Trans Fertility and GAHT

CONTENT WARNING: We wanted to let you know ahead of time that we make several references to reproductive body parts and processes below. They are used for reference and clarity and do not relate to a trans person’s gender identity or preferred language for their own body. For some folks, this can trigger dysphoria, so just FYI before you continue reading.

Understanding The Impact Of Gender-Affirming Hormone Therapy On Fertility

Gender-affirming hormone therapy (GAHT) is lifesaving for many within our trans and nonbinary community, providing a path to align our bodies more closely with our identities. In the largest source of self-reported data by transgender adults on the desire for having genetically related children, 26% of transgender and gender-diverse individuals initiating gender-affirming hormone therapy expressed a desire for genetically related children or were unsure about it. Factors like age, sex assigned at birth, and insurance status influenced this desire. The findings highlight the importance of fertility counseling in gender-affirming care, underscoring the need for healthcare providers to discuss fertility preservation options with trans patients before starting hormone therapy.

Fertility For Transmasculine Folks

When starting this transformative journey, it’s important to recognize the potential impact GAHT has on fertility. The use of testosterone in transmasculine people often leads to a change in ovulation (releasing eggs) and disrupts menstrual cycles. This suppression of the reproductive system can make it difficult to conceive; however, the full impact is not known, and a person can become pregnant while using testosterone.

Studies on transmasculine folks are limited, but one promising study from a prominent reproductive endocrinology center showed that trans men had similar egg yields to cis patients after undergoing IVF, or in vitro fertilization (what is IVF?). 

What does this mean? It shows that in this study, when transmasculine folks stopped their testosterone and went under the same techniques and hormones used in IVF to get their bodies to release eggs, they had the same number of eggs as cis women. This doesn’t guarantee that an individual person will be able to use their eggs or become pregnant, but it’s encouraging.

Fertility For Transfeminine Folks

Transfemme folks on estrogen therapy often find a decrease in sperm health and production. Testosterone is crucial for sperm production, and a lack of it can lead to lower sperm count and motility. This reduction directly affects one’s ability to contribute genetically to conception without medical assistance.

In one of the largest studies reviewing sperm counts, the amount of sperm was markedly lower in transfemme folks when compared to cis men. However, in a very small study of nine transfemme patients, six of the nine were eventually able to produce functional-appearing mature sperm after stopping GAHT. (Only three patients were able to use that sperm for a successful pregnancy.)

Studies like this suggest that GAHT may not lead to permanent infertility for some transfemme patients. This is important both for future planning for those who might want biological children in the future, but also to caution those on GAHT that they cannot rely on feminizing hormones for birth control.

Given the unknowns, it’s important for all trans patients to review fertility issues with their providers, including pre-GAHT options for egg or sperm preservation.

The Role Of Tucking And Environmental Factors In Fertility

Tucking, a technique used by some transfemmes to achieve a smoother, more traditionally feminine shape, can also affect fertility. This practice involves positioning the testes upward into the inguinal canal and securing the penis in a way that is not visible through clothing.

While effective for its intended purpose, tucking can raise the temperature around the testes and restrict blood flow. These conditions are not ideal for sperm health and production. Sperm cells are highly sensitive to temperature changes, and extra heat can lead to low sperm count and motility. Studies have shown that tucking can reduce both overall sperm count and the number of motile or moving sperm by over 90%.

Other chemical exposure can also create fertility challenges. Exposure to pesticides, phthalates, and other hormone-disrupting compounds, can affect reproductive health. These substances can change hormone levels and impair the body’s natural fertility processes. Smoking and drinking too much alcohol also can play a role in fertility. Both activities have been linked to reduced fertility in studies across genders, with effects ranging from poor sperm quality to lowered ovarian reserve.

Given the potential risks posed by tucking and environmental exposures, it’s important for transgender and nonbinary people to be proactive about their fertility if they wish to conceive someday. This might include limiting the time and frequency of tucking, using safer tucking methods that minimize heat and pressure, and taking steps to reduce exposure to harmful chemicals. It’s also good to adopt a healthy lifestyle through a balanced diet, regular exercise, and avoiding smoking and excessive alcohol intake. 

The Effects Of Gender-Affirming Surgery On Fertility

Gender-affirming surgeries can be important for many in our community. However, these surgeries will greatly impact fertility. For transfemmes, an orchiectomy (removal of the testicles) completely removes the ability for a person to make sperm; this leads to permanent infertility. Most patients undergoing vaginoplasty will have an orchiectomy in combination; it’s important to discuss this with your surgeon and determine if sperm preservation is desired before the testicles are removed. 

Transgender men might opt for surgeries like hysterectomy (removal of the uterus) or oophorectomy (removal of the ovaries). This eliminates the possibility of carrying a pregnancy or producing eggs that could be used in fertility treatments. While these surgeries can help align your body with your gender identity, it’s important to consider your future fertility goals before moving forward.

If you are thinking about any of these gender-affirming surgeries, talking to your doctor about fertility preservation is important. Options such as egg freezing or embryo freezing and sperm banking should be explored. It’s best if you discuss this before starting hormone therapy, for reasons discussed in the first section of this article. 

Egg And Sperm Freezing

Fertility preservation through egg and sperm freezing is a path for those who may wish to have biological children later in life. Egg freezing, scientifically known as oocyte cryopreservation, is a process where eggs are harvested from the ovaries, frozen unfertilized, and stored for future use. This procedure typically requires a temporary pause in testosterone therapy, as it involves stimulating the ovaries to produce multiple eggs. It’s a crucial consideration for those who wish to attempt pregnancy later.

On the flip side, sperm freezing or cryopreservation allows individuals assigned male at birth to store sperm before starting estrogen therapy. This process is relatively straightforward and can often be started with minimal disruption to the transition process. Sperm freezing provides an opportunity for transgender women and non-binary individuals to preserve the option of genetic parenthood.

Family Building For Trans People

Transmasculine or nonbinary folks on testosterone who desire to have kids have various options, including methods that use their own genetic material (technically known as oocytes and more commonly referred to as “eggs”) and those that don’t.

For folks who are not concerned about having a child that is “genetically” or “biologically” related, adoption is a great option. For those who want to use their own genetic material, options include carrying the pregnancy on their own after conception with a partner, or from intrauterine insemination (IUI) or in vitro fertilization (IVF) through a sperm donor. 

If you’re thinking about having children in the future, IVF can let you use your own genetic material while having someone else—like a partner, family member, or gestational surrogate—carry the pregnancy. For transfeminine people with access to fresh or frozen sperm who are partnered with someone who has a uterus and ovaries, IVF is a great option. Transmasculine people who still have a uterus and ovaries, and can pause hormone therapy, might also consider IVF if they want to carry a pregnancy themselves. For transmasculine people who are partnered with someone who has a uterus, they can explore reciprocal IVF, where their partner carries the pregnancy using the transmasculine person’s eggs.

If you’re thinking about preserving your genetic material for later, cryopreservation is another option. This involves freezing either non-fertilized eggs or embryos, which can be used later when you’re ready to start a family, regardless of whether you’ve been on hormone therapy.

Age-Related Considerations In Fertility For The Transgender Community

Navigating the landscape of fertility as transgender and non-binary people also involves grappling with the factor of age. Most people know that age can impact fertility, whether you’re cis or trans. However, for those of us in the transgender community, age is an additional layer to think about in addition to any hormone therapy or surgery.

It’s important to know that we have a limited fertility window. For people assigned female at birth, egg quality and quantity begin to diminish more noticeably around the age of 35. Those assigned males at birth usually see sperm quality start to decline around the age of 40. However, the exact age is different for everyone. If it’s important to you to have biological children, it’s important to consider these decisions before you reach these ages, if possible.

Talking To Your Doctor About Fertility

For many within our community, navigating fertility concerns is a journey marked by complex emotions and decisions. The nuances of hormone therapy, the implications of surgical interventions on fertility, and the psychosocial aspects of decision-making around parenthood are all at play.

A truly supportive healthcare environment is characterized by professionals who are not only well-versed in the complexities of transgender health care but are also deeply committed to providing care that is affirming of our identities and experiences. Our Care Team at Plume is proud to uphold this type of inclusive gender-affirming care. Our team’s expert background in trans healthcare allows us to co-create a care plan for you to meet both your gender-affirming and fertility needs. 

Equally important to inclusivity is ensuring that this care is accessible. Financial barriers often disproportionately affect our community, making the availability of affordable fertility preservation services a critical concern. Options such as Legacy Fertility enable our community to more easily access such care.

Creating pathways to parenthood that respect and affirm our identities involves more than just medical treatments; it requires a holistic approach that considers our emotional, psychological, and financial wellbeing. This means offering information on all available options, from egg and sperm freezing to adoption, and recognizing the diverse ways in which we may choose to build our families. Ultimately, a healthcare environment that truly supports our fertility concerns is one that sees us, hears us, and respects us. It is an environment that is an ally in our journey, offering not just solutions but also understanding and affirmation every step of the way