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Should — and could — uterine transplantation be an option for transgender women?
Click here to read the Cover Story, "For transgender patients and providers, fertility preservation options bring choices, concerns."
Yes, if it can be shown to work.
LGBT rights in Sweden have been regarded as some of the most progressive in Europe. In 2013, a previously valid requirement of sterilization for legalization of gender change was ruled unconstitutional in court. Prior to that, we could not research whether something like uterine transplant for transgender women could be a possibility because we did not have the ability with our legislation to offer that health care. Today, in Sweden, transgender patients may now be included in clinical programs for fertility preservation before sex-reassignment surgery.
Uterine transplantation started in Gothenburg, Sweden. The group that has done this work has been extremely careful, moving from small animal research to large animal models until researchers had enough knowledge to present their findings to an ethics committee and begin uterine transplantation trials in humans. In my consultations, some transgender men ask if they could donate their uterus to someone else to have a baby in the future. However, one important aspect of the success of the Swedish project on uterine transplantation was that each uterus came from a woman who had already given birth. The donated uterus must be “tested” before it is transplanted.
For transgender women, theoretically, uterine transplantation would be possible, but it would require a lot of research to demonstrate that a male body can accept a uterus transplant and that the transplant can work. This is sensitive for our patients, and such research would need to be done responsibly.
There are a lot of considerations for something like this, including the legislation in the country where you live. It would be important to perform experimental research using animal models first, to demonstrate that it can work. As far as I know, no one has done that yet. I do not think it is impossible, but it must be shown and proven before translated to humans.
Each person is different in how they wish to achieve their goal of having a family. For some, they wish it to be biological — my genes, my gametes. For others, this is not important, and children can be achieved with donated eggs, sperm or adoption. We are all different. We want to offer transgender patients all the possibilities for the life they have in front of them.
Kenny A. Rodriguez-Wallberg, MD, PhD, is associate professor and head of the Program of Fertility Preservation at the Department of Reproductive Medicine, Karolinska University Hospital, Stockholm. Disclosure: Rodriguez-Wallberg reports no relevant financial disclosures.
Just because we can do something, does not mean we should do something.
Uterine transplantation for women who were born with male genitals can work. The pelvis is the pelvis. We often think of men as being from Mars and women from Venus, but the truth is we share 99.9% of the same DNA and our bodies and pelvises are not that appreciably different. Even the ovaries and testicles develop from the same basic structures. So, it could work, technologically. The bigger question is, if cost were no issue, should someone pursue uterine transplantation or consider surrogacy or other assisted reproductive technologies that are more established?
My stance on the issue of uterine transplantation for transgender women has evolved. My initial reaction was that this was overstepping. From a cost-efficiency standpoint, what is more responsible is that patients recognize that they are born with a set of gametes, genetic material that can lead to offspring, and they need to consider those options before transition, especially hormonal and surgical transition. Male-assigned infants born with testicles have sperm, and female-assigned infants born with ovaries have eggs, and they should be treated accordingly, regardless of transition. However, with the ever-increasing number of transgender kids choosing to begin a pubertal blocker, there is going to be a new cohort of people who, you could argue, have reproductive rights as well, just as much as someone who had a hysterectomy or had significant fertility issues where they themselves needed a uterine transplant. But we must consider where we are allocating health care dollars. If you are going to allocate $100,00 or more for someone to have a uterine transplant, require anti-rejection drugs and have a very complicated, medicalized pregnancy — only to need more surgery afterward to remove the uterus — I think that is perhaps an overreach.
Currently, 19 states mandate coverage for transgender procedures. What I think the LGBT community has not done well is explain that being transgender is a normal part of humanity, is not anything to be feared, and is deserving of medical treatment. For now, that is what deserves more of our health care dollars.
Marci Bowers, MD, is a pelvic and reconstructive gynecologist with Mills-Peninsula Medical Center in Burlingame, California, and Mount Sinai Beth Israel Hospital in New York, and is considered the first transgender woman to perform transgender surgery. Disclosure: Bowers reports no relevant financial disclosures.