Fertility Options for Transgender People

There are an estimated 2 million transgender people across the United States, and between one-quarter and one-half are parents. Yet, many more transgender and nonbinary individuals have a desire to have children but feel as though it's not an option.

This couldn't be farther from the truth, says Dr. Brian Levine, MD, MS, FACOG, a board-certified physician in reproductive endocrinology and infertility and the practice director of the CCRM Fertility Clinic in New York City.

"Being transgender doesn't have to be a nonstarter to having a family," he says. And if there's one thing he wishes was more well-known among the transgender community, it's that fertility options are readily available—and so are medical professionals.

"As a [medical] community, we are committed to helping them achieve their goals," he explains. Fertility doctors are well-accustomed to working in a team approach, and effective collaboration with other medical specialists is the key to helping transgender individuals and couples with their fertility goals, he says.

But, what specific fertility treatments are available for transgender couples and individuals? Here, we take a look at transgender fertility rights, the different factors that may affect reproduction, and which treatment options can be explored.

Ethics of Transgender Fertility Treatment 

In February 2021, the American Society for Reproductive Medicine (ASRM) published an ethics review of transgender and nonbinary access to fertility services. Any denial of treatment is unjustified, they said.

The report also concludes that professional autonomy, in this case, is limited by "a greater ethical obligation, and in some jurisdictions, a legal duty, to regard all persons equally, regardless of their gender identity." Dr. Levine praised the publication, calling it "amazing."

Factors That May Affect Reproduction

While the transgender community faces many of the same fertility issues as cisgender patients (those whose gender identities match their sex assigned at birth), there are some transition-specific factors to consider. Depending on how far along in the process, testosterone or estrogen therapy could impact the ability to conceive.

Gender confirmation surgery can also affect fertility, especially if a hysterectomy or orchiectomy has been performed. Here's what you need to know about the factors that can affect reproduction.

Hormonal Therapy

As part of the transition process, some transgender individuals will choose to undergo hormonal therapy. Some of the main types include:

• Testosterone therapy: Used in transgender men to induce masculine physical characteristics (facial and body hair, deepening voice, etc.) and suppress feminine characteristics
• Estrogen therapy: Used in transgender women to help increase feminine physical characteristics (breast development, body hair reduction, etc.)
• Testosterone blockers (anti-androgens): Used by transgender women in addition to estrogen to help suppress natural testosterone

Many transgender patients fear hormonal therapy will negatively affect their fertility. Because it is still being studied, there is a lot of uncertainty surrounding the overall impact. That said, a landmark study conducted by infertility specialists, Boston IVF, in 2019 produced 8 years of patient data that found transgender men who had begun testosterone therapy "had similar egg yields as those of cisgender female patients."

These findings disprove the idea that transgender men need to undergo egg freezing before starting any hormonal therapy in order to have a family. Their results show that even if they begin testosterone treatments, they can still find similar success in having children as cisgender patients.

“Based on these results, our goal is to continue encouraging patients to evaluate their options before starting testosterone therapy – but also reassure individuals that if you are on hormones – you still have good options to preserve your fertility or start a family," says Boston IVF Reproductive Endocrinologist Nina Resetkova, MD, MBA.

While this study is certainly reassuring to the transgender community, every person and situation is different. The best plan of action is to speak with your doctor about your options.

Gender Confirmation Surgery

For some, gender confirmation surgery is a critical component for affirming the transition process. This surgery is typically the final step for someone who has been diagnosed with gender dysphoria—the discomfort caused by identifying with a different gender than the one they were assigned at birth.

Depending on the complexity of the surgery, infertility is possible. For example, during a female-to-male (FTM) transition, a hysterectomy may be performed to remove the uterus, which eliminates any chance of carrying a successful pregnancy.

Additionally, if both testicles are removed (orchiectomy) during a male-to-female transition (MTF), the patient will be unable to have biological children. Of course, every situation is different, and there are exceptions based on which surgery has been completed.

The bottom line: Speaking with your doctor about your future fertility goals will help you determine the best route for gender confirmation surgery.

Fertility Preservation

Before beginning their transition, many transgender individuals will choose to preserve eggs or sperm for future use. Their options include:

Sperm Cryopreservation (Freezing)

Sperm freezing is a fairly simple process for transgender women who are planning a future family or are about to begin estrogen treatments (which can affect sperm production). A sperm sample is collected either by the patient or is surgically retrieved and analyzed to determine how many more samples are needed. They are then stored in vials and frozen with cryoprotectant agents to protect the sperm cells.

The sample can be used later on for assisted reproduction, such as in vitro fertilization (IVF). A 2019 study determined that long-term storage of semen does not affect clinical outcomes, although there is a small decrease in its survival rate after five years.

Egg and/or Embryo Freezing

Transgender men may elect to undergo egg or embryo freezing. The patient will take fertility drugs weeks in advance, and once the eggs are developed, they are retrieved vaginally with a nonsurgical method and immediately frozen. They can later be used for IVF.

There is also the option to freeze embryos. This process involves retrieving the patient's eggs, fertilizing them with partner or donor sperm, and freezing the embryos for future IVF use.

Fertility Options for Transgender Individuals

Depending on their transition stage, there are different options for transgender individuals to start a family. Whether you choose to embark on the journey as a couple or individually, there are safe, effective ways to have children. Here's an overview of the fertility options available.

Intrauterine Insemination (IUI)

Intrauterine Insemination (IUI) is a relatively simple process that involves placing sperm directly into the uterus, which helps increase the chances of egg fertilization.

For transgender men, IUI options include:

• Using their partner's sperm
• Using a donor's sperm

For transgender women, IUI options include:

• Using a fresh semen sample or one that was previously frozen
• Placing the sperm into their partner's uterus
• Placing the sperm into the uterus of a gestational carrier

In Vitro Fertilization (IVF)

During the process of IVF, an egg and sperm are placed together in a laboratory setting to allow fertilization to take place. Once the egg is fertilized, the embryo is placed into the patient's uterus.

There is also the option for ICSI-IFV (intracytoplasmic sperm injection). Instead of placing the egg with many sperm and waiting for fertilization to occur, an embryologist will inject a single sperm directly into the egg.

For transgender men, IVF/ICSI options include:

• Using eggs of their own, from their partner, or from a donor
• Implanting the embryo into their own uterus, or the uterus of their partner or a gestational carrier

For transgender women, IVF/ICSI options include:

• Using the eggs of their partner or a donor
• Implanting the embryos into their partner's uterus or using a gestational carrier

A Word From Verywell

Starting a family is an exciting journey that every person has the right to experience. After all, there's only one thing you truly need to be a parent—love. If you're a transgender individual hoping to have children, doctors and specialists are ready and willing to guide you every step of the way.

Dr. Levine knows all too well the complexity of the process. "It takes a lot and we’re used to working collaboratively—and that’s how the transgender approach has to be," he says.

While it might not be an easy journey, it's a worthwhile one, and being transgender will never change that.