Fertility

Fertility considerations for trans and non-binary people

Why do I need to think about fertility?

Fertility may be the last thing on your mind when you’re experiencing the distress of having a body that doesn’t match your gender identity. Understandably, many trans and non-binary people are keen to begin treatment to align their physical body with their sense of self as quickly as possible.

However, you may find it a source of regret if you have treatment without preserving your fertility and then realise later on that it is not possible, or more difficult, to have a biological family.

Thinking through all these issues now and understanding your options will help you make an informed decision.

It is not known fully how or if hormone treatment affects people’s fertility, and everyone is different. Taking medication will mean that it is likely that your egg or sperm production will decrease and you will reduce the ability to produce eggs or sperm when needed. Hence, storing these ‘gametes’ is an important consideration for you if you wish to have biological children in the future.

Storing sperm is a much easier option than storing eggs, so please do consider this carefully as it is important and a common source of regret later in life.

What if I am the parent/carer of a transgender child?

If you are the parent of a transgender young person, their future parenting options will be something you need to consider together. Medical intervention to suspend puberty with wholy reversible treatment will not affect their fertility, however gender affirming hormones, as the next step, may do so.

Another consideration is that young people taking puberty blockers at the start of puberty may not have reached the stage of being able to produce sperm or eggs to store. This has to be balanced with the masculinisation or feminisation that would occur if you waited for puberty to progress far enough to allow gamete production.

Chapter 16 of the recently released WPATH Standards of Care Version 8 covers reproductive health. This chapter provides recent data on fertility perspectives and parenthood goals in gender diverse youth and adults, advances in fertility preservation methods (including tissue cryopreservation), guidance regarding preconception and pregnancy care, prenatal counselling, and chest feeding. Contraceptive methods and considerations for TGD individuals are also reviewed.

What effect do Puberty blockers, Anti-androgens, Oestrogen and Testosterone have on fertility – short and long term?

Puberty blockers:

If you are taking puberty blockers at the start of puberty, then you may not have reached the stage of being able to produce sperm or eggs to store. This has to be balanced with the masculinisation or feminisation that would occur to your body if you waited for puberty to progress far enough to allow gamete production.

Anti-androgens:

These will suppress sperm production and the ability to have erections. Again, stopping these may mean that function returns.

Oestrogen:

Taking oestrogen will suppress sperm production, but this may come back if you stop taking it. For transgender women, this international study from February 2023 may be useful: Fertility preservation and realignment in transgender women.

Testosterone:

Taking testosterone may affect egg production and fertility. However, many trans masculine people have stopped testosterone temporarily in order to conceive. However, testosterone cannot be considered to be a contraceptive and it could be harmful to the foetus if you got pregnant while taking it.

A useful resource for learning more about the research into pregnancy and fertility for trans masculine people can be found here at the Trans Pregnancy Project.

Do I have to preserve fertility before I start treatment?

If you’ve already gone through puberty you may be able to freeze your eggs or sperm and store them until you’re ready to use them in treatment.

If your eggs, sperm or embryos are not used immediately in treatment, you may wish to store your eggs, sperm or embryos so they can be used for treatment in the future. To be stored eggs, sperm or embryos are frozen. You will need to think about how far in the future you might want or be able to use stored eggs, sperm or embryos and the potential costs of storing. This is something you should discuss with your clinic.

You should be aware that embryos can only be stored if both you and the egg or sperm provider have given consent. This may be your partner or may be a donor (if donated eggs or sperm were used in treatment).

What if I change my mind later?

The chances of achieving either gamete storage or a successful pregnancy are completely unique and individual to each person. Your expectations of success will be affected by the medical interventions that you have had, including all aspects of hormone therapy and surgery. If you need help to consider your options, speak to your local healthcare provider.

How do I store sperm?

Sperm freezing involves masturbating or undergoing vibratory stimulation to produce a sperm sample, which is then frozen and stored. If you do not feel comfortable producing sperm in this way, it is possible to extract the sperm in different ways (such as through surgical sperm extraction) although these involve more invasive surgical procedures.

How do I store eggs?

Egg freezing involves taking fertility drugs to stimulate your ovaries and then collecting the eggs by a surgical procedure whilst you’re sedated. It is mostly very safe, although there is a risk of ovarian hyperstimulation, which can need hospital treatment and in very rare cases can be fatal.

If I store my gametes will they definitely work?

This is a complex question, and there isn’t enough research to answer this definitively, however in the UK, the NHS have statistics for IVF success rates that you may find useful, even though they are not directly applicable to transgender people. You may need to use other means to have your own biological children in the future such as surrogacy.