Fertility Concerns of the Transgender Patient

Philip J. Cheng; Alexander W. Pastuszak; Jeremy B. Myers; Isak A. Goodwin; James M. Hotaling


Transl Androl Urol. 2019;8(3):209-218. 

In This Article

Fertility Options for Transgender Men

Cryopreservation of Oocytes or Embryos

For post-pubertal transmen who have not undergone oophorectomy, currently available options for FP include oocyte and embryo banking, both of which require hormonal stimulation for egg retrieval and assisted reproductive technology (ART) for future conception. Embryo banking would require sperm from a donor or partner for IVF/ICSI and could allow for preimplantation genetic diagnosis (PGD) or screening (PGS) prior to cryopreservation. Hormonal stimulation of the ovaries for oocyte retrieval lasts for at least 2 weeks and will lead to increased estrogen, which may exacerbate gender dysphoria for some individuals and become a barrier to FP. After cryopreservation, ART can be done with the transgender individual if the uterus has been preserved, or with a gestational surrogate.

In a case report of 3 transgender men who underwent oocyte cryopreservation before starting GAHT, 1 patient was an adolescent while the 2 adults both had partners that carried pregnancies with the preserved oocytes.[42] Some transmen who undergo cryopreservation of oocytes experience hesitation and anxiety over having to undergo pelvic and transvaginal examinations.[43] There are also physical and mental challenges to dealing with the effects of testosterone cessation such as fatigue, changes in voice and odor, and resumption of menstruation, which can make them feel like they are becoming more feminine, and thus, increase their gender dysphoria.[43] These results highlight the importance of healthcare provider sensitivity when working with this vulnerable population.

A potential future option for transgender men that would avoid having to undergo ovarian stimulation is to preserve the ovarian tissue following oophorectomy. As mentioned previously, some studies have shown preserved ovarian histology following prolonged androgen therapy.[15] A large number of cumulus-oocyte complexes (COC) can be retrieved from the oophorectomy specimens.[15] If these COCs can then be activated and matured in vitro, then transgender men would be able to have children through IVF without having to ever stop GAHT.[38,44]

Uterus Preservation

For transmen who undergo GAS that includes hysterectomy or genital reconstruction with vaginal occlusion, gestational pregnancy is no longer a possibility. However, most transmen have not undergone GAS and retain their female reproductive organs, which allows for gestational pregnancy as a family-building option.[4,45,46] No studies have evaluated the incidence of pregnancy in transmen, but it is well documented that they can experience planned and unplanned pregnancy during and after GAHT.[8–10] In a survey of 197 transgender men, 60 pregnancies were reported, 10 (17%) of which occurred after stopping testosterone and 1 (1.6%) while taking testosterone regularly.[8] 30 participants erroneously believed that testosterone was a form of contraception.[8] It is currently unclear what sort of effects low dose hormone from contraception can have on exogenous testosterone use in transmen.

In another study of 41 transmen who had been pregnant or delivered after transitioning, the majority had intentional pregnancies (28, 68%), used testosterone before pregnancy (25, 61%), and used their own oocytes (36, 88%).[9] Twenty resumed menstruation within 6 months of testosterone cessation, while 5 conceived while still amenorrheic. Pregnancy, delivery, and birth outcomes did not differ based on prior testosterone use, though the effect of prior testosterone use on obstetrical complications has not been thoroughly investigated. About half of the men (21, 51%) chest (breast) fed, but were less likely to do so if they had previously used testosterone.[9] Transgender men have strong preferences for either a cesarean section (i.e., to avoid having genitals exposed during birth) or vaginal birth (i.e., because it was an emotionally meaningful experience).[47]

Transmen who have children through pregnancy often feel isolated by the lack of support and resources available to them.[9,47] Some individuals feel comfortable in their bodies during pregnancy, while others report that it worsened their gender dysphoria.[9,46] Many have negative experiences with healthcare providers and staff,[10,46] which could be a reason why they are more likely to use non-physician providers and non-hospital birth locations than the general public.[9]