子宮移植 爲不孕婦女帶來新希望
CLEVELAND — Six doctors swarmed around the body of the deceased organ donor and quickly started to operate.
克利夫蘭——六名醫生圍繞在器官捐獻者的遺體周圍，迅速開始手術。
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.
他們首先取出了死者的腎臟。然後，團隊開始了另一項細緻的解剖工作，目的是取出一個此前很少——是說，如果曾經有過的話——從捐獻者體內摘取的器官。90分鐘之後，他們成功了，一名外科醫生用手掌捧着它：子宮。
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.
這是一次試驗性的手術。在接下來的幾個月內，克利夫蘭診所(Cleveland Clinic)的外科醫生們有望完成美國的首例子宮移植手術。手術的受者將是天生缺失子宮，或因故切除子宮又或者子宮受損的女性，她將因此獲得懷孕和生育的能力。但這只是暫時性的移植：當受者生下一兩個孩子後，子宮就會被移除，這樣受者就無需繼續服用抗排斥藥物了。
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.
子宮移植是一個新興的前沿領域，它集結了從醫學和倫理學上均以創新和突破極限著稱的生殖醫學和移植手術這兩方面的專家。它的成功將爲衆多婦女帶來福音：在美國，估計有5萬名女性沒有子宮。只不過，這個程序並非全無潛在危險。
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，不同於那些因爲心臟或肝臟衰竭而不得不需要依靠移植手術來救命的患者，子宮移植的受者在其他方面都非常健康，該程序卻令她們面臨動手術和接受抗排斥藥物所帶來的風險。其次，由於胎兒在從已逝的供者體內摘取的子宮內發育，且將不可避免地接觸到抗排斥藥物，妊娠風險非常高。
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，已有八名來自全美各地的婦女前往克利夫蘭診所接受篩選，希望能被選爲移植受者。其中一名已經領養了兩個孩子的26歲女性稱，她仍然希望自己有機會可以懷孕和生育。
“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.”
“我渴望能擁有那樣的體驗，”她說。“我想要體會孕吐、腰痠背痛和雙腳腫脹的感覺。我想要感受寶寶在我體內活動。這是我自記事以來一直的期望。”
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.
她自費跋涉1000多英里（約合1609千米）來到了克利夫蘭診所。爲了保護她家人的隱私，本文按她的要求隱去了她的名字和家鄉。
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.
由於一直沒有月經來潮，她在16歲時接受了內科檢查，這才發現她雖然有卵巢卻沒有子宮——這是一種在4500名新生女嬰中才有1例的綜合徵。她來自一個大家庭，她說，她一直以爲自己會生很多孩子。這個檢查結果對她來說簡直是一場災難。
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.”
該項目的發起人，克利夫蘭診所醫院（Cleveland Clinic hospital，位於佛羅里達州韋斯頓市）的實體器官移植外科主任安德烈亞斯·G·察基斯(Andreas G. Tzakis)博士說：“出於個人、文化或宗教原因，有些婦女不能領養孩子或找人代孕。”他還說：“這些婦女很清楚這項程序到底是怎麼一回事，她們瞭解它可能的風險和收益，也有很多時間去反覆思考。而我們的工作是使其儘可能地安全和成功。”
Laying the Groundwork
打下基礎
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.
醫院計劃先實驗性地進行10次這樣的程序，然後再決定是否繼續下去。察基斯博士說，他希望終有一天美國可以推行這樣的手術。
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過子宮移植手術的國家。所有這些手術均在哥德堡大學進行，而且子宮均來源於活體供者。共有九名女性接受過移植，其中四人已經生育，第一名嬰兒在2014年9月出生。還有一名婦女的預產期在明年1月。這些嬰兒雖然早產，但都健康地降生了。有兩例移植遭到失敗（一例是出現了血凝塊，另一例是因爲感染），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進行過一次類似的嘗試，但均以失敗告終。美國其他醫院以及英國也紛紛準備試驗這樣的手術，但他們的進展都遠不及克利夫蘭診所的團隊。
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.
察基斯博士認爲抗排斥藥物是安全的，並指出，成千上萬接受了腎臟或肝臟移植，不得不在懷孕期間繼續服用抗排斥藥物的孕婦都生下了健康的寶寶。這些孕婦比其他人更容易患上先兆子癇（一種與高血壓有關的妊娠併發症），且她們的孩子往往個體較小，不過目前尚不清楚這些問題是藥物引起的，還是因最初導致受體女性失去子宮的那些疾病造成。察基斯博士說，由於接受子宮移植的都是健康的婦女，他樂觀地認爲，併發症的發生率應該很低。
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.
與該研究無關的一名醫療倫理學家，約翰斯·霍普金斯大學(Johns Hopkins University)的傑弗裏·卡恩稱(Jeffrey Kahn)表示，該手術並沒有令他覺得不妥。
“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.”
“我們正在以前所未有的方式，大力幫助人們擁有自己的孩子，”卡恩說。“子宮移植手術正是其中之一”。
A Complicated Process
複雜的程序
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.
瑞典的團隊使用的是活體供者，並證明，來自絕經期女性的子宮在移植到年輕受者體內後，依然具備妊娠功能。其中五例手術的供者是受者的母親，這也就造成了一個能把人繞暈了的可能性——受者將從曾經孕育她自己的那同一個子宮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.”
克利夫蘭診所的醫生們將使用已故捐贈者的子宮，以避免將健康女性置於危險之中。察基斯博士說，對活體供者進行手術，遠比標準的子宮切除術更爲複雜，也需要更長的時間（7至11小時），他還補充道：“（而且）你將不得不在她的重要器官附近完成複雜操作。”
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.
外科醫生需要切除供者的部分陰道以及將子宮連接到受者體內所需的其他組織，還必須在不損害供者的前提下剝離小血管。
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.”
子宮血管纏繞在負責將尿液從腎臟輸送到膀胱的器官——輸尿管的周圍。“它們像蠕蟲一樣纏在輸尿管上，”察基斯博士說。“剝離它們可是非常麻煩的苦差事。”
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.
在已故的捐贈者身上做手術，就不需要這麼多的顧慮了。器官可以更快地被摘除，如果保持低溫，它可以在體外存活至少六至八小時。
Because the fallopian tubes will not be connected to the transplanted uterus, a natural pregnancy will be impossible.
因爲移植子宮上並未連接輸卵管，所以受者不可能自然懷孕。
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.
她們將接受體外受精。在移植前，這些婦女會接受激素治療，刺激她的卵巢排出多個卵細胞。體外受精約需要十個卵細胞，因此激素治療可能不止一輪。然後，醫生將收集這些卵細胞，使用這些女性各自伴侶的精子分別對它們授精，待受精卵發育到一定階段後再將其凍存起來。待到攢夠10個凍存胚胎，這名婦女就會被排入移植等待名單。
When a donor with matching blood and tissue type becomes available, the transplant will take place.
此時，只要有血液和組織型都匹配的供者，就可以進行移植手術了。
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.
移植手術預計需要五個小時左右。在這個過程中，醫生們會將子宮兩側的動脈和靜脈與受者的血管相連。該子宮會帶有供者的部分陰道，它也將縫合在受者的陰道上。附着於子宮的支持組織亦將被縫入受者的骨盆，以穩定移植物。但無須連接神經。
The woman will wait one year to heal from the surgery and adjust the doses of anti-rejection medicine before trying to become pregnant.
受者將需要一年的時間從手術中痊癒並調整抗排斥藥物的劑量，其後才能開始嘗試懷孕。
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.
然後，醫生將會向子宮內植入胚胎，每次一個，直到受者成功妊娠。爲避免移植子宮遭受分娩的壓力，嬰兒將在預產期前以剖宮產的方式降生。
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.
生完孩子後，母親可以選擇保留子宮，試着再生一個孩子（出於安全原因，兩個孩子是極限），或者將其移除，以便停用抗排斥藥物。如果受者不願意做手術，醫生表示也可以選擇停藥，讓免疫系統來排斥子宮，令它逐漸萎縮。
Initial Skepticism
起初的疑慮
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.
克利夫蘭診所的婦產科主任托馬索·法爾科內(Tommaso Falcone)是察基斯博士的合作伙伴之一。他回憶起自己第一次聽說子宮移植是在大約10年前，醫學會議上介紹了一些早期研究。最初，他是持懷疑態度的。
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變了他的看法。那是在2013年——他說，當時他是本着眼見爲實的原則，想要去親眼看看那個團隊的工作。他觀看了手術，並採訪了幾對想要接受手術的夫婦。
“I almost cross-examined them,” Falcone said. “I was thinking, `There's got to be something wrong with these people.”'
“我幾乎是在盤問他們，”法爾科內博士說。“我當時覺得：‘這些人肯定有毛病。’ ”
But, he said, he came to understand how much pregnancy meant to them.
不過，他繼續說道，後來他慢慢明白了懷孕對那些人的意義有多麼重大。
“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.”
“這要求合情合理，”他說。“當我登上回程的飛機時，我就知道我將會帶頭致力於在克利夫蘭診所嘗試同樣的工作。”
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歲的移植候選人說，得知自己沒有子宮後，她一度懷疑是否有人願意娶她。在她結婚後，除了領養了幾個孩子外，她和丈夫還考慮過代孕，但他們無法負擔費用。而這次子宮移植和妊娠的大部分費用將會由診所的研究經費和醫療保險支付。
“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.”
“我很清楚箇中風險，”她說。“這是一次高危妊娠。不過，我相信我們會得到最棒的醫護。我想我們應該可以應對將會發生的任何事情。”
She recently began the hormone treatments to stimulate egg production.
最近，她開始接受激素治療，以刺激排卵。
She belongs to a nondenominational Christian church, and members are praying she will have the transplant, she said.
她說，她所屬的無宗派基督教教堂的成員們都在爲她祈禱，期望她能獲得移植的機會。
“I know there will be people who don't understand or agree,” she added. “But this is not a whim.”
“我知道一定會有很多人不理解或者不贊同我的選擇，”她補充道。“但我絕不是一時衝動。”
