Cisgender people aren’t the only ones who face trouble when trying to conceive a child. One of the most vulnerable groups in this regard is transgender people.
Trans people are exposed to various additional obstacles to having biological children because, apart from various cultural and other resentments, there are some legal hurdles.
For example, in New York, although current insurance laws require insurers to cover infertility treatment services, same-sex and trans couples sometimes must pay out of pocket for infertility treatment, such as testing and therapeutic donor insemination procedures, before claiming coverage.
In addition, many trans people do not receive adequate fertility counseling. Not everyone is aware that they cannot be on hormone treatment to change gender if they want to use their own genetic material (eggs or sperm), or that before going through hormone therapy, they need to preserve their fertility by freezing eggs or sperm. In this article, we will review aspects of transgender fertility planning and answer the questions that arise with trans patients who want to start a family.
Aspects of Fertility Planning for Transgender People
Since some medical and surgical gender-affirming therapies can reduce fertility or lead to permanent sterility, it is essential that health care providers counsel trans people about the options for fertility preservation before the initiation of such therapies.
In order to improve fertility care for trans patients, health care providers need to become familiar with their reproductive health, inquire about their gender identity, pronouns, and preferred terms for body parts, and revise clinic forms to include that information.
When ready to start a family, there is a wide spectrum of fertility treatments that transgender and gender-diverse patients may choose from:
Insemination – Insemination is the introduction of sperm into a female’s reproductive system for the purpose of impregnating, also called fertilizing, the egg for reproduction.
In vitro fertilization (or IVF) – The fertilization of the egg and the initial stages of embryonic development take place in vitro, in a laboratory rather than in the human body. The egg and the sperm are placed in a culture dish with a special nutrient media, and then the most active sperm penetrates the egg and fertilizes it. If there is an issue with the sperm such as very low sperm count, motility, or morphology,
then ICSI (intracytoplasmic sperm injection) is performed where the embryologist will inject a single sperm into each egg to maximize fertilization rates. The resulting embryos are cultured in special incubators in conditions as close to the human body as possible. On the 3rd, 5th, or 6th day, the best embryo is transferred into the uterine cavity.
Third-party reproduction with a gestational surrogate – A gestational-carrier arrangement, in which the surrogate has an embryo transferred to her uterus and carries the pregnancy. The surrogate has no biological tie to the pregnancy but is contracted and paid to be the carrier of the pregnancy to become pregnant for other people.
Donor sperm – A genetic material used in fertilization if a couple cannot conceive on their own because of health problems in the person with male reproductive organs or if the couple or individual started out as biological females and do not produce sperm. It is used also in cases when it is necessary to avoid transmitting serious hereditary diseases to children.
Donor eggs – A genetic material used in fertilization, when the person with female reproductive organs has no own eggs, their own eggs are of poor quality, or their use is undesirable on medical grounds. Donor eggs can also be used when the couple has a history of multiple unsuccessful IVF attempts with their own biomaterial.
Obstacles to Fertility Preservation
Parenthood and pregnancy have been routinely framed within the context of cisgender, heteronormative family structures. Patients whose gender and sexual identities fall outside this framing have historically been discriminated against and denied access to assisted reproductive technologies, and have even had their competency as parents called into question. For transgender people, surgical gender reassignment surgery often results in infertility, but fertility preservation techniques are rarely available to them.
While the right to access fertility services regardless of gender identity is now widely recognized, there is still much work to be done by the medical community to establish equity in fertility care. There is a need to understand the potential barriers to care these individuals face, including the cost of care, the risk of elevated dysphoria, limited access to fertility centers in rural communities, and the fear and lived experience of discrimination.
Apart from possible health care discrimination, various other factors arise when the couple or one of the partners decides they want to have a child. Many couples consider stopping HRT because they would prefer to have their own biological children with a partner rather than adopt. Sometimes, just one person in the couple dreams of conceiving via in vivo fertilization. In this case, there is a fear of hurting the other partner when asking them to postpone their transition so that they regain fertility and are able to have a child.
Fertility Preservation for Trans Adults
There are quite a few things that you need to know about your genetic material. One is that you must preserve your fertility by freezing eggs or sperm before going through hormone therapy. And if you want to use your own genetic material, you cannot currently be on hormone treatment to change gender.
Also note that in this regard, various age limits apply to transgender people the same as they do to cisgender individuals. For example, the optimal time to freeze eggs of a trans man is before 35, when they are still at, or near, their best reproductive potential. It is possible to freeze eggs after 35 but fertility testing should be done to determine the number and possible quality of the eggs that might be retrieved for an egg freezing cycle.
Some patients do not tolerate the extended cessation of estrogen therapy required to achieve completely normal levels of spermatogenesis (> 39 million sperm per sample). They can be counseled to bank a semen sample before the complete restoration of spermatogenesis. In vitro fertilization with intracytoplasmic sperm injection requires low numbers of sperm, which renders the freezing of samples with even very low numbers of sperm (thousands or tens of thousands of sperm per sample) a feasible option.
Fertility Preservation as a Trans Man
All people with ovaries are born with a finite number of eggs, which diminish over the next 5 decades. Therefore, trans men are subject to a decline in egg quality and quantity throughout their lives. This is why it is often not recommended to perform egg freezing after age 40 due to substantially lower efficiency, quality, and cost-effectiveness.
Trans people with ovaries can undergo ovarian stimulation for egg retrieval and freezing. Even those who have received androgen therapy will respond to ovarian stimulation, although a temporary cessation of testosterone is recommended. In the past, protocols required a minimum of 3 to 6 months to allow for the return of menses before egg freezing, which is an unacceptable prerequisite for most trans patients.
On the day of egg retrieval, individuals have the option of freezing their eggs unfertilized or inseminating them and culturing embryos for freezing (vitrification). The latter requires that the individual choose sperm from either a donor or a partner to be available at the time of egg retrieval. Freezing embryos instead of eggs has some advantages, such as providing more clarity about how the eggs may fertilize and grow into good-quality blastocysts.
Embryos also have a higher vitrification-warming survival rate of 95% to 98% or higher, compared to 80% for eggs. Finally, embryos at the blastocyst stage can undergo preimplantation genetic testing for aneuploidy, whereas eggs cannot. The principal disadvantages of preserving embryos are the lack of flexibility to change one’s mind about the sperm source in the future and the dual consent required to use the embryos if a partner’s sperm was used.
Ovarian Tissue Freezing
Ovarian tissue freezing, when ovarian tissue is collected (often during oophorectomy), cryopreserved, and retransplanted in the future, has resulted in a reported 130 live births in cisgender women to date worldwide. The “experimental” label was removed from this promising therapy in 2019. However, the American Society for Reproductive Medicine states that ovarian tissue freezing should be offered only to carefully selected patients, given the limited data on its safety, efficacy, and reproductive outcomes. Currently, this procedure is not widely performed in the US and is rarely used relative to standard egg freezing.
Fertility Preservation as a Trans Woman
In trans people with sperm, the use of gender-affirming estrogen therapy can suppress gonadotropin levels via negative feedback to the hypothalamus and pituitary. Reduced or absent follicle-stimulating hormone and luteinizing hormone levels result in lower stimulation of the Sertoli (sperm-producing) and Leydig (testosterone-producing) cells, which leads to lower serum and intratesticular testosterone levels and absent spermatogenesis.
The extent of luteinizing hormone and follicle-stimulating hormone suppression may be dose-dependent. One retrospective cohort study of trans patients with sperm reported that there was a trend toward worsening semen parameters in those who had previous exposure to estrogen compared to those who were estrogen-naive. The subjects who were using exogenous estrogen at the time of the study had a higher prevalence of abnormal semen analysis results, and three of the seven current users had no sperm at all (azoospermic). Stopping estrogen therapy is recommended to assess the recovery of sperm parameters before trying to conceive.
Common Questions About Transgender Fertility Planning
Can I have children even though I’ve been transitioning for years?
As mentioned above, there are numerous options for transgender people to have children. However, many trans couples find out they want to have kids after transition − without being aware that surgical interventions such as hysterectomy and/or gonadectomy may result in permanent sterility unless gonadal tissue, sperm, or eggs are frozen ahead of time.
Although there are no guarantees, being on HRT alone is not a sure sign for permanent sterility. There were people who went off the hormone therapy after 5 years or later and produced offspring. The difficult part may be to stop HRT.
As for patients who have completed the aforementioned surgical procedures, there are currently no fertility preservation options available. For trans men who undergo hysterectomy without oophorectomy, egg retrieval for in vitro fertilization or egg freezing can still be performed.
How much time is needed for fertility to recover after ceasing hormone treatment?
First, if you and your partner have frozen sperm and eggs available, you can attempt pregnancy with your partner without even stopping your hormone therapy. Frozen sperm and eggs can be used in various methods of conceiving, including IUI and IVF, depending on the quantity and quality of the sample once thawed.
As for trans women who have stopped estrogen therapy, one study suggests that within 6 months, 67% of subjects with male reproductive organs recovered a normal sperm count. However, the impact of medical gender transition on fertility seems to vary from individual to individual.
A study from a fertility clinic and research organization in Boston, based on eight years of patient data, revealed that transgender men who stopped taking testosterone for an average of four months had similar egg yields to cisgender women when undergoing ovarian stimulation.
Fertility treatment is a significant investment, both financially and emotionally. Determining how to pay for these expenses is an important part of planning your family. There are many resources such as EMD Serono’s financial assistance programs for fertility medications. The Family Equality Council also has a list of family-building grants that help LGBTQ+ families afford fertility treatment. Be sure to ask your fertility clinic about available financial assistance programs and payment plans. Dreams Fertility offers interest-free financing for those patients who qualify. Ask your Dreams team member for how you can apply. We believe in equal access to affordable and accessible care at Dreams Fertility.
The situation with assistance to trans people is improving over time. For example, in New York, at Governor Cuomo’s direction, the Department of Financial Services will direct insurers to provide immediate coverage for fertility treatment services for same-sex couples to eliminate delays and additional costs. The proposal was introduced by the Governor in the 2021 State Report as a key component of the women’s rights agenda and builds on a number of leading actions to protect the rights of both women and LGBTQ New Yorkers, including required coverage of fertility services by insurance companies providing mass insurance, the passage of the Marriage Equality Act, GENDA Act, legalization of gestational surrogacy, ban on conversion therapy and protection for gay and transgender people.
Dr. Luis Murrain joined Dreams Fertility in 2021, providing specialty services in Fertility and Reproductive Genetics. With a shared vision that everyone deserves to have the family of their dreams, we are dedicated to helping all of our patients. We believe that families come in all shapes and sizes, and all of them are beautiful. We are proud to have a long history of providing services to all, including gay, lesbian, and transgender individuals and couples on their road to parenthood.