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 Women

Cryopreservation of Sperm or Embryos

Transwomen who have not undergone orchiectomy can utilize sperm banking by providing a semen specimen through masturbation. From a psychological perspective, some individuals find it impossible to masturbate in order to produce a specimen.[13] Accordingly, testicular sperm extraction is a potential option, as it is for transgender women who may have fertility problems, such as ejaculatory disorders or azoospermia. Embryo banking would require an oocyte from a donor or partner for IVF/ICSI. Although sperm cryopreservation is ideal before initiating GAHT, new data show that within months of discontinuation of GAHT, some transgender women may produce a semen specimen with sperm concentration and motility adequate for intrauterine insemination (IUI) or spontaneous conception.[32]

The largest study evaluating the incidence of sperm banking and semen quality among transwomen revealed an increasing incidence of sperm cryopreservation in this population.[48] Surprisingly, compared to cisgender sperm bankers, the 78 transwomen included in the study had worse semen parameters, including sperm concentration and total motile sperm count.[48] Similarly, another study showed high rates of oligozoospermia, asthenozoospermia, and teratozoospermia, though there was no control group.[49] Possible explanations of the worse semen parameters could be that hormonal therapy in these patients was not reported, or there could be a confounding variable that is disproportionately affecting the spermatogenesis of transwomen compared to ciswomen. For instance, many transwomen engage in "tucking", a term used to describe the hiding of testicles and the penis.[50] The testicles may be pushed into the inguinal canal or compressed between the legs, which could create a suboptimal environment for spermatogenesis.

Uterus Transplantation

More than 42 uterus transplantations have been performed around the world and at least 12 live births have been reported.[51] The first uterus transplant was performed in 2002 in Saudi Arabia using a live donor, but the graft failed several months later and had to be removed.[52] In 2011, the first cadaveric uterus transplant and first pregnancy occurred in Turkey, though the pregnancy was not successful.[53] In 2014, Swedish physicians reported the first successful live birth of a child from a uterus transplant, and they also carried out several living mother-to-daughter uterus transplants.[54,55] In 2015, a team in China used a robotic approach for the donor hysterectomy and successfully used ovarian veins rather than uterine veins for venous drainage, significantly reducing the duration of the operation.[56] The first live birth after a uterus transplant in the United States occurred in 2016.[57] That same year, researchers from Sweden and Japan were able to bioengineer uterine tissue that could support pregnancy in a rat model.[58]

It is clear that uterus transplantation is a rapidly developing field, so it is likely that this treatment option will become more available in the future. The ASRM acknowledged uterus transplantation as the first successful medical treatment of absolute uterus factor infertility,[59] but it has not yet been performed in a transgender woman. The Montreal Criteria for the Ethical Feasibility of Uterine Transplantation, which was developed in 2012 to guide physicians and researchers in ethically carrying out uterus transplants, require that the recipient be a cisgender female due to safety and efficacy concerns.[60] Animal and human trials have only been performed in cisgender females and there are concerns about creating adequate vasculature for the uterus in a transgender female, placement of the uterus in a non-gynecoid pelvis, and the hormones needed to sustain pregnancy.[60] Some transwomen may have the desire to gestate because it aligns with their gender identity.[61] Uterus transplantation offers the same solution for transwomen who wish to get pregnant and avoid the use of a gestational carrier as it does for cisgender women with uterus factor infertility.[62] Jones et al. argue that uterus transplantation in transwomen may be ethically and legally permissible based on considerations of justice and equality.[51]

Transmen could be potential donors for uterus transplant in transwomen. When transmen undergoing hysterectomy and bilateral salpingo-oophorectomy for GAS were asked about their attitude towards uterus donation, 84% wanted to volunteer for donation.[63]