Preserving fertility before transition 

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

When to consider fertility preservation 

Many transgender people are interested in becoming parents, which may include a desire to have a genetically related child (a 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 counselled about, fertility preservation methods.

In addition to using one’s own gametes (sperm or egg), some individuals may also be interested in carrying a pregnancy. 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, for various reasons, including personal preference as well as factors such as cost and barriers to health access.ⁱⁱⁱ Fertility preservation rates reported in the literature are variable. A 2019 systematic review noted that rates were much lower in transgender men cryopreserving oocytes (0-16.7 percent) compared to transgender women cryopreserving sperm (9.6-81.8 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 that have been identified include cost, invasiveness of cryopreservation techniques, 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 with the invasiveness of the egg retrieval process for transgender men or the sperm collection process for transgender women.^vii,viii

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Fertility preservation in transgender women 

There are multiple options for fertility preservation in transgender women who have not undergone gender affirmation surgery. These include sperm cryopreservation (freezing) with sperm obtained via masturbation or surgical extraction, as well as testicular tissue cryopreservation.^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 albeit not required.^xiii Patients can present directly to a sperm bank, some of which may offer discounts to transitioning individuals (e.g., the California Cryobank PRIDE program). Providers may recommend having a semen analysis prior to freezing sperm in order to assess parameters such as sperm concentration, motility, and morphology. This is because there is some evidence to indicate that these parameters may even be reduced prior to starting gender-affirming hormonal medication.^xiv The reason for this is unclear, but may be a result of psychological stress, scrotal temperature with genital-tucking behavior, body mass index, and reduced masturbation, among others.^{xv,xvi,xvii,xviii,xix}

Some transgender women may find it psychologically challenging or unacceptable to masturbate to produce a specimen.^xx Individuals also may report experiencing gender dysphoria when delaying or stopping hormone treatments, which is typically necessary to preserve or restore sperm production.^xxi In this case, there are other options available such as surgical sperm extraction. Surgical sperm extraction is also a treatment option for individuals with azoospermia or other ejaculatory disorders, though this procedure would require consultation with a reproductive urologist.^xxii,xxiii

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

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Fertility preservation in transgender men 

Fertility preservation in transgender men who have yet to transition involves the cryopreservation (freezing) of oocytes, embryos, or ovarian tissue.^xxviii,xxix Oocyte 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).^xxx 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” (egg retrieval or oocyte pick-up). The oocytes can then be cryopreserved (frozen), for later use.^xxxi  

Like oocyte cryopreservation, embryo cryopreservation involves hormonal stimulation of the ovaries and subsequent oocyte retrieval. This is followed by in-vitro oocyte 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.^xxxii  

In transgender males who are pre-pubertal, the only current option for fertility preservation is using cryopreservation of ovarian tissue, followed by autotransplantation. This was considered an experimental treatment until 2019 and its availability is extremely limited.^xxxiii,xxxiv Ovarian tissue cryopreservation involves a laparoscopic procedure and removal of a piece of the ovary, which is then cryopreserved for later use after a process known as “in-vitro maturation;” this 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 will resume normal function. The patient can then undergo IVF with the transplanted cryopreserved ovarian tissue.^xxxv To date, the number of live births resulting from successful re-transplantation of cryopreserved ovarian tissue reported is approaching 200.^{xxxvi,xxxvii,xxxviii,xxxix,xl}

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

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.

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Fertility for trans women in transition 

Gender-affirming hormone therapy (GAHT) in transgender women typically involves the use of exogenous 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.^xliv  

Studies have shown that hormone therapy does not lead to permanent infertility in transgender women. However, there is conflicting evidence on the extent to which fertility returns following cessation of GAHT in transgender women.^xlv A study by de Nie et al (2023) of nine transgender women who stopped hormone therapy found that spermatogenesis resumed in all of the subjects after cessation. They found that four of the nine transgender women stopped hormone therapy to conceive with their partners, and of these four individuals, the partners of three of them were able to conceive. The successful pregnancies were achieved 4, 20, and 40 months after stopping hormone therapy.^xlvi In a study of 72 transgender women who were taking GAHT for >1 year, and underwent gender-affirming orchiectomy, researchers found that 81% 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).^xlvii

While in many transgender women spermatogenesis is restored with cessation of hormone therapy, there may be some level of permanent decline in semen analysis parameters in some of these patients.^xlviii A study of 28 transgender women by Adeleye et al (2019) found that the semen parameters may be persistently compromised by hormone therapy even after cessation. They found that semen volume, concentration, percent motility, and total motile count was greatest in those who had never undergone hormone therapy. These values were all slightly lower in those who had previously taken hormone therapy but had stopped (on average the time since cessation was 4.4 months). The semen parameters were all markedly reduced in individuals who were still using hormone therapy.^xlix

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Fertility for transgender men in transition 

Transgender men in transition can still experience pregnancy if they have a uterus, even while using hormone replacement therapy. However, testosterone use during pregnancy is teratogenic (meaning that it can cause fetal abnormalities during pregnancy). Testosterone can cause abnormal vaginal development, labial fusion (when the lips of the vulva become fused together), and clitoromegaly (an enlarged clitoris) in female fetuses exposed to testosterone in utero.^l Even though testosterone often causes amenorrhea, it does not act as a contraceptive that reliably prevents pregnancy. Therefore, there is a need for contraception in transgender males who are sexually active and taking testosterone.^li

Stopping testosterone use often results in the normal resumption of menses. A study by Light et al (2014) investigated 41 transgender men who experienced pregnancy. Of these 41 men, 24 had previously used and then stopped testosterone therapy. Of these 24 subjects, 80 percent experienced a normal return of menses within six months of stopping testosterone. Therefore, fertility restoration is possible even after hormone therapy in transgender men.^lii

Surrogacy and trans parenthood 

If a transgender male undergoes gender-affirming surgery with a hysterectomy, they are no longer able to carry a pregnancy. If they have a partner who also does not have a uterus, a gestational carrier may be utilized to achieve pregnancy.^liii Even if a transgender male is still biologically capable of pregnancy (i.e., no hormone therapy, has not undergone gender-affirming surgery), they may prefer conception with a gestational carrier to prevent the gender dysphoria that can occur as a result of pregnancy.^liv,lv

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 > 70 uterine transplantations globally, with at least 12 live births as a result.^lvi,lvii 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.^lviii  However, the evidence supporting this option is still preliminary and experimental.^lix There are various anatomical, hormonal, fertility-related, and obstetric considerations that would need to be surmounted.  To begin an assessment of feasibility, further research that relies on animal studies and the use of cadaver donors is required such that anatomical considerations can be assessed.^lx

An alternative option for transgender individuals wishing to become parents is co-parenting, foster care, and/or adoption. Individuals may choose to pursue adoption as a first choice for parenting, out of a desire to not delay the transition process with fertility preservation, because having a biogenetic link to children is not a priority, or after fertility problems or pregnancy loss during attempting conception.^lxi,lxii At the same time, there remain considerable barriers to adoption, including financial constraints due to the high costs involved.

Pregnancy, childbirth, and human lactation for trans men 

Overall, there is a lack of clinical data on pregnancy in transgender males, and no high-quality evidence exists to indicate whether these patients are at a higher risk of peripartum complications.^lxiii

Pregnancy care for transgender males is within the scope of obstetricians; however, it does require appropriate training for these clinicians to navigate the unique psychosocial concerns of these individuals. A positive perinatal experience requires gender-affirming, inclusive care from start to end of the healthcare experience. This includes using appropriate names and pronouns, and tailoring care to the individual’s needs. All the clinicians involved with the patient should be trained in this, including the receptionists, nurses, social workers, allied health practitioners, and physicians.^lxiv

Unfortunately, there are still many gaps in the care that transgender individuals receive. Recent research has provided recommendations for healthcare providers to enhance their clinic’s cultural humility in providing gender-affirming care. Some recommendations for clinic set-up and intake include the following:^lxv

• Ensure accessible, non-gendered restrooms
• Ensure that signage and pamphlets include a diverse patient population including those of diverse gender identities
• Proper staff training that involves identifying pronouns, documenting them, and using them consistently
• Broadly displayed gender-affirming statements

Some recommendations for clinical encounters involve clinicians:^lxvi

• Reflecting the language patients use to describe their bodies (i.e., chest instead of breast)
• Explaining why sensitive questions are relevant to the individual’s care and not motivated by curiosity

A study by Light et al (2014) studied 41 transgender males 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 United States. They also found that only half of these study participants received prenatal care from a physician. While this study did not delve into the reasons for this, they speculated that this may have been due to real or anticipated negative gender-based experiences by healthcare providers. They also speculated that there may have been other factors such as access to insurance.^lxvii

Childbirth for trans men 

Transgender men have historically faced barriers and been subjected to microaggressions during delivery. Some of the microagressions reported include endorsement of gender binary norms, misuse or incorrect use of pronouns, insufficient privacy, or exoticization.^lxviii

Providing gender-affirming, trauma-informed care to transgender individuals continues to become increasingly prioritized in society. 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. They studied interventions they provided and their impact on perinatal care for a transgender male patient. Some of the interventions they provided to improve gender-affirming care 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 male.^lxix

Being a transgender man does not seem to have a negative impact on pregnancy or birth outcomes, although there are limited studies on this.^lxx

During labor and delivery, it is possible for hospitals to provide increased privacy to transgender patients to reduce intrusive attention and unnecessary examinations. Healthcare facilities can do this by ensuring that only essential healthcare providers are present during the delivery (i.e., 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 draped/covered during exams.^lxxi

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Human lactation or chestfeeding 

Following pregnancy, transgender males may decide to engage in feeding 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 males who had experienced pregnancy and delivery, they found that 73 percent chose to chestfeed for some time, 18 percent chose not to chestfeed, and 1 percent of participants were either pregnant or miscarried, and therefore had not yet had the opportunity to chestfeed.^lxxii Importantly, chestfeeding is an individualized decision. An individual may decide not to chestfeed for any personal reason, including an increased sensation of gender dysphoria.^lxxiii

When considering restarting hormone therapy after delivery, it is important to know that testosterone can decrease milk production for chestfeeding.^lxxiv It is also important to consider the fact 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 <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.^lxxv

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 those 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.^lxxvi

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. Of these individuals who had children, 60.5 percent said their relationships were either good or excellent.^lxxvii

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. Therefore, the stress is usually not related to the gender transition itself.^lxxviii 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.^lxxix

Conclusion

Transgender fertility research is essential in addressing the unique challenges faced by the transgender community when it comes to fertility and 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 this population. While there are still many challenges to be addressed, the growing interest in transgender fertility research offers new opportunities to address the needs of the transgender community and ensure that all individuals have access to the care they need.

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