Forty-five years after the world’s first “test-tube baby” was born, surgeons are preparing for another historical first: transplanting a womb inside the body of someone born male.
Several teams are “actively working” to make uterine transplants for transgender women a reality, according to an article published in the medical journal Fertility and Sterility, with the first such procedure likely to happen “within the next few years, if not sooner.”
A team at Ohio’s Cleveland Clinic, the first in North America to transplant a uterus from a dead donor into a woman born without one, authored the paper.
If the anatomical challenges in transgender women can be overcome — and surgeons have said none seem insurmountable — uterine transplants would make it possible for trans women to gestation and give birth to a child.
The baby would be delivered by caesarean section.
In some cases, the donor womb might come from a transgender man — someone who was born female who is transitioning to male and who no longer desires a uterus.
Others have sketched a hypothetical but plausible case in which a transgender woman who underwent a uterine transplant carrying a pregnancy conceived with her own previously frozen sperm — raising ethical and legal issues regarding what “parental title” she should be given. mother? Father?
“It appears that (uterus transplantation) in transgender female patients will soon become a reality, and so we must pre-emptively plan for the challenge that these parents will face,” a team from Temple University Hospital’s plastic and reconstructive surgery program wrote last May .
“De-gendering” legal parenthood, they said, “may be the simplest and most ethical solution.”
If there is no clear purpose or benefit for designing a parent as a mother or father, then why do we need it at all?
Temple University Hospital’s plastic and reconstructive surgery program
“If there is no clear purpose or benefit to designating a parent as a mother or a father,” the Temple group wrote, “then why do we need it at all? The ultimate goal should be to provide a child with unconditional love and care from their guardians, regardless of gender or title.”
The issue is sensitive and controversial. Some have called uterus transplants for trans women a “dystopian biological experiment.” Others have argued that the procedures would allow trans women to attain “body-completeness through having a key female reproductive organ.”
At least 80 womb transplants have been performed in over 10 countries (excluding Canada) worldwide since the first baby was born following a uterine transplant in Sweden in 2014. More than 35 healthy babies have been delivered.
Bioethicist Gwendolyn Quinn said trans women should deserve equal access to a medical procedure offered to other women. “If this is something that’s available to humans, it should be available to all humans,” said Quinn, a professor at New York University School of Medicine and a member of the American Society of Reproductive Medicine’s ethics committee.
But from a philosophical, and feminist, perspective, she finds uterus transplants in general “really troubling.”
There are many cis-gender women who don’t have a uterus but they’re still women
“Is that what makes us women, having a uterus? There are many cis-gender women who don’t have a uterus but they’re still women,” she said.
“Woman is an identity that you hold,” Quinn said. “Having gender affirming treatment doesn’t make you genetically female. You’re still an XY person, you’re not XX.” However, transgender women are women, she said, regardless of whether they obtain gender affirming treatment.
The first womb transplants followed more than a decade’s worth of research and experiments on first mice, sheep and pigs, and later baboons. The marathon operations take 12 hours or more to retrieve the donor wombs, either from a brain-dead donor or a living donor, as well as the blood vessels attached to the sides of the uterus, and to stitch the organs into a recipient.
It’s considered the first-ever cure for absolute uterine factory infertility, or AUFI. Women are born without a uterus, or with a uterus unable to sustain a pregnancy. Others lose their uterus after undergoing a hysterectomy for tumors or other life-threatening problems.
Canadian doctors were among the first to publish an ethical framework that helped move womb transplants from experiments in animals to humans. The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation stipulated that the recipient be a “genetic female” of reproductive age.
But others argue that excluding trans women violates their right to gestation, and that a biological male who identifies as female could arguably have uterine factor infertility that’s no “functionally different” than a female who can’t get pregnant because she lacks a uterus, or a functioning one.
The narrower male pelvis isn’t made to give birth to a child. But Dr. Alireza Hamidian Jahromi, director of the Gender Affirmation Surgery Center at Temple University Hospitals in Philadelphia, said “everything that you need for a successful uterine transplant is present in transgender women, too.”
They have similar vascular anatomy. Both men and women have iliac arteries that carry blood to the lower extremities, including the reproductive organs in the pelvis. The donor womb, with its attached blood vessels, could be connected to vessels in the trans woman’s pelvis.
It would require a vaginal passage, usually constructed during gender-affirming surgery. Artificial hormones would be needed to mimic the proper hormonal environment. Pregnancy could be achieved by transferring an embryo created via IVF. If a trans woman has stored sperm, she can use it to fertilize a donor egg.
Normally, uterus transplants are temporary, the organs are removed after a maximum of two children, so that women don’t have to stay on anti-rejection drugs for life. But some trans women, write the authors of the Fertility and Sterility editorial, may wish to keep their transplanted uterus indefinitely for “enhanced gender alignment.” The risk-benefit ratio, they said, “is unclear and potentially worrisome.”
One study found that more than 90 per cent of 182 transgender women surveyed felt a uterus transplant would lead to greater happiness, “enhance feelings of femininity and alleviate (gender) dysphoric symptoms.”
“Most did not have children prior to transitioning and expressed a desire to have children in the future,” the authors wrote.
Others have reported that a high proportion of transgender males undergoing a hysterectomy as part of their own gender-affirming surgery would be interested in donating their otherwise healthy uterus to infertile women.
Quinn said many women would empathize with a trans woman’s “long and desire to experience pregnancy.”
But there’s a level of medical danger, she said. Multiple attempted transplants have failed after the woman’s body rejected the donor uterus. “People have lost circulation in their legs and had to have the uterus removed so they didn’t lose their legs,” Quinn said. “There have been a lot of adverse outcomes that the public doesn’t know about.”
There are other ways of being a parent besides giving birth, she said, including adoption or using a surrogate.
Hamidian Jahromi, of Temple University, said part of feeling feminine for a transgender woman “has been the capability of becoming pregnant, and having their own biological child.
“That’s part of what makes a woman a woman, although I appreciate not every cisgender woman wants to be pregnant or have a baby. But this is the right they have.”
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