We’re writing you from San Francisco, where we’re just a few days away from the Pride Parade and Celebration. The weekend-long event celebrates the culture and heritage of lesbian, gay, bisexual, and transgender people. At Modern Fertility, we’re dedicated to creating dialogue around overlooked topics, especially in the reproductive health space. This week especially, we’re excited to ask and explore the question: What do fertility and reproduction — everything from periods to pregnancy — look like for trans individuals?
To encourage as much knowledge, compassion, and acceptance as possible, we sat down Dr. Erin Fagot, a doctorally-trained nurse practitioner in Nashville who is passionate about trans healthcare, and Kori Doty, a sexual health educator in British Columbia, for an interview on this topic.
Before moving onto the Q&A, let’s start with some important terminology — just to make sure we’re all on the same page.
- Transgender: A person whose gender identity differs from the sex that was assigned at birth.
- Transgender man: Someone with a male gender identity and a female birth assigned sex.
- Transgender woman: Someone with a female gender identity and a male birth assigned sex.
- Cisgender: A non-transgender person.
- Gender identity: A person's internal sense of self and how they fit into the world, from the perspective of gender.
- Gender expression: The outward manner in which an individual expresses or displays their gender. This may include choices in clothing and hairstyle, or speech and mannerisms. Gender identity and gender expression may differ.
- Sex: Historically, this refers to the sex assigned at birth, based on assessment of external genitalia as well as chromosomes and gonads.
- Sexual orientation: Describes sexual attraction and is not directly related to gender identity. It is often described based on the lived gender; a transgender woman attracted to other women would be a lesbian, and a transgender man attracted to other men would be a gay man.
- They/Them/Their: Neutral pronouns used by some who have a nonbinary or nonconforming gender identity.
MF: Thanks for talking with us, Kori and Erin. Let’s dive in. Based on your own experiences, how is fertility impacted for transgender individuals?
EF: Those who feel safe enough to live openly as their preferred gender often augment their transition with hormones and/or surgery. It helps them live as their preferred gender as it fits into their own framework. As a provider who initiates and manages gender affirming hormones, I see a lot of patients who use hormones, other medications, and surgical or cosmetic procedures as tools to live as their preferred gender. These modalities help with gender dysphoria and can be very uplifting for those transitioning.
MF: Let’s talk about hormones specifically, since you specialize in this area. You also have personal experience with this, Kori. What type of impact do they have on fertility specifically?
KD: I’m a trans masculine person who started medically transitioning with testosterone about 13 years ago. One of the things that often happens when someone is on full dose of testosterone is that their menstrual cycle will stop. I also experienced secondary sex changes, like growing a beard and having different muscle and fat distribution.
EF: I have textbook charts you can reference. Here are a couple of examples: For transgender women taking the recommended course of estrogen, they will notice decreased libido spontaneous erections in one to three months. Like Kori mentioned, for transgender men taking the recommended course of testosterone, menstruation typically ceases in two to six months.
Effects and Expected Time Course of Estrogen Hormones
Image provided by Dr. Fagot
MF: So how does all of this influence conception and pregnancy?
EF: The longer a person has been on gender affirming hormones, the more challenging pregnancy can be. But it’s not impossible. If transmen have not undergone a hysterectomy as a part of their transition, they should be able to conceive with the help and guidance of a medical professional. Transmen who are using testosterone as a part of their transition no longer menstruate after a month or two on hormone therapy, as mentioned above. So, stopping testosterone should enable them to resume menses and in theory ovulate. But again, the longer someone has been using testosterone as a part of their transition, the longer it will take for them to resume menstruation.
Transwomen who are using hormones as a part of their transition often stop having spontaneous erections and notice a change in the quality of their ejaculate and orgasm. There are many variables for these people and it is often recommended that they take a temporary hiatus from estrogen while trying to conceive or freeze their sperm before they begin their transition, if possible.
KD: When I decided I wanted to use my reproductive system, I stopped taking testosterone. In six to seven weeks, my cycle came back. One of the things that gets talked about a lot is how testosterone will impact your fertility and ability to get pregnant. I had no trouble getting pregnant — it happened right away, when my cycle returned. I did have an early miscarriage, but later carried a baby full-term and gave birth to my child in November 2016. It’s anecdotal, but I know of people in my community who were on testosterone for 10 to 15 years but were still able to get pregnant with ease.
MF: Erin, you mentioned sperm freezing — is fertility preservation important for transgender men and women interested in one day conceiving?
EF: The desire to parent and the desire to transition coexist. Everyone's perspective and understanding on gender can influence how they want to parent, particularly on the values they wish to pass on to their children. So, how someone responds to the ability of preserving their fertility in the face of a medical situation depends on their desire to parent. There is a school of thought that eventually hormone therapy will render trans patients infertile, but there are many variables to this and someone needs to be on hormones for a long time before this becomes a concern.
A lot of patients I interact with try to time their transition and conception at different times. Getting into the mindset of becoming a parent and transitioning are experiences that impact every aspect of a person's life. This is a generalization, but often, people want to be living their lives as their preferred gender before they become a parent. But there are also people who find themselves in situations where they want to conceive before this transition is complete.
MF: Kori, what advice would you give another transgender individual beginning the conception process?
KD: Because we’ve been living in bodies that have been pathologized for much of our history, we’ve come to relate to our bodies as being problematic or deficient. I think that one of the things that is super helpful and important is for people to remember that their bodies are capable. Our bodies have incredible power. But it’s easy to be out of touch with that power when the story that we’ve been told about our bodies is that there’s a problem with them. To be able to set the intention and go through process of conception and gestation, you have to actually believe that you’re capable of doing it.
MF: As a community, how can we promote more understanding and acceptance of fertility issues and processes for trans people?
KD: This is particularly true in United States but has been true in the Western world for last few hundred years. We take the most trusted views on reproductive health from men who don’t have uteruses. More information and more dialogue from a wide variety of perspectives is critical.
EF: I think it starts with recognizing trans people as people. They have needs and desires just like everyone else, including conception, birth, and parenting. If we can start recognizing the importance of pronouns and other needs that trans people have, we can create a safe space for them.
Happy Pride Month from all of us at Modern Fertility. If you’re in the Bay Area, will we see you at the parade or other events this weekend? We look forward to celebrating and supporting lesbian, gay, transgender, and bisexual communities this weekend and beyond, and doing our part to help educate the world on what reproduction and fertility can look like for them.