Fertility Preservation for Transgender People

Many transgender individuals want to have children, regardless of whether or not they will be genetically related. A study revealed that 40 percent of transgender individuals using gender- affirming services also use fertility preservation technologies.

Many gender-affirming hormone treatments and surgeries have adverse effects on fertility. Some reports revealed that estrogen reduces sperm counts, and the result is irreversible in some male-to- female transgender individuals. This is different from the use of testosterone in female-to-male transgender individuals. In the latter, when the hormone is stopped, regular ovulation resumes and conception is possible if the natal reproductive system is intact. Children born in this manner are no different in health status than those born from biological females who never use testosterone. However, pregnancy can be an unpleasant experience to some, as it symbolizes femininity.

Gonadectomy prevents transgender individuals from producing eggs or sperm. Therefore, they cannot have children genetically related to themselves naturally. Additionally, a hysterectomy will prevent female-to-male transgender individuals from conceiving. Transgender individuals should consider fertility preservation before receiving gender-affirming treatments that irreversibly affect fertility, such as taking feminizing hormones or undergoing genital gender-affirming surgery. Healthcare providers should provide counsel and planning on fertility preservation, including guidance on family building, before treatment is started.

Fertility preservation for male-to-female transgender adolescents and adults

Male-to-female transgender individuals who have not undergone genital gender-affirming surgery and stop taking hormonal therapy may produce semen and have children of their own. Physicians can consider fertility preservation by stopping the prescription of feminizing hormones and waiting until more sperm is detected, at which time referrals to the appropriate specialists can be completed.

• If male-to-female transgender individuals can ejaculate, semen cryopreservation should be taken into consideration.
• If male-to-female transgender individuals cannot ejaculate or have a low sperm count or no sperm at all, semen, sperm and testicular tissue cryopreservation are recommended.

If no egg from a natal female is available for fertilization, male-to-female transgender individuals may consider freezing their sperm. If available, they can have their sperm fertilize donated eggs or eggs from their lawful spouse with a stable relationship. Fertility preservation can be accomplished by either cryopreserving the fertilized embryo or sperm cryopreservation alone. Alternatively, both methods can be used together. Sperm should be collected before gender-affirming hormone treatment or as soon as possible after starting estrogen. Alternatively, testicular tissue may be saved during genital gender-affirming surgery. Male-to-female transgender individuals who wish to preserve their fertility should be referred to a suitable institution to assess available fertility preservation methods as mentioned above.

Fertility preservation for prepubertal male-to-female transgender children

Male-to-female transgender children receiving puberty-suppressing GnRH analogs can preserve fertility by stopping the drug. After puberty, they will be able to ejaculate and get sperm cryopreservation. Physicians should advise patients that the cessation of GnRH analogs will result in the appearance of male secondary sex characteristics. If male-to-female transgender children do not wish to stop GnRH analogs due to concerns about the potential appearance of male secondary sex characteristics, ejaculation for sperm cryopreservation will not be possible. In that case, physicians may put in a referral to specialists for sperm and testicular tissue cryopreservation. However, this method has not been widely used and is still under research. Therefore, it has less available supporting data than sperm cryopreservation.

Fertility preservation in female-to-male transgender adolescents and adults

For female-to-male transgender individuals who still have a uterus and ovaries and use masculinizing hormones, stopping hormonal therapy will make it possible to resume ovulation. Conception before resumption of menstruation is possible. If patients wish to undergo a hysterectomy and oophorectomy yet preserve fertility, they should be referred to an appropriate fertility preservation facility. The facility may use several methods such as ovarian stimulation, egg retrieval, and egg cryopreservation. These individuals should be advised that ovarian stimulation monitoring and egg retrieval can be performed via either the transvaginal or transabdominal route. They must stop taking gender- affirming hormones during this process.

Another issue female-to-male transgender individuals should consider in fertility preservation is that ovarian stimulation leads to an increase in female sex hormones and subsequent menstruation. This may cause frustration. Therefore, in such cases, physicians may consider prescribing aromatase inhibitors to lower estrogen levels during the ovarian stimulation process to prevent increased manifestations of female secondary sex characteristics.

If female-to-male transgender patients find the side effects or potential complications secondary to ovarian stimulation and egg retrieval prohibitive, physicians may consider referring them to a suitable facility for surgical ovarian tissue cryopreservation. In those planning on undergoing genital gender-affirming surgery, ovarian tissue can be collected during the oophorectomy. Ovarian tissue cryopreservation is currently considered a standard fertility preservation method for women receiving treatments that affects their fertility, such as chemotherapy for cancer.

Female-to-male transgender individuals may consider freezing their eggs, having their eggs fertilized with donated sperm, or sperm from their lawful spouse with a stable relationship. Fertility preservation may be done by either cryopreserving the fertilized embryo, egg cryopreservation alone, or a combination of both methods.

Fertility preservation for prepubertal female-to-male transgender children

Male-to-female transgender children receiving puberty-suppressing GnRH analogs can preserve fertility by stopping the drug. After puberty, they will be able to ejaculate and get sperm cryopreservation). Physicians should advise patients that the cessation of GnRH analogs will result in the appearance of male secondary sex characteristics.

If male-to-female transgender children do not wish to stop GnRH analogs due to concerns about the potential appearance of male secondary sex characteristics, ejaculation for sperm cryopreservation will not be possible. In that case, physicians may put in a referral to specialists for sperm and testicular tissue cryopreservation. However, this method has not been widely used and is still under research. Therefore, it has less available supporting data than sperm cryopreservation.

Refer: Reproductive Services for Transgender People, The Thai Handbook of Transgender Healthcare Services, Center of Excellence in Transgender Health, Chulalongkorn University