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Transition & Fertility
Testosterone’s Impact on Fertility
For most people, testosterone will negatively impact fertility while it’s being taken—it usually prevents ovulation (the process whereby an egg would be released and pregnancy or fertility treatments are possible).
There is currently no long term data on the impacts of taking testosterone on a person’s eggs. But many people are able to become pregnant without assistance or through IVF after stopping testosterone.
One fertility clinic’s data revealed that, in IVF, egg numbers were similar between cis women and trans men who had previously transitioned using testosterone. A number of small, underpowered studies had similar findings. And, although this is promising, it’s important to remember that these only demonstrated the ability of trans men to produce a similar number of eggs—there was no data giving us an understanding of egg quality.
Again there’s no long term data, but from the information currently available, but anecdotally, babies born after a parent stops testosterone seem to be healthy.
Finally, most providers still suggest that testosterone shouldn’t be relied upon as a sole form of birth control, because its suppressive impacts vary across individuals. Additionally, testosterone should not be taken while pregnant. It’s a hormone that may cross the placental barrier, and its effects aren’t fully known.
Gender Affirming Surgery & Fertility
If one's transition includes surgery to remove the ovaries, this impairs the ability to have a child. Ovaries contain “follicles” that ultimately produce eggs; if the ovaries are not available, neither are eggs.
If a trans man is considering surgery to remove ovaries, we suggest taking the step to freeze eggs (or embryos). Thereafter, we’d also consider taking the step to preserve the extracted ovarian tissue in the event one day scientists are able to extract eggs from such tissue (which hasn’t been made possible yet, but hopefully will happen in the future) — this step could prove especially important for transgender youth who have not had a menstrual cycle yet, as no other preservation options are available.
If a trans man chooses to have a hysterectomy to remove his uterus, he will no longer be able to carry a pregnancy. A genetic tie to future children is still possible though. For this to happen, a trans man can provide eggs during an IVF process, and embryos that result from those eggs can be transferred either to the uterus of a partner or a gestational carrier so long as it’s in accordance with FDA regulations.
Going Off Testosterone for Fertility
Because testosterone usually impacts fertility while someone is taking it, if someone has already transitioned with hormones wants to either pursue a pregnancy or freeze their eggs, it will be required that they stop taking testosterone for a period of time.
After stopping testosterone, the menstrual cycle resumes in three to six months.
Going off of testosterone can be difficult, both emotionally and physically. The process can result in mood swings, depression, or increased gender dysmorphia. It's important to think through the resources, like support groups, to call upon before starting the process.
The good news is that typically changes to one’s physical appearance take much longer than emotional changes. For example, going off testosterone to try to conceive or freeze eggs may not have much impact on physical appearance at all; the process does not usually impact body hair or vocal pitch.
Hormones & the Postpartum Period
When a trans man carries a pregnancy, there are several areas to think through in terms of hormones and the postpartum period. Unfortunately, there’s not a lot of data on any of these topics.
Postpartum Healing
It’s a difficult decision of when to resume testosterone after childbirth, and one that can’t really be guided by any data. Medical professionals stress that estrogen is important for healing after childbirth, particularly healing tissues like in the genital area. Patients who have genitals which are not healing well postpartum are likely to benefit from use of a topical estrogen cream (which typically does not have a “systemic” effect).
Also, the time immediately after childbirth is a high risk period for blood clots, so this is something doctors should be sensitive to in terms of hormones that will impact clotting.
Lactation
Lactation, or chest feeding, is another big decision point when it comes to resuming testosterone. If you want to lactate, but you go back on testosterone too early, that could suppress milk production. There’s also a concern that testosterone could get into the milk and the baby could consume that testosterone — we do not know what the impacts of that would be on a baby.
Commonly trans men are advised to wait until they establish a milk supply before going back on testosterone. However, it’s important to remember that it’s still unclear the degree to which testosterone finds its way into the milk supply, and if it does, any impact it has on the baby.
Reproductive Options for AFAB Trans People
Trans men have several options when pursuing biological parenthood, ranging from unassisted conception (penetrative sex with a partner), IUI, IVF (which can be aided with donor eggs, donor sperm, or surrogacy). Generally speaking, but not always, the odds of success, costs and burden can escalate with each successive approach.
When it comes to characterizing how often each approach works, we have virtually no data pertaining specifically to trans men. Instead, unfortunately, we’re often left to rely upon the data from infertile, cisgender, heterosexual couples, which you can see below.
Unassisted Conception
Many trans men stop taking testosterone and conceive without medical assistance if they are having penetrative intercourse with a partner. While pausing testosterone can be a major challenge, almost every approach today requires it, unless pregnancy or fertility treatments are pursued prior to hormonal transition.
To the positive, unassisted conception helps spare a trans-man (or couple) an enormous financial and physical burden associated with medical approaches like IUI and IVF.
IUI or Artificial Insemination
One of the most accessible fertility treatments in terms of cost and invasiveness is IUI, or intrauterine insemination. It’s also sometimes referred to as artificial insemination.
This treatment is also probably the closest to unassisted conception. During an IUI procedure, a doctor, nurse, or midwife uses a thin, flexible tube to deposits sperm (that’s been processed) into the place where the fallopian tube meets the uterus. This helps ensure that significantly more sperm reach this pivotal location than would ordinarily happen during intercourse. The sperm can be from either a partner or a donor.
The reality is that IUI success rates can vary widely depending upon a few factors, primarily the age of the person who will be carrying the pregnancy. Below are IUI success rates for people with no identified fertility issue (in this case, cis-women who were either single or part of a lesbian couple). This is a useful analogy because many transgender people will have no underlying infertility diagnosis.
Another factor when it comes to IUI success rates, costs, and risks depends on whether the carrying partner takes fertility drugs (and which drugs) during the IUI cycle. For instance, the decision to take gonadotropins can mildly improve the odds of success, but it substantially increases the cost ($2,000), logistical burden (monitoring required) and health risk (in the form of a multiple pregnancy) to the patient.
For full information on IUI, including the costs, logistics, and success rates, you can see our full course about IUI here.
IVF
IVF, or in vitro fertilization, allows for many different options for transmasculine family building.
Let’s start with the basics of IVF. The process entails a doctor retrieving eggs from the body, a laboratory fertilizing those eggs and growing embryos, and then a doctor transferring those embryos into a uterus.
The IVF process is flexible and allows for the eggs, sperm, and uterus to be provided by any number of people.
- A trans man can newly provide eggs or use eggs they’ve previously frozen and preserved
- A trans man may also receive the embryos and carry the pregnancy presuming the uterus has not been removed as part of transition
- Sperm can be provided by a partner or donor
- Eggs can also be provided by a partner or donor
IVF success rates tend to track the age of the person providing eggs at the time those eggs were retrieved, as you can see from the data below. We should point out this data is taken from mostly infertile, cisgender, heterosexual couples. While the specific IVF per cycle success rates may not apply to all scenarios involving trans men, the trend below is likely still relevant.
Since IVF seldom works on the first cycle, it’s common for patients to undergo multiple cycles, often with varying levels of productivity that usually depends upon the age of the person providing the eggs.
Often the costs to do IVF (including the costs to retrieve eggs) reach about $20,000 per cycle in most major US cities. In the next section, we’ll touch on resources that may be helpful towards assuaging the financial burden.
For more information on IVF, including the costs, logistics, and success rates, you can see our full guide to IVF here.
Using “Third-Party Reproduction”
As we alluded to, IVF can still be successful (and often times more successful) when donated eggs or a gestational carrier are included in the process.
Below you can see how IVF success rates spike when the eggs from an egg donor are incorporated into the process. For trans men who are not able to produce eggs that will lead to a pregnancy, using an egg donor is often a helpful option. The biggest extra cost associated with using an egg donor are compensating the person providing eggs. An egg donor can be a friend or sibling (who may ask for little in the way of compensation) or someone introduced to you by a clinic or agency (in which case the total costs can reach well beyond the $10,000–$20,000 range).
Gestational Carrier or Surrogacy
If a trans man has had gender affirming surgery to remove the uterus, or simply isn’t comfortable discontinuing hormones and going through the pregnancy process, there is the option of having a gestational carrier or a “surrogate” to carry a pregnancy. IVF success rates with properly-vetted gestational carriers (provided the embryos are of good quality) tend to be excellent.
A gestational carrier would carry an embryo created either by the trans man himself or by a separate egg donor.
Surrogacy is the costliest of all the fertility treatments, because it involves not only IVF, but also coordinating with a surrogacy agency (unless you have a known gestational carrier who is volunteering to assist) and reproductive attorneys fees as well. Using a gestational carrier can add an additional $20,000–$50,000 and sometimes more.
Financial Resources
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 LGBTQ or single employees remains uneven.
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 equally to all patients). These states include Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Maryland, Delaware, and Illinois. If you live in one of these states, it’s more likely your insurance plan can help cover the cost of IVF.
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 U.S. 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."
Transmasculine Fertility Preservation
For trans masculine individuals who were assigned female at birth, there are a few fertility preservation options to consider. Whenever possible, it’s ideal to have fertility preservation conversations with providers priortext in italic to hormonal or surgical transition steps.
The purposes of preserving fertility before transition are twofold:
- We lack the data on the long term effects of transition through testosterone hormone replacement therapy, so it’s possible that some people might not recover their full fertility potential after hormonal transition. Preserving fertility allows someone to “lock in” some of their pre-transition fertility levels
- If someone plans to surgically transition and remove the ovaries, preserving fertility can offer the only chance to keep options open to one day have a biologically related child
The most proven and the most commonly available option to preserve fertility is egg freezing, which we’ll explain in depth below.
There are also more experimental, unproven, procedures that involve freezing ovarian tissue.
Egg Freezing for Preservation
The purpose of egg freezing is to preserve eggs that can later be used, if needed, as the “egg” input for IVF. These eggs might be higher quality than those harvested later on, both because younger eggs perform better than older eggs, and because eggs removed prior to transition won’t be impacted by taking testosterone for transition.
The process of egg freezing involves injecting yourself with hormones to mature several eggs at once (hopefully much more than the usual one or two eggs the ovaries would produce every month in their natural state).
Unfortunately, this process does mean that the ovaries will produce high levels of estrogen, which of course might be the exact opposite direction that you’re hoping to go with hormones if you need testosterone as part of a transition. The effects might be uncomfortable, both emotionally and physically—there are reports of emotional changes, and some reports of breast development, which can be permanent, although it seems that’s a rare occurrence.
Once the ovaries have produced a sufficient number of large follicles (the containers for eggs that are likely to be mature), those eggs will be extracted in an egg retrieval surgery. This is usually done under general anesthesia, while a doctor uses an ultrasound-guided needle to suction out the contents of each ovarian follicle.
Extracted eggs are then frozen or “vitrified” by a fertility clinic’s lab, and stored for later use.
At a later time, you can have the eggs thawed and inseminated with sperm. Once the eggs have been fertilized, resulting embryos will grow in an IVF laboratory for several days, until they reach a point when they can be placed in a uterus—either yours, a partner’s, or someone else’s.
Egg Freezing Success Rates
While egg freezing technology has improved tremendously over the past decade, when a person freezes eggs, it does not guarantee that they’ll be able to successfully use those eggs to have a baby.
In general, the ability of an egg to become a viable pregnancy and a successful delivery is tightly correlated with the age of the person at the time they froze eggs. This is illustrated in the chart below, which plots IVF success rates (Y axis) against the egg provider’s age (X axis). This is a relevant datapoint, because as you may recall, freezing eggs and then using them (having them fertilized, grown into embryos and then transferred to the uterus) constitutes an IVF cycle.
However, this chart is built from data on mostly infertile, cisgender couples. It’s plausible the specific rates of success don’t portray the reality for trans men, many of whom may not have an underlying fertility issue.
There’s not as much data available as we’d like to answer the question of how many eggs frozen yields what percentage chance of having a baby. But there is one small study out of Spain — you can see that data below, where it appears that 10 frozen eggs yields a 60% chance of having a baby for people who froze eggs at ages 35 and younger, and a 30% chance for those who froze from age 36 on. We should note this data was collected on patients assigned female at birth and who have not transitioned. That said, the axiom that “more eggs collected at a younger age increases the odds of success” probably holds.
It’s also critical to understand that the chances of success with egg freezing are inextricably tied to the quality of the lab at the fertility clinic you use. A spectacular lab can double the chances of success, while an average lab can probably achieve far less.
For egg freezing in particular, where many new clinics are popping up and marketing themselves as doing egg freezing without ever having thawed and used a single egg to make a baby, digging into the quality and experience of the lab where you freeze is critical.
We have an entire course dedicated to laboratory quality, but in the context of egg freezing, you’ll specifically want to ask your laboratory about their “oocyte cryosurvival rate.” This is a measure of the percentage of eggs that the laboratory freezes that are ultimately useful when thawed. An 80% rate is often considered a “passable” and anything above 90% should be considered reassuring.
For more detail on lab quality, and the questions you can ask to assess it, you can see our guide to the laboratory here.
The Cost of Egg Freezing
There’s no getting around the fact that freezing one’s eggs is an expensive process. On average, a single cycle of egg freezing costs $15,000 or more.
Clinics often quote just their baseline fees, which don’t include the cost of the pricey medications that are used to stimulate the ovaries. Those quotes also leave out the cost of storage which, at $500 - $1,000 per year, can end up eclipsing the cost of the initial treatment. Below is a simple snapshot of the costs associated with egg freezing.
Another thing to keep in mind about the cost of egg freezing is that the results of a cycle are ambiguous. Unlike with IVF, where a cycle either results in a baby or it doesn’t, with egg freezing there’s only a “number of eggs frozen” with no guarantees attached. That means that most egg freezers end up doing more than one cycle (as you can see from our data below), so they end up spending far more than twice as much as they’d anticipated.
Finally, if you end up deciding to use frozen eggs, there are significant costs associated with using them to do IVF — you’ll need to pay for the laboratory fees to grow embryos, transfer an embryo, and freeze any remaining embryos. Those costs typically range between $7,500 and $12,500 with the major swing factor being whether you decide to genetically test the embryos before transferring them. Below is a simplified breakdown of the costs to use one’s frozen eggs.
For more details and analysis on the costs of egg freezing, see our guide here.
Embryo Freezing
Once eggs are retrieved they can be frozen (egg freezing) or, instead, immediately fertilized with sperm, grown into embryos, and then frozen. This process is called embryo freezing.
Visibility and Reliability: Advantage - Embryo Freezing
Freezing embryos (rather than eggs) can have a real benefit. First, as you can see in the diagram below, not all retrieved eggs will become embryos. Embryos are a requirement to having a baby. Some patients will have none of their eggs develop into embryos, which is devastating news but information that would be helpful to have immediately after the cycle (in which case the patient can try again) rather than years later, when the quality of a patient’s eggs is likely to have diminished (as you’ll see in a moment below).
Sperm Optionality: Advantage - Egg Freezing
The value of freezing eggs is that the patient keeps the option to fertilize them with anyone else’s sperm in the future (this could be a partner, a friend, a donor). By contrast, when a patient freezes embryos, the eggs are immediately fertilized: if the patient changes their mind and wants to use the sperm of someone else, that option is off the table.
Short Term Cost: Advantage - Egg Freezing
Additionally the up-front steps involved in growing embryos are costly (often at least $3,000) and if the patient never returns to use the embryos, that may have spent money on something they never needed.
Risks of Freeze and Thaw: Advantage - Embryo Freezing
Eggs are a single cell, they are more sensitive to a change in conditions and more likely to suffer damage during the freezing and thawing process. Embryos, by contrast, are more durable and can more easily weather a change in environment. Add to this the fact that most clinics have a proven track record of successfully freezing and thawing embryos (which is less true for eggs) and a patient takes on less risk by freezing embryos.
Post-Transition Egg Freezing
It is possible to freeze eggs after a hormonal transition with testosterone, but currently this process does require going off testosterone for at least a few months before undergoing ovarian stimulation for egg freezing.
This is often less preferable compared with freezing eggs before transition because trans men often find it difficult to stop taking hormones once they have begun.
What’s less clear is whether having taken testosterone has an impact on the quality of eggs produced during an egg freezing cycle.
Transitioning Before Puberty
With people transitioning earlier in life, the question of how to preserve fertility in people who have not yet undergone puberty becomes more relevant.
As part of transition some youth take pubertal blockers to prevent them from going through puberty in their natal sex. The problem with that, is that never undergiong puberty in one’s natal sex reduces options in terms of fertility preservation. If the menstrual cycle has not yet started, then the ovulation cycle has not started either, so extracting mature eggs won’t yet be possible.
One experimental method of fertility preservation for very young people who are transitioning is freezing some ovarian tissue. There are currently studies underway assessing the capabilities of frozen ovarian tissue — whether that tissue can be re-implanted into an individual later or, ideally, if that tissue could successfully be used to grow matured eggs in a petri dish. This technique is still in the early experimental phases, so it’s unclear whether it would really be a viable means of preserving fertility. But if someone needs to transition before puberty and before other fertility preservation is possible, it could be better than doing nothing.
Alternatively, some case studies have found that transgender youth can engage in egg harvesting between puberty blockers and the initiation of testosterone.