If you are planning to take hormonal or surgical steps towards transitioning, one of the most important things to consider is cryopreservation of either your eggs or sperm prior to the start of hormone blockers or surgical procedures that may impact your fertility. A doctor explains why.
In this article:
- We Need to Talk About Trans Fertility
- How does testosterone impact fertility?
- How does estrogen impact fertility?
- Can I still have a biological child after transitioning?
- What does the sperm freezing process involve?
- What does the egg freezing process involve?
- How long can eggs and sperm stay frozen?
- I haven’t frozen any eggs or sperm - what should I do?
- How are frozen eggs or sperm used for family building?
- Your next step? Talk to an expert!
We Need to Talk About Trans Fertility
Along with the other unique challenges and considerations trans folks have to navigate, those who wish to have biological children in the future must also take into account the impact of hormonal or surgical steps before transitioning.
Cryopreserving (freezing) eggs or sperm is a great option to consider, since preserved gametes (eggs or sperm) can be used in the future to help complete a biological family-building journey – whether you’re single or partnered at that time.
If you've already taken steps to transition but haven't yet cryopreserved any eggs or sperm, there are still many different ways for you to become a parent - and we'll discuss those options too.
We believe that every person should have the chance to become a parent if they desire to do so, and a big part of that is providing education around fertility and family building. In addition to our resources here at Gay Parents To Be, we encourage you to watch this informative webinar on trans fertility by Trystan Reese.
Let's dive into this important conversation by answering some common questions we receive from our trans patients to help you better understand the ins and outs of preserving your fertility.
Note: Even if you identify as non-binary, this information will still be helpful!
How does testosterone impact fertility?
Testosterone can have various effects on fertility for trans folks assigned female at birth (AFAB) who are taking testosterone as part of their transition. Here are a few ways testosterone may impact fertility:
1. Menstruation Cessation
Testosterone typically leads to the cessation of menstruation in AFAB individuals. According to a study performed by Boston IVF, it took around four months for menstrual cycles to return once individuals stopped taking testosterone.
2. Ovarian Function
Testosterone can lead to a decrease in ovarian reserve (the number of eggs available for fertilization), though studies show that AMH levels only decrease mildly. There is also evidence showing that the amount of oocytes (eggs) retrieved for AFAB trans folks is on par with that of their cisgender counterparts.
3. Irregular Ovulation
Some individuals may experience irregular ovulation while taking testosterone. This can make it more challenging to predict when ovulation occurs, making the timing of intercourse for conception more difficult.
4. Changes in Cervical Mucus
Testosterone can alter the consistency of cervical mucus, making it thicker and less conducive to sperm survival and movement. This can reduce the likelihood of successful fertilization.
The takeaway? Testosterone can have an impact on fertility, but your chances of conceiving a baby are still excellent - even if hormonal therapy has been initiated.
An Important Note About Conception
While testosterone can have effects on fertility, it is not a guaranteed form of contraception. Pregnancy can still occur, especially in the early stages of testosterone treatment or during irregular hormonal fluctuations.
Also, if you become pregnant while on testosterone and plan to carry the pregnancy to term, it is critical that you stop taking your hormones immediately. Testosterone can cause serious harm to the developing fetus.
How does estrogen impact fertility?
As part of their transition process, trans women (those assigned male at birth, or AMAB) may take estrogen and/or androgen blockers.
Estrogen in particular has a big impact on sperm production (by reducing the body's ability to produce sperm). In some cases, AMAB individuals are able to produce sperm again after stopping estrogen hormone therapy. However, each individual case is different, so it's important to work with a fertility expert who can provide accurate guidance and monitoring.
To learn even more about fertility for trans women, check out this free course from FertilityIQ.
Can I still have a biological child after transitioning?
The best first step is to talk to your physician about the options and ask about the possibility of freezing your eggs or sperm before undergoing hormonal or surgical treatment that may affect your fertility. If you wish to keep the door open for future biological family building, make sure your care team knows and can provide accurate, timely guidance.
With the right planning and support, many trans folks can still have genetically-linked children post-transition, as long as they have retained the necessary reproductive function.
What does the sperm freezing process involve?
The process of sperm freezing involves a semen analysis (to evaluate your specimen before freezing), and bloodwork around the time that you freeze sperm. Fertility practices are evaluated by the FDA, and this testing will allow you to use your frozen specimen in the future.
How much sperm should you freeze? This will depend on many factors indicated by your initial semen analysis report. Your fertility specialist will be able to help you determine how many samples you should cryopreserve.
Note: It is important to have support and strategies for navigating the process of going off of hormone therapy, experiencing potential dysphoria around your changing body, and the emotional impact of undergoing fertility-related procedures as a trans person.
What does the egg freezing process involve?
Compared to freezing sperm, the egg freezing process is a little bit more complicated. That being said, egg freezing is now quite common, so you should not have trouble finding a board-certified reproductive endocrinologist who is able to help you.
You would first take a few tests to evaluate your baseline fertility levels. Then, you would take fertility medication over the span of two weeks in order to ready your ovaries for a short in-house procedure called a transvaginal egg retrieval.
You would also need to complete bloodwork around the time you freeze your eggs. Fertility practices are evaluated by the FDA, and completing this bloodwork will allow you to use those frozen eggs in a future conception cycle.
How long can eggs and sperm stay frozen?
To date, there is no known limit to how many years specimens can be cryopreserved. This allows trans people the opportunity to preserve their fertility earlier on in life, and then pursue family building in their 30s or 40s - whenever they feel ready to grow their family.
Of course, your family-building plan will need to be personalized for you and your partner (if applicable). A chat with a reproductive endocrinologist is a good first step to build that plan and get all of your questions answered.
I haven’t frozen any eggs or sperm - what should I do?
Talk to your physician about your fertility options. They will likely refer you for a consultation with a fertility specialist to help you find the best path forward. What a fertility specialist recommends for you will depend primarily on two factors:
1) Whether you have taken surgical or hormonal steps towards transitioning yet
2) When (and how) you want to become a parent (for example, if you're pursuing biological parenthood, your options will look different than if you want to pursue adoption)
Your family-building options may include:
- Fertility treatment
- Using an egg or sperm donor
- Gestational surrogacy
- Adoption or foster-to-adopt
How are frozen eggs or sperm used for family building?
If you've already transitioned (or are in the process of transitioning) and are curious about what your future family-building options will look like, here are the different pathways that may be available to you.
If you are a trans woman (assigned male at birth) and have previously frozen sperm, these are the main options to consider for a biological family-building journey:
- If you’re in a relationship with a cisgender female partner, you can use your sperm and your partner’s eggs to undergo IUI or IVF treatment.
- If you’re in a relationship with a cisgender male partner, you can use an egg donor and gestational carrier (surrogate) to create embryos with one or both of your sperm, and complete a pregnancy journey.
- If you’re currently single, you can use an egg donor and a gestational carrier to create embryos and complete a pregnancy journey.
If you are a trans man (assigned female at birth) and have previously frozen eggs, these are the main options to consider for a biological family-building journey:
- If you’re in a relationship with a cisgender female partner, you can use your eggs and donor sperm to complete a reciprocal IVF cycle.
- If you’re in a relationship with a cisgender male partner, you can use donor sperm or your partner’s sperm to complete a pregnancy journey. Some of these journeys may require a gestational carrier (surrogate).
- If you’re currently single, you can use donor sperm to complete a pregnancy journey. This may require a gestational carrier depending on various factors.
Note: If you feel like your personal situation doesn't fit into any of the categories above – not to worry! The first step to creating your family-building plan is to chat with a fertility specialist, who will evaluate your options and help you navigate your path to parenthood.
Your next step? Talk to an expert!
Finding a provider that is LGBTQ-friendly is important – family and fertility are such personal topics, and you should feel as comfortable as possible as you embark on your path to parenthood. One tool that we recommend for choosing an LGBTQ-friendly practice is the Healthcare Equality Index (HEI) put out each year by the Human Rights Campaign.
Gay Parents To Be and Illume Fertility have been named an HEI leader for the last six years in a row, highlighting our continued dedication to upholding the highest standards of LGBTQ+ inclusivity for patients and staff.
While it can feel overwhelming to begin this process, know that there are an increasing number of helpful resources and support available to you. You have many options for fertility preservation and family building as a trans parent-to-be, and deserve the highest level of care as you work to grow your family.
We wish you all the best on your journey!
Dr. Mark P. Leondires is the Founder and Medical Director of Illume Fertility, a fertility clinic with 5 locations in Connecticut and New York. Dr. Leondires is board-certified in both Obstetrics and Gynecology and Reproductive Endocrinology and Infertility.