Ethics, Science, and History of Uterine Transplants In Males
Illustration by Cynthia (@PTElephant).
Medical technology, as of this publication, will not accommodate for a human male to gestate and give birth. This is a biological fact of life. Yet, many transwomen still dream of a day where they can get pregnant or get an abortion. (Yes, some transwomen have expressed the interest in having an abortion. I don't pretend to understand it.) Since the first uterine transplant in the US in 2016, doctors have been theorizing if a uterus transplant could be possible for a transwoman, who is male.[1]
To understand if this is possible, we need to look at how such a procedure happens in females, along with the risks and complications involved with the procedure.
There has been a long history of experiments, both on animals and on humans, attempting uterine transplants. The first recorded uterus transplant in humans took place in Saudi Arabia in 2000. The 26 year old woman in question had lost her uterus due to a hemorrhage (uncontrollable bleeding) during a Cesarean surgery. To save her life, they had to remove her uterus. The donor for this surgery, a woman in her 40s, volunteered to donate her uterus. The surgery went well, but after the 26 year old woman's second menstrual cycle, the blood supply to the new uterus failed and the uterus began to die, requiring surgeons to remove the organ just three months after the transplant.[2]
In 2014, a live birth after a uterine transplant was reported from a medical group in Sweden. The woman, 35 years old, had a DSD (disorder of sex development) known as MRKH which caused her to be born without a uterus. The uterus was donated by a woman who was 61 years old. The patient was able to become pregnant via IVF (in-vitro fertilization) one year after the transplant. The patient suffered three rejections of the uterus during her pregnancy and had to be treated with steroids to maintain the pregnancy. This is on top of being on three different anti-rejection medications during the pregnancy.
The patient developed pre-eclampsia at 31 weeks of pregnancy, a serious condition that, if not treated, can result in seizures and death of both mother and child. At that time she had to be hospitalized. Less than a day later, they had to perform a Cesarean section for the safety of the infant and the mother. Despite being born over 2 months premature, the infant was healthy.[3]
Since then there have been a few dozen cases of live births after uterine transplants, but just how successful are they? A review looked at the 52 published cases of uterus transplants and their outcomes; the results paint a mixed picture.
The 52 transplants consisted of organs donated by 43 live donors and 9 deceased donors. There was a bigger chance of complications involved with transplants from deceased donors, but organs from live donors also had complications. Of the 52 uterus transplants, 2 of them failed because the uterus began to decompose and the surgeries had to be canceled. Of the remaining 50 patients, 12 had complications due to surgery and had to have the organ removed. This means only 38 patients of the 52, or about 73%, were able to successfully gain uterine function.
Of the 38 cases, only 14 women were able to get pregnant via IVF, about 37%. Two women were lucky enough to get pregnant a second time. Of the 16 pregnancies, 6 mothers experienced major complications during pregnancy, about 38%. In 10 of the 16 cases, the babies were born preterm, roughly 63%. Pre-eclampsia was the most common pregnancy complication. Unfortunately, most studies do not report on long term outcomes after birth, but the vast majority of those who successfully give birth have a subsequent hysterectomy. These transplants have never been designed to be permanent.[4]
In addition, health of the infant in terms of other developmental factors have not been documented, but late preterm infants, those born between 32 and 37 weeks, are at higher risk for death and neurological congenital conditions than those born at full term. They also carried risks of low blood sugar, temperature instability, increased rates of sepsis and other infections, as well as breathing problems.[5]
It is for all of these reasons and all of these risks and complications that it is not recommended to use a uterine transplant as a way to treat infertility. As Dr. Robyn Horsager-Boehrer, a professor of obstetrics and gynecology, states:
“The high-risk pregnancy doctors in our practice do not recommend uterine transplantation. We strongly believe that women can become mothers in a variety of ways, and uterine transplantation is not worth the risks.”[6]
Despite all of these risks, many are still interested in performing these uterus transplants for transwomen. Dr. Kaushik, a doctor from India, has stated his intention to perform a uterus transplant on a transwoman with the hopes that it will allow a transwoman to become a mother. But other scientists are skeptical. Many have brought up many important factors, including that medications used to help a transwoman lactate are medications with side effects that are known to cause birth defects.[7]
Another to consider is that pregnancy requires a careful balance of hormones to maintain, one that the female body naturally performs. How would such a balance be achieved in a male? Particularly complicated is the hormone progesterone, essential to maintain a pregnancy, but in male bodies acts as a precursor to testosterone.[8]
In recent years, scientists have been begging doctors like Dr. Kaushik to wait for animal studies to be done before attempting a uterus transplant in human males. To my knowledge, only one animal experiment has been done, but the results have many scientists questioning if there is any real world application.[9]
The study in question comes from Shanghai Naval Medical University, which involved a complicated surgical process called parabiosis. Explained simply, the researcher took a male and a female rat and surgically connected the two so that the two rats were using the same blood, and more importantly, the same hormones. The male rat was castrated and given a uterus. Then, scientists placed embryos in both the female rat and the transplanted uterus of the male rat.
The results were not great. Out of the 46 pairs of rats, a little more than half resulted in pregnancy. In a third of the 46 rats, only the female rat became pregnant. There were zero cases of only the male being pregnant. In just 6 pairs, both the male and female rats became pregnant. That is a pregnancy success rate of 13%. As dismal as this seems, this isn't the end of the bad news. All of the fetuses of the pregnant rats were delivered via Cesarean sections. Of the rats born to females, 50% of the rats died within 2 hours of birth. Of the rats born to males, 67% died within 2 hours of being born. Something of note that was documented of the rats born to males is that many had "unusual characteristics", including degradation and inflammation of the placenta. Only 4% of the embryos implanted into the uterus of the male rats survived.
As stated by biologist Clint Kelly of the University of Quebec at Montréal, this study has proved one thing:
“...females are not simply males with a uterus, as any biologist could have told you prior to this study being conducted. Successful pregnancy clearly requires more than a uterus and sufficient exposure to progesterone and estradiol.”[10]
In terms of safety, a uterus transplant in females is already considered risky and experimental, but for males it is virtually impossible. To date, there has never been a successful uterine transplant in a male. I say successful because it has, in fact, been attempted in humans, with horrific consequences.
The date is September 1931, and after three preparatory surgeries, Einar Wegener, better known as the transwoman Lili Elbe, is at the Woman's Clinic in Dresden, Germany. The next surgery will involve the transplantation of a uterus and the creation of a vaginal canal. But something goes wrong. We don't know exactly what happened, as surgical notes and cultures were not typically used. Most of what we do know has come from the partial diary/biography about Elbe's life, which does not give specific medical details.
We can only assume that it was related to one of two potential causes: necrosis of the uterus or organ rejection. I am personally inclined to believe it was necrosis as Elbe's condition continued to worsen after the uterus was removed. As it is, Penicillin would not be used as an antibiotic treatment for another 10 years. For whatever reason, Elbe continued to worsen until the transwoman's heart gave out on September 13th, 1931.
Uterus transplants are barely a treatment for infertility and carry very serious risks. To consider uterus transplants as part of a treatment for gender dysphoria seems not only impractical given that uterine transplants are temporary, but it borders on inhumane. It is something that is impractical in theory and in practice could be deadly.
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