A survey of public attitudes toward uterus transplantation, surrogacy, and adoption in Japan.

In 2014, the first live birth after uterus transplantation (UTx) from a live donor was achieved in Gothenburg, Sweden [ 1 ]. Thereafter, recent trials of the procedure using living donors in Sweden and the USA have resulted in more than 10 live births [ 2 ]. Furthermore, the first live birth after UTx from a deceased donor was recently reported by Ejzenberg et al. [ 3 ]. Currently, trials of UTx have begun in other countries [ 4 ]. In Japan, many animal experiments have been conducted in preparation for the realization of UTx [ 5 , 6 ]. Accordingly, UTx could be a potentially feasible option for patients with absolute uterine factor infertility in the future, although it is still at the early clinical experimental stage. At the same time, the introduction of UTx as a clinical procedure raises major ethical implications. This technique would allow women who do not have a uterus (or who have undergone hysterectomy due to malignant or benign uterine disease) to carry their own fetuses. Thus, UTx can be an alternative to gestational surrogacy and adoption, and can also affect the attitude of the public about them. In Japan, in particular, gestational surrogacy is not performed [ 7 , 8 ], and UTx might be considered as an alternative. While discussing whether UTx should be performed in Japan, it is important to evaluate the public opinion in Japan regarding UTx to understand the perceived safety and ethical challenges. In a previous survey on UTx conducted by Kisu et al., 40% of the respondents, who were all females of reproductive age, felt positively about UTx [ 9 ]. However, females older than 40 years and males should be included to reflect the attitude of the public as a whole. Particularly, women older than 40 years may be involved in UTx as living donors, and it is important to survey their attitudes toward their potential roles as donors. Therefore, we conducted a survey of the attitudes toward UTx among male and female members of the public aged 20–60 years.

We sent out questionnaires to 14,990 people; 3931 responded and 1938 submitted completed responses (response rate, 12.9%). We randomly extracted 1600 samples with equal segments of age and gender. The study thus consisted of a total of 1600 respondents with an equal number across each age group (20s, 30s, 40s, and 50s). Responses from equal numbers of men and women in each age group were obtained. Among the respondents, 47.7% were unmarried and 52.3% were married. In this study, we asked whether respondents have any experience of infertility. The subjects were those who had infertility even if they had not undergone fertility treatment or screening. In this study, of the 307 respondents with experience of infertility, 93 did not undergo infertility screening or treatments. The characteristics of the respondents are shown in Table 1 and S1 Table . Regarding the social and ethical acceptance of UTx, 36.5% of participants thought it “should be approved,” 17.0% thought it “should not be approved,” and 46.5% were “indecisive” ( Table 2 ). A higher proportion of participants aged 30–39 years thought it “should be approved” than that of participants aged 50–59 years. Among participants aged 50–59 years, more females than males felt that UTx “should not be approved”. Regarding the social acceptance of gestational surrogacy, 31.0% of participants felt that it “should be approved”, 19.9% felt that it “should not be approved,” and 49.1% were “indecisive.” A higher number of male and female participants aged 20–29 years or 30–39 years felt that gestational surrogacy “should be approved” than that among participants aged 40–49 years or 50–59 years. These results were similar to those obtained for UTx. A,B,C,D,E,F,G,H denotes significantly high compared to group A,B,C,D,E,F,G, or H respectively (P<0.05). As shown in Table 3 , the frequency of a “positive attitude” toward UTx or gestational surrogacy was higher among males or females with infertility than among those without infertility, and indecisive responses were also less frequent in this group. Furthermore, participants were more likely to think that UTx and gestational surrogacy should be socially approved when they knew more about UTx ( Table 4 ). However, more male participants who were familiar with UTx believed that “UTx should not be approved” or “gestational surrogacy should not be approved”. A,B,C,D denotes significantly high compared to group A,B,C, or D respectively (P<0.05). A,B,C,D,E,F,G,H denotes significantly high compared to group A,B,C,D,E,F,G, or H respectively (P<0.05). The most common reasons why respondents thought that UTx should be approved were: “…because UTx will give hope to people with absolute uterine infertility” (67.1%), “…because there is a genetic linkage with the born child, and the recipient can be a birth parent” (66.3%), and “…the risks associated with pregnancy and parturition are borne by the recipient and not third parties such as surrogate mothers” (44.3%) ( S2 Table ). In addition, the most frequent reasons why respondents thought that UTx should not be approved were: “…the risk of UTx surgery is high” (52.6%), “…because the recipient is at a high risk during pregnancy and birth” (38.2%), and “…because UTx does not necessarily lead to pregnancy and birth” (36.4%) ( S3 Table ). The reasons why respondents thought that gestational surrogacy should be approved were: “…because both the client and the surrogate mother agree” (68.3%), “…because it is an option for women with absolute uterine infertility” (66.3%), and “…because the client can receive a child without undergoing a difficult operation” (47.6%) ( S4 Table ). Furthermore, the reasons why respondents thought that gestational surrogacy should not be approved were “…because the surrogate mother is at high risk during pregnancy and parturition” (46.9%) and “… the parent-child relationship will be unnatural” (41.5%) ( S5 Table ). Next, we asked the question “Who is an eligible recipient of UTx?” In response, “a woman who do not have a uterus congenitally,” “a woman who has had her uterus removed due to malignant or benign disease,” and “a woman who has lost uterine function after endometritis or surgery for miscarriage” were regarded as acceptable recipients by 52.9%, 53.4%, 46.8%, and 46.4% of respondents, respectively ( Table 5 ). More females than males responded that these women were acceptable recipients. A,B,C,D,E,F,G,H denotes significantly high compared to group A,B,C,D,E,F,G, or H respectively (P<0.05). Further, we asked the question “Who is an eligible donor of UTx?” In response, “mother,” “sister,” and “deceased donor” (brain death or cardiac death) were regarded as acceptable donors by 39.4%, 37.9%, and 27.6% of respondents, respectively ( Table 6 ). A,B,C,D,E,F,G,H denotes significantly high compared to group A,B,C,D,E,F,G, or H respectively (P<0.05). To obtain personal opinions, we asked whether respondents would choose to receive UTx, gestational surrogacy, or adoption, assuming that they or their partners suffered from absolute uterine factor infertility. In response, 4.3%, 4.1%, and 8.2% of participants would opt for UTx, gestational surrogacy, and adoption, respectively ( Table 7 ). The proportions of those who would opt for UTx, gestational surrogacy, and adoption if their spouse wished to were 30.1%, 27.8%, and 32.1%, respectively. Among all age groups, 1–7% of participants would opt for UTx. A higher proportion (approximately 10%) of females than males would opt for adoption. More males than females would opt for UTx, gestational surrogacy, and adoption if their spouses wished to. Furthermore, a higher proportion of participants who would opt for UTx, gestational surrogacy, and adoption and those would choose these options if their spouse wished to had infertility ( Table 8 ) or knew much about UTx ( Table 9 ). When asked to choose the most favorable option, 10.1%, 5.8%, and 14.3% of respondents chose UTx, gestational surrogacy, and adoption, respectively ( S6 Table ). Particularly, higher proportions of males (26.3%) or females (16.1%) with infertility would choose UTx than those without infertility ( Table 10 ). In addition, 25.5% of males and 37.5% of females who knew much about UTx selected it as a more favorable option ( Table 11 ). A,B,C,D,E,F,G,H denotes significantly high compared to group A,B,C,D,E,F,G, or H respectively (P<0.05). A,B,C,D denotes significantly high compared to group A,B,C, or D respectively (P<0.05). A,B,C,D,E,F,G,H denotes significantly high compared to group A,B,C,D,E,F,G, or H respectively (P<0.05). A,B,C,D,E,F,G,H denotes significantly high compared to group A,B,C,D,E,F,G, or H respectively (P<0.05). A,B,C,D,E,F,G,H denotes significantly high compared to group A,B,C,D,E,F,G, or H respectively (P<0.05). To investigate the opinions of the participants from the donor’s point of view, we asked whether the responders would like to be donors or whether they would like to ask their spouse to be a donor if their daughter was suffering from absolute uterine factor infertility. Among female participants, 15.9%, 16.4%, 7.1%, 19.5%, and 41.1%, responded “…want to be a donor,” “…want to be a donor if there is no other donor,” “UTx is acceptable, but I do not want to be a donor,” “…do not want my daughter to undergo UTx,” or “indecisive,” respectively ( Table 12 ). More participants aged 30–39 years than those aged 50–59 years, and more patients who knew much about UTx than those who had not heard about UTx would “want to be a donor.” The proportion of participants who “do not want their daughter to undergo UTx” was highest in the 50–59 year age group. A,B,C,D,E,F,G,H denotes significantly high compared to group A,B,C,D,E,F,G, or H respectively (P<0.05). Among males, 7.6%, 29.1%, 5.9%, 12.5%, and 44.9% responded “…would ask my spouse to be a donor,” “would ask my spouse to be a donor if there was no other donor,” “UTx is acceptable, but I do not want my spouse to be a donor,” “…do not want my daughter to undergo UTx” or “indecisive,” respectively. More participants with infertility than those without infertility, and more respondents those who knew much about UTx than those did not know much, responded that they would “want to ask my spouse to be a donor” ( S7 Table , S8 Table ). The proportion of participants who “do not want their daughter to undergo UTx” was highest in the 50–59 year age group.

In the present study, we clarified the attitudes of male and female members of the public toward UTx, surrogacy, and adoption in Japan. Our results suggested that UTx is the most acceptable option among UTx, gestational surrogacy, and adoption. The effects of gender, age, infertility, and the level of understanding of UTx affected the attitude toward UTx. On the other hand, there are concerns about the safety of UTx for recipients, donors, and babies. It is important to continue to understand public attitudes to inform the development and safety of UTx, to enhance the discussion on the ethical consensus regarding UTx.

The study protocol was approved by the ethics committee of the University of Tokyo Hospital. This study was carried out as a part of a research initiative of the Japan Agency for Medical Research and Development. We conducted a web-based survey to assess the attitude of the public toward UTx, surrogacy, and adoption as we previously reported [ 10 ]. The sampling frame was developed by an internet research company (NEO MARKETING INC., Tokyo, Japan), which sent a questionnaire through the website and collected the responses. Respondents were asked to read a summary page explaining the purpose and content of the questionnaire prior to starting the survey. They provided informed consent before answering the questionnaire. Respondents read the study description and then chose to participate or not to participate in the study. Respondents started to answer the questionnaire after they selected “Yes” to a question of whether to participate in the survey. We also explained that respondents can stop answering and withdraw all answers if they want to withdraw from our survey halfway. Reference materials ( S1 Fig ) were also included to enable respondents to better understand UTx, surrogacy, and adoption when responding to the questionnaires. The questionnaire also included items regarding age, gender, marital status, number of children, and the experience of infertility ( S1 Document ). In Japan, infertility is defined as unsuccessful attempted conception for 12 months or longer. The web-based questionnaire was available online from October 24 to 25, 2017. In this program, only completed questionnaires could be submitted. One thousand six hundred participants were recruited with an equal segregation of age (20s, 30s, 40s, and 50s) and sex. Because we assumed that uterus transplantation donors and recipients could be women aged 20 to under 60, this study targeted men and women between the ages of 20 and 60. We asked the internet research company to collect 200 samples for each group of men and women in their 20s, 30s, 40s, and 50s. The upper limit of each sample collection was determined to be 250 samples. When the upper limit was reached, the collection of samples was closed, and further samples were not obtained. For each group, 200 samples were selected randomly. Through this process, the internet research company extracted 1600 samples with equal strata of age and gender. Finally, we received the responses of these 1600 participants from the internet research company and subsequently used these for the analysis. The statistical analyses were performed using JMP Pro version 14 (SAS Institute Inc., Cary, NC, USA). Categorical data were analyzed using the chi-square test and Fisher’s exact test, as appropriate, and are presented as numbers and percentages. P values < 0.05 were considered statistically significant.

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