The team that made these artificial wombs says they are motivated solely by the desire to save the most vulnerable humans on Earth. Emily Partridge, Marcus Davey and Alan Flake are neonatologists, developmental physiologists and surgeons who work with extremely premature babies at the Children’s Hospital of Philadelphia (CHOP). After three years of tweaking, their latest prototype is designed to give babies born too early a greater chance of survival than ever before.
The Biobag was born in the public consciousness in April 2017, when the CHOP team published their research in the journal Nature Communications. They had found a way of gestating the fetuses of sheep outside the maternal bodies; fetuses that would eventually become lambs would be no different from those that had grown up in the womb of the sheep. (Sheep are the reference animals in obstetric research because they have a long gestation period and the fetuses are the same size as ours.)
Their invention is a replacement placenta: an oxygenator plugged into the umbilical cord of the lamb, which also removes carbon dioxide and provides nutrients. The blood is completely pumped by the heartbeat of the fetus, just as it would be in the womb. The bag acts like an amniotic bag filled with warm, sterile, laboratory-made liquid that the lamb breathes and swallows, as a human fetus would.
The communications department of CHOP has released a very smooth short film, Recreating the Womb, to coincide with the release of the paper. There are no fetuses in sight. Instead, there are neat diagrams of lambs in Biobag systems, slightly awkward images of Partridge, Flake and Davey pretending to be researching lamb without a lamp in a blank lab and heartbreaking clips of incredibly small super-premature babies. Then there are carefully written interviews with the team. “In the future, we anticipate that the system will be in the neonatal intensive care unit and will look something like a traditional incubator,” said Davey. Biobags would be kept in a dark environment to mimic the human womb, but babies would be more visible than ever: “Parents can actually watch their fetuses in real time,” said Flake.
Normal human pregnancy is 40 weeks; any baby born before 37 weeks is considered premature. The 23-24 week period is the borderline of viability, after which modern medicine currently has hopes of keeping babies alive, and doctors will try to resuscitate a newborn baby. For the NHS, a baby born dead at 24 weeks is classified as stillborn, while a baby born born at 23 weeks and six days is a miscarriage. It’s a brutal border.
In countries with good hospitals, there is a 24% chance of keeping a baby born at 23 weeks alive. But 87% of those who do will experience major complications, such as lung disease, intestinal problems, brain damage and blindness. As more premature babies survive in richer countries, the number of people with chronic diseases has also increased dramatically. Premature birth is the leading cause of death and disability in children under the age of five in the developed world.
Incubators take care of certain functions for which a premature newborn needs help, but they do not allow the gestation process to continue; Biobag does this, treating the baby like an unborn baby. Women at risk of getting into labor very early may have their babies transferred to an artificial womb. It sounds extreme, but if it could mean a healthy future instead of illness and disability, who could deny it?
CHOP researchers want their device to be considered ethically trivial. “Our goal is not to extend the limits of viability, but to offer the potential to improve outcomes for infants who are already resuscitated regularly,” says their article. Extending the current limits on the viability of a fetus would create an ethical minefield. The legal abortion limit in the UK was lowered from 28 to 24 weeks in 1990 because advances in newborn care meant that fetuses born at the time were more likely to live. If artificial uteruses help smaller and smaller babies survive, this could have far-reaching implications for women. But women are not mentioned in the work of CHOP.
The Biobag patent application, filed in 2014, is revealing. There is no timidity in extending the limits of human viability here: it is explicitly stated that possible “subjects” include “pre-viable fetuses (eg 20-24 weeks)”.
I am not allowed to go to Philadelphia to see the work of the team. I was so close: Flake told me I was welcome and we set a date. But I was suddenly intrusive. They want to be able to put human babies inside Biobag in a few years, and the prospect of my visit had made the legal department nervous. “There is a great deal of caution in doing anything that could jeopardize FDA approval,” a press officer told me.
“This is not a new field,” said Matt Kemp wearily. He heads the perinatal laboratory of the Women & Infants Research Foundation (WIRF) in Western Australia, and the artificial belly of his team, Ex-Vivo Uterine Environment or EVE Therapy, reported his first great successes in an article published a few months after CHOP . The Biobag stole the thunder from EVE, and although Kemp makes little reference to it, it seems a bit strange.
“The Karolinska Institute in Sweden published a document in 1958 showing the use of this type of platform with pre-viable human fetuses,” he said. “Groups in Canada in the early 1960s experimented with sheep using this system. As early as 1963, the Japanese did seminal work on the ground … Anyone who tells you that they did it for the first time is dishonest. He doesn’t name names.
In the incubator there is a lamb, its breast rising and falling, immersed in a yellowish liquid in a transparent bag
There is no patent application for EVE (“It’s not patentable,” says exasperated Kemp, “it’s all been in the public domain since 1958”), so he’s happy to answer questions – unless that they do not concern the reason why he decided to name his artificial uterus after the first woman and mother of humanity. He doesn’t want to get caught up in discussions about the symbolism of his work: “It was just a practical way to describe it, I guess. ”
Kemp has been developing EVE since 2013, with researchers from Tohoku University Hospital in Sendai, Japan. No official image has been published, but I found a YouTube video uploaded to the WIRF channel. It looked like it wasn’t supposed to be online (and has since been deleted): it was clearly filmed on a phone and had only 56 views in a year. After the thoroughly cleaned images of CHOP, this 44-second clip dropped my jaw.
It starts with sound monitors in a neonatal intensive care unit; a healthy heartbeat beating red on a black screen. The panoramic camera has an incubator next to him and instead of a baby, there is a lamb, its breast rising and falling, lying in a yellowish liquid in a transparent bag from which comes out a mass of tubes, like veins filled with blood. This is what an artificial uterus really looks like.
The big difference between the work of WIRF and CHOP is the age of the lambs. The youngest fetus put in the Biobag was 106 days old; EVE was 95 years old. Kemp is cautious about translating into human terms, but it’s between 21 and 23 weeks. No one else has ever reported working with such young fetuses. And while CHOP raised their lambs for several weeks, often to term, and let some live, Kemp’s team kept them in the artificial womb for a week, then killed them all to analyze their organs. He says they could easily have kept them alive longer: “They are stable and healthy animals. ”
Even within a week, the lambs change dramatically, gain weight, and flex and swallow. “I’ve never been pregnant,” says Kemp, “but my wife says a fetus does these movements. He kicks, makes a small movement and goes back to sleep. ”
But clinical trials involving human babies are far away. “Anyone who tells you they are going to do it in two years has a lot of data that is not in the public domain or is a little sensationalist. ”
Is he talking about someone in particular?
I lost a baby at 20 weeks. If a false uterus could save a sick fetus, could it also save a healthy 20-week-old child?
“I am not,” he said firmly. “All the experiments to date have been carried out on fetuses from healthy pregnancies. This is simply not the case for a 21 or 22 week old human fetus. They will not be healthy babies. Putting it into clinical use is going to be incredibly difficult. To create an argument that an ethics committee will buy, you have to have a chance to give a much better result than the technology currently in use, “he said. “What is the first likely demography? A very sick 21-week fetus. ”
This surprised me. I lost a baby at 20 weeks old – a son, who would have been my second child. There was nothing wrong with him. He was perfect. I had appendicitis when I was almost 19 weeks pregnant. I spent a week in the hospital while obstetricians and gynecologists were scanning and pushing, trying to figure out why I was sick. And then I started work. It happens: if you are pregnant, a serious infection can cause the cervix to open. Between contractions, the obstetrician told me that if I was 24 weeks pregnant, everything would have been different. Even though my son was a real baby, who was wrapped up and given to hold, he died while I was giving birth to him. A miscarriage, not a stillbirth.
It happened three years ago. I have since taken out my appendix and had a daughter. But, like anyone who has lost a baby, I will always be haunted by what could have been done differently. If an artificial uterus could save the life of a very sick 21-week-old fetus, could it also save a 20-week-old woman who was perfectly healthy but unlucky enough to be inside a sick woman?
I swallowed hard. “If the first time you put a human fetus in your system,” I say, “it will not be viable otherwise, questions will arise to push the limits of viability. Can you not imagine that the parents of even more premature babies want their child to have a chance that an artificial uterus could offer? ”
“It’s a really easy question,” he says. “It is a human – or a fetus, or a baby – who is sick. If you had a three-year-old child who was not well and someone was developing a new therapy, would you have any qualms about it? ”
” Of course not. ”
“So this is it. From our point of view, it is no different. ”
In other words, as long as they have a chance to save a baby’s life, they’ll try to do it. But there are limits.
“We don’t think we are pushing the boundaries of viability more and more: if you can’t put a catheter in and the heart isn’t developed enough to circulate blood through the system, it won’t work. So any concern about harvesting eggs and placing them in these artificial devices is completely repealed by this. It just isn’t possible. “
As we improve the lifespan of embryos outside the womb and keep more and more premature babies alive, there will come a point when these two points come together. The barriers will be legal and ethical, not technological. IVF was once science fiction, then an ethical conundrum, then the tip of assisted human reproduction. Now, it’s a normal part of making families. Once the bags and tubes can replace a uterus, pregnancy and childbirth will be fundamentally redefined. If gestation no longer takes place inside a woman’s body, she will no longer be female. And the meaning of motherhood will also be changed forever.
“Pregnancy is barbaric,” says Dr. Anna Smajdor. “If there was a disease that caused the same problems, we would consider it very serious.” I’m sitting in her office at the University of Oslo, in front of a calendar with pictures of her cats. She is a bioethicist and associate professor of practical philosophy, but looks like a playful teenager.
“The number of women who suffer from tears and incontinence, and things that damage them for the rest of their lives, is really high, but it is not recognized enough,” she said. “All of this is linked to the high value we attach not only to motherhood, but also to childbirth.”
I have been looking forward to meeting Smajdor since I read his groundbreaking academic articles on artificial uteruses. She maintains that ectogenesis – reproduction outside the human body – would allow a fair redistribution of reproductive work in society, so there is a moral imperative for more research.
“There is an undisputed assumption that women are going to have babies and a failure to notice how bizarre it is that we have to produce new human beings from our own bodies. And how dangerous it is. ”
To demonstrate her point, she tells me about a colleague with a wisdom tooth. Smajdor suggested filming it, as a great experience to savor: “That’s it! And look, here are the seams! Wow – you did this without painkillers! ”
The comparison is completely perverse, but I can see its point. Our attitude at birth is very strange. There is blood, pain and seams even if everything is going well, and we are supposed to ignore it. Maternal mortality and stillbirth rates are falling around the world, but Smajdor says this is not necessarily good news. “The more the drugs progress, the more the women are crazy. I see a trajectory towards knowing so much about the fetus, and what is good or bad for it, that women themselves become almost ectogenetic gestators, their whole function being to maximize what is good for the baby. “
I really felt like an ectogenetic gestator. I had to lie down while a 20 cm needle was plunged into my belly so that the doctors could extract my son’s DNA because something on a CT scan made them think that he could have Down. (He didn’t, but I had appendicitis.) I had to stop gagging while forcing a disgusting glucose concoction because a late analysis of my daughter showed that I could have gestational diabetes. (I didn’t do it.) I had to lie down with my legs apart while a surgeon was sewing my cervix because a scan showed that I was likely to start labor early. Being pregnant is a remarkable experience, and I loved carrying my first child, but I never felt more like a thing, being acted only because my very dedicated doctors knew too much about what could is happening in me.
Smajdor was “not very surprised” when she saw the CHOP lambs. “These people were smart in their -” she chose the word carefully – ” marketing. And, of course, not wanting to talk about ectogenesis is part of the PR approach. “Instead of dedicating resources to saving premature babies, she says we should be raising them in artificial wombs from the start,” because it’s a trauma to the fetus, being removed from the womb even he then enters a Biobag and survives ”.
Smajdor uses provocative ideas to raise difficult questions. It works: it made me think about how “normal” our notions of childbirth, pregnancy and motherhood are.
If perfect ectogenesis could ever exist, there is a long list of women who would want to use it: women with epilepsy, bipolar disorder or cancer, for whom pregnancy would mean risking their lives or the lives of their fetuses by stopping or when starting treatment; women whose uterus has been removed for medical reasons. Ectogenesis will also help women in circumstances much less likely to attract public sympathy: surrogacy clients and older women, whose male counterparts have thoughtless babies. You could conceive of an embryo during your youth and grow it in a bag after retirement.
But perhaps the people most likely to be empowered by this technology are those who were not born: single men, gay men and trans women desperate for their own biological children. I ask Smajdor what the benefits of ectogenesis are for them.
“I do not support anyone’s right to have a child. I support the right of people not to interfere with their bodies. Then she left the world of philosophical logic for a moment. “Assuming we could get perfect ectogenesis, it seems like something we should be doing, in a fully just society. The problem is that our societies are not entirely fair. In a society that believes natural reproduction is the most amazing part of a woman’s life, ectogenesis is going to be very problematic and more likely to be used in ways that harm women. ”
“What kind of ways? ”
“When we talk about saving very premature babies, there is a risk of wanting to save babies because their mother is not fit to carry the fetus,” says Smajdor. Around the world, inappropriate behavior during pregnancy is increasingly viewed as child abuse. Since the 1950s, dozens of US states have prosecuted women for drug use during their pregnancy. If you can save a baby from the dangers of premature birth, wouldn’t you be ready to save it from a reckless mother?
It’s easy to imagine a future where the type of “help” already offered by employers in Silicon Valley and beyond, allowing staff to freeze their eggs so they can focus on their career, could include the possibility of growing babies in an artificial uterus. The use of a true uterus inside the body could ultimately become a sign of poverty, chaotic lives, unplanned pregnancies or even a potentially dangerous “frenzy”, choosing to have a baby without any medical help.
The biggest existential threat facing unborn babies today comes not from women “unfit” to be pregnant, but from reluctant mothers. Once a woman’s body is no longer the incubator, abortion can be both pro-choice and pro-life. In the ectogenetic future, fetuses aborted by mothers who did not want them to exist could be “saved” and adopted. In this world, some women may be looking for clandestine abortions that would end their baby’s life, rather than legal abortions that would allow them to live. It’s a horrible thought. But it could happen if the right to life of the fetus trumps that of a woman to refuse to become a mother.
Artificial uteri will be an incredibly powerful new technology. How this power manifests depends on who requests, manufactures, controls and pays for the technology. Once IVF has become common, research on the treatment of fertility problems such as blocked fallopian tubes has practically stopped. Why bother, if the problem can be overcome by assisted human reproduction? The same could happen with research that makes it easier and safer for women to have babies without being sliced, probed and torn. What is the use, if the solution is already there?
Women earn much more than we lose by having children: the creative power of being a mother, the right to choose whether or not to become a parent. Can the freedom to have babies without being pregnant be worth the sacrifice?
Complete ectogenesis will not exist for decades, but artificial uteri are arriving. We must ensure that, when they arrive, it is in a society that values women beyond their reproductive capacity and that they are used for the benefit of people who cannot be pregnant for biological reasons rather than social. . We still have time. But the race for innovation may not mean enough.
“This is certainly a project that would have looked more like science fiction,” said Emily Partridge at the end of the CHOP video. “But more than three years of relentless pursuit, it has become very real. ”
• This is an edited excerpt from Sex Robots & Vegan Meat: Adventures At The Frontier Of Birth, Food, Sex & Death, by Jenny Kleeman, published July 9 by Picador at £ 16.99. To order a copy for £ 14.61, visit guardianbookshop.com.