The culture around having children is often filled with rosy gender-normative images of cisgender women (who are usually white and thin — except for their perfectly round pregnant bellies, of course). For transgender, gender-queer, and nonbinary (TGNB) individuals who are hoping to have children, it can be challenging to see where you fit into the fertility equation.
Though talking about your fertility options with your doctor is important, it’s difficult to find informed medical care and fertility resources: In fact, 52% of the TGNB individuals we surveyed as part of the Modern State of LGBTQ+ Fertility 2019 feel uncomfortable talking about fertility with their health providers (as compared to 18% of cisgender, heterosexual women).
It’s high time we start closing that gap. To that end, Modern Fertility teamed up with Dr. Darcy Broughton, MD, of Pacific Northwest Fertility to demystify the family planning process and fertility services for transgender individuals. You can watch our free informational session on YouTube (also embedded below) and read a recap here.
What you’ll learn
- How hormone replacement therapy (HRT) can affect your reproductive health
- The potential effects of taking puberty blockers
- The fertility preservation options for anyone who’s having gender-affirming surgery
- How to find supportive and affirmative healthcare
How can medical transition impact fertility?
A unique aspect of fertility for transgender people is considering how transitioning can have an impact. Because hormone replacement therapy (HRT) often begins in young adults around age 16, many teens who identify as transgender or nonbinary are asked to make decisions about their fertility before they’ve even gotten their driver’s licenses. This might, understandably, feel like a lot of pressure for teens or for their parents. But with more information about the effects of different types of medical transition on fertility, people can make the right decisions for them — and better plan for children in the future.
Puberty blockers (or GnRH agonists)
If you have just begun to go through puberty and you’re not old enough to begin hormone treatment (this usually applies to transgender youth between the ages of 12 and 16), your doctor may put you on gonadotropin-releasing hormone agonists (also known as puberty blockers) so that you don’t develop secondary sex characteristics associated with your sex assigned at birth. When you’re older, you can begin HRT (through testosterone or estrogen hormone therapy) to develop the secondary sex traits of your identified gender.
How can taking puberty blockers affect conception in the future? Dr. Broughton says that the medical community doesn’t know for sure yet.
“The effects are certainly reversible in adults, but … we’re not sure if doing blockers prior to a regular puberty transition has a long-term effect on fertility,” she explains. But according to the journal Translational Andrology and Urology, blockers can reduce the size of testicles, which could make sperm production more difficult.
Data suggest that testosterone, even when used for many years, does not appear to destroy ovary function in transmen. According to the University of California, San Francisco, 80% of people will begin ovulating again within six months after going off testosterone.
Dr. Broughton adds, “We do know there’s an effect on the ovaries… but we really don’t think there is a long term impact on the ovary.” Plus, any effects are likely reversible. Dr. Broughton recommends taking good care of yourself and starting on a prenatal vitamin to ensure the best possible outcomes for conception.
While you can be on T for many years and still use your own eggs to have biological children, each person’s experience is, of course, unique to them. Here’s what happened for Kyle, a transgender man using intrauterine insemination (IUI) to conceive: “I was on testosterone for four years. I came off it in January of 2019. After about three months, my cycles returned and I ovulated. Shortly after that, I stopped ovulating. I have since required progesterone to start all my cycles.”
Because testosterone therapy prevents ovulation, you will have to stop using T and resume getting periods when you are trying to conceive. This has the potential to bring up unwanted experiences of gender dysphoria. If you’re anxious about how stopping HRT could make you feel, plan to bring in extra support — talking to your friends, connecting with a community of people going through the same thing, and working with a therapist can help during this time.
Unlike testosterone, for transwomen, Dr. Broughton says, using your own sperm to create a baby after estrogen therapy might be more difficult.
“Estrogen is a little bit different,” she explains. “It certainly has an effect on sperm production and sperm parameters (meaning count of sperm and movement of sperm), [but] the hard thing is that we’re not quite sure how reversible the effect of estrogen is. And we think that even after cessation of estrogen, there might be some long-term impacts on sperm production.”
If estrogen therapy is part of your transition journey and you’re interested in using your own sperm in the future to have a baby, Dr. Broughton advises that you can freeze your sperm using cryopreservation for later use through fertility treatments like IUI, intracervical insemination (ICI), or in-vitro fertilization (IVF).
Gender-affirming surgery (GAS)
Many different surgeries can be a part of someone’s transition, but “bottom” surgery (where someone’s reproductive organs are removed or changed) has the biggest potential to impact fertility.
Dr Broughton says, “When we’re talking about trans masculine people who choose to undergo a hysterectomy, that only impacts the ability for that person to be pregnant and carry a pregnancy in the future. If we’re thinking about people that undergo removal of the gonads (either ovaries or testes), that removes the ability for them to use their gametes (eggs or sperm) in the future to have a pregnancy.”
If these gender-affirming surgeries (sometimes known as sex-reassignment surgeries) are a desired part of your transition, you still have treatment options for having children using your own gametes:
Transgender men or masculine individuals
- Oocyte cryopreservation, or egg freezing
- Embryo cryopreservation, or embryo freezing
- Ovarian tissue cryopreservation, or ovarian tissue freezing
Transgender women or transfeminine individuals
- Sperm cryopreservation, or sperm freezing
How can you find affirmative healthcare?
Because transgender, gender nonconforming, and nonbinary individuals have often been overlooked or erased in reproductive medicine, it can be challenging to find informed healthcare providers to support them while trying to conceive.
A Center for American Progress study found that 29% of transgender people said a doctor or other healthcare provider refused to see them because of their actual or perceived gender identity. So, it’s no surprise that many trans-identified individuals feel uncomfortable or scared to start a conversation about fertility with their doctor.
For any couples thinking about starting their conception journeys, Kyle recommends, “If you are going to use a reproductive specialist, do your research first. Our doctor has been nothing but amazing with my gender identity and inclusive to my wife. It's nice to feel safe and supported with my doctor during this time.” Family Equality has great resources for TGNB family building.
How to find support
Fertility, conception, and pregnancy are very personal processes that can be filled with lots of hope and lots of emotions. Most of us have expectations for how our journey to parenthood will look — and it can be frustrating and stressful to hit roadblocks. This is why it’s important to have support and affirmative resources that you can rely on during this journey.
You can also look for Facebook groups in your area where you can connect with other LGBTQ+ people who are navigating the path to parenthood — or join the Modern Community and get real talk from other folks.
We all deserve to feel supported and affirmed when we’re ready to begin that exciting and unpredictable journey to parenthood.