Fertility Details For Trans Men

Transition & Fertility

Testosterone’s Impact On Fertility

Typically trans men will take testosterone as part of transition. In most people, testosterone negatively impacts fertility while someone is taking it — 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 after stopping testosterone — either unassisted (meaning via penetrative sex with a partner) or through in vitro fertilization (IVF).

Again there’s no long-term data, but from the information currently available, those eggs seem to be healthy, and babies born after a parent stops testosterone seem to be healthy.

Most doctors still say that testosterone shouldn’t be relied on as a foolproof form of birth control, because it doesn’t always suppress ovulation in all people. Also, testosterone should not be taken while someone might be pregnant. It’s a hormone that can cross the placenta and get to a fetus, and we don’t fully understand the impacts of that yet.

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.

Going Off Testosterone For Fertility

Because testosterone usually impacts fertility while someone is taking it, if a trans-man who has already transitioned with hormones wants to either pursue a pregnancy or freeze eggs, it will be required that he stop taking testosterone for a period of time.

After stopping testosterone, most people’s menstrual cycle resumes within about six months.

There’s not a lot of data about when, or how, someone should come off testosterone from a fertility perspective, but it seems possible to either stop all at once, or to taper.

Going off of testosterone can be very difficult emotionally and physically. It can result in mood swings, depression, or gender dysmorphia. Be sure to think through the resources, like support groups, that you can call upon before you start 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 and conceive or freeze eggs may not even have an impact at all, and does not usually impact someone's body hair or vocal pitch.

Hormones & The Postpartum Period

When a trans-man carries a pregnancy, there are several issues to think through in terms of hormones and the postpartum period. Unfortunately, there’s not a lot of data on any of those issues.

Physical 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. This makes them wary of resuming testosterone too soon after childbirth.

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 Trans Men

Trans men have many avenues to have a child, ranging from unassisted conception (penetrative sex with a partner) to IUI to 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.

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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 with a partner is the most financially and logistically straightforward way to achieve a pregnancy.

IUI or Artificial Insemination

One of the lowest-level 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 IUI, a doctor or nurse 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 natural conception. The sperm can be from either a partner or a donor.

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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 is IUI success rates for people with no identified fertility issue (in this case, cisgender women who were either single or part of a lesbian couple). This is a useful analogy because many trans men 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.

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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.

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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.

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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.

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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).

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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.

This is the costliest of all the fertility treatments, because it involves not only IVF, but coordinating with a surrogacy agency 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. 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 (12 months of heterosexual intercourse without success) 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 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.

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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.

Transmasculine Fertility Preservation

For trans masculine individuals who were assigned female at birth, there are a few options in terms of methods to preserve fertility. We know it’s not always possible, but when it is, this is a conversation that’s best had with your healthcare provider before beginning hormones for the transition process.

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 - Preserving fertility can allow someone the choice to not de-transition at a later point when they want to start a family

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.

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