Surrogacy versus uterus transplantation: what's best from the womb-provider's point of view?

Transplanting a uterus may have a thing or two to recommend it.

So often we discuss reproductive technologies from the point of view of the people who want children. So it was refreshing to see a paper from three British researchers looking at the relative merits of surrogacy versus uterus transplantation strictly from the point of view of the people providing the wombs. Alexandra Mullock and Dunja Begovic, both from the School of Law at the University of Manchester, and Elizabeth Chloe Romanis, from Durham Law School, explore the pros and cons of surrogacy versus uterus transplantation.

5 minute read

There are currently two potential options for assisted gestation: surrogacy and uterus transplantation. Both are legal in the UK, but both have stumbling blocks. Where surrogacy is concerned, agreements are not legally binding, and as for uterus transplantation, it's not yet available as a treatment.

Nevertheless, from the point of view of the person who is helping — the womb-provider — what are the pros and cons of each? 

The points that follow come from a paper entitled "Surrogacy and uterus transplantation using live donors: Examining the options from the perspective of 'womb-givers'" which was recently published in the journal Bioethics

Just in case it's not completely clear, I want to underscore that currently, uterus transplantation is still rare and experimental. It involves complex surgeries for both the donor and the recipient; the recipient has to take drugs to prevent rejection; and the donated womb has to be surgically removed after family-building is complete. It's possible, even likely, that the procedure will someday be less complicated and more routine, but for now at least, that is not the case

But that doesn't change the fact that this is an interesting thought experiment. As the authors point out, the perspective of the third party is too often overlooked.

A surrogate lends a womb, a donor donates it permanently. Both processes involve self-sacrifice and medical risk. Both are potentially harmful to the womb-provider: pregnancy and childbirth are dangerous, and uterus transplant surgery even moreso. But there also might be specific benefits to the womb-provider, and these are seldom explored. Any experience will be highly personal, but here are some things to consider.

The possible downsides of transplantation

Normally, consent to donate an organ is regulated by the UK's Human Tissue Authority, which tries to ensure that consent is freely given. There's a worry that prospective womb-providers might be pressured into consenting by people they know.

A post-menopausal womb-provider will have to undergo hormone treatment for three months in advance of donating. This is to ensure that, among other things, the uterine lining can grow properly. 

The surgery to harvest a womb for transplant is much more complex than a routine hysterectomy. The operation typically takes more than five hours. There are the usual risks of surgery, including infection and a reaction to anaesthesia, plus specific risks of hemorrhage, injury to the ureter, bladder, bowel or intestine. Although no donor has died so far, there have been serious complications that have required additional surgery. 

The average hospital stay is six days and recovery could take six to eight weeks. The womb-provider's life may be restricted during that time: no driving, no exercise, no sex. There will be time away from work and from family. There may be post-operative pain, scarring, stress.

The surgery could be unsuccessful. Perhaps the womb can't be transplanted. 

The womb might be rejected by the recipient's body.

The recipient might never get pregnant, or might never have a live birth. It might seem like all harm and no benefit. Failure might make the womb-provider feel guilty.

The possible upsides of transplantation

Some people might be happy to donate their uterus. For various reasons, they might not care about keeping it or they may even prefer not having it.

Some people might prefer even complicated surgery to the burdens of getting pregnant, staying pregnant, and being pregnant. Pregnancy can last 40 weeks. 

Some people don't want to give birth. They might not want to give birth to another person's child.

The removal of the uterus is invasive, but surrogacy is invasive in a different way. Ultimately, donating a womb could mean a lot more autonomy for the womb-provider.

The relationship between the donor and recipient may become more deep and meaningful.

The womb-provider may establish a rewarding relationship with the child.

The womb-provider may benefit just from knowing they helped the recipient; the altruistic reward may be significant.

The possible downsides of surrogacy

The length of the average surrogacy, from start to finish, is much longer than just the length of an average pregnancy — about 24 months, say the authors.

The womb-provider has to go through an embryo transfer and take fertility drugs to launch the pregnancy. 

The womb-provider's ability to carry a pregnancy might have diminished with age. For various reasons, this might be a more difficult pregnancy than earlier ones.

There may be no pregnancy. There may be a miscarriage. There may be no live birth. This can be emotionally difficult for the womb-provider and she may feel guilty.

If a pregnancy is established, there will be hormonal changes — and these could cause significant emotional changes.

Sometimes pregnancy symptoms are challenging. Morning sickness, swollen limbs, limited mobility; preeclampsia, gestational diabetes, uterine infection.

The recipient may pressure the womb-provider to accept a special diet, limits on exercise or pregnancy-specific medical interventions. Autonomy may be limited.

If there are complications, the surrogate may feel responsible.

There are the usual risks of pregnancy and childbirth. Though rare, a few surrogates have died of complications from their surrogate pregnancies. 

The pregnancy may feel "publicly owned." 

Vaginal delivery might lead to tearing, pelvic floor injury or incontinence. The womb-provider could hemorrhage, suffer infection, require a hysterectomy. A c-section might be needed, with the usual risks of surgery. There will be time in hospital and time to recover.

The surrogate may experience emotional pain upon handing over the baby. 

The possible upsides of surrogacy

By and large, pregnancy is much safer than transplant surgery. By and large, pregnancy is much less complicated than transplant surgery.

The relationship between the donor and recipient may grow deeper and more meaningful.

The womb-provider may establish a rewarding relationship with the child.

The womb-provider may benefit just from knowing they helped the recipient; the altruistic reward may be significant.

What struck me most about this exploration was that, if uterus transplantation were to become more streamlined and less dangerous, there are probably some womb-providers who would prefer it: there's less intrusion into their personal lives, a shorter interaction time with the recipient, the outright gift of an organ rather than an organ (and body and life) on loan, fewer complexities around the gestation and birth and potentially less ownership of any failure to achieve a live birth.


Alexandra Mullock, Elizabeth Chloe Romanis and Dunja Begovic. "Surrogacy and uterus transplantation using live donors: Examining the options from the perspective of 'womb-givers'." Bioethics. 2021. 

HeyReprotech. "Uterus transplants: read the fine print." 2019.