advances have transformed the lives of transsexual woman since the
1950's. Hormones provide huge physical and mental benefits, whilst
with advances in 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. An increasing number of transsexual women now lead their
lives without their sexual partners and even husband ever suspecting
that they were born anything other than a woman.
One study found that transsexual women are as
likely to have reproductive dreams and daydreams as any other women.
transwomen still cannot bear children due to their lack of internal
female reproductive organ. Further, a transsexual woman 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 western bias to this finding.
example, very few Thai or Brazilian MTF transsexuals (typically
transitioning in their early 20's) have sired any children before having
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.
Famous models and actresses often flaunt their pregnancy in the
- unfortunately causing distress for some infertile women
Ayana Tsubaki -
a Japanese post-SRS transsexual starlet - 'photo-shopped' as a
pregnant woman for an advertisement.
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. 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.
Even if just
1 in 20 transwomen suffers from infertility stress, that is still
amounts to tens of thousands of women. However, the situation may
eventually improve.... 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 vital supportive hormone treatment and surgery. It now
seems quite possible that a transwoman will give birth by 2020.
potentially viable medical approaches were long ago identified for
transsexual women seeking to bear a baby - uterus transplant or ectopic
pregnancy. In recent years the former has emerged by far the most
likely, but but both are discussed below.
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
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 in good light).
However, the 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. 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
By far the most
promising approach that could allow a transsexual woman to become
pregnant is a uterus (aka womb) transplant.
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
Essentially the transwoman will receive a transplanted womb - ideally
from a close female relative (mother or sister) - for long enough to
her to conceive and give birth by Caesarean section. 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.
Because only one organ is being transplanted, the chance of success is
significantly increased. 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 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 associated with every pregnancy.
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
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.
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
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.
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
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.
(Above right and above) Two graphics
illustrating how a uterus transplant operation works. The top
right graphic is generic and assumes an organ donation from a deceased
woman. The lower graphic reflects the fact that 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.
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.
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 expressed concern about womb peddling and the
possibility of "gynecological care that routinely results in women
going in for a check-up and only finding out later they've been
given a hysterectomy" 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.
long race for the first successful uterus transplant and pregnancy
reached another small milestone when in
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.
Procedure for the removal of a Uterus from a Living Donor
Step 1. The uterus is taken from the donor through an incision
in the abdomen and placed on a bed of ice
Step 2. The blood vessels to the uterus is flushed with cold
3. The three hour operation of the donor ends after the top of the
vagina is sewn up.
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:
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
, 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"
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
In January 2014, Dr Mats
Brannstrom and the University of
Gothenberg revealed that the team had
now 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.
Dr Brannstrom told Associated Press that
he and his colleagues will run the first
workshop on how to perform womb
transplants and they plan to publish a
scientific report on their efforts soon.
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). 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
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
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
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
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
Assuming the mother and her medical team have determined that the
risks are acceptable, the exact process for an ectopic pregnancy is:
Suitable doses of female hormones are administered to make the
transsexual woman receptive to the pregnancy.
Hormone levels in
a woman during pregnancy, after steadily building up for 9 months,
progesterone and oestrogen levels drop precipitously after the birth.
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
Step 3: Embryo
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.
On first appearances the website "Pop!
The First Male Pregnancy" seems to be monitoring the
first ever male pregnancy by the Ectopic method.
Although just a sophisticated hoax, the web site is still worth a brief
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
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.
there are several other options that a transsexual woman can take in
order to be genetically related to her baby:
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.
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
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
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
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.
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.
3. Transsexual mother is implanted with the embryo, becomes
pregnant and eventually gives birth.
And finally, the
most advanced and technically challenging option of all:
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.
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.".
2001 the fertility researchers from Cornell University
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.
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
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
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.