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子宫移植,为不孕妇女带来新希望

更新时间:2015-11-17 10:15:33 来源:纽约时报中文网 作者:佚名

Uterus Transplants May Soon Help Some Infertile Women in the U.S. Become Pregnant
子宫移植,为不孕妇女带来新希望

CLEVELAND — Six doctors swarmed around the body of the deceased organ donor and quickly started to operate.

克利夫兰——六名医生围绕在器官捐献者的遗体周围,迅速开始手术。

The kidneys came out first. Then the team began another delicate dissection, to remove an organ that is rarely, if ever, taken from a donor. Ninety minutes later they had it, resting in the palm of a surgeon's hand: the uterus.

他们首先取出了死者的肾脏。然后,团队开始了另一项细致的解剖工作,目的是取出一个此前很少——是说,如果曾经有过的话——从捐献者体内摘取的器官。90分钟之后,他们成功了,一名外科医生用手掌捧着它:子宫。

The operation was a practice run. Within the next few months, surgeons at the Cleveland Clinic expect to become the first in the United States to transplant a uterus into a woman who lacks one, so she can become pregnant and give birth. The recipients will be women who were either born without a uterus, had it removed or have uterine damage. The transplants will be temporary: each uterus will be removed after the recipient has had one or two babies, so she can stop taking transplant anti-rejection drugs.

这是一次试验性的手术。在接下来的几个月内,克利夫兰诊所(Cleveland Clinic)的外科医生们有望完成美国的首例子宫移植手术。手术的受者将是天生缺失子宫,或因故切除子宫又或者子宫受损的女性,她将因此获得怀孕和生育的能力。但这只是暂时性的移植:当受者生下一两个孩子后,子宫就会被移除,这样受者就无需继续服用抗排斥药物了。

Uterine transplantation is a new frontier, one that pairs specialists from two fields known for innovation and for pushing limits, medically and ethically: reproductive medicine and transplant surgery. If the procedure works, many women could benefit: an estimated 50,000 women in the United States do not have a uterus. But there are potential dangers.

子宫移植是一个新兴的前沿领域,它集结了从医学和伦理学上均以创新和突破极限著称的生殖医学和移植手术这两方面的专家。它的成功将为众多妇女带来福音:在美国,估计有5万名女性没有子宫。只不过,这个程序并非全无潜在危险。

The recipients, healthy women, will face the risks of surgery and anti-rejection drugs for a transplant that they, unlike someone with heart or liver failure, do not need to save their lives. Their pregnancies will be considered high-risk, with fetuses exposed to anti-rejection drugs and developing inside a womb taken from a dead woman.

首先,不同于那些因为心脏或肝脏衰竭而不得不需要依靠移植手术来救命的患者,子宫移植的受者在其他方面都非常健康,该程序却令她们面临动手术和接受抗排斥药物所带来的风险。其次,由于胎儿在从已逝的供者体内摘取的子宫内发育,且将不可避免地接触到抗排斥药物,妊娠风险非常高。

Eight women from around the country have begun the screening process at the Cleveland Clinic, hoping to be selected for transplants. One, a 26-year-old with two adopted children, said she still wanted a chance to become pregnant and give birth.

目前,已有八名来自全美各地的妇女前往克利夫兰诊所接受筛选,希望能被选为移植受者。其中一名已经领养了两个孩子的26岁女性称,她仍然希望自己有机会可以怀孕和生育。

“I crave that experience,” she said. “I want the morning sickness, the backaches, the feet swelling. I want to feel the baby move. That is something I've wanted for as long as I can remember.”

“我渴望能拥有那样的体验,”她说。“我想要体会孕吐、腰酸背痛和双脚肿胀的感觉。我想要感受宝宝在我体内活动。这是我自记事以来一直的期望。”

She traveled more than 1,000 miles to the clinic, paying her own way. She asked that her name and hometown be withheld to protect her family's privacy.

她自费跋涉1000多英里(约合1609千米)来到了克利夫兰诊所。为了保护她家人的隐私,本文按她的要求隐去了她的名字和家乡。

She was 16 when medical tests, performed because she had not begun menstruating, found that she had ovaries but no uterus — a syndrome that affects about 1 in 4,500 newborn girls. She comes from a large family, she said, and always assumed that she would have children. The test results were devastating.

由于一直没有月经来潮,她在16岁时接受了内科检查,这才发现她虽然有卵巢却没有子宫——这是一种在4500名新生女婴中才有1例的综合征。她来自一个大家庭,她说,她一直以为自己会生很多孩子。这个检查结果对她来说简直是一场灾难。

Dr. Andreas G. Tzakis, the driving force behind the project, said, “There are women who won't adopt or have surrogates, for reasons that are personal, cultural or religious.” Tzakis is the director of solid organ transplant surgery at a Cleveland Clinic hospital in Weston, Florida. “These women know exactly what this is about,” he said. “They're informed of the risks and benefits. They have a lot of time to think about it, and think about it again. Our job is to make it as safe and successful as possible.”

该项目的发起人,克利夫兰诊所医院(Cleveland Clinic hospital,位于佛罗里达州韦斯顿市)的实体器官移植外科主任安德烈亚斯·G·察基斯(Andreas G. Tzakis)博士说:“出于个人、文化或宗教原因,有些妇女不能领养孩子或找人代孕。”他还说:“这些妇女很清楚这项程序到底是怎么一回事,她们了解它可能的风险和收益,也有很多时间去反复思考。而我们的工作是使其尽可能地安全和成功。”

Laying the Groundwork

打下基础

The hospital plans to perform the procedure 10 times, as an experiment, and then decide whether to continue. Tzakis said he hoped to eventually make the operation readily available in the United States.

医院计划先实验性地进行10次这样的程序,然后再决定是否继续下去。察基斯博士说,他希望终有一天美国可以推行这样的手术。

Sweden is the only country where uterine transplants have been completed successfully — all at the University of Gothenburg with a uterus from a live donor. Nine women have had them, and four have given birth, the first in September 2014. Another is due in January. Their babies were born healthy, though premature. Two transplants failed and had to be removed, one because of a blood clot and the other because of infection.

瑞典是全世界唯一成功完成过子宫移植手术的国家。所有这些手术均在哥德堡大学进行,而且子宫均来源于活体供者。共有九名女性接受过移植,其中四人已经生育,第一名婴儿在2014年9月出生。还有一名妇女的预产期在明年1月。这些婴儿虽然早产,但都健康地降生了。有两例移植遭到失败(一例是出现了血凝块,另一例是因为感染),不得不摘除了移植物。

Two earlier attempts — one in Saudi Arabia, and one in Turkey — failed. Other hospitals in the United States, and in Britain, are also preparing to try the surgery, but are not as close as the team in Cleveland is.

此前,沙特阿拉伯和土耳其也各自进行过一次类似的尝试,但均以失败告终。美国其他医院以及英国也纷纷准备试验这样的手术,但他们的进展都远不及克利夫兰诊所的团队。

Tzakis said the anti-rejection drugs were safe, noting that thousands of women with donor kidneys or livers, who must continue taking anti-rejection drugs during pregnancy, had given birth to healthy babies. Those women are more likely than others to have pre-eclampsia, a complication of pregnancy involving high blood pressure, and their babies tend to be smaller. But it is not known whether those problems are caused by the drugs, or by the underlying illnesses that led to the transplants. Because the women receiving uterine transplants would be healthy, Tzakis said, he was optimistic that complication rates would be very low.

察基斯博士认为抗排斥药物是安全的,并指出,成千上万接受了肾脏或肝脏移植,不得不在怀孕期间继续服用抗排斥药物的孕妇都生下了健康的宝宝。这些孕妇比其他人更容易患上先兆子痫(一种与高血压有关的妊娠并发症),且她们的孩子往往个体较小,不过目前尚不清楚这些问题是药物引起的,还是因最初导致受体女性失去子宫的那些疾病造成。察基斯博士说,由于接受子宫移植的都是健康的妇女,他乐观地认为,并发症的发生率应该很低。

A medical ethicist not connected with the research, Jeffrey Kahn, of Johns Hopkins University, said the procedure did not set off any alarms with him.

与该研究无关的一名医疗伦理学家,约翰斯·霍普金斯大学(Johns Hopkins University)的杰弗里·卡恩称(Jeffrey Kahn)表示,该手术并没有令他觉得不妥。

“We're doing lots of things to help people have babies in ways that were never done before,” Kahn said. “It falls into that spectrum.”

“我们正在以前所未有的方式,大力帮助人们拥有自己的孩子,”卡恩说。“子宫移植手术正是其中之一”。

A Complicated Process

复杂的程序

The Swedish team used live donors, and showed that a uterus from a woman past menopause, transplanted into a young recipient, can still carry a pregnancy. In five cases, the donor was the recipient's mother, which raised the dizzying possibility of a woman giving birth from the same womb that produced her.

瑞典的团队使用的是活体供者,并证明,来自绝经期女性的子宫在移植到年轻受者体内后,依然具备妊娠功能。其中五例手术的供者是受者的母亲,这也就造成了一个能把人绕晕了的可能性——受者将从曾经孕育她自己的那同一个子宫中分娩出自己的孩子。

The Cleveland doctors will use deceased donors, to avoid putting healthy women at risk. For a live donor, the operation is far more complicated than a standard hysterectomy and takes much longer, seven to 11 hours, Tzakis said, adding, “You have to work near vital organs.”

克利夫兰诊所的医生们将使用已故捐赠者的子宫,以避免将健康女性置于危险之中。察基斯博士说,对活体供者进行手术,远比标准的子宫切除术更为复杂,也需要更长的时间(7至11小时),他还补充道:“(而且)你将不得不在她的重要器官附近完成复杂操作。”

The surgeons have to remove part of the donor's vagina and other tissue needed to attach the uterus to the recipient. And they must tease away tiny blood vessels without harming the donor.

外科医生需要切除供者的部分阴道以及将子宫连接到受者体内所需的其他组织,还必须在不损害供者的前提下剥离小血管。

The uterine vessels are wound around the ureters, which carry urine from the kidneys to the bladder. “They're like worms wrapped around a tube,” Tzakis said. “It's very tedious to separate them.”

子宫血管缠绕在负责将尿液从肾脏输送到膀胱的器官——输尿管的周围。“它们像蠕虫一样缠在输尿管上,”察基斯博士说。“剥离它们可是非常麻烦的苦差事。”

With deceased donors, there is no need to worry about injuries. The organ can be removed faster, and can survive outside the body for at least six to eight hours if kept cold.

在已故的捐赠者身上做手术,就不需要这么多的顾虑了。器官可以更快地被摘除,如果保持低温,它可以在体外存活至少六至八小时。

Because the fallopian tubes will not be connected to the transplanted uterus, a natural pregnancy will be impossible.

因为移植子宫上并未连接输卵管,所以受者不可能自然怀孕。

Instead the recipients will go through in vitro fertilization. Before the transplant, the woman will be given hormones to stimulate her ovaries to produce multiple eggs. Ten will be needed, so she may have to go through more than one cycle of hormone treatment. Doctors will collect the eggs, fertilize them with her partner's sperm and freeze them. Once there are 10 embryos in the freezer, the woman will be put on the waiting list for a transplant.

她们将接受体外受精。在移植前,这些妇女会接受激素治疗,刺激她的卵巢排出多个卵细胞。体外受精约需要十个卵细胞,因此激素治疗可能不止一轮。然后,医生将收集这些卵细胞,使用这些女性各自伴侣的精子分别对它们授精,待受精卵发育到一定阶段后再将其冻存起来。待到攒够10个冻存胚胎,这名妇女就会被排入移植等待名单。

When a donor with matching blood and tissue type becomes available, the transplant will take place.

此时,只要有血液和组织型都匹配的供者,就可以进行移植手术了。

The transplant surgery is expected to take about five hours. It requires connecting an artery and a vein on either side of the uterus to the recipient's blood vessels. The organ will have part of the donor's vagina attached, and that will be stitched to the recipient's vagina. Supporting tissue attached to the uterus will be sewn into the recipient's pelvis to stabilize the transplant. No nerves have to be connected.

移植手术预计需要五个小时左右。在这个过程中,医生们会将子宫两侧的动脉和静脉与受者的血管相连。该子宫会带有供者的部分阴道,它也将缝合在受者的阴道上。附着于子宫的支持组织亦将被缝入受者的骨盆,以稳定移植物。但无须连接神经。

The woman will wait one year to heal from the surgery and adjust the doses of anti-rejection medicine before trying to become pregnant.

受者将需要一年的时间从手术中痊愈并调整抗排斥药物的剂量,其后才能开始尝试怀孕。

Then doctors will implant one embryo at a time in the uterus, until the recipient becomes pregnant. The baby will be delivered by cesarean section before the due date, to protect the transplanted uterus from the strain of labor.

然后,医生将会向子宫内植入胚胎,每次一个,直到受者成功妊娠。为避免移植子宫遭受分娩的压力,婴儿将在预产期前以剖宫产的方式降生。

After giving birth, the mother can either keep the uterus so she can try to have one more baby (two is the limit, for safety reasons), or have it removed so she can stop taking the anti-rejection drugs. If she does not want to have surgery to have it removed, doctors said it may be possible to quit the drugs and let the immune system reject the uterus, which should then gradually wither away.

生完孩子后,母亲可以选择保留子宫,试着再生一个孩子(出于安全原因,两个孩子是极限),或者将其移除,以便停用抗排斥药物。如果受者不愿意做手术,医生表示也可以选择停药,让免疫系统来排斥子宫,令它逐渐萎缩。

Initial Skepticism

起初的疑虑

One of the surgeons working with Tzakis will be Dr. Tommaso Falcone, the Cleveland Clinic's chairman of obstetrics and gynecology. Falcone said he first heard of uterus transplants about 10 years ago, in early research described at medical conferences. Initially, he was skeptical.

克利夫兰诊所的妇产科主任托马索·法尔科内(Tommaso Falcone)是察基斯博士的合作伙伴之一。他回忆起自己第一次听说子宫移植是在大约10年前,医学会议上介绍了一些早期研究。最初,他是持怀疑态度的。

A trip to Sweden changed his mind. He went there in 2013 — like a doubting Thomas, he said — to see what the team was doing. He watched the surgery and spoke to several couples who wanted it.

直到一次瑞典之行改变了他的看法。那是在2013年——他说,当时他是本着眼见为实的原则,想要去亲眼看看那个团队的工作。他观看了手术,并采访了几对想要接受手术的夫妇。

“I almost cross-examined them,” Falcone said. “I was thinking, `There's got to be something wrong with these people.”'

“我几乎是在盘问他们,”法尔科内博士说。“我当时觉得:‘这些人肯定有毛病。’ ”

But, he said, he came to understand how much pregnancy meant to them.

不过,他继续说道,后来他慢慢明白了怀孕对那些人的意义有多么重大。

“It's a legitimate request,” he said. “I got on the plane and knew I would be at the forefront of trying to make this program work at the Cleveland Clinic.”

“这要求合情合理,”他说。“当我登上回程的飞机时,我就知道我将会带头致力于在克利夫兰诊所尝试同样的工作。”

The 26-year-old candidate said that finding out she had no uterus had made her wonder if anyone would ever want to marry her. She did marry, and in addition to adopting children, she and her husband considered surrogacy, but could not afford it. Much of the transplant and pregnancy costs will be paid for by research money from the clinic and health insurance.

上文提到的那位26岁的移植候选人说,得知自己没有子宫后,她一度怀疑是否有人愿意娶她。在她结婚后,除了领养了几个孩子外,她和丈夫还考虑过代孕,但他们无法负担费用。而这次子宫移植和妊娠的大部分费用将会由诊所的研究经费和医疗保险支付。

“I know the risks,” she said. “It's a high-risk pregnancy. But I think we're in the best of hands. I think we can handle anything that comes our way.”

“我很清楚个中风险,”她说。“这是一次高危妊娠。不过,我相信我们会得到最棒的医护。我想我们应该可以应对将会发生的任何事情。”

She recently began the hormone treatments to stimulate egg production.

最近,她开始接受激素治疗,以刺激排卵。

She belongs to a nondenominational Christian church, and members are praying she will have the transplant, she said.

她说,她所属的无宗派基督教教堂的成员们都在为她祈祷,期望她能获得移植的机会。

“I know there will be people who don't understand or agree,” she added. “But this is not a whim.”

“我知道一定会有很多人不理解或者不赞同我的选择,”她补充道。“但我绝不是一时冲动。”

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