Preserving fertility before transition

There are a number of reproductive options for individuals who want to preserve sperm, eggs, and/or embryos prior to transition. 

When to consider fertility preservation

Many transgender people are interested in becoming parents and may desire the experience of carrying a pregnancy or having a genetically related (biological) child. Gender-affirming medical treatment — in particular surgery and hormonal treatments — may harm one’s current and future fertility. For this reason, prior to undergoing gender-affirming treatment that might include genital reconstructive surgery, individuals should be fully aware of and counseled on fertility preservation options. The World Professional Association for Transgender Health (WPATH) Standards of Care recommends that fertility preservation be discussed with all patients prior to undergoing transition.ⁱⁱ

Of course, not all individuals choose to undergo fertility preservation prior to transitioning. The reasons may be personal, but factors such as cost and barriers to healthcare access may also come into play.ⁱⁱⁱ Fertility preservation rates reported in the literature are variable. A 2019 systematic review noted that rates of transgender men freezing eggs (0 to 16.7 percent) were much lower compared to transgender women freezing sperm (9.6 to 81.8 percent).^iv A study in Sweden found rates of fertility preservation were 26.2 percent in transgender men and 75.6 percent in transgender women following fertility consultation.^v

Some barriers to fertility preservation may include cost, invasiveness of procedures, and not wanting to delay transitioning.^vi For example, individuals often report the challenges of gender dysphoria when stopping or delaying hormone treatments, and/or the invasiveness of the egg retrieval process for transgender men or the sperm collection process for transgender women.^vii,viii ‍

Fertility preservation in transgender women

There are multiple options for fertility preservation in transgender women who have not undergone gender affirmation surgery. Sperm cryopreservation (freezing) with sperm obtained via masturbation or surgical extraction and testicular tissue cryopreservation are possible paths to fertility preservation.^ix,x

Sperm cryopreservation is the most reliable form of fertility preservation for individuals assigned male at birth. It is usually achieved by collection of the ejaculate from either masturbation or vibratory stimulus.^xi,xii The optimal number of vials of frozen sperm is difficult to predict and depends on the reproductive goals of the patient. As such, consultation with a fertility specialist is recommended, although not required.^xiii Transgender patients can also make an appointment directly with a sperm bank. Some banks may offer discounts to transitioning individuals (for example, the California Cryobank PRIDE program).

Fertility specialists may recommend having a semen analysis prior to freezing sperm to assess parameters such as sperm concentration, motility, and morphology. There is some evidence to indicate that these parameters may be reduced even prior to starting gender-affirming hormonal medication.^xiv The reason is unclear, but it may be a result of psychological stress, scrotal temperature with genital tucking, body mass index, or reduced masturbation, among other potential causes.^{xv,xvi,xvii,xviii}

Some transgender women may find it psychologically challenging or unacceptable to masturbate to produce a semen specimen.^xix Individuals also may report experiencing gender dysphoria when delaying or stopping hormone treatments, which is typically necessary to preserve or restore sperm production.^xx In these cases, there are other options available such as surgical sperm extraction. Surgical sperm extraction is also a treatment option for individuals with azoospermia (no sperm within the ejaculate) or other ejaculatory disorders. This procedure requires consultation with a reproductive urologist.^xxi,xxii

In transgender females who are pre-pubertal, spermatogonia (sperm stem cells) and testicular tissue cryopreservation are technologies under development as possible methods of fertility preservation. However, these methods are in the experimental phase and may not be clinically available except as part of a research study.^{xxiii,xxiv,xxv,xxvi}

Fertility preservation in transgender men

Fertility preservation in transgender men who have yet to transition involves the cryopreservation (freezing) of eggs, embryos, or ovarian tissue.^xxvii,xxviii Oocyte (egg) cryopreservation involves a combination of drugs that hormonally stimulate multiple oocytes within the ovaries to develop and mature. This process is known as controlled ovarian stimulation (COS).^xxix Once the oocytes are adequately stimulated, a needle is inserted into the vagina under transvaginal ultrasound guidance, and the oocytes are aspirated into the needle in a process known as oocyte retrieval (also called egg retrieval or oocyte pick-up). The oocytes can then be frozen for later use.^xxx

Like oocyte cryopreservation, embryo cryopreservation involves hormonal stimulation of the ovaries and subsequent oocyte retrieval. These steps are followed by in vitro fertilization with a sperm cell. The fertilization of the oocyte can be completed with a partner’s sperm, or with donor sperm. The embryo is then cryopreserved and can be thawed and used to achieve pregnancy when the individual is ready.^xxxi

In transgender males who are pre-pubertal, the only current option for fertility preservation is using cryopreservation of ovarian tissue, followed by autotransplantation. It was considered an experimental treatment until 2019, and its availability is extremely limited.^xxxii,xxxiii Ovarian tissue cryopreservation involves a laparoscopic procedure and removal of a piece of an ovary, which is then frozen for later use after a process known as “in vitro maturation,” which matures the ovarian tissue so it can function properly. The transgender individual will then complete their transition after the tissue preservation. When ready, the ovarian tissue can be transplanted back into the pelvis and, in theory, it will resume normal function. The patient can then undergo in vitro fertilization (IVF) with the transplanted cryopreserved ovarian tissue.^xxxiv To date, the number of reported live births resulting from successful re-transplantation of cryopreserved ovarian tissue is approaching 200.^{xxxv,xxxvi,xxxvii,xxxviii,xxxix}

The rate of fertility preservation in trans men is lower compared to trans women.^xl,xli In most cases, freezing eggs is much more cost-prohibitive compared to freezing sperm. In addition, the egg retrieval procedure is significantly more invasive, and individuals often report the resultant psychological impact and gender dysphoric triggers as a barrier.^xlii

Fertility during and after transition

Transitioning involves several medical interventions, including hormone therapy, that can affect an individual's reproductive system and fertility. There are numerous factors to consider regarding fertility before and after a transition for both transgender women and transgender men, including the different options available for preserving fertility.

Fertility for trans women in transition

Gender-affirming hormone therapy (GAHT) in transgender women typically involves the use of estrogen and anti-androgen therapy (medications such as spironolactone that block testosterone). Studies suggest that this regimen suppresses spermatogenesis (sperm production in the testes). A study by Vereecke et al (2020) looked at 97 transgender women who underwent hormone therapy prior to orchiectomy (removal of testes). They found that the hormone therapy suppressed testosterone in 92 percent of individuals, and that there was no evidence of spermatogenesis in any of the testes after removal. Therefore, conception is very unlikely in transgender women on hormone therapy prior to orchiectomy, though it remains possible, and GAHT should not be viewed as an effective form of birth control.^xliii

Studies have shown that hormone therapy does not lead to permanent infertility in transgender women. In a study of 72 transgender women who were taking GAHT for over a year and underwent gender-affirming orchiectomy, researchers found that 81 percent of the testicles still contained germ cells (the initial stem cells that will undergo spermatogenesis), and 40 percent contained spermatids (non-motile sperm cells that have completed spermatogenesis and will next develop into mature motile sperm cells).^xliv However, there is conflicting evidence on the extent to which fertility returns after stopping GAHT in transgender women.^xlv A study by de Nie et al (2023) of nine transgender women found that sperm production resumed in all the subjects after they stopped hormone therapy. The researchers also found that four of the nine transgender women stopped hormone therapy to conceive with their partners, and the partners of three of those four individuals were able to conceive. The successful pregnancies were achieved four, 20, and 40 months after stopping hormone therapy.^xlvi

While sperm production is restored in many transgender women after stopping hormone therapy, there may be some level of permanent decline in the amount and quality of sperm in some of these patients.^xlvii A study of 28 transgender women by Adeleye et al (2019) found that semen parameters may be persistently compromised by hormone therapy even after people stop taking it. They found that semen volume, concentration, percent motility, and total motile count was greatest in individuals who had never undergone hormone therapy. These values were all slightly lower in people who had previously taken hormone therapy but had stopped (on average, these participants had stopped the therapy 4.4 months before the study). The semen parameters were all markedly reduced in individuals who were still using hormone therapy.^xlviii

Fertility for transgender men in transition

Transgender men in transition can still become pregnant if they have a uterus, even while using hormone replacement therapy. However, testosterone use during pregnancy can cause fetal abnormalities. In female fetuses exposed to testosterone in the womb, it can cause abnormal vaginal development, labial fusion (when the lips of the vulva become fused together), and clitoromegaly (an enlarged clitoris).^xlix Even though taking testosterone often causes transgender men to stop having menstrual periods, it does not act as a contraceptive that reliably prevents pregnancy. Therefore, transgender men with a uterus who are taking testosterone and are sexually active with partners who may produce sperm need to use contraception.^l

Stopping testosterone use often results in the return of menstrual periods. A study by Light et al (2014) evaluated 41 transgender men who experienced pregnancy. Twenty-four of them had previously used and then stopped testosterone therapy. Of these 24 participants, 80 percent experienced a normal return of menstruation within six months of stopping testosterone. Therefore, fertility restoration is possible even after hormone therapy in transgender men.^li

Additional current and future options for trans parenthood

There are other potential roads to parenthood for trans individuals beyond preservation of fertility including surrogacy, adoption, foster parenthood, and potential uterus transplantation in the future.

Surrogacy

If a transgender man undergoes gender-affirming surgery with a hysterectomy (removal of the uterus), they are no longer able to carry a pregnancy. If they have a partner who also does not have a uterus, a gestational carrier — also called a surrogate — may be used to achieve pregnancy.^lii Even if a transgender man is still biologically capable of pregnancy (i.e., they are not taking hormone therapy and have not had gender-affirming surgery), they may prefer conception with a gestational carrier to prevent the gender dysphoria that can occur with pregnancy.^liii,liv

Foster care or adoption

Alternative options for transgender people wishing to become parents are co-parenting, foster care, and adoption. Individuals may choose to pursue adoption as a first choice for parenting out of a desire not to delay the transition process with fertility preservation, or because having a biogenetic link to children is not a priority. Or they may turn to adoption after fertility problems or pregnancy loss.^lv,lvi

Uterus transplant

An evolving option for transgender parenthood is the future possibility of uterus transplantation for transgender women who wish to become pregnant. In cisgender individuals, there have been more than 70 uterine transplantations globally, with at least 12 live births as a result.^lvii,lviii Advancements in equality and inclusion for reproductive healthcare, combined with advancements in uterus transplant research, have led to discussions about the future potential for uterus transplants in trans women.^lix However, the evidence supporting this option is still preliminary and experimental.^lx There are various anatomical, hormonal, fertility-related, and obstetric considerations that would need to be addressed, and more research is needed to do so.^lxi

Pregnancy, childbirth, and lactation for trans men 

There is a lack of clinical data on pregnancy in transgender men.^lxii Although the research is limited, being a transgender man does not seem to have a negative impact on pregnancy or birth outcomes.^lxiii

A study by Light et al (2014) studied 41 transgender men who experienced pregnancy after the female-to-male transition. They found that 78 percent of study participants delivered in the hospital, compared to 99 percent of overall deliveries in the U.S. They also found that only half of these study participants received prenatal care from a physician. While the study did not explore participants’ reasons for not seeking care, the researchers speculated that it may have been due to real or anticipated negative gender-based experiences with healthcare providers, among other potential factors such as access to insurance.^lxiv

Pregnancy care for transgender men is within the scope of obstetricians. However, some clinicians may need appropriate training to navigate the unique psychosocial concerns of trans individuals. If there is a choice of hospitals or birthing facilities, patients can aim for a positive perinatal experience by asking questions to ensure the facility provides gender-affirming, inclusive care from start to finish. All staff involved with the patient — including receptionists, nurses, social workers, allied health practitioners, and physicians — should use appropriate names and pronouns and tailor care to the individual’s needs.^lxv

Unfortunately, there are still many gaps in the care that transgender individuals receive. Recent research has provided recommendations for healthcare providers to enhance their clinics’ gender-affirming care:^lxvi

• Ensure accessible, non-gendered restrooms.
• Include a diverse patient population including individuals with diverse gender identities on pamphlets and signage.
• Broadly display gender-affirming statements.
• Identify pronouns, document them, and use them consistently.
• Reflect the language transgender patients use to describe their bodies (e.g., chest instead of breast).
• Explain why sensitive questions are relevant to the individual’s care and not motivated by curiosity.

Childbirth for trans men

Providing gender-affirming, trauma-informed healthcare to transgender individuals continues to become increasingly prioritized in society. Transgender men have historically faced barriers and microaggressions during childbirth, such as healthcare providers endorsing gender-binary norms, misusing pronouns, or providing insufficient privacy.^lxvii

People choosing where to give birth can ask potential doctors or midwives about their facilities’ policies and options during labor and delivery to ensure they align with their needs and wishes. For example, it is possible for hospitals to provide increased privacy to transgender patients to reduce intrusive attention and unnecessary examinations. Healthcare facilities can ensure that only essential doctors and nurses are present during the delivery (i.e., by minimizing learner involvement by medical students and nursing students). It may also be possible to decrease the number of required cervical examinations to track the progression of the labor, and to minimize genital exposure by ensuring the patient is adequately covered during exams.^lxviii

A study by Hahn et al (2019) describes pregnancy and delivery as an especially sensitive time for transgender individuals, as transgender men may experience increased sensations of gender dysphoria during delivery. The researchers studied interventions they provided and their impact on perinatal care for a transgender patient. Interventions included a tour of the labor and delivery unit prior to labor, as well as a labor and chestfeeding workshop. They also recommend ensuring that the electronic medical record (EMR) in the labor and delivery unit can accommodate the pronouns of a non-binary individual or transgender man.^lxix

Lactation or chestfeeding

Following pregnancy, transgender men may choose to feed milk to their baby through their chest, a lactation practice that is commonly referred to as chestfeeding. In a study by MacDonald et al (2016) of 22 transgender men who had experienced pregnancy and delivery, they found that 16 chose to chestfeed for some time, four chose not to chestfeed, and two of the participants were either currently pregnant or had miscarried, and therefore had not yet had the opportunity to chestfeed.^lxx Importantly, chestfeeding is an individualized decision. An individual may decide not to chestfeed for any personal reason, including an increased sensation of gender dysphoria.^lxx

When considering restarting hormone therapy after delivery, one factor in the decision is that testosterone can decrease milk production for chestfeeding.^lxxii It is also important to consider that testosterone is transmitted to the infant through the milk obtained through chestfeeding. A study by Oberhelman-Eaton et al (2021) analyzed the milk produced by a transgender man who initiated testosterone therapy while chestfeeding. They found that the testosterone reached a therapeutic level in his blood after two weeks, and that the concentration of testosterone in the milk increased to 35.9 ng/dl. The relative dose of testosterone to the infant was found to be less than 1 percent, and there were no adverse effects to the baby. The baby’s serum testosterone levels remained undetectable. Therefore, it may be possible for some individuals to restart hormone therapy even while chestfeeding.^lxxiii

Support for transgender families

One study by Carone et al (2021) studied a group of 1,436 individuals controlled for age, education, and language, and compared outcomes for individuals who were transgender versus cisgender. Of this sample, 274 identified as transgender, and 18.8 percent of these participants were parents. Their encouraging findings indicated that there were no significant differences between transgender and cisgender parents in terms of mental or physical health.^lxxiv

A study by Erich et al (2008) of 91 transgender individuals found that 46.2 percent of these individuals were parents. The majority (88.1 percent) had come out to at least one of their children, and 60.5 percent said their relationships were either good or excellent.^lxxv

Studies have indicated that when children are present during a parent’s transitional process, the main stressors are usually related to tension between parents, and separation or divorce that may occur as a result. The stress is usually not related to the gender transition itself.^lxxvi

Studies also show that having a transgender parent is unlikely to impact developmental milestones for the child, and that there is no evidence to indicate that having a transgender parent impacts the child’s gender identity or sexual orientation development.^lxxvii

Conclusion

Transgender fertility research is essential in addressing the unique challenges faced by the transgender community when it comes to reproductive health. By identifying the specific needs of transgender individuals and developing new treatments and interventions, research can help increase access to care and improve outcomes for prospective parents. While there are still many challenges to be addressed, the growing interest in transgender fertility research offers new opportunities to ensure that all individuals have access to the care they need.