"I just want to have a baby..."
Medical advances have transformed the lives of transsexual woman over the last 50 years. Hormones provide huge physical and mental benefits, whilst surgery can provide effective female genitalia that permit a normal sex life - other than pregnancy.
With the advance of Sex Re-assignment Surgery techniques, it has become increasingly difficult to distinguish the vulva (external genitalia) of a genetically XY male-to-female (MTF) transsexual women from that of a XX women - in some cases an intimate medical examination is needed. Some transsexual women now lead their lives without their sexual partners and even husband ever suspecting that they have had sex re-assignment.
Nevertheless, transwomen cannot bear children due to their lack of internal female reproductive organ. A transsexual women seeking to have children and be a mother faces even more barriers than a genetic XX women in relation to adoption, or the use of a surrogate mother. Fortunately it seems that few transsexual women have a great desire to bear children - but there is probably a huge bias to this. For example, very few Thai or Brazilian MTF transsexuals (typically transitioning in their early 20's) have been married or sired any children before having SRS. By comparison, more than half of European transsexuals (with a typical transition age in their late 30's or early 40's) have been married at least once, and most of these have had children.
However some transwomen - typically those who transitioned at very young age - experience extreme broodiness, jealousy of pregnant women, anger at the "unfairness of life" and even clinical depression. The denial of the basic female right to have children and enjoy the wonderful and unique experience of motherhood is a tragic loss for some transsexual women - as it is for other infertile women. 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 MTF transsexual still her 20's said "I just want to be a Mum ... with a pile of kids".
However, the situation may eventually improve. ntil 2000 the idea of a genetic male (XY) being pregnant with a baby was still in the realm of science fiction, but since then advances in female fertility treatment have made it a real possibility. In addition, transsexual women have the huge advantage that they are prepared to undergo the vital supportive hormone treatment and surgery. We are now just waiting for the first transwoman to give birth - assuming that someone desperate enough and rich enough hasn't quietly done so already. At the moment there seems to be two possible approach's - uterus transplant or ectopic pregnancy. The former seems far more likely, but both are discussed below.
Female Reproductive Organs
Before going any further it is necessary to consider, very briefly, what are the internal female reproductive organ?
The normal female reproductive organs include the 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), the cervix (the lower part of the uterus that separates the body of the uterus from the vagina), the uterus (a hollow, muscular structure), the ovaries (two glands that produce certain hormones and contain tissue sacs in which eggs develop), and fallopian tubes (two muscular channels that connect the ovaries with the uterus). Finger-like projections called fimbriae (located at the opening of the fallopian tubes) sweep an egg released from an ovary into the tube where it can be fertilised by sperm before passage in to the uterus (womb) where it may settle and grow in to a baby. Additionally of course, women have a unique secondary sexual characteristic that becomes important after giving birth, their breasts.
With a transsexual woman who 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 indistinguishable from other women. However, the neo-vagina does not lead on to a cervix. Indeed the cervix, uterus, ovaries, fimbria and fallopian tubes are all missing. For the foreseeable future it seems impossible 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. Certainly it is possible to transplant individual organs but transplanting ovaries, fallopian tubes, uterus et al - and then establishing ovulation, periods and fertility - would be very major task, if not impossible.
The most promising approach that could allow a transsexual woman to become pregnant is a uterus (aka womb) transplant. The uterus is the womb in which a baby normally forms and grows, and IVF is now commonly used to implant fertilised eggs in a woman's uterus. Because no other organs are transplanted, the chance of success is significantly increased. The baby will have to be delivered by Caesarean section because the transwomen 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.
A huge medical effort is currently being undertaken to successfully a transplant a uterus into to a genetically female woman for fertility reasons, there is no reason why the same cannot be done for a genetically male transsexual woman.
For the transsexual women 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 is the person who takes the health risks with every pregnancy.
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 to go 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 be reduced by taking large quantities of 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.
A paper published in the International Journal of Gynaecology and Obstetrics in March 2002 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.
The Saudi approach has been avoided since while researchers sought better ways of "plumbing" in the transplanted uterus. In June 2003 a Swedish Team led by Dr Brännström of Sahlgrenska University in Gothenburg, told a "European Society of Human Reproduction and Embryology Conference" in Madrid that a better approach has now been found. In the new technique 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 be attached to the vagina and to the round and sacral ligaments to hold in place, but not to the Fallopian tubes. This means that 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 is considered simpler and less risky than most other transplant operations as no major blood vessels or vital organs are involved.
The donated womb would have to come from a woman with a close genetic match to the recipient in order to minimise the chance of rejection, as the womb does not deteriorate greatly from age it could come come from a post-menopausal woman. According to Dr Brännström "It could well be a relative. You could get it from your mother. You could give birth to a baby from the uterus that you yourself were birth from." Patients would need to take immunosuppressant drugs to help stop their body rejecting the womb, but researchers believe that modern immunosuppressant drugs do not have any negative effects on a feotus. Also, the drugs would not need to be taken for life, which might result in undesirable long term side-effect. After the woman has had her children, the transplanted womb could be removed.
Dr Brännström says that it might be possible to transplant a womb in to transsexual women, allowing them to become pregnant with using donated eggs, though anatomical barriers would have to be overcome. "It should be technically possible, but I don't know if it's ethical. The pelvis of men also is not exactly the same shape as the pelvis of women, and that might pose problems."
Also in November 2006 Dr Giuseppe Del Priore, from New York Downtown Hospital, said he had been given the go-ahead to carry out a womb transplant operation and claimed to have found a number of potential donors. Dr Del Priore said: "It is cautionary approval but it is approval. If the right patient shows up the [hospital] independent review board has stated we could go-ahead. Technically we are capable of doing it. If we had everything in order we could do it tomorrow." However any would-be patient will have to go through months of counselling and tests before approval - including seeing a psychologist and reconsidering adoption or surrogacy, as well as seeing a pregnancy risk specialist and transplant support team. The organ is likely to be sourced from a dead donor who had previously had a child. They would have to have the same blood group and be immunologically matched.
The long race for the first successful uterus transplant and pregnancy reached another small milestone when in October 2009 Dr Richard Smith- a consultant gynaecological surgeon at Hammersmith Hospital in London - claimed that his teams research on animals had “cracked” how to ensure a good blood supply to a transplanted womb.
The Hammersmith team now hope to be able to give women a new womb for long enough to allow them to conceive and give birth. They could use eggs from a donor fertilised by their partner and placed in the implanted uterus. After birth, they would then remove the organ, to reduce the women’s exposure to the high strength immune suppressing drugs most transplant patients have to take all their lives.
However Hammersmith and Gothenburg may have been overtaken in the race by doctors at Akdeniz University Hospital in southern Turkey. On 9th August 2011 they transplanted -in a seven hour operation - a uterus from a woman who had died in a car crash to a genetically XX 21 year old woman, Derya Sert, who was born without a uterus. Micro-surgeon Omer Ozkan, said: "The surgery was a success ... [But] we will be successful when she has her baby. ... For now we are happy that the tissue is living.'
Mrs Sert then spent six months in hospital and was given powerful immunosuppressant drugs to stop her body rejecting the new womb. However her periods started just three weeks after the operation, a signal that the new womb was working well. Scans showed its lining to be healthy - Doctor Munire Erman Akar said "We can see it from the ultrasound that the endometrium lining is perfect", but added that if she did became pregnant "there are many risks like congenital anomalies because of the immunosuppressive (drugs), and intrauterine growth retardation, preterm labour." Lowering the dose of the drugs is critical for Mrs Sert to carry a healthy baby through pregnancy.
The next step will 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, on 18 September 2012 the Gothenburg team announced their latest advance, stating that:
Both donating women started in-vitro fertilisation before the surgery, and frozen embryos could be thawed and transferred to transplanted uterus' if the receiving women are considered in good enough health after a year-long observation period. "We are not going to call it a complete success until this results in children," said Michael Olausson, one of the Swedish surgeons.
Ectopic pregnancy - the development of the baby outside the uterus (womb) - is another promising 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). However it is possible that the first babies with transsexual mothers will be born this way because of the initial simplicity - no difficult transplants of a uterus or other organs.
The technique would involve attaching the foetus (the term used for developing babies under 8 weeks from conception) to the muscles inside the transsexual woman's abdomen, or even fashioning a [disposable] artificial womb from abdominal tissue. Attachment to the bowel, with its good blood supply, is another attractive option, but perhaps the worst in terms of post delivery trauma.
Preliminary female hormone treatment will be vital for supporting and encouraging the foetus' placenta to produce enzymes which then eat into whatever internal organ it is placed on, so that the placenta can attach and tap into the blood vessel to obtain nutrition. The baby will then develop inside the woman's abdomen, and the woman will carry the baby for its full term before giving birth by caesarean section.
Sustaining the pregnancy will require further large amounts of female hormones to be taken, in particular high levels of oestrogen and progesterone must be maintained during the first three month of pregnancy. The feminising effects of these may be a problem for a man who wants to become pregnant but doesn’t wish to develop breasts, but it's hardly a problem for a MTF transsexual woman who takes such hormones every day of her life!
There are though two main catches to this procedure:
There is a real possibility that the mother will require urgent life saving surgery, either during her pregnancy, immediately after the caesarean, or during the recovery period afterwards.
Up until our current time, embryos have always been formed by the union of a sperm (supplied by a XY male) and an egg or ovum (supplied by a XX female). Both the sperm and the ovum provide DNA, but the ovum also provides a “house” in which the embryo grows during the early stages of development. An ovum is therefore absolutely essential for reproduction.
A post-SRS transsexual woman faces two major problems in passing her genes on to a child, regardless of whether this is to be carried by a surrogate mother or [in the future] by the transsexual woman herself. Firstly she lacks her own ovaries to produce ovum containing her genes, and secondly having a baby with her husband or a male partner would involve the genetic union of two males - known as "same-sex parenting".
One method for providing the embryo to be implanted is to obtain an egg from an unrelated woman and have it fertilised by sperm from the husband or partner. But while this method is already occasionally used (the baby being carried to term by a surrogate mother), this approach is unsatisfactory for transsexual woman as she has no genetic relationship with her baby.
However, there are several other options that a transsexual woman can take in order to be genetically related to her baby:
In the next few years there may become available several new and exciting options which use a cloning technique called "membrane fusion" to create a fertilisable egg:
And finally, the most advanced and technically challenging option of all:
Approach 4 is perhaps the most promising in the short- to medium-term. On 5 Sept 1999 the UK's Sunday Times reported a major advance by a team headed by Zev Rosenwaks at the Cornell University Medical Center, New York. They had been able to take immature egg cells from the ovaries of a donor, remove the nucleus (containing the donor's genetic material) and replace it with genetic material taken from an ordinary body cell of another animal. The researchers have found they can reprogramme the DNA genetic blueprint from any living cell to make it behave like an unfertilised egg. The donor egg cell thus acts as an "envelope" for the prospective genetic mother's genetic material. Once the reconstituted egg cell is mature, it could be fertilised in the laboratory using IVF techniques and the embryo then implanted 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 (as of June 2002) that the increasingly common animal clones are 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.
NursingThe female hormones taken by transsexual women induce breast development ranging from the slight to full. Typically their breasts are smaller than genetic women and about 50% of transsexual women have breast augmentations. However even very small breasts - particularly those of women who begin hormones before their 30's - can often function as nature intended, i.e. feed a baby.
Once the baby is born, the transsexual mother may well be able to experience the final physical act of pregnancy and birth and attempt to nurse her new baby - albeit with many assumptions such as being well enough after the delivery and her breasts are adequately developed and haven't been badly damaged by augmentation. There are already a few instances of transsexual women lactating and even breast feeding the babies of ex-wives or female partners.
Breastfeeding normally strongly recommended by doctors, it is by far and away the best and most convenient way to feed a baby. Not only will the baby be healthier, but it also helps the new mother lose weight more easily. Calories are burned during milk production; indeed some of the weight gained by a woman during pregnancy is intended to be used during lactation.
Breastfeeding also releases a hormone in the woman's body that acts as a natural tranquillizer, filling the mother with a sense of calm and well-being while she is breastfeeding.
Breast augmentation, common in transsexual women, does not normally prevent breast feeding. The main reason that breastfeeding may not be recommended or encouraged by the physician is if the drugs and other hormones being taken by the mother may make the milk unsuitable for nursing.
It's very probable that the pregnancy and birth, and the associated hormone levels, will in itself be enough to induce lactation in the mother.
Inducing and maintaining lactation requires:
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Copyright (c) 2007, Annie Richards