Uterus transplantation for trans MtF (male born)

Not only 'pregnant men' (trans FtMs, born women) as covered by L'Espresso: bioethical criteria for uterus transplants have recently been revised. The uterus can also be received by trans-MTFs, i.e. biologically male. For a complete transition
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The cover of the latest issue of l'Espresso probably appears to most as a provocation. Those who follow certain scientific literature, however, know that what has been designed is already reality, and has been for some time.. Pregnancies in women who identify themselves as men - FtM, the acronym (Female to Male) - like the one drawn on the cover of the weekly magazine - are certainly nothing new: just look in the sector databases (Scopus o WOS o Pubmedrecognised for scientific publications assessed for university competitions) and consult the extensive literature emerging.

By way of example, in 2014 the magazine Obstetric & Gynecology  (of the American College of Obstetricians and Gynecologists) published an article entitled Transgender Men Who Experienced Pregnancy After Female-to-Male Gender Transition, on a study approved by the University of California, San Francisco Committee on Human Research. Twenty-five FtM used testosterone before pregnancy and only six of them were unplanned; most of them had their babies with their partners, five had recourse to anonymous donors or sperm banks, three to known donors, 21 with their own oocytes. And recently, scholars from the Rutger Robert Wood Johnson Medical School, New Brunswick, in the USA, on the obstetrical treatments for 'transgender men with advanced paternal age', i.e. FtM with more than 35 years of age, whose advanced age is defined as "but at the same time we talk about labour, childbirth and the etc. We don't know how many FtM births there are so far, but according to experts these numbers are increasing.

On the other hand, for some time now there has been ample space in the scientific literature for 'transgender health', which includes the health of transgender people. fertility preservation treatmentsThe aim is clear: to be able to be genetic mothers in the future (and also gestational mothers if they do not undergo a hysterectomy) and biological fathers by being, respectively, social and often anagraphic fathers and mothers. It should be remembered that the possibility of these treatments is also offered to adolescents, including those given puberty blockers, provided, of course, that sufficient sexual maturity has been attained: it remains a mystery as to how a 13-year-old could be aware of this, when expressing their informed consent in this regard, just as doubts remain as to the real freedom of consent of parents, who are called upon to give legal approval to these paths.

It is still at the level of academic discussion, however, that the possibility of uterus transplantation to 'transgender individuals': the journal Bioethics recently published an article whose lead author is Jacques Balayla, a gynaecologist at McGill University, in Montreal, Canada. He is one of the three signatories of the "Montreal criteria', i.e. the international ethical reference criteria for uterine transplants. It should be noted that the text was updated by the same authors in 2013, a year after publication, with some ethical openings to uterus transplantation in men or trans women, but confirming its exclusion from the clinical point of view. In the article published this year, the ethical reasoning is resumed by re-reading the first of the required criteria - the recipient is a genetic female of reproductive age with no medical contraindications to transplantation - because "the condition that the patient is a genetic female inherently disqualifies transgender, certain non-binary, gender-diverse and cis-gender women who have a non-XX karyotype ("transgender UTx")", where UTx stands for "uterine transplantation".  

The authors state that so far there have been no uterus transplants on 'transgender UTx', but in the article they develop a number of arguments to show that this is not the case.ethical acceptability, with reference to the well-known bioethical principles of autonomy, non-maleficence, beneficence and justice. The Montreal Charter is then reread with comments such as "If a cis-gender person who identifies as female but lacks a womb can ethically have one, then the principle of justice indicates that this opportunity should be offered to all such persons, regardless of the circumstances of their birth.". And if the purpose of uterine transplantation according to the Montreal Charter is to procure a pregnancy, invoking the principle of beneficence can be thought of as "making uterine transplants available to those suffering from gender dysphoria"as long as clinical safety criteria are met. UTx could become 'part of gender reassignment surgery', therefore, as also argued in earlier work by a team of British surgeons, cited in the article.

Finally, some considerations on the construction of the possible vaginal access to the uterine cavity: the authors felt the need to specify, to avoid misunderstandings, that this is a treatment applicable only to trans-females and not to trans-females. for cis-males, the latter being called upon if they were hypothetically interested in carrying a pregnancy without gender transition. In a few words and without emphasis, that's where you want to go with this.

(for the incredulous, in the original textAs we mentioned previously, though UTx may well be transitory to void the need for lifelong immune-suppression, the gender re-assignment surgery and orchiectomy needed to ensure the success of UTx are permanent - a consideration that would not apply to cis-males who would seek to carry pregnancy without transitioning. Indeed the ready convenience of access to the uterine cavity both for embryo transfer and biopsy via the cervix prefers that a transgender patient seeking to become pregnant through UTx should have previously undergone surgical construction of a neo-vagina that may be connected to the transplanted canal and cervix. Such a reality would only apply to trans-females and not cis-males).

Assuntina Morresi

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