Oregon Health & Sciences University
A gender affirming transition — including the hormones and the surgeries considered — can have lasting impacts on one’s fertility. If possible it’s best to think through these downstream impacts to fertility before the transition process begins.
As part of transition, trans women typically take estrogen and sometimes androgen blockers.
Estrogen in particular has harmful effects on sperm production. In many cases those effects can cause permanent damage, impeding the ability to produce sperm.
In some cases, though, people are able to produce sperm after coming off of estrogen. When asked to come off estrogen for between three to six months, it is occasionally possible to produce some sperm, but when interviewing doctors about their clinical experience, they say that it’s usually only a very small amount of sperm that can be produced, meaning that conception without medical assistance isn’t likely — IUI or, most likely, IVF will be required.
But there is very little data about the amount of time one should be off of estrogen before trying to collect sperm, or what the rates of sperm production are after varying periods of exposure to estrogen. A typical spermatogenesis or sperm growth cycle is at least three months, so there’s no reason to expect results before then.
Gender affirming surgery, depending on which surgery is chosen, can have permanent impacts on a persons’ fertility. Namely “bottom surgery,” or removing a persons testes, will permanently compromise that person’s fertility unless fertility preservation is undertaken beforehand.
Transfeminine individuals have several reproductive options depending on their stage of transition, their social situation, and whether or not they have undergone some form of fertility preservation. The main options are unassisted conception with a partner, IUI with a partner who has a uterus, and IVF either with a partner who has a uterus or a gestational carrier. In the future, uterine transplant might be a possible way that a transfeminine woman could carry a pregnancy.
Below we characterize the rates of success, the costs and the burden for each treatment. Typically, the cost, burden and rates of success tend to increase with each new approach. That said we should point out that the “success rates” below are built from datasets that comprise infertile, cisgender, heterosexual couples. Its plausible that rates of success could look dramatically different (better or worse) for trans women.
Although in most cases estrogen impacts one’s ability to produce sperm, it is sometimes possible for a trans feminine individual to come off of estrogen for a period of months and, if they are willing and able to engage in penetrative intercourse with a partner, conceive a pregnancy without medical assistance.
Of course, if someone has not yet started hormonal transition and also has not had their testes removed, then unassisted conception is possible as well.
While it’s far from a perfect reference point, the data below collected from cisgender, heterosexual couples shows that if unassisted conception hasn’t happened in the first six to twelve months, the odds of it happening in any subsequent months are fairly low.
For cisgender, heterosexual couples, the definition of medical infertility kicks in after 6 months of trying to conceive after age 35, or a year of trying until age 35. Trans women who have been on hormones should seek guidance from a fertility specialist before this time frame, though, to ensure that sperm counts are acceptable for trying naturally.
IUI, which is also called intrauterine insemination or artificial insemination, is another avenue for trans feminine individuals who have a partner with a uterus.
This is a somewhat simple procedure where sperm in injected directly into the uterus of a partner who would carry the pregnancy.
The sperm used in IUI would ideally be sperm preserved or banked prior to hormonal transition, but it’s also possible for some individuals to do IUI with sperm they produce after coming off of estrogen.
IUI success rates vary and depend most closely on the age of the person who will be carrying a pregnancy, as you can see below. Unfortunately this data is from cisgender women with a history of infertility.
Additionally, IUI success rates and costs vary dramatically depending upon which, if any, fertility medication the person carrying a pregnancy has taken. Similarly, the rate of risk for a “multiple pregnancy” varies depending upon which drug is used. The table below illustrates the point, though the success rate data it contains comes from infertile, cisgender, heterosexual couples. It’s plausible that rates may be different for couples where one partner is a trans woman.
It’s worth noting that we characterize carrying a multiple gestation pregnancy as a “risk” because it tends to increase the odds there will be a major complications with the pregnancy and delivery.
If sperm was banked before transition, and that sperm appeared to be of high quality (see our section on the semen analysis below), then IUI success rates might be more analogous to success rates in cis lesbians, who are presumed not have an underlying fertility problem.
Data shows that cis lesbians enjoy higher success rates than their counterparts who were studied in infertile, heterosexual couples. Success rates from cis lesbians can be seen below. By the 5th IUI, more than half became pregnant, which is a staggeringly high rate of success for IUI.
If sperm has not been banked prior to transition, the ability to engage in IUI will depend on the quality of sperm that is produced after going off of estrogen. Based on doctors’ clinical experience, not data, they say that there is rarely enough sperm produced after coming off of estrogen to consider an IUI cycle.
As you can see in the data below (which was focused on cisgender men), rates of IUI success go down once sperm counts have crossed below certain thresholds. Below you can see how IUI success rates coincide with a lower total motile count, or TMC, which is the number of sperm that swim forward.
IVF, or in vitro fertilization, entails fertilizing eggs with sperm in a petri dish before placing a resulting embryo into the uterus of a person who will carry the pregnancy. This requires that one person use fertility hormones to prompt the ovaries to produce a large number of eggs and eventually have a surgical procedure to remove those eggs.
Generally speaking, the two crucial points to note are that IVF is expensive and seldom works the first time. As for cost, as you can see below, in most major US cities, each IVF cycle costs around $20,000. Below you’ll find our section on how to think through paying for care.
Unfortunately, the first IVF cycle often does not work. As you can see from the data below, success rates are often tied to the age of the person whose eggs are being used.
A fundamental question is how many IVF cycles a person will need to undergo to have a baby. As you can see from the data below (captured from mostly cisgender infertile people), cycles #2 - 5 can be either worthwhile, or somewhat less-productive, depending upon the age of the partner whose eggs are being used.
The sperm that is used for IVF can come from frozen sperm preserved before transition, from sperm produced after discontinuing hormones like estrogen, or from a sperm donor.
In the case that ejaculation is not possible, or no sperm is found in semen that is ejaculated, it is sometimes possible to surgically retrieve sperm directly from the testes using techniques like testicular sperm extraction or TESE. When these procedures work, a very small number of sperm are typically extracted, meaning that the only way to effectively use this sperm is through IVF and a special fertilization technique called ICSI, whereby a single sperm is injected directly into a single egg.
As you can see in the data below (based upon cisgender men), IVF success rates tend to be lower when this surgical approach is requred.
It’s possible to do IVF with a partner who has eggs and a uterus, but it’s also possible to use donor eggs, donor sperm, the uterus of a gestational carrier, or any combination of those components.
When there’s an issue with sperm and donor sperm is used instead, IVF success rates often improve.
In the case of an egg-related issue, the gains made by using donor eggs can be even more remarkable — they can increase IVF success rates by five to eight times in some cases. The data below is from cisgender women at 42-years-old.
Paying for IVF is a challenge for most hopeful parents and there are a few concepts to keep in mind as you prepare for the costs.
First, many companies now cover the cost of at least one IVF cycle for their employees. Unfortunately, the degree to which these companies cover treatment for non-heterosexual, non-partnered, or transgender employees remains uneven. Here is our annual list of the companies we know of that cover IVF for their employees in some form or another. The companies that have no preauthorization are those with more inclusive policies, meaning that medical infertility isn’t necessary to access the benefit.
Second, we’ve compiled a list of grants and charities that dispense money for IVF treatment. For instance, the State of New York sets aside over $1M annually to cover IVF bills for those who make around $200,000 or less. In California, UCSF runs a no-frills IVF program that can lower the costs by over 80% for those who earn below a threshold amount.
Third, in a small handful of states legislators have required most employers to offer insurance plans that cover IVF (though not to all patients equally). These states include Massachusetts, Rhode Island, Connecticut, New Jersey, Maryland, Delaware and Illinois.
Fourth, there are typically loan options available with annual rates that are generally competitive compared to loans offered for other types of medical services. Below you can see a general depiction of the options (specifics may change, always remember to read the fine print) and the tradeoffs for each. Generally speaking, patients need a FICO score of above 600 and thereafter there is a tradeoff between convenience, speed, and annual interest rates.
Fifth, half of US clinics offer patients the chance to buy cycles in bulk for a discount (known as a package) or with a refund feature (known as "shared risk"). We have mixed opinions on these programs (as you can see in our detailed rundown), but typically believe that shared risk programs are offered to patients who are likely to succeed early in treatment (2/3 of refund patients succeed in the first cycle, see below) and thus these customers dramatically overpay for results they would have gotten anyhow. What's more, the list of medical exclusions is large (medication, genetic testing, pre-treatment testing) and as a result most patients spend 25 - 50% beyond the quoted "sticker price."
That said, patient levels of satisfaction with these programs are high, though we personally believe that’s irrational. If you are being offered access to a shared risk program, consider why, the success rates others like you in the program enjoyed (at which cycle), and the real cash outlay you're likely to incur.
In the future, uterine transplant might offer a possibility for trans women to carry pregnancies. This would be made possible through using IVF, either with their sperm or a donor’s sperm, and either a partner’s eggs or a donor’s eggs.
To date, there has been recorded success with people receiving a transplanted uterus and going on to have a healthy pregnancy and delivery. At this point, uterine transplant has only been performed on people who were born with ovaries, so it hasn’t been attempted on a trans woman. But in the future this option could open up an entirely new way for trans women to think about and experience reproduction.
Because fertility potential is usually compromised through the use of hormones like estrogen during transition, and completely negated through gender affirming surgery when testes are removed, fertility preservation strategies can offer an important chance to preserve one’s options to have a family, even well after transition. Fertility preservation can drastically increase the odds that treatments like IUI or IVF will succeed if natural conception is not possible.
The best time to consider fertility preservation is before transition, but of course that’s not always possible. If you haven’t considered fertility preservation but have already begun hormonal transition, there are still options which we’ll cover below.
Unfortunately there is currently no data on this topic, but there has been a question raised in the field about whether trans women have lower sperm counts or lower sperm quality compared with cisgender men, even before transition.
In our minds, this makes it even more important to be sure to have sperm quality tested in a semen analysis before transition, and to have those results interpreted by a provider who is well versed in the implications of those results.
The most straightforward way to preserve fertility is by freezing sperm. This is easiest when ejaculation is possible. Freezing ejaculated sperm can cost between $400 - $1,000, and there is usually an annual storage fee after that of $200 - $500.
In the process of banking sperm through ejaculation, sperm quality should be tested via a semen analysis. The semen analysis has three core components: concentration, motility and morphology.
While the semen analysis is imperfect, it’s crucial you have it done on your sample and make sure that it’s read and explained to you by a reproductive urologist or, at minimum, a doctor who is well versed in semen analysis results. Here’s why:
Generally speaking, we think it’s best to try and freeze as many samples as possible before transitioning. While this can cost more, it can pay off because:
When ejaculation for sperm freezing is not possible, there is a new experimental technique of freezing testicular tissue. This is still in the early experimental phases, so it’s unclear how viable it will be.
Essentially the hope is that freezing testicular tissue would allow that tissue to either be reimplanted into an individual at a later date or, even better, be used to grow mature sperm cells in the laboratory setting. The hope is that laboratory-grown sperm could be used or IVF in the future.
Young people are now transitioning earlier and earlier, and that has implications for the ability to preserve fertility.
For example, if a trans girl goes on pubertal blockers, she will never go through puberty in her sex that was assigned to her at birth. That means there is no real way to preserve her fertility without at some point having to stop those blockers and go through puberty in her natal sex.
In the future, the hope is that some testicular tissue could be frozen at that point, and either be re-implanted or used to make sperm in a laboratory to be used in a future IVF cycle.