What if Cis, Queer Men Could Get Pregnant and Carry Their Own Babies?
2024 marks a decade since the first successful pregnancy from a transplanted uterus (1).
Uterine transplantation (UTx) comes with some unique characteristics compared to other solid organ transplantations.
In this article, I want to briefly review UTx, discuss the emerging field of UTx for transgender women, and ask the question:
Would cis, queer men, undergo such a procedure in order to get pregnant and carry our own children?
My husband and I are currently on our journey to fatherhood via surrogacy, and as cis, queer identified men, this is a topical and interesting hypothetical scenario that warrants some reflection and discussion.
History of Uterine Transplantation
Mats Brännström (2) led a group of researchers at Gothenburg University to develop the protocol and conduct the first human UTx that resulted in a successful pregnancy and delivery in 2014 (3). This research was built on the foundation of extensive preclinical (animal) testing of UTx, including studies in mice, rodents, rabbits, sheep, pigs, and non-human primates conducted at various research institutions all over the world.
Some interesting aspects to the human UTx protocols include the following (3):
Donors could be from living - even postmenopausal - or deceased donors.
Immunosuppression is tailored to the minimum amount and stable for 1 year post transplantation before implantation of an embryo.
The child is born via cesarean section, and the uterus is removed after the pregnancy and delivery. However, in some cases the same transplanted uterus could be used for up to 2 pregnancies.
This last point is one of the aspects that makes UTx unique compared to other solid organ transplantations. Obviously, there are some organs (i.e. kidneys) where humans have more than one and so transplantation from living donors is possible, while singular organs such as the heart must come from deceased donors. Also, immunosuppression is a hallmark of all transplantation in order to prevent rejection, but in order to avoid the toxicities of a lifetime of immunosuppression, the uterus is removed after performing its reproductive function.
This temporary nature of UTx is a novelty, as is the ability for a living donor who is postmenopausal and so ‘done’ utilizing her uterus to donate it for continued use. No other organ can be ‘used up’ and still ‘shared’ in this way.
Current Landscape of Uterine Transplantation
In 2021, over 60 uterine transplants had been performed in the world (4).
In the United States, the procedure has been conducted since 2016, and a retrospective study in 2022 looked at the results of these procedures (5).
During this time there were 33 uterus transplant recipients in the United States, with high rates of success. The data showed that more than 80% of recipients who had not rejected the transplanted uterus at 1 year achieved at least 1 live birth. The conclusion of this study was that UTx was shown to be safe for the recipient, living donor, and child (5).
Ethical Guidelines for Uterine Transplantation
Given the complexity of UTx from a medical, surgical, psychological, and reproductive perspective, guidelines have been developed to ensure the process is as ethical as possible.
The Montreal Criteria (4) set conditions for the recipient, the donor, and the health care team involved in UTx:
The recipient is a genetic female, with the ability to consent, with no medical contraindications to transplantation, has uterine disease that has failed other therapy, and has "a personal or legal contraindication" to other options (surrogacy, adoption).
The recipient needs to be considered suitable for motherhood, deemed to be psychologically fit on evaluation, is likely to be compliant with treatment and the medical team, and understands the risks of the procedure.
The donor is a female of reproductive age with no contraindication to the procedure who has concluded her childbearing or consented to donating her uterus after her death. There is no coercion and the donor is responsible and capable of making informed decisions.
The health care team belongs to an institution that meets criteria regarding institutional stability and has provided informed consent to both parties. There is no conflict of interests, and anonymity can be protected unless the recipient or donor waives this right.
There are two components to the Montreal Criteria that are worth focusing on. The first is that the recipient must have a personal or legal reason for not pursuing surrogacy or adoption. This is interesting as it places UTx as truly an option of last resort for assisted reproduction. Second, the recipient is required to be a genetic female.
This second point has come under scrutiny in recent years. In 2021, a revision to the Montreal Criteria was published with an ethical framework for consideration of genetic XY individuals to be eligible for uterine transplants (6). However, to this date there have not been any clinical trials or case studies of UTx in transgender women.
Uterine Transplantation in Transgender Women
Even though the procedure has not yet been performed, this has not stopped scientists and physicians from discussing how the procedure could be done.
In 2018, an article was published that outlined the anatomical, surgical, and hormonal considerations for UTx in transgender women (7). The authors concluded that despite these challenges, ‘there is no overwhelming clinical argument against performing UTx’ in transgender women. Their primary concern was that it may require a larger area of tissue to be surgically removed from the donor, and so living donation may not be as viable for transgender women and UTx. However, they also pointed out that transgender men may be willing to accept the risks and donate their uteruses, which does suggest the possibility for amazing reciprocal support within the queer community.
More recently in 2023, the American Society of Reproductive Medicine (ASRM) published an article that suggested that UTx in transgender women is approaching reality and discussed the nuances of how best to conduct such a procedure (8).
Perhaps one of the most crucial aspects to the procedure for transgender women is the need for orchiectomy (or surgical removal of the testes) prior to the UTx. Interestingly, hormones such as estrogen and testosterone are not needed to become pregnant or carry a pregnancy to term, as cis-female patients without ovaries can sustain normal pregnancies through IVF and hormone replacement therapy until the placenta can then generate its own hormonal production.
However, high testosterone exposure to a developing fetus can negatively affect development. So, transgender women would need to remove their own testosterone source prior to UTx and pregnancy.
In addition to this hormonal consideration, I do not want to downplay the surgical complexities of dealing with natal-male anatomy with regard to pelvic structure and vasculature. Attaching blood vessels and supporting the transplanted uterus in the abdominal cavity so it can then carry a baby to term requires nuanced surgical techniques, but the authors state that these are not insurmountable and almost seem up to the challenge.
Question: Would Cis, Queer Men Undergo Uterine Transplantation?
I started this article with the question above in order to take the argumentation for UTx in transgender women one step further and see if it could be a reproductive solution for cis, queer men.
I know this is a somewhat radical idea, but I also believe it is a possible solution to the challenges around gestational surrogacy.
As I see it, there are two medical barriers that would have to be overcome for this to be viable for cis, queer men:
The surgical procedure involved for UTx would have to be performed so as to not require attachment of the uterus to a cervical/vaginal canal, as cis, queer men would not have undergone any gender affirmation surgery and so would not have this anatomy for the uterus.
There would need to be a hormonal solution that does not require orchiectomy, or removal of the testes. Gonadotropin-releasing hormone agonists (GnRH agonists) such as Lupron are used in IVF and in transgender medical therapy to block hormonal production. While medications like these are contraindicated in pregnancy, studies have shown that when they have been accidentally used during the first trimester of pregnancy, it does not always result in birth defects (9). Perhaps a novel medication could be used to block the testes from producing testosterone safely during pregnancy that can then be reversed after the delivery.
If these two aspects of UTx could be developed, I would consider it for myself. After all, we ask our gestational carriers to assume the risks of pregnancy for us, and so, if I could assume this risk on my own, I would prefer to do that. I know that GCs in the U.S. are well informed of the risks and accept them in order to help build families, and this is truly an amazing gift to offer. However, if there was a way to not have to ask for this help and to accept the responsibility ourselves, I believe that many men would do this.
Another interesting part about UTx for cis, queer men, is it does fit into the vision I have for BabyMoon Family as an all inclusive LGBTQ+ family building center (https://www.babymoonfamily.com/original-articles/babymoon-family-vision).
As mentioned above, transgender men could be a source of uterine donation. Also, queer women who have finished their families, even if they are postmenopausal, could also donate their uterus, and this may be preferable to becoming a gestational carrier for a queer male couple.
This is a complicated topic, but I believe it could be an interesting path forward for LGBTQ+ assisted reproduction. The uterus is an incredible organ with the unique ability to sustain and grow a human person, and now, that organ can be transferred to other people, even after a woman has passed her reproductive years.
Perhaps the transferability of the uterus exists so that everyone who wants to have children can do so, regardless of their gender identity or sexual orientation. Until science progresses to the point where we can recreate the uterine environment synthetically in an artificial womb, a topic I discussed in a previous article (https://www.babymoonfamily.com/original-articles/artificial-womb-pod-generation), then UTx remains a viable path forward for assisted reproduction and a step beyond surrogacy that should be considered for all types of family building.
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