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. 

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 - 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:

• 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 into the uterus 
• Uterus (womb) - a hollow, muscular structure where a fertilised egg may settle and grow into 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 male penis can penetrate the vagina to deposit typically a hundred million sperm at the entrance to cervix - from where an ever smaller number swim onwards seeking an egg that just one can fertilise.

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.

When 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
confirmation surgery.  Clearly the latter is missing many of the organs essential for
pregnancy, with the neovagina not leading to a uterus.

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.

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.

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.

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 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 foetus.  Also, the drugs would not need to be taken for life, which might result in undesirable long-term side-effects.  After the woman has had her children, the transplanted womb could be removed.  

Mrs Derya Sert

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.   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.  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, would be inserted into her womb.  However no further information was ever published, so presumably a problem sadly occured.

On 18 September 2012 the Uterus Transplant Project at the Sahlgrenska University Hospital Women's Clinic in Gothenburg announced their latest advance, stating that:

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"

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 revealed that the Gothenburg team had now conducted nine womb transplants on women who were born without a uterus or had it removed because of cervical cancer.  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" (so oddly not a relative).  Dr (now Professor) Brannstrom described the birth as a moment of "fantastic happiness".  Two more of the women had given birth by the end of November 2014. 

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.
 

A pre-requisite for a uterus transplant is a donors womb.  A Hungarian newspaper claims that  "girls from the Hungarian countryside are selling their wombs to rich yuppies from New York".  Akció means 'for sale (special offer)'.

The Uterus Transplant Procedure

 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."

After her GCS surgery in February 2021, 38-year old Jessica Alves claimed that she was having a uterus implant procedure in Brazil.

On 15 February 2019 the Daily Mail newspaper quoted Christopher Inglefield, founder of the London Transgender Clinic, 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."

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".  

It's rumoured that several Brazilian transwomen have received uterus transplants.

However, as of 2024 no transwoman has had a successful uterus transplant and become pregnant - at least publicly.  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, possibly even including uterus transplants. The cost of this risky and very dubious procedure is rumoured to be about $45,000, including a payment of just $10,000 to the uterus donor.

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. 

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

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."

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:

• 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 gestation, depending how well the pregnancy is progressing. 
• The uterus is then removed or a second and final pregnancy is induced. 

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 possible 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 fertilise an egg provided  by a sister.

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. 

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

Pregnancy via the implant procedure
Assuming that the mother and her medical team have determined that the risks are acceptable, the key steps are thus:

Step 1: Uterus transplant
The uterus of a donor is transplanted into the abdomen of the transwoman,  Ideally this will be from her monther or a sister. Drugs are prescribed to help prevent rejection.

Step 2: Hormonal Preparation
After a few months of healing, hormones are administered to simulate periods and make the uterus receptive to pregnancy by growing a endometrial lining, also known as the uterine lining, in preparation for an embryo.

Step 3: In Vitro Fertilisation
IVF techniques are used to fertilise eggs, which are then inplanted into the hormonally prepared uterus with the hope (perhaps one chance in three) of a pregnancy then resulting.

Step 4: Establishment of the Foetus
If a pregnancy does result, the first trimester is critical, with a high probability of a miscarriage.  The developing foetus will be carefully monitored development, i.e. foetal heart monitoring, chronic villus sampling, ultrasound scanning, and a constant watch kept over the mother's health.  Once the embryo is established, hormone treatment can be reduced because the pregnancy itself will take over.  The plaventa and embryo secrete sufficient natural hormones to maintain growth and development.

Step 5: Growth of the Baby
Self evidentally this step involves the development of the baby.  The mother typically becomes aware of its movements between 16 and 24 weeks of pregnancy.

Step 6: Delivery
The delivery will require surgery (Caesarean section) to remove the baby and also the placenta.  Manual removal of the placenta is essential as a natural "afterbirth" is improbable, even if the uterus has been connect to the neovagina.

Step 7. Uterus Removal
Unless the implanted uterus has an exceptional tissue match to the patient (typically because it was donated by a mother or sister) and there are also no indications of rejection, it will need to be removed after 2-3 years. A maximum of two preganancies is thus possible.

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.

Genetic Parentage

Anne Jakrajutatip is a transwoman and the mother of two children conceived with a suurogate German woman using her sperm taken just before her SRS age 39.

For perhaps a millions of years, human embryos have always been formed by the union of a sperm (supplied by a gentically 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 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.

Many transitioning transwomen now freeze a sample of their sperm before "bottom surgery".  This can later be used for IVF.  Pictured are Taylor Vanmalsen, her cis-female partner Sarah, and their baby Valerie.

However, there are now several options that a transsexual woman can take in order to be genetically related to her baby - whether born by herself or a surrogate mother.  These usually involve having frozen a sample of sperm before gender confirmation surgery.  A few examples include:

1. The most extreme option is that unfrozen sperm is used to fertilise a donated ovum (egg) from her mother or a sister.  The transwoman would then potentially share an extraordinary 75% of her chromosones with the baby.  This option is ethically dubious, but few countries currently have laws that address this possibility. 
2. Unfrozen sperm is used for IVF to fertilise the egg of a female partner.  They will both have the normal 50% shared chromosones with the baby.
3. Unfrozen sperm is used to fertilise a close female relative of her husband/partner - such as a sister or even mother.  The transwoman would then have normal 50% shared chromosones with the baby, and her husband/partner 25%.
4. The transwoman's sister or mother donates an ovum for fertilisation by sperm from the father and gestation by a surrogate - in this instance the transsexual mother will share 25% of her babies genes, and her husband/partner a normal 50%.

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. 

 

 

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

Transwomen Still Face Major Obstacles

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"
 

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Last updated: 17 February, 2023