How Do You Get Pregnant With No Vagina?

Hi Wendy from the future here. If we had our time again, we would have produced this episode differently. We got carried away with the wildness of this story from a scientific perspective and didn't take time to think about the fact that this is the story of a 15 year old who would have been going through an extremely difficult time. As one of our listeners commented, quote, "Despite the science itself being fascinating, these are very young human beings involved in this case." Another person called us cavalier. And both of these people, you are absolutely right. So I just want to say sorry and thank you for picking us up on this. We have changed some of our language in this episode based on the feedback. There's more details in the show notes. But like I said, we really should have done things differently. Okay, I'm with the show. Hi, I'm Wendy Zuckerman and you're listening to Science Faces. Today on the show, a new segment that we're calling case files. And this is where we take case reports, which are basically stories from academic literature where really weird things have happened to patients that are often so out of the norm that doctors have to write them down for posterity. So think about the kid who went to the hospital with a case of blue balls, classic case report. But today, we have a case report for you that could perhaps top all case reports. And to process it all, we've got friend of the show at science journalist Joel Werner. Hello, Joel. Hey, Wendy. Okay, this story was published in the British Journal of Obstetrics and Gynecology in 1988. It begins with a lovers quarrel and ends with what might be one of the unlikliest events in scientific history. But it's so unlikely that we're wondering if perhaps it is indeed a fairytale with some like marriage elements. Wow. That is some hype. All right. We're in Lusutu, which is a very small country within the borders of South Africa. And the case report starts off like this quote, "The patient was a 15 year old girl employed in a local bar. She was admitted to hospital after a knife fight involving her, a former lover, and a new boyfriend. Who exactly stabbed whom was not quite clear? But all three participants in the small war were admitted with knife injuries." Wow. So this young woman comes into the hospital with stabbed wound to the upper part of her stomach. They have a look and it's actually sort of punctured two holes into her stomach. The doctors operate on her, close up the wounds, keep her for observation. But ultimately, she gets to go home after about a week and a half and she's fully recovered. But of course, our story can't end there. Months later, she returns to the hospital with a very different issue. It's about nine months later, actually. And she's complaining of serious stomach pain. It's coming in these very intense waves where the pain gets really bad and then it goes away and then it comes back again. Doctors examine her, what do you think is going on, Joel? Like, I got two kids and that sounds like contractions. Yes. Yes. Okay. Yes. She is pregnant. Wow. Fully in labor. She didn't know she was pregnant. She did suspect something was off because her belly was getting bigger. Now, again, you might be thinking, okay, this happens 15-year-olds. They get pregnant sometimes. But here's where things get strange. So as the doctors start getting her ready to have this baby, they realize that something is a little bit different about this 15-year-olds. She has no vagina. What? So, yeah, so she is pregnant. She's not trans. But she has no vagina. And more on her story is coming up just after the break. Welcome back. Before the break, we told you about a 15-year-old who was pregnant and in labor, but has no vagina. Okay. And so let's just talk about this no vagina for a moment. So basically, when this girl was in the womb, the lower part of her vagina didn't develop properly. And that can sometimes be caused by a condition called vaginal agenesis. Right. Okay. It happens to about one in 5,000 people. And this case report said that where her vagina was supposed to be, only a shallow skin dimple was present. We think she had a urethra, the inner and outer lips of the vulva. But then instead of an opening where the vagina was supposed to be, there was skin with a little dent in it. So think about it like kind of pressing your cheek a little, like a little dimple. And this condition is usually brought on by a syndrome with a very long name. Mayor Rookatansky Kuster-Hauser syndrome. It's a mouthful. It sounds like a law firm, to be honest. Right. Well, his mouthful was said by Dr. Neil Shah. He's at OBGYN and the chief medical officer at Maven Clinic. He's based in Massachusetts. And he's treated people who have this condition before. When I was in residency, I took care of people at Boston Children's Hospital that would fly in from all over the worlds who had this syndrome. Now Neil told us that on top of the vagina that hadn't properly formed, people with this condition can also have a uterus that is not fully developed. But in this case, with the pregnant hero of our story, her uterus was fully formed, working perfectly and could support a fetus soon to be a baby. It just seems there was no vagina. So the big question is, of course, how did the sperm get in? And I guess part two, how does the baby get out? Okay. So the baby got out by a C-section. That's the quick one. Okay. But now back at the hospital, the doctors and nurses, they were curious themselves about how the sperm got in there. And so they start asking questions. And here is what they found out. So this teenager had apparently tried multiple times to have gotten variety, penis, and vagina sex, but that didn't work. So turned to oral sex, which ends up being key here. So, Joel, do you remember the fight that broke out at the start of the story? Oh, yeah. I can't stop thinking about it. The knife has to bits. It's Chekhov's knife. Okay. So it seems that that fight all started because her ex-lover caught her going down on her new partner. And doctors think that this wild combination of giving for ratio, swallowing the sperm and the fight might have led to this pregnancy. What? All right. So the first thing we need is some way for the sperm to get to the egg. And normally the sperm has a pretty direct root through the vagina, sneak you way up the cervix, yada yada yada, basically, home-frame. But in this case, when she swallowed the sperm, it would have been stuck in her stomach. And our producer, Ketifoster Keys, Osnell, are the stomach and the uterus connected in any sort of way? Uh, not without a knife. But we had a knife, right? But maybe let's just start this journey with the sperm inside the stomach because she just swallowed it. Right. But Neil actually told us that at that point, it should have been game over. Wow. Okay. The most extraordinary thing is that sperm does not survive acid. Gastric acid in the stomach is basically as acidic as it gets. Yeah. So he's just shocked. And other doctors we reached out to as well, shocked that it would have survived the stomach at all. Other science journalists as well. I'm just perpetually shocked at the moment. So those stomach acids are so toxic to sperm. In one study, researchers actually looked into how different acids would affect sperm, whether it would immobilize or kill human sperm. And so they mixed semen with stuff that is generally less acidic than the contents of our stomach. And what they found was that within a minute, the sperm could no longer move. And within 10 minutes, all the sperm were dead. So based on that study, the odds of the sperm surviving the stomach were perhaps even less than the odds of this woman not having a vagina. Here's Neil. They've never seen sperm survive in the stomach in my whole career. So do they know what length of time there was between and her going down on her new lover and her getting stabbed in the. Was she caught in the act? And so the sperm could like maybe have just been freshly in the stomach. - Yeah, it appears she was caught in the act. All of this must have happened quickly. It couldn't have just been sitting in the stomach 'cause then sperm would have been dead. - Absolutely. - It has to have happened very fast, the swallow. And then so we know saliva is a nicer pH. For sperm we also know that seminal fluid is not, is not acidic, it's actually a little bit basic. So maybe the two of them acted like a coating to protect the sperm on top of that eating food can lower the acidity in your stomach. So maybe if she'd had a big meal before all this happened and one thing that Neil read in the case report made him think that maybe this did all happen quickly. - But they say in the case report is that she vomits. - So what the case report actually says is that her stomach was empty when she had surgery. But Neil knowing what he knows about medicine reckoned that that could be from vomiting. So maybe what happens is she swallows the sperm and it's somehow protected in the saliva and the seminal fluid and then maybe she vomits and that act of vomiting propels a tiny bit of sperm out into the little hole in the stomach that the stab wound created. So he's Neil. - So it basically has to be like perfectly positioned anatomically to be near the place where it would exit based on where the stab was. - Which explains our exit from the stomach, but there's still, this is just the first step of a long journey I'm imagining. - Right. - And then it gets even wilder. - Right, because when it exits the stomach, like you say, it's not as if the egg is just hanging around saying hello and right here, the egg should be in the pelvis and the hole was in the stomach. - Absolutely, yeah. - Now once the sperm gets out of the stomach, it moves into this liquidy space that's between the organs in the abdomen. It's called the peritoneal cavity. And this peritoneal cavity is actually a nicer place. We think for the little fragile spermies to survive and thrive because the pH in the peritoneal cavity is about the same as vaginal fluid. - Oh, okay. - Which is the stuff that protects the sperm as it travels through the vagina, all right? For those who have a vagina. - Now, there have been two other case reports that we found where sperm was found in the peritoneal fluid of men suggesting that maybe it can survive there. And so from this peritoneal cavity, the sperm then would have had to have swum, pass the intestine into the pelvis and ultimately to reach the egg. - Look, this is, do you know those guys who over-analyses the Zapruder film of JFK's assassination? And they're like rewinding and going, "Oh, the bullet had to have come in through." Like Neil reminds me of one of those guys. He's just gone, "No, look, it sounds far-fetched, but maybe there's this like magic sperm that can like roll the coastwards way through the abdomen and then magically. - Well, there is second chewed up. - Exactly. So that is one way, maybe. So after the break, the final unbelievable chapter. (upbeat music) - Welcome back to the show, how the teenager with no vagina got pregnant. Here's where we're at, based on the facts on the ground. It looks like the only way this could have happened was that the sperm that she swallowed after giving oral to her boyfriend somehow survived the acids in her stomach, escaped the stomach through a stab wound and then swam down the obstacle course that is her body and merged with the egg. - Unbelievable. - Unbelievable. And by the way, we looked into this, there are a bunch of ways that the sperm is guided towards the egg because of things that the egg is doing, like it releases certain chemicals that sort of say come hither to the sperm and there's changes to temperature and the flow of fluid in the body that can help guide sperm to the egg. But all of that stuff tends to happen when you're already pretty close to the target. It's not kicking in up in the stomach. And I imagine that we haven't evolved to help sperm from, was it the peritoneal? - Yes, cavity. - The cavity to then find its way. It's not like we usually get sperm, which is part of the body. - No, no, no, no, no. And this takes us to the final, rather unbelievable part of this story, which is the egg. So what's very curious about what happened here is that we don't think this teenager had ever had a menstrual period before. Because without a vagina, there'd be no hole for the blood to escape into. And so if she had released an egg and this blood was coming down, the body really doesn't like blood in places it shouldn't be. If it was pulling there, it probably would have caused her a lot of pain and she probably would have had to go to the hospital to deal with it. And plus, when they opened her up to deliver the baby, they would have seen blood from past periods and they didn't, he is now. - Now, when they deliver her, her cervix is completely dilated and it empties into nowhere. And there's no blood anywhere. And apparently she's never menstruated before. So the other extraordinary timing is this is the first time she's ever ovulated in her entire life, she's 15. And she ovulates at the exact perfect time for fertilization to happen. - What, what, the series of coincidences are stacking up? - Yes. - So the first time she's ever, her body is ever released in egg, there just happens to be sperm that's made its way. From oral sex, out of wound in her stomach from a stab fight on a magical journey through her abdominal cavity. And then it fertilizes the only egg that's ever been there to be fertilized. - Yeah, and by the way, the baby was born healthy. - Amazing. - He's Neil. - This baby is born at the expected weight and nothing apparently wrong with it because there's a lot of other things that can happen. She doesn't miscarry. So then you're like in all of human existence, what are the odds that this happened once? - So this is like the unicorn of all unicorns of all of medical cases. - Yeah, yeah, I would say so. You know, the odds are lower than the odds of one person being struck by like, ning a hundred times. - Wow. It's sort of, I mean, often when we're talking about these unbelievable stories in science, I think about that amazing documentary Jurassic Park and it's famous line, life finds a way, but this is like the perfect example of life finding a way. The odds have been completely stacked against this fertilization event ever occurring and somehow there's a healthy child at the end of it. - Yeah, and we look, we reached out to the doctor who wrote the case report several times, but we didn't hear back. He's now retired. We also asked a bunch of other doctors what they made of this report because it is so wild. And a couple of doctors said they just didn't believe it. Too unlikely. Others were like, maybe one told us quote, sperm a persistent little guys. And that doctor actually described a patient that they had had, who had no obvious vaginal opening, who had apparently never had penetrative sex and also got pregnant and given birth to a kid, it was C-section as well. - Wow. So yeah, she was like, you know, it's unlikely, but stuff happens. Some of the doctors that we heard from also said that there might be another explanation for what's going on here and that maybe that dimple where her vagina sort of should have been wasn't totally closed off. Maybe there was a tiny hole in there that was missed and sperm somehow got in that way, just sort of the more regular way. And the fact that all of this happened, you know, some 40 years ago, one doctor told us that they didn't have the technology on hand that we use today to diagnose someone with vaginal agenesis. - Well, this is a thing, you know, from the very first time you start studying science, you told the simplest solution is often the accurate solution. - Yeah. - And if this story we're being told is the simplest solution, like it makes you think like, [BLANK_AUDIO] other other mechanisms by which this could have occurred. Yeah, and, you know, but on the other hand, Drs pointed out, you know, this was a case report written in a legit peer reviewed medical journal. As for Neil, he said, you know, it was extremely unlikely to have happened, but who knows? Nothing is impossible. Like as a physician also, you have to, you know, you see all kinds of extraordinary things. Wow. Now, do we know what happens? Is there any resolution to the love story? The case report says that about two and a half years later, baby is still perfectly healthy. It says, quote, the young mother, her family and the likely father adapted themselves rapidly to the new situation and some cattle changed hands to prove that there were no hard feelings. I love these stories where they're just completely almost impossible coincidences that lead to an event. And it sort of challenges our notion of kind of like what is likely, you know, like if this, if this can be true, if this somehow is the way that that sperm and that egg found each other, then, you know, it gives you a sort of sense of like, I kind of like want to believe, like I want to lean in and just like believe that life will find a way. Thanks, Joel. Thanks Wendy. And Joel Lennon has a brand new podcast out. It's a historical thriller called Assassin's from the ABC, the Australian Broadcasting Corporation, and it's hosted by Aslan Pahari, who maybe you know as the hello, my friend guy from TikTok. He's really great. And each episode of Assassin's tells the story of one of history's most shocking assassinations from Abraham Lincoln to Tupac. And there's some science in some of the episodes too, like for three thousand years, the death of Pharaoh Ramsey's III was a mystery until some scientists came along and solved the riddle. You can find assassins wherever you get your podcasts. This episode was produced by a Kedi foster keys with help from Wendy Zuckerman, Michelle Deng, Rose Rimler, and Meryl Horn. We're edited by Blythe Chorrell, fact checking by Diane Kelly. Mixed in Sound Design by Bobby Lorde, Music Written by Emma Munger, So Wiley, Peter Leonard, Boomi Hidaka, and Bobby Lorde. Thank you to all the scientists we spoke to for this episode, including Dr. Sarah Acquired, Dr. Sarah Collins, Professor Adam Taylor, and Dr. Kathy Flood. Special thanks to Joseph Lovalle Wilson and the Zuckerman family.