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

Barriers to Care

Transgender individuals face many obstacles when it comes to accessing healthcare.[4,45] Historically, patients who deviate from the norm of the heterosexual, cisgender population have been denied access to ART.[6] In some countries, cryopreservation is not available to the transgender population.[64] In places where FP is available, there is resistance from some clinicians in providing those services to transgender individuals based on personal biases.[65] In the first study that evaluated the experiences of transgender people who sought or accessed assisted reproductive services to have biologically-related children, James-Abra et al. found that 7 of 11 people interviewed had negative experiences with the provider.[66] Transgender individuals face discrimination in essentially every aspect of society, including the healthcare setting.[67] Some examples include being mis-gendered or refused services altogether solely based on gender identity.[9,10,66] In the 2015 U.S. Transgender Survey, 23% of respondents did not see a doctor when they needed to because of fear of being mistreated.[4]

For those who may be interested in fertility services, another barrier is the lack of information.[68] A cross-sectional survey of the websites of all fertility clinics (n=379) listed on the Society for Assisted Reproductive Technology (SART) database showed that 53% contained LGBTQ content, and only 32% included information for transgender individuals.[69] Clinicians need to provide the appropriate information that is specific to this population, but many do not have the education or expertise to adequately counsel patients. The WPATH Standards of Care is based on expert opinion and can guide physicians providing FP and reproductive care to transgender individuals, but ultimately, much of the burden of medical decision-making will be placed on the providers.[3]

Some individuals lack access due to a scarcity of FP centers.[21] Even those who have access to a center may not be able to get the care they seek due to the costs.[68] FP can be expensive, with overall costs compounded by the costs associated with gender transitioning, such as GAHT and GAS. There are fees for the consultations, hormones to stimulate oocyte production for transmen, harvesting tissue, tissue processing, the retrieval of gametes, shipment of the specimens, and long-term storage. On top of the costs of FP, there are the costs of ART to consider when a decision is made to use preserved gametes to have children, especially if a gestational surrogate is needed. Insurance coverage for these services remains limited. Many transgender individuals lack social and/or financial support from family and friends, which creates another obstacle.[68]

In addition to financial costs, there can be an emotional cost to FP. Transmen who need to take hormones for oocyte harvesting and transwomen who need to masturbate to provide a semen sample may experience distress and worsening gender dysphoria.[13,43,68] Some transmen may find it emotionally challenging to preserve their uterus or to gestate given its association with a female identity.[9,46]