Motherless births through the artificial womb?

An artificial womb is an apparatus that would allow a fetus to grow to term, outside of the maternal uterus. This artificial “uterus” should be able to bring to term the product of conception in permitting exchanges in oxygen and nutrients as well as removal of the waste between the fetus and the machine to which it is connected to.  In 1924, J.B.S. Haldane called a pregnancy occurring in an artificial environment, from Fertilization to Birth: “Ectogenesis” and predicted that by the year 2074, this technique would be able to account for 70% of all human births.

Can you imagine walking into a hospital nursery full of pre-term babies with no incubators but bag of fluids with infants tucked securely inside? It may appear futuristic, but this looks like Medicine is venturing in a world that can easily remind us of Science Fiction.

In the Greek Mythology, Daedalus, a skillful craftsman and artist, father of Icarus, the uncle of Perdix, strived through his inventions to bring humans to the level of gods. Haldane thought about issues of his time, namely Eugenics with the first widespread debates over contraception and population control. He would be able to justify Ectogenesis with the aging mothers especially on a societal point of view.

The artificial uterus would be a replacement of the usual uterus but would have multiple implications. We would expect it to assist male or female couples in the development of the fetus. It can be compared to a neonatal incubator with specific functions assuming the fetal viability and even allowing possible surgical interventions if needed while responsible for the nourishment and the evacuation of the fetal waste during the early stages of development. One in 10 US babies are born premature, less than 37 weeks of gestation age and improvements in neonatal medicine have made premature births less than a problem. Many fetuses born from a 22-weeks of gestation have a 50% rate of survival coupled with a high mortality rate due to their lack of formation of internal organs. Unfortunately, they will also suffer from severe disabilities.

Are we ready for such conception of birth? The last 30 years have stimulated an interest in the process. Yoshinori Kuwabara, a Japanese investigator at the Juntendo University in Tokyo has developed an extra-uterine fetal incubation (EUFI) to help in the development of immature newborns, in 1996. He worked on 14 goat fetuses which were placed into artificial amniotic fluid under similar condition encountered in a mother goat. He succeeded to keep them alive for 3 weeks. They believe that they will be able to improve the system and later used it on human fetuses.

Twenty years later, researchers at the Philadelphia Children’s Hospital, in 2017, Alan Flake and his team, developed also an extra-uterine fetal incubation system in which they used fetal lambs placed in a plastic bag filled with amniotic fluid. The umbilical cord of the lambs was attached to a machine to simulate a placenta providing oxygen and nutrients. By the same mechanism, the waste was extracted. The embryos were kept in a dark room while the sounds of the mother’s heart were played loudly. This experience lasted one month, rendering the team to believe that in the years to come, they would be able to repeat such challenge on human fetuses. 

Parallelly, advancements in neonatal intensive care has pushed back the minimum gestational age from which human fetuses can be kept alive. We have already seen babies from mother with a gestational age less than 22 weeks survive, which represent almost half way to the entire pregnancy (40 weeks). Nowadays, such babies will require extensive NICU care through expensive pieces of equipment. At the University of Edinburg, Colin Duncan, a professor in reproductive medicine, discovered that the use of steroid injection for women at risk of delivering a premature baby, helped accelerate the development of the lungs as it did in the sheep models, improving the survival rate worldwide.

Various institutions have developed and modified their biotechnology to visualize an ex-vivo uterus environments supporting the growth of a mammalian fetus, early in pregnancy while the fetus develops substantially his internal organs during the second half of pregnancy. In the NICU, a premature infant can continue his/her development as a normal fetus of the same gestational age would do inside the mother’s uterus but while in the womb, oxygenated, nourished blood comes in and the waste is carried out through the placenta and the umbilical cord. Once delivered, the premature must breath through his lungs, clean his blood with its liver and kidneys and get nutrition through its gastrointestinal tract.

So, the fetal organ system must be functional prior to a transfer from the womb to the NICU. Therefore, the 22-week gestational age appears to be an absolute limit for a fetus who will have to breathe through his/her lungs as well as other organs functioning adequately.

Do we have any other options? An artificial amniotic fluid environment is being implemented with animal models on goats. Another option is an embryo transfer from the uterus of his own mother to the one of a surrogate mother able to assume the nourishment or in an in-vitro model. Such technology will have to be perfected to assure the normal development. We will be able to push the limit further to be able to practice a total Ectogenesis. 

An artificial womb may sound futuristic or may appear to be a way to control birth rate, the kind of human being to come to life, the choice in genetic features and even the traits to get passed down to future generations of kids. One will have to measure the impact of an artificial womb in our actual society. Luckily, we are not there yet because, the early days of gestation remain too complex and mysterious for researchers to rear a fetus from zygote to viability through maturation of organs. This miraculous invention, “the artificial womb”, may prove to be a hard sell.

Contraceptives devices have so far regulated pregnancy and birth rate. We know well how to sterilize, castrate or render fertile a man. We have made progresses in inducing pregnancies or implanting embryos through in vitro fertilization. We have used surrogate mother uterus to bring to term pregnancies. Do we really need an artificial uterus? Can we visualize a society which routinely uses an artificial uterus to achieve a successful pregnancy? One will say, unless the woman has problems to become fertile? An artificial uterus certainly moves the pregnancy outside of a woman’s body.

The notion that a woman has the right to choose and the right to control her body is still being debated with Abortion and religious convictions, but this may offer an alternative when part or the totality of a pregnancy is considered into an artificial womb. If the survival limit of a fetus and the timing in viability is being challenged while NICU are getting more sophisticated, Ectogenesis will certainly provide the same options. How do abortion laws that hinge on viability, can change when a fetus could technically survive outside of the womb at any given point? How do parental rights change?

Conservatives can appreciate how it can become easier for a male gay couple or a transgender to have babies of their own. There may not be a need to be supplemented with a surrogate mother. It will be more practical and cheaper. On the other side, artificial wombs will present major implications for the heterosexual women able to become pregnant preferring to carry their pregnant without hiring a human surrogate.

On an ethical point of view, if abortion remains an option, the fetus can be transferred to an artificial womb and then, may challenge the right to terminate the pregnancy. There may be some arguing that children who grew up in such condition may lack essential bonding with their mother, or others contrarily making the argument that the artificial womb would free women from the tyranny of their reproductive biology as stated by Firestone in his book The Dialectic of Sex, written in 1970.

More, in his column, on the Guardian, Prasad opiniated that the ideas of Gender, Family, Equality may change, inviting men to have a child entirely without a woman. We will then question the concept of Parenthood in women, same sex couples, trans genders etc. without any prejudice would be able to conceive. Let us be ready to challenge the abortion rights while the parental rights will change and the babies will grow in a deficient psychological world.

Maxime Coles MD


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