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Unlocking Parenthood: A Guide to Trans Fertility

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Until now, conversations about transgender health have mainly focused on the need for and access to gender-affirming care. There’s still a long way to go on this front, but a shift is starting. As more transgender people receive the care they need, they’re starting to dream about life post-transition. Specifically, many are exploring the idea of parenthood. 


While organizations like the World Professional Association for Transgender Health (WPATH) advocate for more fertility counseling, resources remain scarce and information murky. In this guide, we aim to demystify trans fertility so that trans people can make informed choices about their reproductive futures. 


Transgender Couple

Fertility Information for Trans Men


Navigating fertility is an essential part of trans healthcare. By understanding the available choices and their implications, trans people feel empowered to make informed decisions about their reproductive futures. 


This section delves into three aspects of fertility for trans men: freezing eggs before transitioning, the impact of testosterone on fertility, and pregnancy options. 


Freezing eggs before hormone replacement therapy


Some transgender men freeze their eggs before starting hormone therapy or undergoing surgical transition procedures to protect their future fertility. This process, known as oocyte cryopreservation, involves taking a medication known as follicle-stimulating hormone (FSH). FSH makes the ovaries produce multiple eggs, which are then retrieved, frozen, and stored for future use.


Freezing eggs before transitioning gives trans men the chance to become biological parents later in life, even if they undergo procedures such as hysterectomies or phalloplasties that affect their reproductive organs. This allows individuals to affirm their gender identity without sacrificing their fertility.


Unfortunately, fertility counseling for transgender men is uncommon, leaving many unaware of this option. Additionally, cost is a significant obstacle. The medications required to stimulate egg production typically range from $3,000 to $6,000, with additional annual storage costs of $700 to $1,000.


The role of testosterone on fertility

Testosterone therapy is a vital part of the transition process for transgender men. Besides promoting physical changes like muscle growth, facial and body hair development, and voice deepening, masculinizing hormones also affect reproductive functions.


In particular, testosterone suppresses ovulation and menstruation, leading to a temporary loss of fertility. We need more research about the long-term effects of testosterone therapy on fertility, but initial studies suggest that recovering fertility is possible, even after years of hormone use.


For trans men hoping to conceive, stopping testosterone often causes ovulation to restart, signaling the potential return of fertility. While there isn't exact guidance on how long to pause testosterone before trying to conceive (TTC), anecdotal evidence suggests that the menstrual cycle typically resumes within three to six months. 


It's important to note that stopping testosterone can bring emotional and physical challenges. Emotional changes, such as mood swings, depression, and increased gender dysphoria, usually occur first, while physical changes are gradual and mild. As an example, stopping testosterone doesn't seem to strongly affect body hair growth or vocal pitch.


Pregnancy options


Discontinuing testosterone is the first step of TTC for trans men. Once your menstrual cycle has resumed, you can start exploring pregnancy options. Healthy trans men coupled with a partner who produces sperm can get pregnant the “old-fashioned” way. Healthy, in this instance, means not having medical conditions that could interfere with pregnancy, like blocked fallopian tubes or uterine fibroids. 


While this approach may seem like the most straightforward route to parenthood, it involves taking on the role of the gestational carrier. This means not taking testosterone during pregnancy and coping with bodily changes, both of which may trigger gender dysphoria.


For single trans men, those facing fertility challenges, or those partnered with someone who has ovaries, alternative options are available. These include using donated sperm for intrauterine insemination (IUI) or in vitro fertilization (IVF). Surrogacy, using embryos created from frozen or fresh eggs, is another possibility, albeit an expensive one.


Trans Woman

Fertility Information for Trans Women


Fifty-one percent of transgender women regret not preserving their fertility before transitioning. This highlights the importance of addressing fertility concerns within the community.


In this section, we delve into three aspects of fertility for transgender women. These include freezing sperm before transitioning, the potential of regaining fertility after taking hormones, and fertility options. 


Freezing sperm before hormone replacement therapy


Due to limited medical knowledge about transgender health and competing priorities, namely initiating the transition process, only about 3% of transgender people preserve their fertility before starting hormone therapy.


This presents significant challenges, particularly for transgender women. Studies indicate that transgender women may already have lower sperm quality and quantity compared to their cisgender male counterparts even before beginning hormone replacement therapy (HRT). 


While the reasons for this are not fully understood, researchers speculate that the heightened levels of anxiety, stress, and depression transgender people experience could negatively impact their fertility. Additionally, practices like wearing gaffs and tucking may diminish fertility, although the exact mechanisms remain unclear.


These preexisting fertility concerns underscore the importance of preserving fertility before HRT. Concretely, this means freezing and storing sperm through a process called sperm cryopreservation.

 

Transgender women can either deposit at a sperm bank or have a doctor collect sperm from testicular tissue during the orchiectomy procedure. While neither process is highly invasive, individuals experiencing dysphoria may find depositing samples at a sperm bank challenging.


Initial testing and freezing typically cost around $1,000 for the first year. After that, annual sperm cryopreservation expenses usually range between $150 and $500.


Regaining fertility after taking hormones


Freezing sperm before beginning a hormone regimen is ideal, but it’s not the only option for trans women hoping to become parents. Many trans women have successfully restarted sperm production after years of taking estrogen.


While there is limited data on how feminizing hormones impact sperm production and quality, a small study revealed that stopping estrogen therapy about four months before providing a semen sample resulted in normal sperm.


Although this is promising, outcomes can vary. Another study found that feminizing hormones may decrease sperm volume, concentration, and motility even after treatment stops.


It's important to note that these studies have small sample sizes, making their findings anecdotal at best. Additionally, it's possible that estrogen may not be solely to blame. In other words, the women may have had fertility issues their entire lives without knowing it. 


Despite the lack of information about the impact of hormones on fertility, the process of testing semen is straightforward. 


After collection, the sample undergoes testing for sperm concentration, motility (the sperm’s ability to move), and morphology (the sperm’s shape). If these findings are normal, the sample can be frozen for later use and the individual can resume hormone therapy.


So far, we've discussed ejaculated sperm, but there's another option for sperm retrieval. If you undergo an orchiectomy, also known as the removal of your testicles, the doctor can collect sperm from the vas deferens, epididymis, and testis tissue. As long as the sperm have a normal concentration and shape, they can be used for achieving pregnancy. However, these sperm haven't matured enough to swim, so they can only be used for conception through IVF.


Fertility treatment options


Transgender women hoping to conceive with a partner who has a uterus can try the traditional intercourse route. Before that happens, you’ll need to stop taking hormones for at least three months. This break gives the body time to produce enough semen for pregnancy.


Be aware that stopping hormone therapy can be challenging. Many transgender women notice additional body hair, increased muscle mass, and shifts in mood and libido. Given these adverse effects, achieving pregnancy as quickly as possible is the goal. Once your partner becomes pregnant, you can resume your hormone regime.  


To improve the chances of pregnancy, both partners should visit a doctor for a fertility check. 


For transgender women, this involves testing semen for sperm quality. The doctor checks things like sperm concentration, movement, and shape to see if natural conception is possible. This saves time and effort if it's not.


If natural conception doesn’t look likely, there are other options to explore, like intrauterine insemination (IUI) or in vitro fertilization (IVF).


Trans Couple

What Does the Future of Trans Fertility Look Like?


There's still a lot we don't know about trans fertility, but medical professionals and the trans community are already thinking about what the future might hold.


At the very least, we need more research about how hormone therapy affects fertility. The little we know comes from a few small studies and a handful of successful pregnancies. With more information, doctors can offer better guidance before and after patients start hormone therapy. 


Another avenue to explore is preserving ovarian or testicular tissue during pre-puberty transition surgeries as a way to restore fertility later in life. At this point, stored ovarian tissue has led to some successful births, but the process for testicular tissue remains uncharted territory.


Finally, there's excitement about uterine implants for trans women. Although this procedure is still experimental, some cisgender women have experienced successful pregnancies with transplanted uteruses. For the time being, this procedure is reserved for cis women with absolute uterine failure infertility (AUIF). It may take years before it becomes available to trans women. Nonetheless, it offers a beacon of hope for the future.


Additional Trans Fertility Resouces 


Hopefully, this article has given you a starting point as you begin your fertility journey. For more information, please check out these additional resources. If you’re ready to move forward with the process, we’ve also included a list of trans-affirming fertility providers. 


  • Trans Fertility Co. - A website providing academic research, personal stories, and videos about trans fertility by a trans gestational parent and fertility educator. 

  • Family Equality - A national nonprofit organization providing fertility resources, LGBTQ+ family-building stories, and a provider directory 

  • Gay Parents to Be - A website with information about LGBTQ+ family-building with a section specifically for trans parents-to-be. 

  • The Prelude Network - An LGBTQ+ affirming directory of fertility providers 


Trans-Affirming Fertility Providers



 

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