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 great 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 using traditional nomenclature - which I'm very reluctant to change. The stress of being infertile, unable to get pregnant, not able to have babies negatively affects the mental health of tens, if not hundreds, of thousands of transwomen around the world. For example, a 26-year-old transwoman in the USA with two adopted children was reported by the New York Times as: "craving to become pregnant ... I want the morning sickness, the backaches, the feet swelling. I want to feel the baby move. That is something I’ve wanted for as long as I can remember."
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 possibility for transsexual women who are prepared to undergo the required supportive hormone treatment and surgery.
Two potentially viable medical approaches were long ago identified for transsexual women seeking to bear a baby - an ectopic pregnancy and a uterus transplant. Both are discussed below, however the later has emerged as by far the most practical - the first baby was born by a cis-woman using this technique in 2014. By late 2021 there had been about 90 successful uterus transplants worldwide, and over 50 babies had been born as a result. The procedure is now moving from an experimental surgery to "just" major surgery. A strong sign that the uterus transplant procedure is becoming mainstream is that medical insurance policies are starting to explicitly exclude a uterus transplant procedure on the grounds that is not a life-saving procedure.
The Female Reproductive System Before going any further it is necessary to consider the primary sexual organs needed to become "pregnant". The internal reproductive organs of a genetically XX woman include:
Additionally, women have a unique secondary sexual characteristic that for a million years was critical to the survival of a baby after birth - their breasts can lactate milk. The Reproductive System of TranswomenWhen high-quality gender confirmation and other feminisation surgery using modern techniques is combined with hormone treatment, the resulting external appearance - including the vulva - of many young XY male-to-female (MTF) transwomen is indistinguishable from that of a cis-woman at their peak fertile of age 20-30. However, their neo-vagina does not lead on to a cervix. Indeed, the cervix, uterus, ovaries, fimbria and fallopian tubes are all missing. The reality is that she lacks the internal organs required to become pregnant.
The internal anatomy of a XX woman (left) compared with a XY
transwoman after gender
There is currently no possibility that a transsexual women can be
given the very complicated reproductive apparatus of a fertile
woman. Whilst the transplant of some individual organs (e.g. a
heart or liver) has been possible for decades, the development or
transplant of all the required organs and then establishing
ovulation, periods and fertility is still far beyond the current
state of medical science.
Theoretically a dramatic hormonal and micro-surgery intervention on
an embryo with male XY genes might result in the development of a
baby with internal female sexual organs, but there is no obvious and
ethical reason for doing this.
On a slightly more positive note, many young transwomen achieve
reasonable breast development and there are an increasing number of
reports of transwomen lactating and even
breast feeding.
Ectopic
Pregnancy For many years an ectopic pregnancy - the development of
the baby outside the uterus (womb) - seemed to be the most likely
procedure for transgender women as it was medically simple because no
transplants were required. The technique involves attaching the foetus (the term used
for developing babies under 8 weeks from conception) to the muscles inside
the woman's abdomen, or an artificial womb formed 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.
Unfortunately there are two big problems with the ectopic
procedure: Natural occurrences of ectopic pregnancy do a occur,
however they are considered very dangerous to the mother. By 2010 interest in this procedure had faded because of
the risks that it involves for the patient, and the advances being with
uterus transplants. Uterus Transplants The possibility of uterus transplants dates back the origins sex-change surgery in the 1930's. 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 were developed, or until advances in cloning or genetic engineering allowed the growth of female reproductive organs such as a uterus that were not "foreign" to the patient. However, in the 1990's the concept of a short-term (one to two years) uterus implant purely to bear a baby emerged, creating what effectively became a competition for the first successful pregnancy via this technique. A paper published in the International Journal of Gynaecology and Obstetrics in March 2002 reported that that doctors in Saudi Arabia had performed the world's first womb transplant. The operation was on a 26-year-old cis-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 initially deemed a success by the 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 menstrual periods before it had to be removed. Researchers then 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.
On 18 September 2012 the Uterus Transplant Project at the Sahlgrenska University Hospital Women's Clinic in Gothenburg announced their latest advance, stating that:
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. The procedure has thus become an established medical treatment and by 2023 about 20-25 hospitals around the world were regularly performing uterus transplants.
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.
Transwomen
and the Montreal Criteria There are no substantial medical reasons preventing the uterus transplant technique being used for a genetically male transsexual woman. 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. 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." In early 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 February 2023 an article by Dr Flyckt and her colleagues at the Cleveland Clinic 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".
Dr
Brännström
says
that it
might be
possible
to
transplant
a womb
into
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."
He is
refering
to 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 a
widely
accepted
ethical
standard,
the
Montreal
Criteria
has
become
controversial
as it
prevents
transwomen
having a
uterus
transplant.
However, there seems to be no likelihood that the criteria will be amended in the near future, so any surgeon or hospital conducting a uterus transplant on a transwoman will be on a risky solo run. A further problem in the UK is that 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. The Uterine Transplant Procedure for Transwomen For a transsexual woman absolutely determined to start a family, a uterine transplant 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. 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. 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. The likely procedure is now very clear:
T he 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.
Pregnancy via the implant procedure
These images of Argentinean television celebrity Florencia de la Vega (Flor) provide a look into the near future. She was born Roberto Carlos Trinidad in 1995 and transitioned age 16. She thereafter worked as a showgirl and TV actress, and probably had SRS in 2010. 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 shows Flor with the newborn twins whilst inside there was a carefully posed picture with her belly emphasised, which could easily be mistaken for showing her pregnant. Whilst the supporting article repeatedly referred to Flora as the twins mother, it never explicitly states that she had been pregnant and given birth to them. In fact the twins are the result of her husband's sperm impregnating a surrogate mother. The magazine continues to regularly feature Flor and her children.
A transwoman lacks the
ovaries needed to produce an ovum containing her genes,
and more specifically 23 of her chromosones. Thus until the
2000's the primary method for a transwoman to gain a baby
was having the egg of a
surrogate mother being fertilised by sperm from her husband or
partner, and the resulting baby being adopted after its birth.
Clearly this approach is somewhat unsatisfactory for the transsexual
woman as she has no genetic relationship with her baby.
Also, for many years
there has been speculation about potentional new options which use a
cloning technique called "membrane fusion" to create a fertilisable egg.
A surprisingly simple technique has now emerged.
Basically a woman donates an ovum egg. The nucleus, containing
this woman's DNA, is removed, and a nucleus with genes (including two
paired sets of chromosones - totally 26) extracted from one of the
transwoman's skin cells is put in to its place. The ovum realises that
it has too many chromosones and discards half of them, thus creating an
unfertilised egg with just one set of 13 chromosomes. Using
standard IVF tchniques the new ovum can then be fertilised by the
father's sperm and implanted in to the uterus of a surrogate moter.
Both the mother and her husband/partner will have a a normal 50% share
of the baby's gene's.
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. Over 20 years later it's clear that all
the major medical barriers have now been overcome. Indeed, it is
quite possible that somewhere in the world (most probably in Brazil) a
transwoman has already quitely given birth. However, transwomen still face significant barriers to
having a baby. As noted above, the most significant problem is the
out-dated Montreal Criteria. Another problem is time and risks.
For example, after she married in 2007, 32-year-old 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 increasingly
concerned about the risks his now 40+ wife faced. She eventually
accepted that spending a year or more either in hospital or under close
medical supervision was simply not practical 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. Although uterus transplants are starting to
become an accepted medical procedure, few public health services or
health insurance policies are likely to cover them due to the very high
cost, indeed health insurance policies are starting to specifically
exclude it. The UK's NHS estimates that a uterus transplant
procedure will cost about £50,000, however the total medical costs for a
transgender woman going from uterus transplant to pregnancy and finally
birth could easily be £500,000.
Pregnancy for transwomen seems destined to be privilege reserved for
those with a substantial personal wealth or a rich husband.
Part 2 of "Transsexual Pregnancy"
(c) 2000 -
2024 Annie Richards Please send any comments, feedback or additions to:
Last updated: 17
February, 2023 |