Uterus transplantation in women who are genetically XY

Abstract

Uterus transplantation is an emerging technology adding to the arsenal of treatments for infertility; specifically the only available treatment for uterine factor infertility. Ethical investigations concerning risks to uteri donors and transplant recipients have been discussed in the literature. However, missing from the discourse is the potential of uterus transplantation in other groups of genetically XY women who experience uterine factor infertility. There have been philosophical inquiries concerning uterus transplantation in genetically XY women, which includes transgender women and women with complete androgen insufficiency syndrome. We discuss the potential medical steps necessary and associated risks for uterus transplantation in genetically XY women. Presently, the medical technology does not exist to make uterus transplantation a safe and effective option for genetically XY women, however this group should not be summarily excluded from participation in trials. Laboratory research is needed to better understand and reduce medical risk and widen the field to all women who face uterine factor infertility.

Uterus transplantation: from research, through human trials and into the future

“…Heretofore, UTx has been performed in genetically XX females. In the future, UTx may be expanded to genetically XY people including transgender male-to-female people ( Balayla et al , 2021 ), to women with the complete androgen insensitivity syndrome ( Sampson et al , 2019 ), and to cis-gender males ( Alghrani, 2018 ). Indeed, the possibility of performing UTx to assist in the gender transition process raises opportunities beyond gestation potential as, for some transwomen, the opportunity to undergo UTx could meaningfully contribute to the success of gender transition ( Voultsos et al , 2021 ).…”

Uterus transplantation: ethical considerations

“…Factors that have been proposed for consideration -some sparking considerable debate -include recipient age, length of time on the waiting list, married/in a long-term relationship, prior children, and childrearing capacity [15][16][17][18][19][20][21]. Additionally, the question has started to be raised as to whether/how far the eligibility criteria for Utx should be expanded -for example, to potential recipients with controlled comorbid medical conditions, to women desiring UTx not to carry a pregnancy but as a means to achieve completeness as a woman, or to females with androgen insensitivity syndrome or transgender females [22]. As Utx expands, reevaluation of the recipient risks, benefits, and autonomy must continue to be at the ethical center of decisions about who to transplant and how to manage the posttransplant course of recipients.…”

Ethical issues in uterine transplantation

“…Questions of transplant eligibility are also more complex in UTx than other forms of organ transplantation. For example, there is ongoing controversy regarding whether transgender women and others who are genetically XY ought to be eligible for UTx [ 7 ].…”

“…There are no more or less “urgent” cases of infertility; a “sickest first” allocation principle does not seem to extend to UTx; and prognosis and quality of life gains are more difficult to quantify for UTx transplants than transplants that serve a direct medical need. When it comes to eligibility, some particular points of controversy are whether UTx should be offered to women who are genetically XY, women in same-sex relationships (where the other party does not have AUFI), and women who are already mothers [ 5 , 7 , 15 ]. It might further be asked whether UTx should be made available to men (either publicly or privately) on the grounds that they, too, lack a functional uterus and are in this sense subject to AUFI [ 13 ].…”