On January 14th, 2020, Dr Helen Webberley attended the Trans Pregnancy: Fertility, Reproduction and Body Autonomy conference in Leeds, UK. The conference brought together some of the leading minds on fertility for gender variant people and it was an enlightening and empowering event.
Dr Webberley took to the stage to talk about Gamete Storage Uptake Rates – based on the attitudes of people using the GenderGP service, towards actively storing their gametes (eggs or sperm) for use at a future date. Her research was based on the data from 3,000 GenderGP patient responses.
While there is a preconception that gender-affirming hormones impairs all future fertility, it is known that some surgical gender-affirming procedures will definitely do so. With this in mind, Dr Webberley talked about the importance of educating all potentially fertile individuals, who may be contemplating gender-affirming interventions, about gamete storage options.
Many trans patients turn down the opportunity for fertility conservation. The reasons for this are often complex but may include: a natural desire not to have children, lengthy and uncomfortable processes for harvesting and storage of gametes, lack of local resources, lack of support from the medical profession, funding issues and financial, ethical and politico-legal issues.
In the UK National Health Service, there is a lack of consistency in terms of the approach to funding for fertility conservation and even adjoining regions may have completely opposing views and funding structures. Funding of gamete storage for cancer patients, on the other hand, is much more widely available and accepted – so a tried and tested model is already in place which may be beneficial for gender variant individuals.
As it stands, the National Institute for Clinical excellence (NICE) does not currently offer guidance for patients with gender dysphoria. Many transgender individuals are put off private services due to storage costs and timing.
At GenderGP, all patients undergo counselling regarding fertility preservation via local services.
Mythbusting: Fertility and gender-affirming hormone treatment
Whether you want to have children, or not, it’s important to understand the effects that your hormone therapy can have on your reproductive health and fertility. When you understand what your body is doing before and during hormone treatment you can make informed choices that are best for you.
Here we look at some of the most commonly held myths around the impact of gender affirming hormones on fertility.
For individuals Assigned Female At Birth (AFAB):
Myth #1: Testosterone will make you infertile
Some studies have shown that testosterone alters the composition of the ovaries, making them look similar to those of people with polycystic ovary syndrome (a condition commonly associated with infertility). This may reduce the likelihood of pregnancy. However, other studies have demonstrated minimal changes in ovarian structure and after a year on testosterone, follicles (where eggs develop in the ovary) still form.
Testosterone will suppress the egg development and release – either partially or totally, and this will reduce fertility while you are taking testosterone as a medication.
As with so many things in transgender healthcare, there is very little data. However, we know that becoming pregnant after taking testosterone is possible as shown by Thomas Beatie, Freddy McConnell, and many other trans men who have become dads after hormone therapy.
In summary: we don’t know exactly how testosterone affects ovaries and egg production. Some people can get pregnant after having been on testosterone therapy, others cannot. If having a family is something you may want in the future gamete storage should be a consideration.
Myth #2: I can’t get pregnant whilst taking testosterone
Testosterone is not a contraceptive. You can get pregnant whilst taking testosterone. Although the likelihood of pregnancy is considerably reduced with testosterone use, the risk of pregnancy is still there. If you have not had your uterus or ovaries removed, and you don’t want to get pregnant, you should use contraception when having sex with a partner where pregnancy could occur..
It is also important to know that testosterone can have a damaging impact on a growing foetus. Therefore, if you think you could be, or suspect that you are, pregnant, see your healthcare professional immediately to discuss your options. It is advisable to stop testosterone at this time until you have made a decision on what to do. Understandably such a situation can make any feelings of dysphoria worse – please seek help straight away if you have to manage this situation.
In summary: If you take testosterone and don’t intend to get pregnant, use contraception when having sex with a partner where pregnancy could occur.
For individuals Assigned Male At Birth (AMAB):
Myth #3: I can’t make someone pregnant whilst taking oestrogen
Oestrogen causes the brain to release less testosterone by acting on the pituitary gland. Testosterone is responsible for producing sperm. The longer you are on oestrogen, the more likely it is that the lack of testosterone will lead to reduced sperm production. However, humans are all on different and studies have shown that whilst some people completely lose the ability to produce sperm, others retain sperm production. This means you can get someone pregnant when taking oestrogen.
In summary: If you take oestrogen and don’t want to get someone pregnant, use contraception when having sex with a partner where pregnancy could occur.
Myth #4: I will never be able to produce sperm after taking oestrogen
The effects of oestrogen on the testicles, and sperm production vary from person to person. If you’re looking to have children with your own sperm it is important to be aware of the changes that may occur/have occurred with hormone usage. Some research shows complete testicular atrophy (loss of tissue) in those who have previously taken oestrogen, suggesting they would be unable to produce sperm after hormone therapy. However, other studies indicate no changes to the testicles or sperm production, with further research illustrating semen analysis ranges within the World Health Organization’s normal values.
In summary: It may be possible for you to produce sperm after hormone treatment. Look into gamete storage if you want to be certain of having access to your own sperm in the future.
As you can see, much more research needs to be done to understand the impacts of gender affirming hormones on fertility. Greater education is also needed, both within the medical profession and the transgender community about access to fertility preservation and the need for contraception.