Like cisgender (non-transgender) people, transgender and gender nonbinary (TGNB) people vary widely in their desires to become parents. When discussing the risks and benefits of gender affirming hormone therapy (GAHT), providers should ask patients about their desires for pregnancy and future family formation and counsel all patients that GAHT may reduce their future fertility. Counseling should also acknowledge that research about GAHT’s impact on fertility is very limited and many TGNB people currently or previously on GAHT have created pregnancies without fertility preservation or other assisted reproductive technology. Because gender affirming hormone therapy (GAHT) may reduce fertility, some TGNB people pursue fertility preservation before beginning GAHT. This allows them to be able to proceed with gender-affirming treatments now and use their stored gametes (sperm or eggs)* to create a pregnancy in the future.
For more information on fertility counseling for gender-diverse youth considering puberty blockers, you can view this webinar from the National LGBTQIA+ Health Education Center. While gender-affirming surgeries may also impact fertility, this article is limited to effects of GAHT.
Fertility for TGNB people assigned female at birth
TGNB people assigned female at birth (AFAB) may use testosterone for GAHT. It is not known to what degree testosterone use reduces current and future fertility. Pregnancies among AFAB people both currently and previously using testosterone are documented in medical literature. At this time, no published data shows what proportion of AFAB people who formerly used testosterone and attempted to become pregnant were unable to conceive. AFAB people using testosterone as GAHT often stop menstruating within the first six months after starting GAHT. However, AFAB TGNB people who retain their uterus and ovary(ies) and have receptive penis-in-vagina sex with a partner who produces sperm could still become pregnant, even when not menstruating due to testosterone use. If they are not seeking pregnancy, they should be offered the full range of contraceptive methods, including emergency contraception as needed.
AFAB patients who are seeking pregnancy should be counseled to stop testosterone prior to attempting to conceive. Testosterone is classified as a teratogen, and can result in fetal changes, especially when testosterone is used during the first trimester of pregnancy. No data exist specifically on safe testosterone "wash out” periods prior to trying to conceive. For a person using testosterone cypionate intramuscular injections who is seeking pregnancy, experts estimate that at least two to four weeks without testosterone use would be needed prior to trying to conceive. The length of this “wash out” period would vary for different methods of taking testosterone, such as gels. AFAB patients currently taking testosterone who experience an unintended pregnancy should be counseled to stop testosterone until pregnancy options have been discussed.
Fertility preservation options for AFAB people
Oocyte (egg), ovarian tissue, and embryo preservation are forms of fertility preservation that may be considered by an AFAB person. These services are often not covered by health insurance and can cost $10,000 or more up front, plus ongoing fees for storage. The oocyte retrieval process is invasive and may be especially difficult for a TGNB person, for whom transvaginal ultrasounds and taking hormones for ovarian stimulation could worsen symptoms of gender dysphoria. Ideally, an AFAB TGNB person pursuing fertility preservation would be referred to a specialist who is both experienced in working with TGNB patients and attentive to trauma-informed care principles.
Fertility for TGNB people assigned male at birth
Research on the fertility of TGNB people assigned male at birth (AMAB) currently or formerly using GAHT is also limited. Some research shows that AMAB people currently taking GAHT are more likely to have fewer and/or less motile sperm compared to AMAB people not on GAHT. Sperm production may return to a person’s pre-GAHT levels after stopping GAHT.
Studies have also found viable sperm from AMAB people currently on GAHT. AMAB people on GAHT may have insertive penis-in-vagina sex with partners capable of pregnancy. If they are seeking to prevent pregnancies with these partners, they should be counseled to use contraception (or a partner contraceptive method).
Fertility preservation options for AMAB people
Semen preservation is often not covered by health insurance but is significantly less expensive than oocyte or embryo preservation. Initial costs for semen preservation can start as low as several hundred dollars, plus ongoing fees for storage. Semen samples are usually obtained through masturbation, which may exacerbate feelings of gender dysphoria for some TGNB people. Some fertility clinics may offer other methods to obtain semen samples.
TGNB AMAB people may experience discomfort or misgendering in a sperm bank setting. When possible, refer patients to specialists with experience in working with TGNB patients. As an alternative, several companies now offer at-home semen preservation through the mail, some specifically marketed toward transgender women. At-home services may be especially beneficial for TGNB patients who feel uncomfortable in a fertility clinic setting.
Bottom line
All TGNB patients seeking to start GAHT should be counseled regarding possible reduction of future fertility due to GAHT. However, the true incidence of infertility among TGNB people currently or previously on GAHT is not known. TGNB people should also be counseled that GAHT does not guarantee infertility, and if pregnancy is not desired, the full range of contraceptive methods should be offered to those who are engaging in sexual activity which could result in pregnancy. Access to fertility preservation increases future family-building options for TGNB people. TGNB people should be offered referral to fertility preservation services, if desired. Numerous barriers may prevent TGNB people from accessing fertility preservation services, including cost, anticipated or experienced transphobia, and worsening of gender dysphoria symptoms associated with the fertility preservation process. However, respectful and research-informed counseling about options from a provider can go a long way to support individuals in achieving their reproductive well-being goals.
*TGNB patients may prefer words to describe their bodies or experiences that differ from the anatomic or medical terms. For example, some people prefer “front opening” instead of vagina or vaginal opening, or “clitoris” instead of “penis.” For clarity, medical terms will be used throughout this article. When speaking with a patient, always ask, “Are there any words you would like me to use or to avoid when talking about your body parts with you?”
