Can a transgender man and a transgender woman marry and have children if they seek medical aid?

Q: A lady professor (Dr. GK) asked me this Q: 

What is the difference between transgender and gay? Can transgender man and transgender woman marry and have children if they seek medical aid?

Krishna: Transgender means a person whose sense of personal identity and gender does not correspond with their birth sex. Transgender, often shortened as trans, is also an umbrella term; in addition to including people whose gender identity is the opposite of their assigned sex (trans men and trans women), it may also include people who are non-binary or genderqueer. Other definitions of transgender also include people who belong to a third gender, or else conceptualize transgender people as a third gender. The term transgender may be defined very broadly to include cross-dressers. The term transgender does not have a universally accepted definition, including among researchers.(1)

 Gay :  homosexual (used especially of a man). Now the word usually means a person who is sexually attracted to people of the same sex. Often that person is also romantically interested in people of the same sex. A gay person can be a male who likes other males or a female (lesbian-a gay woman) who likes other females (3). 

Modern medicine offers a range of solutions that can help transgender men and women become moms and dads.  An array of treatment choices are available for transgender men and women (2). But how easy or difficult the process is  depends on a number of factors. 

For example, it is far more difficult to save gametes for eventually assisted reproduction for people who medically transition before puberty. On the other hand, a transgender man or transgender non-binary person who is not opposed to carrying a child and who has a partner with a penis may be able to carry a child with relative ease (8).

With the exception of certain individuals who are born with disorders of sexual differentiation, sperm can only be retrieved from individuals who are assigned male at birth. In contrast, only people who are assigned female at birth can make eggs. Therefore, in order to make a baby, you need genetic contributions from at least one person assigned male at birth and one assigned female at birth. You also need an assigned female with a functional uterus who can carry that infant to term. Couples trying to conceive do not always have access to everything they need to make a baby. They may need donated eggs or sperm if they only have one or the other. They may also need to find a surrogate (an assigned female who carries a baby) to carry their child if they live in a place where doing so is legal (9).

Factors that affect the complexity of being able to have biological children for someone who is transgender include (9):

• Their assigned sex at birth
• If, when, and how they medically transition
• If, when, and how they surgically transition
• Whether they have used fertility preservation techniques to store gametes (sperm/eggs)
• Their partner's sex
• Their access to insurance coverage for assisted reproduction or their ability to pay out-of-pocket for fertility care
• Local laws around assisted reproduction, surrogacy, and related concerns

Transgender men and some non-binary people are assigned female at birth, meaning they are born with ovaries and a uterus. This means that they are capable of becoming pregnant and carrying a pregnancy to term (10) Transgender pregnancy is not very common, but it has been shown to be safe for both the parent and the baby.

If a transgender man or non-binary person assigned female at birth has a cisgender woman as a partner, either of them can potentially carry their child. However, the couple will need donor sperm in order to become pregnant.

If a transgender man or non-binary person assigned female at birth has a cisgender man as a partner, things may simpler. They can potentially have a child that is biologically both of theirs and carried by the transgender partner to term.

This is also possible if the partner of a transgender man or non-binary person assigned female at birth is a transgender woman or non-binary transfeminine person. However, the chance of successful conception will be influenced by aspects of both of their transitions(10).

 Transgender pregnancy is the gestation of one or more embryos or fetuses by transgender people (4). Currently, the possibility is largely dependent on the individual's natal reproductive organs, with transition-related treatments impacting fertility.   Pregnancy is possible for transgender men who retain functioning ovaries and a uterus (5).

Regardless of prior hormone replacement therapy treatments, the progression of pregnancy and birthing procedures are typically the same as those of cisgender women(6). It has been shown that historical HRT use may not negatively impact ovarian stimulation outcomes, with no significant differences in the markers of follicular function or oocyte maturity between transgender men with and without a history of testosterone use.  Research also found that prior use of testosterone did not affect pregnancy. Testosterone therapy affects fertility, but many trans men who have become pregnant were able to do so within six months of stopping testosterone.

Some transgender women request for uterine transplants. But there are several complications involved with this (7). 

 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.

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.

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.

Experts disagree about what would be the biggest barrier to pulling off these theoretical transplants and pregnancies. Some  think  the hormones would likely prove the biggest obstacle.

According to others a consistent and ample blood flow to the fetus can be a huge problem.  They are concerned about dangers to the fetus from a potentially unstable biological environment and unforeseen risks for the mother-to-be. 

Costs and ethics also pose significant barriers.

So, the answer is 'yes' in some cases and 'somewhat difficult to not possible' in the present circumstances with regard to other cases which are too complicated. 

Footnotes: 

1. https://en.wikipedia.org/wiki/Transgender

2. https://www.yalemedicine.org/conditions/transgender-reproductive-op...

3. https://simple.wikipedia.org/wiki/Gay

4. https://en.wikipedia.org/wiki/Transgender_pregnancy

5.  Beatie, Thomas (April 8, 2008). "Labor of Love: Is society ready for this pregnant husband?". The Advocate. p. 24.

6. Obedin-Maliver, Juno; Makadon, Harvey J (2016). "Transgender men and pregnancy". Obstetric Medicine. 9 (1): 4–8. doi:10.1177/1753495X15612658. PMC 4790470. PMID 27030799.

7. https://www.scientificamerican.com/article/how-a-transgender-woman-...

8. Obedin-Maliver J, Makadon HJ. Transgender men and pregnancy. Obstet Med. 2016;9(1):4–8. doi:10.1177/1753495X15612658

9. https://www.verywellhealth.com/transgender-pregnancy-4582219

10. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gend.... Obstet Gynecol. 2014;Dec;124(6):1120-7. doi:10.1097/AOG.0000000000000540

Other Qs related to this: 

Q: Is it possible for a male person to have XX chromosomes.

Krishna: Yes, that's possible. There's trans men and men with de la Chapelle syndrome (XX male syndrome).

Yes, you can have an XX male if the SRY gene has migrated from a Y chromosome to an X. 

The person is sterile. Very rarely it can happen without an SRY gene, when a different gene which is normally present on the X mutates.

There are also freemartins. This happens when the placentas of male and female fraternal twins become entangled, and androgens from the male twin seep through to the female one and cause it to become masculinised - although not usually to the point of appearing fully male.

This is leaving aside the issue of trans people, who probably have a cortical homunculus (the bit of the brain that maps to the body) which doesn’t match the bits they were born with.

XX male syndrome, also known as de la Chapelle syndrome, is a rare congenital intersex condition in which an individual with a 46, XX karyotype (otherwise associated with females) has phenotypically male characteristics that can vary among cases. Synonyms include 46,XX testicular difference of sex development (46,XX DSD), 46,XX sex reversal, nonsyndromic 46,XX testicular DSD, and XX sex reversal.

In 90 percent of these individuals, the syndrome is caused by the Y chromosome's SRY gene, which triggers male reproductive development, being atypically included in the crossing over of genetic information that takes place between the pseudoautosomal regions of the X and Y chromosomes during meiosis in the father. When the X with the SRY gene combines with a normal X from the mother during fertilization, the result is an XX male. Less common are SRY-negative XX males, which can be caused by a mutation in an autosomal or X chromosomal gene. The masculinization of XX males is variable.

People with XXY chromosomes would also meet your definition of “male with female chromosomes”.