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Transwomen Pregnancy
[Part 1]

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.

Medical advances have transformed the lives of transsexual woman since the 1950's.  Hormones provide huge physical and mental benefits, whilst advances in Sex Re-assignment Surgery techniques make it difficult to distinguish the vulva (external genitalia) of a genetically XY male-to-female (MTF) transsexual women from that of a XX women.  An 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, a 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. 

Infertility stress affects tens, if not hundreds, of thousands of transwomen around the world. 

 


Caption: "I've just got a text saying I've been accepted by the university's uterus transplant programme.  I might be the first transwomen to have a baby!"

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 a 'now or never' point for women who want to have children, and 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 or Brazilian MTF transsexuals typically  transition in their early 20's (median age) and very few have sired any children before having SRSBy comparison, in the early 2000's the median age of European MTF transsexuals was late 30's or early 40's - and the majority had been married at least once, and most of have genetically related children via a wife who's a cis-woman.


A study found that transsexual women are as likely to have reproductive dreams and daydreams as any other women.

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.


Famous models and actresses often flaunt their pregnancy in the media
- unfortunately causing distress for some infertile women



Ayana Tsubaki and Jenny Hiloudaki - post-SRS transsexual women 'photo-shopped' as pregnant for  advertisements. 

Some transwomen - typically those who transitioned at very young age (as is becoming increasingly common) - experience extreme broodiness, jealousy of pregnant women, anger at the "unfairness of life" and even clinical depression.  Seeing other women having children or even worse complaining about their fertility and worse seeking abortions is often hard to bear.  One very frustrated British male-to-female (MTF) transsexual in her 20's said "I just want to be a Mum ... with a pile of kids". The denial of the basic female right to have children and enjoy the wonderful and unique experience of motherhood is a tragic loss for these women - as it is for all infertile women.

Until 2000 the idea of a genetic male (XY) being pregnant with a baby was still in the realm of  science fiction, but since then huge advances in female fertility treatment have made it a real possibility for transsexual women who are prepared to undergo the required supportive hormone treatment and surgery. 


Transgender woman Nicole Ferri, faking being pregnant in a short movie.

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.

 

The Montreal Criteria

No transwoman has yet had a successful uterus transplant and become pregnant - at least publically.  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:

“A woman who is born without a uterus and a man who transitions into a woman because of gender dysphoria have a similar claim to maternity if we consider them to have equivalent rights to fulfil the reproductive potential of their gender.  While still theoretical, it appears that implantation of a donated uterus and gestation in the body of a transgender individual should pose no physiological barrier if various conditions are met."


Female Reproductive Organs

Before going any further it is necessary to consider the organs needed to become "pregnant".

The internal reproductive organs of woman include:

  • Ovaries - two glands that produce certain hormones and contain tissue sacs in which eggs develop
  • Fallopian tubes - two muscular channels that connect the ovaries with the uterus
  • Fimbria - finger-like projections at the opening of the fallopian tubes which sweep an egg released from an ovary into the tube where it can be fertilised by sperm before passage in to the uterus 
  • Uterus (womb) - a hollow, muscular structure where a fertilised egg may settle and grow in to a baby. 
  • Cervix - the lower part of the uterus that separates the body of the uterus from the vagina
  • Vagina - a muscular passage that connects the cervix with the external genital organs - one of which is a sensitive mound of tissue called the clitoris.  A penis will penetrate the vagina to deposit sperm at the entrance to cervix - from where ever smaller numbers swim onwards...

Additionally, women have a unique secondary sexual characteristic that million's 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 Transplantation

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.

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 who who used as an organ donor (a 'cadaver' in medical terminology), also a recent development is possibility 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 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. 

 

A Brief History of Uterus 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 was 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 Caesaeran.  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." 


In reaction to news that womb transplants may be imminent, a Hungarian newspaper worried about doctors conducting unnecessary hysterectomies in order to sell the uterus, and "girls from the Hungarian countryside selling their wombs to rich yuppies from New York".  Akció means 'for sale (special offer)'.

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. 

However the next millstone 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 Derya Sert

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:

A team of researchers at the University of Gothenburg performed the world’s first mother-to-daughter uterus transplantation. The procedure was completed without complications. ...  On September 15-16 [2012], a team of researchers, physicians and specialists from the University of Gothenburg performed the world’s first mother-to daughter uterus transplantation, when two Swedish women received new wombs donated by their mothers.  ...The first patient had her uterus removed many years ago because of surgery for cervical cancer; the other patient was born without a uterus.  Both women, who are in their 30s, have undergone IVF-treatment well before transplantation. ... The aim of the uterus transplant research project is to enable women who had their uterus removed at a young age due to cervical cancer or who were born without a uterus to receive a new womb through transplantation"

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.


Malin Stenberg decided to go public about her experience when her son, Vincent, reached one year old.  She wanted to tell her story to give hope to others in the same situation.

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. 

On 5 October 2014, one of these women - Malin Stenberg - become the first in the world to have a baby after having a womb transplant.  The 36-year-old mother, who was born without a uterus, received a donated womb from a post-menopause 60-year old friend in 2013.  Professor Brannstrom described the birth as a moment of "fantastic happiness".  Two further women had given birth by the end of November 2014.

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 Cesarean 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.


Jessica Alves

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.


It's rumoured that several Brazilian transwoman have had uterus transplants.
In late 2021 there were media reports that Jessica Alves, a Brazilian transgender woman age 38 who has already had extensive feminisation surgery (including GRS in February 2021) was planning uterine transplant surgery in the hope that she could bear a child.

 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 dubious procedure is speculated to be about £30,000 or $45,000. 


Lab-Grown Vagina's

The photos show a uterus 'scaffold' being built, cells incubated, and muscle cells being attached to the growing womb before another incubation and eventual implant.

Another 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:

  1. Scans of the woman's pelvic region were used to design a tube-like 3D-scaffold for the patient.
  2. A small tissue biopsy was taken from the poorly developed vulva and grown to create a large batch of cells in the laboratory.
  3. Smooth muscle cells were attached to the outside of the scaffold and vaginal-lining cells to the inside.
  4. The vaginas were carefully grown in a bioreactor until they were suitable to be surgically implanted into the patient.

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 real possibility.  The technique seems to be totally 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.

 

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.


Hayley with her two new-born babies, Darcey and Avery, whom she breast feeds.

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 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 then tried to contact Halley directly but she and her family had disappeared from social media by mid-2015 and I couldn't find any way of doing this.  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, but she may well suffer from another medical condition.  As such I extend my congratulations to her and her husband on the birth of their twin babies - presumably now school kids!  

 

Ectopic Pregnancy

Ectopic pregnancy - the development of the baby outside the uterus (womb) - is another possible approach for transsexual women seeking to become pregnant.  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 had faded significantly since 2000 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.

preg-man.jpg (18157 bytes)

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. 

preg2.jpg (7937 bytes)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:

  • Firstly, there is a severe risk of a massive haemorrhage (copious bleeding from damaged blood vessels) when the ectopic ruptures; this is actually the most common cause of women dying in pregnancy.
  • Secondly, if the foetus is implanted in a place where it can thrive without killing the mother, then it can grow to the point where it is a viable baby and can be delivered surgically.  However, this leaves the big problem of what to do about the implantation site.  While the uterus is designed to cope with the eight-inch wound left when the placenta separates; other organs have no mechanism for helping the placenta to separate and then contracting around themselves to stop the bleeding.  Current medical practice with genetic women is to cut the umbilical cord close to the placenta and leave it inside the uterus.  If all goes well, it will eventually shrink and be reabsorbed, however with transsexual women there would be a serious risk of infection and other complications with this approach, and surgical removal may be the marginally better option. 

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
Assuming the mother and her medical team have determined that the risks are acceptable, the exact process for an ectopic pregnancy is:

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Step 1: Hormones
Suitable doses of female hormones are administered to make the transsexual woman receptive to the pregnancy.

Step 2: Implantation
IVF (in vitro fertilisation) techniques are used to obtain and fertilise egg(s), and then induce an ectopic pregnancy by implanting an embryo and its placenta into the abdominal cavity, into or just under the peritoneum.  The peritoneum is the smooth serous membrane which lines the cavity of the abdomen, it surrounds the large interior organs and forms a nearly closed sac.

Step 3: Embryo Growth
Once implantation is complete and the embryo is established, hormone treatment can be reduced because the pregnancy itself will take over.  The embryo secretes sufficient hormones to maintain its own growth and development.

Step 4: Growth of the Foetus
The foetus will be carefully monitored during its development, i.e. foetal heart monitoring, chronic villus sampling, ultrasound scanning, and a constant watch kept over the mother's health.

Step 5: Delivery
The delivery will requires open surgery (Caesarean section) to remove the baby and the placenta. Removal of the placenta is the real danger because it forms such intimate connections with surrounding vessels that a massive haemorrhage is likely.   Implantation may have also involved other structures in the abdomen, including the bowel and it is possible that parts of other organs may need to be removed.

 


Hormone levels in a woman during pregnancy, after steadily building up for 9 months,
progesterone and oestrogen levels drop precipitously after the birth.

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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.

preg6.jpg (11586 bytes)However, there are several other options that a transsexual woman can take in order to be genetically related to her baby:

  1. If possible, before sex re-assignment surgery, she could have a sperm sample frozen, indeed nearly half of MTF transsexual patients now make this provision before their SRS.  The unfrozen sperm could then be used to fertilise a donated ovum (egg) from an unrelated woman.  The mother would then have normal 50% shared genes with the baby, but unfortunately the husband/partner would have no genetic relationship unless the ovum came from a close female relative such as a sister.
  2. If no sperm sample is available, then the transsexual's sister or even her mother could donate an ovum for fertilisation by the father - in this instance the transsexual mother will share 25% of her babies genes, and her husband/partner a normal 50%.

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:

  1. An unrelated woman donates an ovum.  The nucleus, containing this woman's DNA, is removed, and an "X" bearing nucleus from one of the transsexual woman's sperm (again frozen from a sample taken before SRS) is put in to its place, creating an unfertilised egg.  The new ovum can then be fertilised by the father's sperm and both the mother and her husband/partner will have a normal 50% share of the baby's gene's.

    Several research teams have reported successes in creating such reconstituted or "hybrid" human eggs, although none have [publicly at least] so far been fertilised for legal reasons - indeed there is a real possibility some countries will make this type of research illegal. 

  1. An unrelated woman donates an ovum.  The nucleus, containing this woman's DNA, is removed, and a nucleus with two sets of chromosome from one of the transsexual woman's cells is put in to its place.  Half the genetic material is removed, creating an unfertilised egg with just one set of chromosomes.  The new ovum can then be fertilised by the father's sperm and both the mother and her husband/partner will have a normal 50% share of the baby's gene's.

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1. Nucleus from a cell of the transsexual woman is removed and transplanted into a donor egg cell from another woman.
2. The hybrid egg cell which now contains the genes of the transsexual woman is fertilised by sperm from her partner.
3. The transsexual mother is implanted with the embryo, becomes pregnant and eventually gives birth.

And finally, the most advanced and technically challenging option of all:

  1. Human embryonic stem cells are developed in the laboratory into primordial germ cells, a form of cell that can subsequently become follicle eggs (or sperm).  This approach potentially allows an engineered egg to produced from a transsexual woman.  Research with mice has confirmed that the first steps are possible, although many obstacles remain.

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 in to 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?
 

These images of Argentinean television celebrity Florencia de la Vega provide a premature look in to the near future. 

In early 2011 she married Pablo Goycochea, age 36.  Soon after, in August 2011, they announced the birth of twin babies - a boy and a girl.  The front cover of Gente magazine showed Flor de la V (her stage name) with the newborn twins whilst inside there was a carefully posed picture, undoubtedly aided by some Photoshop editing (but perhaps no more than is routinely applied by magazines) that apparently showed her pregnant.  Whilst the supporting article repeatedly referred to Flora as the twins mother, it never explicitly stated that she had been pregnant and given birth to them.  As shown (right), the magazine has since published numerous additional articles following the family as the children grown up. 

What Gente never mentioned was that Flor had SRS in 2010, The twins are the result of her husbands sperm impregnating a  surrogate mother.  In 2014 Flor was out'ed by a journalist as beng a transgender woman, although this had been widely speculated on the Internet for many years.  Flor subseqently stated that she considers herself to be a male transvestite rather than a transsexual woman, which supports some controversial theories.

 


Jennifer Dinge (USA) was born without a uterus due to having MRKH syndrome.  But after a uterus transplant in 2016 she successfully had two babies.

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."

Chelsea Jovanovich after a 12-hour uterus transplant operation in February 2020 at the University of Pennsylvania, USA. She gave birth to a baby boy, Telden, in May 2021.

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.


This graphic shows a rather optimistic surgical transformation from physically male to a post-GRS transwomen with a uterus.

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".... Beauty - Part 2
 


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Last updated: 17 February, 2021