleveland Clinic beginning their trial of uterus transplants, they received a question about the possibility of male pregnancy. Dr. Rebecca Flyckt, an obstetrician gynecologist and a member of the Cleveland team answered the question for them:

Although theoretically this would be possible, it would be a huge surgical and endocrinologic undertaking and involve not just the creation of a vagina but also surgical reconstruction of the whole pelvis by someone skilled in transgender surgery. After this procedure and the grafting of a donor uterus, a complex hormone regimen would be required to support a pregnancy prior to and after embryo transfer (although this could be done, as we provide similar hormone regimens to menopausal women to support a pregnancy). The interesting thing is that these embryos would be created using the patient’s sperm (rather than eggs as in our protocol) and a partner or donor’s eggs. This sperm would have had to be frozen prior to their transgender surgery, which people are doing more routinely now.

In short, uterus transplants could be performed on men with a few extra adjustments. But so far Baylor’s medical team is limiting their trial to cisgender women with working ovaries. Although the question was about men, Flyckt noted that she expected interest from the transgender community—and rightfully so. Afterall, the first known uterus transplant surgery took place in 1931, on Lili Elbe, the transgender artist the movie The Danish Girl is based on. Elbe’s transplant didn’t end successfully, and she died three months after her surgery when her body rejected the uterus. It wasn’t until the sixties, decades after her death, that immunosuppressant drugs—which prevent the body’s immune system from rejecting a transplant—became widely used.

Uterus transplants are broadening the frontiers of medical science, but they’re also raising interesting ethical concerns. There are the questions of the benefits of a transplant surgery which would be purely elective, unlike surgeries for kidney or heart transplants, just to provide women with the chance to experience birth. Afterall, the U.S. isn’t like Sweden, where surrogacy is illegal, though Baylor’s doctors argue that the transplant is more ethical than surrogacy since the mother will be bearing all the risks of her pregnancy and won’t be using a system that can exploit poor women. There are also concerns about both live and deceased donors: what if deceased donors hadn’t anticipated their uteruses being used?

In the U.S., the concerns about live donors are numerous. The surgery for removing a uterus is a complicated one similar to a radical hysterectomy. It involves the removal of part of the donor’s vagina in addition to the cervix and uterus, and the procedure can last from seven to eleven hours. As Dr. Tzakis, a member of the Cleveland team, explained to the New York Times, it’s an operation that requires careful work around vital organs.There’s also the post-surgery recovery that live donors face. The donors in Sweden trial spent six days in the hospital after the surgery and were on sick leave for two weeks. One donor received further treatment for “postsurgical complications.” Such precise care is unnecessary for the deceased donors, which the Cleveland trial relies on exclusively.

It’s illegal to buy and sell organs in the U.S., and guidelines are in place to prevent potential donors from being coerced into donating with financial incentives. Unfortunately, that also means that we have a system that can discourage donors due to what the National Living Donor Assistance Center identifies as “financial disincentives.” In addition to the medical care costs not covered by insurance or federal or state programs, donors can shoulder “travel, lodging, meals and incidental expenses,” not to mention the loss of wages that could come from an extended sick leave.  These financial difficulties are why the supply for live-saving organs such as kidneys don’t meet the demands of people who need donations. According to the National Kidney Foundation, of the 129,678 people awaiting live-saving donations, 100,791 of them are for kidneys. In 2014, there were just 5,538 donors. When donors for live-saving transplants are hard to come by, will they come forward for elective procedures such as uterus transplants? Will the older live donors past menopause be pressured to donate their uteruses?

The team at Baylor have a host of ethical and medical challenges ahead of them as they begin screening candidates for the ten positions in their clinical trial. But even with these concerns looming, doctors on the team are excited about the opportunity uterus transplants will provide for the thousands of women whose only options for having a child have been adoption or surrogacy. This possibility holds special meaning for Dr. Colin Koon, a surgeon on the Baylor team who specializes in gynecological oncology.

“As a cancer surgeon, you sometimes have to remove uteruses on very young women who were hoping to be able to have children themselves,” Koon told the Dallas Morning News. “This is an opportunity to go back several years later and add a uterus back to them and see if we can get them to have their own children.”

Baylor’s requirements for a uterus transplant candidate:

  • Women with AUI
  • Ages 20-35, with working ovaries
  • BMI of less than 30
  • Cancer free for at least 5 years
  • Negative for HIV, hepatitis B and C, chlamydia, gonorrhea and herpes
  • No history of diabetes
  • Non-smoker

Baylor’s requirements for uterus donors:

  • Ages 40-65
  • At least one full-term delivery
  • BMI of less than 30
  • Cancer free for at least 5 years
  • Negative for HIV, hepatitis B, C and G/C, and herpes