How a Transgender Woman Could Get Pregnant
如何让变性女人怀孕
The uncharted territory of uterus transplants is sparking patients’ interest, but surgeons and endocrinologists remain wary
子宫移植的未知领域引起了患者的兴趣，但外科医生和内分泌学家仍然保持警惕
When Mats Brännström first dreamed of performing uterus transplants, he envisioned helping women who were born without the organ or had to have hysterectomies. He wanted to give them a chance at birthing their own children, especially in countries like his native Sweden where surrogacy is illegal.
当Mats Brännström首次梦想子宫移植的时候，他设想帮助没有此类器官的，或者不得不进行子宫切除术的女性。他希望能给这些人一个拥有自己孩子的机会，尤其是在像他自己所在的瑞士这样的国家，在这里，代孕是非法的。
He auditioned the procedure in female rodents. Then he moved on to sheep and baboons. Two years ago, in a medical first, he managed to help a human womb–transplant patient deliver her own baby boy. In other patients, four more babies followed.
他首先在雌性老鼠身上做了这个实验，然后又在羊和狒狒身上。两年前，在一次医学试验中，他设法帮助一位子宫移植病人拥有自己的孩子。随后，他又帮助其他病人进行同样的实验，然后四个孩子紧随其后出生了。
But his monumental feats have had an unintended effect: igniting hopes among some transwomen (those whose birth certificates read “male” but who identify as female) that they might one day carry their own children.
但是，他这些不朽的成绩有了意想不到的效果：在这些移植妇女（那些出生证明上写着男性，但却是女性的人）身上诞生了一个希望，那就是可能将来的某一天，他们会拥有自己的孩子。
Cecile Unger, a specialist in female pelvic medicine at Cleveland Clinic, says several of the roughly 40 male-to-female transgender patients she saw in the past year have asked her about uterine transplants. One patient, she says, asked if she should wait to have her sex reassignment surgery until she could have a uterine transplant at the same time. (Unger’s advice was no.) Marci Bowers, a gynecological surgeon in northern California at Mills–Peninsula Medical Center, says that a handful of her male-to-female patients—“fewer than 5 percent”— ask about transplants. Boston Medical Center endocrinologist Joshua Safer says he, too, has fielded such requests among a small number of his transgender patients. With each patient, the subsequent conversations were an exercise in tamping down expectations.
Cecile Unger是Cleveland Clinic的一名女性医学专员。她说在去年，大约有40名“男变女”性别转换患者向她咨询了子宫移植术。一名患者问她能否等到她在进行子宫移植术的时候同时可以变性。Cecile Unger的回答是否。Marci Bowers是位于米尔斯–半岛医疗中心的北加利福尼亚的一名妇科医生。她说，在她的“男变女”患者之中，只有不到5%的患者询问了子宫移植术。波士顿医学中心的内分泌学家Joshua Safer说，他也遇到了同样的情况，询问他这种移植术的成员也不多。每个病人的随后谈话都是一种被减少了预期的练习而已。
To date there are no hard answers about whether such a fantastical-sounding procedure could enable a transwoman to carry a child. The operation has not been explored in animal trials, let alone in humans. Yet with six planned uterine transplant clinical trials among natal female patients across the U.S. and Europe reproductive researchers are hoping to become more comfortable with the surgery in the coming years. A string of successes could set a precedent that—along with patient interest—may crack open the door for other applications, including helping transwomen. “A lot of this work [in women] is intended to go down that road but no one is talking about that,” says Mark Sauer, a professor of obstetrics and gynecology at Columbia University.
到目前为止，都很难说，这种子宫移植术能否帮助一名患者拥有孩子。在动物试验中都没有进行探索，更别说在人类身上了。可是，在美国和欧洲的生育研究者中，已经有6个子宫移植的临床试验，希望未来会有更多的此类试验。这一系列的成功可以设置一个先例，随着病人的兴趣一起，打开其他应用的大门，比如说帮助移植妇女。有很多妇女希望走这条道路，但是没人谈论这个。哥伦比亚大学的妇产科教授Mark Sauer说道。
Such a future is hard to imagine, at least in the near term. The surgery is still very experimental, even among natal women. Just over a dozen uterus transplants have been performed so far—with mixed results. One day after the first U.S. attempt, for example, the 26-year-old Cleveland Clinic patient had to have the transplanted organ removed due to complications. And only the Brännström group’s procedures have led to babies. More efforts are expected in the United States: Cleveland Clinic, Baylor University Medical Center, Brigham and Women’s Hospital, and the University of Nebraska Medical Center are all registered to perform small pilot trials with female patients who are hoping to carry their own children.
这种未来很难想象，至少在短期内是很难设想的。手术仍然处在试验阶段，即使对于产后妇女也是一样的。迄今为止，已经进行了数十次此类试验，伴随着混合结果。比如说，在美国进行第一次试验后的第二天，在Cleveland Clinic的26岁的患者就不得不将这种移植器官拿掉，因为产生了并发症。只有Brännström 团队的试验诞生了婴儿。在美国，更多的期望产生了，Baylor University Medical Cente, Brigham and Women’s Hospital的Cleveland Clinic，以及the University of Nebraska Medical Center都注册了此类试验，能够让女性患者怀上孩子。
A RISKY PROSPECT
一个危险的前景
The trouble is that uterine transplants are extremely complex and resource-intensive, requiring dozens of health personnel and careful coordination. First a uterus and its accompanying veins and arteries must be removed from a donor, either a living volunteer or a cadaver. Then the organ must be quickly implanted and must function correctly—ultimately producing menstruation in its recipient. If the patient does not have further complications, a year later a doctor may then implant an embryo created via in vitro fertilization. The resulting baby would have to be born through cesarean section—as a safety precaution to limit stress on the transplanted organ, and because the patient cannot feel labor contractions (nerves are not transplanted with the uterus). Following the transplant and throughout the pregnancy the patient has to take powerful antirejection drugs that come with the risk of problematic side effects.
子宫移植术的困难在于手术的极端复杂性和资源密集型，它需要十几个医护人员，以及细致的配合。首先，子宫以及伴随子宫的动脉和静脉必须从捐赠者身体中取出来，无论这些捐赠者是活人还是死人。然后，这个器官必须快速移植，并被正确使用。最终在被移植者身体中产生月经。如果患者没有进一步的并发症，那么一年以后，医生可能会植入一个通过体外受精的胚胎。由此产生的婴儿，将不得不通过剖腹产出生，用剖腹产的原因是为了有安全预防措施，以限制移植器官的压力，因为病人无法感受到力量压缩（神经部分没有和子宫一起被移植）。移植后，在患者怀孕期间，患者必须通过服用抗排斥药物，以防以此带来的副作用风险。
The dynamic process of pregnancy also requires much more than simply having a womb to host a fetus, so the hurdles would be even greater for a transwoman. To support a fetus through pregnancy a transgender recipient would also need the right hormonal milieu and the vasculature to feed the uterus, along with a vagina. For individuals who are willing to take these extreme steps, reproductive specialists say such a breakthrough could be theoretically possible—just not easy.
怀孕的动态过程还需要比简单的子宫怀孕更多的东西，所以对于移植女性来说会更重大。需要通过怀孕得到婴儿的患者也需要在子宫中拥有适当的荷尔蒙和血管，跟随阴道一起。对于想要采取这些极端措施的跟人，生殖学家说，这样的突破在理论上可能是成立的，但是并不容易实现。
Here is how it could work: First, a patient would likely need castration surgery and high doses of exogenous hormones because high levels of male sex hormones, called androgens, could threaten pregnancy. (Although hormone treatments can be powerful, patients would likely need to be castrated because the therapy might not be enough to maintain the pregnancy among patients with testes.) The patient would also need surgery to create a “neovagina” that would be connected to the transplant uterus, to shed menses and give doctors access to the uterus for follow-up care.
这种移植手术的工作过程是这样的：首先，患者需要进行阉割手术，以及大剂量的外部激素的服用，因为高水平的雄性激素（雄激素），可能会危及妊娠过程。（虽然激素处理可以实现，但是患者还是需要被严格，因为治疗不足以维持患者的*丸睾**，在患者的妊娠阶段）患者还需要通过手术被创造一个“阴道”，它会被连接到移植子宫上，流出月经，给医生的后续治疗留下入口。
A small number of surgeons already have experience creating artificial vaginas and connecting them to uterine transplants. Most of Brännström’s transplant patients have been women with a condition called Rokitansky syndrome, and as a result they lack the upper part of the vagina and had to have a neovagina surgically made—typically by extending the lower vagina. Separately, surgeons that specialize in working with transwomen also often create neovaginas after castration, using skin from the penis and the scrotum.
少数医生已经进行过创造人工阴道，并且连接他们到子宫移植的试验。大多数的Brännström’s的患者都是患有Rokitansky综合征的病人，这种病症的结果就是导致患者缺少阴道上部，不得不进行阴道手术，通常这是通过延长阴道下部来实现的。此外，从事子宫移植工作的外科医生也经常在手术后创造阴道，通过使用阴茎和阴囊的皮肤来完成这种工作。
BIOLOGICAL CONNECTION
生物连接
Even if the hormonal and anatomical challenges are overcome, for someone who was born producing sperm instead of eggs there would be one more hurdle: Before castration that person’s sperm must be collected and combined with a donor’s or partner’s egg to make an embryo via in vitro fertilization, and that embryo would have to be frozen until the transplant patient is ready. If the embryo is successfully implanted, the transwoman would then naturally produce the placenta required to sustain the pregnancy and begin to lactate in preparation for breast-feeding, Cleveland Clinic’s Unger says.
即使克服了荷尔蒙和解剖学生的挑战，对于那些一生下来就是精子代替卵子的人来说，还有一个障碍需要克服：在去势之后，人的精子必须被收集起来，以供与卵子结合，以使得胚胎在体外受精，然后胚胎要被冷冻起来，直到移植病人准备好。如果胚胎移植成功，移植妇女将会自然产生乳酸，这需要维持妊娠，准备在哺乳期，Cleveland Clinic的Unger说道。
Experts disagree about what would be the biggest barrier to pulling off these theoretical transplants and pregnancies. Giuliano Testa, a transplant surgeon at Baylor University Medical Center who will soon be directing uterine transplant surgeries among natal women, says the hormones would likely prove the biggest obstacle. “It would really be a feat of unknown proportions,” Testa says. “I would never do this.” But he concedes the transplants are not out of the question. “At the end of the day it is two arteries and two veins that are connected with fine surgical techniques.”
专家们不同意说这种有什么最大的障碍，以拉离这种理论移植和受孕。贝勒大学医学中心的Giuliano Testa，是一名很快将要被指导子宫移植术的外科医生，她说激素问题可能是最大的障碍。他说，这是一种未知的领域。我不会这么做。但同时他也承认，说移植不是问题。未来有一天，通过外科技术，将会产生2个动脉，和2个静脉。
Unger—who is not involved in Cleveland Clinic’s uterine transplant team trial—worries about a consistent and ample blood flow to the fetus. Bowers, who is transgender herself, says she is concerned about dangers to the fetus from a potentially unstable biological environment and unforeseen risks for the mother-to-be. “I respect reproduction and I don’t think we will ever see this in my lifetime in a transgender woman,” she says. “That’s what I tell my patients.”
昂格尔谁不参与克利夫兰诊所的子宫移植团队试验担心一致和充分的胎儿血流量。鲍尔斯，本身就是变性人，说她是担心危险，胎儿从一个潜在的不稳定的生态环境和不可预见的风险为准妈妈。“我尊重再现，我不认为我们会在我一个变性女人一生的看到这一点，”她说。“这就是我告诉我的病人。”
Costs and ethics also pose significant barriers. Many transgender patients have already been saving for years to pay for male-to-female genital surgery— which can cost around $24,000 without insurance coverage—so a uterine transplant could be out of financial reach, Unger says. And some doctors working on the frontlines with transgender patients have expressed concerns about the ethics involved in the risks. Sauer, the gynecologist from Columbia, says that with options including surrogacy and adoption available in many locations, an experimental surgery to help patients give birth—not save their lives—seems like a huge risk. Safer, medical director for the Center of Transgender Medicine and Surgery at Boston Medical Center, agrees. “If you are going to die without a transplant, of course you take [antirejection] drugs. But this is not the case here,” he says. “This is not life and death.”
成本和伦理也构成重大的障碍。这些病人已经被保存多年的支付男女生殖器手术，花费大约24000美元保险。没有覆盖所以子宫移植可以超出预算，Unger说。一些医生在和变性患者的前线都表达了对参与风险的伦理问题。今年，来自哥伦比亚的妇科医生，说与选项包括代孕和在许多地方可采用实验手术，帮助患者生育而不是拯救他们的生命，就像一个巨大的风险。安全，在波士顿医疗中心的变性医学中心的医疗主任，同意。“如果你没有移植就快要死了，当然你需要抗排斥药物[ ]。但在这里这不是问题，“他说。“这无关生死。”
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