Uterus Transplantation

I’ve been having a think about uterus transplantation. The view currently is that uterus transplantation is about to move from the margins to the mainstream – ie from experiment to viable therapeutic option. Forty-two uterus transplantations have been performed globally, resulting in twelve live births.

The women’s rights advocate in me can't help but wonder how many women and neonates have died easily preventable deaths during the period of this grand experiment? How much suffering could have been prevented or eased if the funds committed to this had been used differently? If a live donor liver transplantation costs around NZ$450k all up, it seems likely that a uterus transplantation will cost a similar amount.

In a world in which 100,000 + women die every year from birth related complications – most of them preventable – and over 1 million neonates die every year, also mostly preventable deaths, how ethically defensible is uterus transplantation for adult human females who have functioning ovaries but no uterus, let alone the additional implications of uterus transplantation into someone who was born reproductively male?

Given solid organ transplantation is usually carried out to save life, and this is not a life saving procedure in the sense that liver, heart and lung, kidney transplantations are, there are complex triaging and funding implications for publicly funded health services – whoever the recipient is.

In the UK it is considered that the reproductive aspirations and desires of male to female (MtoF) transgender women have equal weight to those of natal women so if uterus transplantation is available to the latter, it must also be available to the former given transgender people who have undergone gender reassignment are protected under the Equality Act (2010). To deny transgender women equal right to a uterus transplantation could be unlawful discrimination.

It seems only a matter of time before we have the first uterus transplantation into a transgender person since Hirschfeld’s medically ill-judged and ethically dubious 1930s experiment. Further, given the recipients are reproductively male, there is no reason why, prior to gender reassignment treatment, they could not freeze their own sperm, use it to fertilise a donor egg in vitro, and gestate their own biological offspring.

Uterus transplantation surgery is risky and complex; it involves extensive and very expensive pre- and post-operative care, and there are the potential adverse effects of immuno-suppressants on the foetus and the person who is gestating it.

These issues apply to uterus transplantation into genetic females who were born without, or who have lost their womb to disease/injury, but in people who are genetically male, there are the added challenges of the different shape of the male pelvis; (1) the positioning and vascularisation of a uterus in a body not designed to hold it; getting the balance of the gestational hormones right, and there are dangers of infection that are a common reason for pregnancy failures in women with neovaginas. 

Immuno-suppression treatment obviously results in a greater susceptibility to recurrent infections. A natural vagina contains epithelium capable of producing a number of protective mechanisms and microflora that help prevent infections which might compromise pregnancy. These do not exist in the penile or intestinal lined neovaginas (2) surgically created for transwomen, XY women, and genetic women born with vaginal agenesis.

To deal with this, researchers propose that a utero-vaginal transplant should be performed, using as much donor vagina and other structures as possible – using a technique similar to a radical hysterectomy with preservation of the vaginal branches of the uterine vessels, as well as a radical retrieval of ligamentous material to compensate for the fact that genetic males don’t have uterosacral ligaments.

This would seem to preclude the use of live donors in light of the fact that, while women might be prepared to donate a uterus they no longer need, (3) they would be highly unlikely to want to undergo such extreme surgery and lose most of their vagina, so a dead donor would be the most likely source.

However, there is a far greater likelihood of graft success from a living donor.  And here’s where it gets really thought-provoking, as interested parties have noted there is a growing pool of live donors who might be happy to oblige, or be persuaded to oblige : FtoM transgender people - transmen.

The best uterus for transplantation is from a healthy young woman who has vaginally delivered a child, and that demand may be met by the growing phenomenon of transmen deciding to have children before undergoing "bottom surgery".

It is claimed that the development of a modified dissection technique has reduced surgical risk, and a reduction in surgery time from 12+ hours to between 4 & 5 hours reduces the risk of venous thromboembolism. The promoters of this technique claim that it "favours minimally invasive retrieval techniques which should enhance recovery and reduce potential morbidity further.” (4) (My emphasis)

As a bonus, given transmen won’t need their ovaries, they can be removed at the same time and the ovarian vascular pedicles can be repurposed to further facilitate the implantation.

This utero-vaginal transplant reduces infection risk, allows for easy checking of the health of the graft and, once the graft is fully operational, the implantation of an embryo etc.

Once the transplant is no longer needed – ie after a foetus has been gestated to the point of viability and is removed via caesarian section – the graft has to be removed which means further surgery to reconstruct the neovagina could be needed.

So, between five and twelve hours of reasonably high risk surgery for the donor; several days in hospital and several weeks before they would be fully healed; use of painkillers and possibly antibiotics; long term implications for general and musculo-skeletal health given scale of disruption to blood vessels, nerves, loss of ligamentous structures etc.

For the recipient, major surgery, lengthy recovery, big doses of anti-rejection and other drugs, complex doses of HRT to kickstart the uterus, plus constant testing for organ rejection, metabolic organ and cardio-vascular health over minimum of 6 to 12 months, and the implantation of single embryos at a time, from a donor eggs, fertilized in vitro – itself a lengthy and expensive process.

This is the riskiest and most expensive of high-risk, expensive obstetrics. It’s stating the obvious that all surgery involves risk. No one should undergo major surgery unnecessarily – I include in that, appearance enhancement.

Nor should doctors encourage it – or see themselves as purveyors of commercial services – al la the US cosmedico who offered transmen  a rebate on a mastectomy during Pride month. (I didn’t see any similar offer for a cut-price penectomy and orchiectomy.)

That aside, what are the ethical and legal implications of seeing transmen as a source of spare parts for womb-less women with neovaginas? Like the use of puberty blockers and cross sex hormones in neurologically immature young people, there are numerous ethical and political quagmires to be negotiated.

Let's stop and think about the reproductive aspirations of the new cohort of young transgender people who have not gone through their genetically determined puberty and who have had a counter-puberty forced by means of cross sex hormones in order to develop the secondary sexual characteristics of the other sex.

FtoM transgender kids who have been given puberty blockers and cross sex hormones are out of the personal reproduction picture; they’ve given up their genetically determined female sex function, and the male sex function - the production and delivery of sperm – can't be simulated by surgery or drug regimes.

They won’t be a source of donor eggs or utero-vaginal transplants as their eggs won’t have matured and their uterus and vagina will be that of a pre-pubescent child. Even if FtoM trans kids go far enough into puberty to produce mature eggs, both the collection of eggs and the long-term storage of them are expensive and have high failure rates.

Similarly, the sperm of MtoF trans kids will never mature and their male genitalia will remain child size and in fact, both cohorts will need to have their developmentally stalled sex organs removed early on as they are at increased risk of cancer if they retain them. Both will undergo complex genital and possibly other surgeries with all the physical trauma and exposure to drugs that involves, and they will be reliant on exogenous hormones all their lives.

MtoF trans kids who have never gone through male puberty, may look more conventionally feminine but to simulate part of the female sex function, the gestation of a foetus, they would have to go through highly invasive and risky surgery; be on immuno-suppressant drugs for at least a year to ensure the graft has taken, then go through a very high risk pregnancy for at least seven months while remaining on anti-rejection drugs, plus increased doses of female hormones, before undergoing yet more invasive surgery to deliver the baby and remove the uterus and all other transplanted tissue and make good any damage to the neovagina.

It would be disturbing even if the world weren’t teetering on the edge of ecological and social disequilibrium – the most likely outcome of which is extreme authoritarianism accompanied by a wave of social conservatism. 

1. The female pelvis differs significantly from their male counterpart, to the extent that they can be used to determine sex at autopsy.
2. Formed from the inverted skin of the penis or from tissue harvested from the bowel or inside of the mouth.
3. There is evidence that removal of a uterus, especially via a radical hysterectomy, can have profound impacts on women’s health.
4. Uterine Transplantion into Transgender Women