Why is Fertility Preservation Important?

Gender-affirming hormone therapy (testosterone or estrogen) and certain gender-affirming surgeries can cause permanent infertility. Many transgender individuals desire biological children in the future. Fertility preservation options allow them to preserve their ability to have genetically-related children before undergoing medical transition.

Timing is Critical:

• BEFORE starting hormone therapy: Testosterone and estrogen can impair or eliminate fertility
• BEFORE gonadectomy (orchiectomy/oophorectomy): Removal of testicles or ovaries eliminates natural gamete production
• Ideally discussed during initial gender care consultation

Fertility Preservation Options for Transgender Women (Assigned Male at Birth):

1. Sperm Banking (Cryopreservation):

• Method: Semen samples collected via masturbation, frozen, and stored
• Best Timing: BEFORE starting estrogen or anti-androgens
• Pros: Non-invasive, relatively affordable, high success rates
• Cons: Can be psychologically difficult (gender dysphoria from masturbation/producing semen); requires multiple samples for optimal results
• Use Later: Intrauterine insemination (IUI), in vitro fertilization (IVF), or intracytoplasmic sperm injection (ICSI) with partner or gestational carrier

2. Testicular Sperm Extraction (TESE):

• Method: Surgical extraction of sperm directly from testicular tissue (for those unable to ejaculate or after hormone therapy has begun)
• When Used: If unable to produce semen sample, or if semen analysis shows azoospermia
• Pros: Can obtain sperm even if ejaculation impossible
• Cons: Surgical procedure, expensive, lower sperm yield

3. Testicular Tissue Cryopreservation (Experimental):

• Method: Testicular tissue removed and frozen before puberty (for prepubertal children)
• Use: Future potential to mature sperm in vitro or via grafting (NOT yet clinically available)
• Status: Experimental; no live births yet

Fertility Preservation Options for Transgender Men (Assigned Female at Birth):

1. Egg Freezing (Oocyte Cryopreservation):

• Method: Ovarian stimulation with injectable hormones (10-14 days), egg retrieval via transvaginal ultrasound-guided procedure, freezing of eggs
• Best Timing: BEFORE starting testosterone
• Pros: Preserves fertility without need for partner/sperm donor at time of freezing
• Cons:
  • Requires stopping testosterone temporarily (if already started)
  • Estrogen surge during stimulation can worsen gender dysphoria
  • Transvaginal ultrasounds and egg retrieval can be distressing
  • Expensive ($10,000-$15,000+ per cycle)
  • Success depends on age and ovarian reserve
• Use Later: IVF with partner's sperm or donor sperm; requires gestational carrier or partner to carry pregnancy

2. Embryo Cryopreservation:

• Method: Same as egg freezing, but eggs are fertilized with sperm (from partner or donor) before freezing
• Pros: Embryos have higher survival/implantation rates than eggs
• Cons: Requires sperm source at time of freezing (partner or donor); legal/ethical considerations (shared embryos with partner)

3. Ovarian Tissue Cryopreservation (Experimental):

• Method: Surgical removal and freezing of ovarian tissue
• When Considered: Prepubertal children (too young for egg freezing)
• Future Use: Could be transplanted back or matured in vitro (experimental)
• Status: Limited data; primarily used in cancer patients

4. Uterine Preservation:

• Some transgender men choose to retain their uterus and carry a pregnancy themselves in the future
• Requires stopping testosterone during pregnancy
• Specialized prenatal care needed

Can Fertility Return After Stopping Hormones?

Transgender Women (Estrogen/Anti-Androgens):

• Sperm production may recover after stopping hormones, but NOT guaranteed
• Recovery can take 6 months to 2+ years
• Longer duration/higher doses of hormones decrease likelihood of recovery
• Do NOT rely on this—fertility preservation recommended BEFORE starting

Transgender Men (Testosterone):

• Ovulation may resume after stopping testosterone, but NOT guaranteed
• Some achieve pregnancy after stopping testosterone, but unpredictable
• Do NOT rely on this—egg freezing recommended BEFORE or early in transition

Barriers to Fertility Preservation:

• Cost: Expensive (especially egg freezing); often not covered by insurance
• Gender Dysphoria: Procedures can worsen dysphoria (masturbation for sperm, vaginal procedures for eggs, estrogen stimulation)
• Lack of Awareness: Not all providers discuss fertility preservation
• Urgency for Transition: Desire to start hormones ASAP may lead to skipping fertility preservation
• Age: Adolescents may not prioritize future fertility

Financial Assistance and Resources:

• Some fertility clinics offer discounted rates for transgender patients
• Grants and financial aid programs exist (e.g., Cade Foundation, Family Equality Council)
• Advocate for insurance coverage (some states mandate fertility preservation coverage)

Ethical and Legal Considerations:

• Informed Consent: Adolescents and adults must understand impact of hormones/surgery on fertility
• Parental Involvement: For minors, parents involved in decision-making
• Future Use of Gametes: Legal agreements if storing embryos with partner
• Disclosure: Discuss with future partners

Key Recommendations:

• Discuss fertility preservation EARLY in gender care (before hormones/surgery)
• Refer to reproductive endocrinology/fertility specialists experienced with transgender patients
• Don't assume patients won't want children—many do, even if not a current priority
• Revisit the conversation periodically (desires may change over time)