A young British transwoman: "I just want to have a baby"
Nomenclature: There is currently (2020) intense pressure from LGBTI+ activists to avoid the use of words such as 'man' and 'woman' in a sexual and reproductive context. This campaign has had increasingly success, for example the Australia National University’s Gender Institute Handbook suggests that the word 'mother' be replaced by 'gestational parent', and 'father' by 'non-birthing parent'. In the UK, the hugely influential charity Stonewall is requiring organisations (including schools and children's hospitals) to replace the words "boy" and "girl" with gender neutral terms such as "they". However, the first version of this article was written in 2001, and traditional nomenclature is still generally used. The stress of being infertile, unable to get pregnant, not able to have babies affects tens, if not hundreds, of thousands of transwomen around the world. Medical advances have transformed the lives of transsexual woman since the 1950's. Hormones provide huge physical and mental benefits, whilst advances in Sex Reassignment Surgery techniques make it difficult to distinguish the vulva (external genitalia) of a genetically XY male-to-female (MTF) transsexual women from that of XX women. An ever-increasing number of transsexual women now stealthy lead their lives without their friends, sexual partners and even husband ever suspecting that they were born anything other than a woman. Nevertheless, transwomen still cannot bear children due to their lack of internal female reproductive organs. Further, an openly transsexual woman seeking to have children and be a mother faces far more barriers than a genetic XX women in relation to adoption or the use of a surrogate mother.
Reproductive Expectations and Aspirations in Transwomen I transitioned full-time in my mid-30's and married a few years later. The mid-to-late 30's is considered a 'now or never' point for women who want to have children, and I was got many broad hints that "the clock was ticking", even from people who knew that I was trans! Also, on an almost a monthly basis, I would hear the exciting news that a work colleague, friend or relative was pregnant. For a while I was very broody, and it was depressing to keep ticking the 'Not Pregnant' box on medical forms. Historically there has been relatively little pressure on the medical profession to aid transsexual women to have children as allegedly few want this. Marci Bowers, a gynaecological surgeon specialising in sex-reassignment surgery says that fewer than 5 percent of her MTF patients ask about this. But there is a huge western and age'ist bias to this finding. For example, Thai and Brazilian MTF transsexuals typically transition in their early 20's (median age) and very few have sired any children before having SRS. Some later go to huge lengths to become a mother, at least by adoption. By comparison, in the early 2000's the median age of transition for European MTF transsexuals was late 30's or early 40's - the majority had been married at least once and had genetically related children via their cis-female wife.
A major change in recent years is the reduction the average of Western transgender women. In 2013 the UK's NHS reported that the average (mean) age of patients being referred to its gender identity clinics was a 42. In 2015 it was just 30 after huge annual rises in the number of teenagers being referred with gender disorder - the Sun newspaper suggesting 1000%. This is very significant as unlike the older cohort, many young transwomen under 30 have never been in a serious relationship with a cis-woman - let alone be married and have had children. A 2020 survey transwomen - Perceptions and Motivations for Uterus Transplant in Transgender Women - is helpful due to its focus on young transwomen, 133 of the 182 respondents (73%) were between age 16 and 29, and only 8 were over 39. Just 8% had had children as a man prior to transitioning, and an extraordinary 94% wanted to be able to gestate and give birth to children as a woman.
The advent of many transwomen marrying at a reproductive age and seeking to be a mother has resulted in an increasing number adopting a baby via a surrogate mother. If the transwoman is passing (or ocassionally even if not!) she may then simulate the pregnancy for the whole nine months, and thus try to avoid the embarrassment of admitting to using a surrogate. There are now companies that specialise in providing high-quality fake silicone pregnancy belly's, originally intended for actors they have discovered an additional market with both cis- and transwomen. At the higher end these are custom manufactured at prices starting from $/£300 for a perfect fit and skin colour match, with a replacement of increased size required every month. At the low-end, false pregnancy belly's can be purchased on-line for under £/$50.
Two potentially viable medical approaches were long ago identified for transsexual women seeking to bear a baby - uterus transplant and ectopic pregnancy. Both are discussed below, however the former has emerged as by far the most practical and the first baby was born using this technique in 2014. By 2021 several dozen babies around the world had been born by this technique - which is now moving from an experimental surgery to "just" major surgery. A strong sign that that the procedure is becoming mainstream is that medical insurance policies are starting to explicitly exclude the costly procedure on the grounds that the transplant is not a life-saving procedure.
No transwoman has yet had a successful uterus transplant and become pregnant - at least publicly. This is probably because of the Montreal Criteria for the Ethical Feasibility of Uterine Transplantation. It's an ethical framework published in 2012 designed to assess whether a woman could be considered as a transplant candidate. Among the list of qualifying criteria is the requirement that the uterus recipient should be a "genetic female of reproductive age". Whilst
surgeons and medical teams are reluctant to risk not complying with
widely accepted ethical standards, the Montreal Criteria have
become controversial. Since 2012, surgeons have increasingly
expressed the view (e.g. Dr Arianna D’Angelo, of the NHS’s Wales
Fertility Institute) that the uterus transplant procedure is as
applicable (with some caveats) to XY transwoman as it is to XX women
born without a uterus. For example Christopher Inglefield, founder
of the London Transgender Clinic, says "the procedure [for transgender
women] is essentially identical to the one performed on women .. and
it's important for trans females to be able to carry their own child." There has thus become a campaign, led by Dr. Jacques Balayla from the McGill University, to remove the reference "genetic female" from the Montreal Criteria. He states in an interview dated March 2021 that:
Before going any further it is necessary to consider the organs needed to become "pregnant". The internal reproductive organs of woman include:
Additionally, women have a unique secondary sexual characteristic that millions of years was critical to the survival of a baby after birth - their breasts and an ability to lactate milk.
MTF Reproductive Organs After surgery, a male-to-female post-operative woman may have the external appearance of woman, but the brutal reality is that she lacks the internal organs required to become pregnant. With modern surgical techniques, if a transsexual woman has had good quality sex re-assignment surgery (SRS), her vulva - including the clitoris and its hood and the opening to the vagina with its lips - should be visually almost indistinguishable from other women. Scaring is the most common give away. However, the vagina does not lead on to a cervix. Indeed the cervix, uterus, ovaries, fimbria and fallopian tubes are all missing. Despite the dramatic medical advances discussed in this article, there is currently no possibility that a transsexual women will be able to have transplanted in to her the full and very complicated reproductive apparatus of a normal fertile woman. Whilst the transplant of some individual organs (e.g. heart or liver) has been possible for decades, transplanting ovaries and fallopian tubes and a uterus - and then establishing ovulation, periods and fertility is far beyond the current state of medical science. A dramatic hormonal and micro-surgery intervention on an embryo with male XY genes might result the development of internal female sexual organs, but there is no obvious and ethical reason for doing this.
Uterine Transplants The possibility of uterus transplants dates back the origins sex-change surgery in the 1930. But until the 1990's uterus implants were not regarded as a viable approach - experiments with dogs and baboons had been unsuccessful as it was found that great difficulties lie in the fact that complex blood vessels that must be connected. Pregnancy also puts huge strain on these connections, with very dangerous consequences if something goes wrong. Another major problem when transferring a uterus from one person to another is the possibility of rejection (i.e. the transplanted womb is recognised by the implanted body as being foreign material and "attacked"), especially if that occurred during a pregnancy. The risk of rejection can only be reduced by taking drugs to suppress the immune system and prevent rejection of the transplant, but most of these drugs are harmful to the early foetus development during a pregnancy. It was thus thought that uterus implants must wait either until less intrusive immunology suppression drugs are developed, or until advances in cloning or genetic engineering allows the growth of female reproductive organs that are not "foreign" to the patient. However the concept of short-term uterus implants in order to bear a baby has emerged... creating what has effectively become a competition for the first successful pregnancy via this technique. The first claimed uterus transplant was in 1992, when newspaper reports suggested that 26-year Cyndi Diori (born Lester) had received a uterus implant at the clinic of Dr Dompeon in Barcelona. A paper published in the International Journal of Gynaecology and Obstetrics in March 2002 claimed that doctors in Saudi Arabia had performed the world's first womb transplant. The operation was on a 26-year-old woman who had lost her own womb because of excessive bleeding after childbirth. The operation used the womb of a 46-year-old woman who needed a hysterectomy, and was performed on 6 April 2000. It was deemed a success by the Saudi doctors but the transplanted womb had to be removed 99 days later when scans revealed a blockage in one of the grafted vessels that cut off blood supply to the uterus. However, the uterus did produce two hormone induced (as would be done in a transsexual woman) menstrual periods before it had to be removed. Researchers now sought better ways of "plumbing in" the transplanted uterus than the Saudi's had used. In June 2003 a Swedish team led by Dr Brännström of Sahlgrenska University in Gothenburg, briefed a "European Society of Human Reproduction and Embryology Conference" in Madrid about a new technique where the transplanted womb is attached to two arteries and three veins on each side, with blood primarily coming from the external iliac artery. It would also be attached to the vagina, and to the round and sacral ligaments to hold it in place, but not to the Fallopian tubes - if the woman has those. The woman would not be able to conceive naturally, but would have to have IVF. She would also have to give birth by Caesarean. The new technique was considered simpler and less risky than most transplant operations as no major blood vessels or vital organs are involved. The donated womb would have to come from a woman with a close genetic match to the recipient in order to minimise the chance of rejection, as the womb does not deteriorate greatly from age it could come come from a post-menopausal woman. According to Dr Brännström "It could well be a relative. You could get it from your mother. You could give birth to a baby from the uterus that you yourself were birth from." Patients would need to take immunosuppressant drugs to help stop their body rejecting the womb, but researchers believe that modern immunosuppressant drugs do not have any negative effects on a feotus. Also, the drugs would not need to be taken for life, which might result in undesirable long term side-effect. After the woman has had her children, the transplanted womb could be removed. Dr Brännström says that it might be possible to transplant a womb in to transsexual women, allowing them to become pregnant with using donated eggs, though anatomical barriers would have to be overcome. "It should be technically possible, but I don't know if it's ethical. The pelvis of men also is not exactly the same shape as the pelvis of women, and that might pose problems."
Also, in November 2006 Dr Giuseppe Del Priore, from New York Downtown Hospital, said he had been given the go-ahead to carry out a womb transplant operation and claimed to have found a number of potential donors. Dr Del Priore said: "It is cautionary approval but it is approval. If the right patient shows up the [hospital] independent review board has stated we could go-ahead. Technically we are capable of doing it. If we had everything in order we could do it tomorrow." However, any would-be patient will have to go through months of counselling and tests before approval - including seeing a psychologist and reconsidering adoption or surrogacy, as well as seeing a pregnancy risk specialist and transplant support team. The organ is likely to be sourced from a dead donor who had previously had a child. They would have to have the same blood group and be immunologically matched. The long race for the first successful uterus transplant and pregnancy reached another small milestone when in October 2009 Dr Richard Smith- a consultant gynaecological surgeon at Hammersmith Hospital in London - claimed that his teams' research on animals had “cracked” how to ensure a good blood supply to a transplanted womb. The the next milestone was reached by the doctors at Akdeniz University Hospital in southern Turkey. On 9th August 2011 they transplanted - in a seven hour operation - a uterus from a woman who had died in a car crash to a genetically XX 21 year-old-woman, Derya Sert, who was born without a uterus. Micro-surgeon Omer Ozkan, said: "The surgery was a success ... [But] we will be successful when she has her baby. ... For now we are happy that the tissue is living.'
Mrs Sert then spent six months in hospital and was given powerful immunosuppressant drugs to stop her body rejecting the new womb. However her periods started just three weeks after the operation, a signal that the new womb was working well. Scans showed its lining to be healthy - Doctor Munire Erman Akar said "We can see it from the ultrasound that the endometrium lining is perfect", but added that if she did became pregnant "there are many risks like congenital anomalies because of the immunosuppressive (drugs), and intrauterine growth retardation, preterm labour." Lowering the dose of the drugs is critical for Mrs Sert to carry a healthy baby through pregnancy. The next step was supposed to be an IVF procedure - planned for September 2012 - when up to two of the eight embryos created from Mrs Sert’s eggs and her husband’s sperm, and frozen ahead of the transplant, will be inserted into her womb. However no information has been published about this, and on 18 September 2012 the Gothenburg team announced their latest advance, stating that: Both donating women started in-vitro fertilisation before the surgery, and frozen embryos could be thawed and transferred to transplanted uterus' if the receiving women are considered in good enough health after a year-long observation period. "We are not going to call it a complete success until this results in children," said Michael Olausson, one of the Swedish surgeons.
In January 2014, Dr Mats Brannstrom and the Uterus Transplant Project at the Sahlgrenska University Hospital Women's Clinic in Gothenburg revealed that the team had conducted nine womb transplants on women who were born without a uterus or had it removed because of cervical cancer. All the transplants were from living relatives. Most of the women are in their 30s and are part of the first major experiment to test whether it is possible to transplant wombs into women so they can give birth to their own children. The transplant operations did not connect the women's uteruses to their fallopian tubes, so they are unable to become pregnant naturally. But all who received a womb have their own ovaries and can produce eggs to be used for IVF treatment.
As of late 2020, roughly 100 uterus transplants have been performed in the world, including about 30 in the United States. If the woman is approved for the procedure, the process starts with creating an embryo using in vitro fertilization (IVF), in which the woman’s eggs are retrieved and fertilized with sperm. Next, a healthy uterus is transplanted into the patient. About six months after a successful uterus transplant, a single embryo is implanted into the uterus. If it leads to a successful pregnancy, the pregnancy is treated as high risk, and the baby will be delivered via Caesarean section, because women with UFI cannot delivery vaginally. Babies born from uterus transplant recipients tend to be born early, at about 35 weeks of gestation. Caring for these premature infants often requires a stay in a neonatal intensive care unit for several weeks. The entire process can take 2-5 years.
As with
other
types of
organ
transplants,
the
woman
must
take
immunosuppressive
medications
to
prevent
the body
from
rejecting
the
transplanted
uterus.
After
the baby
is born
and if
the
woman
does not
want
more
children,
the
transplanted
uterus
is
removed
with a
hysterectomy
procedure,
and the
woman no
longer
needs to
take
anti-rejection
medications.
A major constraint for uterus
transplants is the availability of a
healthy uterus that is suitable and
compatible with the recipient. A major advance occurred in early
2014 when doctors at Wake Forest Baptist
Medical Centre in North Carolina, USA,
announcing that they had successfully
grown and implanted vaginas for four
teenage women born without vagina's in a
four-stage process:
After surgery, the woman all reported normal levels of "desire,
arousal, lubrication, orgasm, satisfaction" and painless intercourse.
Although they still can't become pregnant through normal intercourse,
IVF is a possibility. The technique is
applicable to transwomen, the main issue is the source of the tissue.
Penile tissue is preferable, but it may not be obtainable from a
post-SRS woman. A biopsy from the uterus of a close female
relative is a second option. A third option is
the use of stem cells -
undifferentiated
biological cells that can
differentiate into specialized cells.
Ten years ago, the use of stem cells to create a uterus was pure science
fiction, now it is a serious possibility, indeed for a transsexual women
this probably the most likely and preferable approach.
By far the most promising approach that could allow a transsexual woman to become pregnant is a uterus (aka womb) transplant. For decades a huge medical effort was undertaken to transplant a uterus into to a genetically female woman for fertility reasons. In 2014 this led to the first successful full-term pregnancies and live births. There is no reason why exactly the same technique cannot used for a genetically male transsexual woman.
No
confirmed
uterus
transplant
operation
has been
performed
on a
transsexual
woman,
but
Brazil
has a
huge and
unregulated
"grey"
market
for
cheap
but
often
risky
MTF
feminisation
surgery,
ranging
from
dangerous
silicone
injections,
to
buttock
implants,
breast
augmentations
and even
vaginaplasty.
In an
interview
with the
British
newspaper
the
Daily
Mail,
Jessica
claimed
that
several
uterus
transplants
operations
had
already
been
carried
out on
transwomen
in
Brazil.
The cost
of this
risky
and very
dubious
procedure
is
speculated
to be
about
$45,000,
including
a
payment
of just
$10,000
to the
uterus
donor.
Essentially the transwoman will receive a transplanted womb for at least
long enough to her to conceive and give birth by Caesarean section.
Ideally this will come from a close female relative (mother or sister),
but other donors are possible such as a deceased woman (a 'cadaver' in medical terminology).
An emerging possibility is that a womb could be grown in a laboratory
from the transwoman's own cells (see below). This has the huge
advantage that possibility of rejection is eliminated, and the uterus
can then remain in place long term.
A graphic illustrating how a uterus
transplant operation works. The chances of a successful pregnancy are
much improved if the transplanted uterus is from a sister, mother or
another close relative - the first transsexual woman to bear a child
seems likely to come via this route.
Eggs from a donor (again, ideally, from a close female relative) will be
fertilised by her partner's sperm via the now common IVF technique and
placed in the implanted uterus. The sperm could even be her own -
from a sample taken and frozen before having SRS. After birth, the
uterus would be removed, eliminating the need for the woman to take
risky immunity suppression drugs long-term.
The baby will need to be delivered by Caesarean section because the
transwoman lacks the organs and muscles involved in natural contractions
and labour, but this is minor obstacle given that about quarter of all
babies are already born by this method in Western Europe, and a third in
the USA. For a
transsexual woman absolutely determined to start a family, uterine
transplants offer some major advantages over surrogacy. The
transsexual is gestationally and socially clearly the mother. She
can also control lifestyle factors such as smoking and drinking alcohol,
and she is the person who takes the health risks associated with every
pregnancy.
Since the late 2010's, the announcement of the birth of a baby born by a
transwoman has seemed imminent. In February 2023 an
article by
Dr Flyckt and her colleagues at the Cleveland Clinic in Ohio explained
both the reasons for the delay, and the progress being made. Dr Flyckt said that it was
now a matter of when the
surgery was conducted, not if: "The first uterus transplant in a
transgender female [will] take place within
the next few years, if not sooner". The article by Dr Flyckt
et al gives little detail as to how the surgery would be
conducted, but other experts believe that the likely procedure is now
very clear: The patient has sperm frozen. The uterus
donor may also have eggs frozen. These can potentially later be
used for IVF. The transwoman patient undergoes gender
confirmation surgery, including removal of the testicles and a
vaginoplasty. A neovagina
is created to provide a base to attach a transplanted womb. After a recovery period following the
vaginoplasty, the transwoman has a uterus transplant. Like other
organ donations, such as kidney or liver, the transwoman the donor will
need to be of the same blood and tissue type. The uterus is removed from the donor, including
the
attached blood vessels required to feed the organ. The uterus is surgically implanted into the
transwoman in a major operation, blood vessels are connected and the
entrance is connected to the neovagina
- this is necessary to keep the uterus correctly placed, not for
intercourse.
Thereafter: The uterus is prepared for pregnancy using hormones
a (a pre-requisite for IVF) An egg is fertilised using sperm in the lab before being implanted
into the womb (the
IVF procedure) The transwoman receives a hormone regime that mimics
those a woman's body produces naturally during pregnancy to support
the development of the baby A Caesarean section
procedure is used to deliver the baby after 7+ months, depending how
well the pregnancy is progressing. None of the above represents a substantial advance on
current medical experience - it's a case of joining all the steps to
together. To maximise the chance of success it's likely that early
transplants will as far as posible use a uterus donated from a close
female relative of the recipient, eggs also from the donor, and sperm from
the transwoman. There are legal limitations on this, e.g. using
sperm to fertilse an egg provided by a sister.
A Genetically XY Women Gives Birth 2014 culminated with news from the UK of another huge medical advance that will give serious hope to many transsexual women. On Christmas Eve, Hayley Haynes, age 28, gave birth to twin girls - Avery and Darcey. This sounds rather mundane, but it made headlines around the world because nine years earlier Hayley had discovered that she suffered from complete androgen insensitivity syndrome (AIS). She was genetically XY male, and lacked internal female sexual organs such as ovaries or a uterus (aka a womb). As a child she didnt have any doubts that she was anything but a girl. Puberty seemed to start normally as her body rounded out and her breasts developed - but she became increasingly worried that her menstruation cycle had not started, i.e. she was not having periods. Discovering that she had AIS was a devastating blow, she says: “When they told me I had no womb I was so confused I felt sick. My biggest fear was never having children." Encouraged by her boyfriend Sam, Hayley sought more help from the NHS. A scan by a specialist at Royal Derby Hospital in 2007 found that Haley had the tiny beginnings of a uterus that had never developed, although just a few millimetres in size it gave hope. Haley was prescribed a cocktail of oestrogens and progesterone hormones to create an environment where her uterus could grow. Astonishingly it did, and in 2011 Hayley was informed that she was now able to have IVF. Unfortunately the NHS refused to conduct this procedure for free; in early 2014 Hayley and Sam (now her husband) reluctantly decided to pay £10,500 (about €12,000 or $16,000) to have the procedure performed by a clinic in Cyprus. 13 eggs were taken from a donor mother similar in appearance to Hayley and two were successfully fertilised using Sam's sperm. These were implanted in Hayley's uterus and a six weeks scan showed that she was pregnant with non-identical twins! The next twelve weeks were nerve-racking as it was vital at this early stage in the pregnancy that Haley took pills to create and accurately simulate the hormone profile of pregnant woman - one day she forgot some pills and briefly feared the worst.
Thankfully everything went well and in December 2014 her doctors at the Royal Derby Hospital decided to induce her two weeks early. On Christmas Eve she gave birth naturally (presumably meaning a vaginal delivery?) to Avery, at 5lbs 3oz, and Darcey, 4lbs 6oz. Although they were slightly premature, the girls were healthy. Hayley told the Irish Mirror newspaper: “Becoming a mother was the single most amazing moment of my life. When I held the babies in my arms for the first time I was overwhelmed. I had spent nine years coming to terms with the fact this might never happen, but in that moment all the pain just washed away ... Darcey and Avery are the most beautiful little girls in the world." Comment: On learning of Hayley's case I was puzzled as this was the first time that I had heard of a woman with AIS possessing a uterus of any size. In a genetically XY foetus with AIS, the Müllerian ducts will inevitably degenerate as result of the hormones excreted by testes, they simply can't develop into female internal genitalia such as a uterus. I contacted the Royal Derby Hospital about this, they asked me to submit my questions in writing and promised a response from the medical team. I did this but never received any answers. I also tried to contact Halley directly but she and her family had disappeared from social media by mid-2015 and I again never received a response. Six years later (2021), there hasn't been any other similar cases publicised. Overall, I've become very doubtful that Hayley actually has AIS or is genetically XY. It seems almost certain that she suffers from another medical condition such Swyer Syndrome, Anyway, I extend my congratulations to her and her husband on the birth of their twin babies - presumably now school children!
Ectopic Pregnancy Since 2000 a uterus transplant has become accepeted as the most likely approach for a transsexual women to become pregnant. However for many years an Ectopic pregnancy - the development of the baby outside the uterus (womb) - seemed more likely as it was medically simpler because no complex uterus transplant was required. Natural occurrences of ectopic pregnancy do a occur, however they are considered very dangerous to the mother and subsequent live births are very rare (one pregnancy in millions). Interest in this procedure has faded significantly because of the big risks it involves for the patient, and huge the advances made in other areas. However it is still possible that that it might be used for transsexual mothers because of its initial simplicity - no difficult transplants of a uterus or other organs.
The technique would involve attaching the foetus (the term used for developing babies under 8 weeks from conception) to the muscles inside the transsexual woman's abdomen, or even fashioning a [disposable] artificial womb from abdominal tissue. Attachment to the bowel, with its good blood supply, is another attractive option, but perhaps the worst in terms of post delivery trauma. Preliminary female hormone treatment will be vital for supporting and encouraging the foetus' placenta to produce enzymes which then eat into whatever internal organ it is placed on, so that the placenta can attach and tap into the blood vessel to obtain nutrition. The baby will then develop inside the woman's abdomen, and the woman will carry the baby for its full term before giving birth by caesarean section. Sustaining the pregnancy will require further large amounts of female hormones to be taken, in particular high levels of oestrogen and progesterone must be maintained during the first three month of pregnancy. The feminising effects of these may be a problem for a man who wants to become pregnant but doesn’t wish to develop breasts, but it's hardly a problem for a MTF transsexual woman who takes such hormones every day of her life! There are though two main catches to this procedure:
There is a real possibility that the mother will require urgent life saving surgery, either during her pregnancy, immediately after the caesarean, or during the recovery period afterwards.
Procedure
Genetic Parentage Up until our current time, embryos have always been formed by the union of a sperm (supplied by a XY male) and an egg or ovum (supplied by a XX female). Both the sperm and the ovum provide DNA, but the ovum also provides a “house” in which the embryo grows during the early stages of development. An ovum is therefore absolutely essential for reproduction. A post-SRS transsexual woman faces two major problems in passing her genes on to a child, regardless of whether this is to be carried by a surrogate mother or [in the future] by the transsexual woman herself. Firstly she lacks her own ovaries to produce ovum containing her genes, and secondly having a baby with her husband or a male partner would involve the genetic union of two males - known as "same-sex parenting". One method for providing the embryo to be implanted is to obtain an egg from an unrelated woman and have it fertilised by sperm from the husband or partner. But while this method is already occasionally used (the baby being carried to term by a surrogate mother), this approach is unsatisfactory for transsexual woman as she has no genetic relationship with her baby. However, there are several other options that a transsexual woman can take in order to be genetically related to her baby:
In the next few years there may become available several new and exciting options which use a cloning technique called "membrane fusion" to create a fertilisable egg:
And finally, the most advanced and technically challenging option of all:
Approach 4 is perhaps the most promising in the short- to medium-term. On 5 Sept 1999 the UK's Sunday Times reported a major advance by a team headed by Zev Rosenwaks at the Cornell University Medical Center, New York. They had been able to take immature egg cells from the ovaries of a donor, remove the nucleus (containing the donor's genetic material) and replace it with genetic material taken from an ordinary body cell of another animal. The researchers have found they can reprogramme the DNA genetic blueprint from any living cell to make it behave like an unfertilised egg. The donor egg cell thus acts as an "envelope" for the prospective genetic mother's genetic material. Once the reconstituted egg cell is mature, it could be fertilised in the laboratory using IVF techniques and the embryo then implanted into the womb or abdomen of the mother. Rosenwaks said: "We are primarily working with animals, but the work is also being pursued in humans. We have no human pregnancies yet.". In June 2001 the fertility researchers from Cornell University reported that they had now created viable manufactured human eggs using human eggs donated by women undergoing in-vitro fertilization. The experimental procedure uses genetic material from a cell taken from the infertile woman and transplants that material into a donor egg, which has had its genetic material removed. The process is somewhat similar to the cloning technique that was used to create Dolly, the first cloned sheep. There is, however, a crucial difference: Cornell is using only half of the genetic code contained in the adult cell - that of the mother. All adult cells carry two sets of chromosomes, one from the mother and a second from the father, so half have to be removed before fertilisation can occur. To do this, the researchers harness the natural ability of the egg to make this happen, using a tiny electrical current, or chemicals, to activate the process of splitting the normal cell's nucleus in half. One half is then taken away so that the reconstructed egg will - according to Professor Palermo, who an assistant professor at the Center for Reproductive Medicine and Infertility at Cornell University Medical Center - "closely resemble a natural, mature human egg", which has only one set of chromosomes. However success rate is low, out of 200 attempts, 17 of the eggs were "haploidised" or made to have the correct number of chromosomes. The second set of chromosomes will come from the fathers sperm, which also only carries a single chromosome set. To fertilise the eggs, sperm would have to be injected through the cell wall just before the electric shock. The Cornell team has not tried human eggs, but has tried fertilising artificial mice eggs with some success. Clearly great progress is being made with this technique which offers considerable hope to transsexual women, but there are still some major potential problems. If sperm is not available then there is concern that using "old" DNA from cells in the mother's body could mean that the new-born baby was the genetic age of the mother. Studies of Dolly the sheep, the first animal to be wholly cloned, suggested that her cells were much older than her chronological age - she prematurely suffered from many medical problems normally associated with old age, and finally had to be put down in 2003 while still relatively "young". Also, some genes are chemically labelled as coming from the mother or the father - a process called "imprinting". These labels would have to be changed, otherwise the resulting embryo would be defective. Finally, there are problems with the sex chromosomes, it is possible to produce embryos with an abnormal set of sex chromosomes and it would for example be necessary to screen the individual sperms to make sure the right combination of sex chromosomes was used. But this would have the bonus of letting the couple choose whether to have a son or a daughter. Dr Ursula Eichenlaub-Ritter, who is a professor of gene technology at the University of Beilefeld in Germany, says that Palermo's technique has the same problems as cloning: It requires many, many failed experiments before a viable egg is produced. She says that she doesn't think the technology is an efficient way to produce this kind of egg.... "I don't see success in the near future.". Dr Palermo thinks that clinical trials on human women are perhaps still 5 years away. It has become clear from the ever-increasing practise of cloning animals, that this is subject to various genetic problems. It is also expected that while humans may well be cloned imminently, the resulting progeny will be subject to similar problems. There is also no reason to believe that the cloning related reproductive techniques just described above won't suffer such problems. However, it is also reasonable to expect that improvements in cloning techniques and new procedures will eventually overcome these issues.
Artificial Womb Technology Aldous Huxley’s Brave New World (1932), describes the process of ectogenesis – the development of embryos in artificial environments. In the book embryos grow on flaps of fresh sow’s peritoneum in bottles on a conveyor belt “travelling at the rate of thirty-three and a third centimetres an hour”. At the time this was pure science fiction. On 25 April 2017, researchers at the Children’s Hospital of Philadelphia described in journal Nature Communications “an extra-uterine system to physiologically support the extreme premature lamb”. Essentially, they had removed lamb embryos from the mother and incubated them in a plastic “biobag” – literally, a womb with a view – supplied with blood and other nutrients to show that “foetal lambs that are developmentally equivalent to the extreme premature human infant can be physiologically supported in this extra-uterine device for up to four weeks”. The lambs survived and were “delivered”, with the researchers stating that their system “offers an intriguing experimental model for addressing fundamental questions regarding the role of the mother and placenta in foetal development”. Although acknowledging that “clinical application of the technology will require further scientific and safety validation . . . ” the researchers are clear: “The initial clinical target population for this therapy will likely be the 23-25-week extreme premature infant.” For humans, artificial womb technology (AWT) is currently seen as an extension of neonatal intensive care – removing an endangered, premature foetus from its mother to an artificial and well-controlled environment. However in the future it is clearly a possible option for women (including transwomen) with intractable uterine problems, obviating the need for uterus transplants or surrogacy. If the
technology does become mainstream, it presents some interesting questions
to society. E.g. Can you be a "real mother" without having
your child develop as an embryo in your womb? Is it acceptable for a
wealthy female actress or supermodel to use this technique to have a baby
whilst avoiding any disruption to their career and unwanted body changes
due to pregnancy?
The Future Has Arrived When the first version of this page was drafted in 2001, the idea of a genetically XY male-to-female transsexual becoming pregnant was still close to science fiction. Fifteen years later, successful uterus transplants by Dr Brännström's team at the Sahlgrenska University in Sweden, plus the birth of twins by Hayley Haynes in the UK show that all the major medical barriers have now been overcome. Vincent, the first child born following a uterine transplant, was born in Sweden in October 2014. This marked the end of a long and hard-fought global race to perform the first “successful” human uterine transplant. In July 2017, Swedish research trials reported six healthy live births via womb transplants. As the uterus transplant procedure moves from experimental to 'just' major surgery, the UK's NHS system is considering suitable transgender patients. Consultant gynaecologist Dr Arianna D’Angelo, of the NHS’s Wales Fertility Institute, believes that this is right from an "ethical point of view". She said in July 2017: ‘We already have fertility preservation [freeze sperm and eggs] for transgender people, to give them the possibility to have their own genetic child. So I don’t see much of a difference between that and actually delivering their own child." The diagram above shows the uterus transplant procedure for a cis-woman. For a transgender woman, step one would be modified, for example: (i) her own frozen sperm is used to fertilise the eggs, or (ii) eggs donated by her mother or sister are fertilised using sperm from her male partner. In November 2017, Dr Richard Paulson, President of the American Society for Reproductive Medicine, told a conference that uterus transplants had now become “mainstream” and that people who had undergone gender reassignment surgery would inevitably want to take advantage. There was no anatomical reason why a uterus could not successfully be implanted into a transgender woman. He said "You could do it tomorrow, ...There would be additional challenges, but I don’t see any obvious problem that would preclude it. ... I personally suspect there are going to be trans women who are going to want to have a uterus and will likely get the transplant." Whilst men and women have a different shaped pelvis, he said that "there would nevertheless be room for an implanted womb."
In the UK, an unintended consequence of the Human Fertilisation and Embryology Act 2008 is that it would be illegal for an IVF clinic in the UK to create an embryo for the purpose of implanting it in a transwoman with a uterus transplant in order to make her pregnant. In December 2018 the BBC reported that a healthy baby girl had been born using a uterus transplanted from a deceased woman. Previous successful uterus transplants had all been from living donors, often the patients mother. The 10-hour transplant operation - and later fertility treatment - took place in São Paulo, Brazil, in 2016. The recipient, age 32, was born without a uterus. A survey of media reports showed that by late 2018 there had been at least 39 uterus transplants, with 11 babies born - including two by the same mother. Aggregated results to late 2019 showed that about three quarters (73%) of uterus implants were successful, and nearly half (48%) of these eventually resulted in a baby. The number of publicised transplants reached 70 in late 2020, and nearly 100 in April 2021. Given the one or two year lag in medical studies being published, and 'no publicity' preference of patients, the actual numbers will be far greater. Whilst the number of operations is increasing by roughly 50% a year, the shear cost, risk and life style impact makes it very unlikely that it will ever become a routine medical procedure. The number will probably stabilise in thousands per year, rather than the millions a year associated with IVF.
The diagram above shows the result of a theoretical uterus transplant procedure for a trans-woman. The transplant includes the cuff of the donors vagina, which is shown connected to a neo-vaginal canal probably constructed from penile skin and tissue - this is very useful for access to the uterus and clearing hormone induced menstrual flows. Obviously there are no ovaries and the uterine tubes have been truncated. After surgery there would be a c.12 week recovery period and the patient would require immunosuppressant drugs so that her body wouldn’t reject the new organ. The patient may need to wait a year before doctors will risk transplanting embryos into the new uterus, carefully prepared with hormones. If all goes well, the patient will become pregnant and carry her baby to term, for birth by C-section. Transwomen Still Face Major Obstacles It is quite possible that somewhere in the world a transsexual woman is pregnant or has already quitely given birth. There is certainly no shortage of candidates, but they face huge non-medical problems. As noted at the top this page, the most significant problem is probably the out-dated Montreal Criteria. Another problem is time. After she married in 2007, South Korean singer and transwoman Harisu frequently expressed her desire to have a baby. In 2015 she was accepted for a uterus transplant by the Daejeon St. Mary's Hospital in Seoul but as she progressed through the program her husband became concerned about the risks, whilst she eventually decided that spending a year or more in hospital or under close medical supervision was simply not practical or affordable for her.
The next problem is cost. Uterus transplants are only just moving from research to mainstream, and as such are still being hugely subsidised. If and when uterus transplants start to become an accepted medical procedure, few public health services or health insurance policies are likely to cover the high cost. The UK's NHS estimates that a uterus transplant will cost about £50,000, however the total medical costs for a transgender woman going from uterus transplant to pregnancy and birth could easily be £500,000. Pregnancy for transgender woman could become the privilege of those with substantial personal wealth or a rich husband. The shear cost of treatment has made the UK a strong contender in the unofficial race for the first MTF transgender mother as in recent years the NHS has greatly increased funding for gender identity treatment. On 15 February 2019 the Daily Mail newspaper published an article with the title "UK surgeons could be the first in the world to transplant a womb into a transgender woman who was born male." The article claimed that “Experts investigating whether the procedure is possible for those who have switched sex to female are convinced it is not only medically feasible but ethically justified." Apparently a surgical team at the Imperial College Oxford University has been given ethical approval for 15 womb transplants on infertile women and is seriously considering several requests to be included by transgender women. Christopher Inglefield, founder of the London Transgender Clinic, is quoted as saying "the procedure [for transgender women] is essentially identical to the one performed on women .. and it's important for trans females to be able to carry their own child."
Part 2 of "Transsexual
Pregnancy"....
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