Dr. Saber’s Blog
Fertility preservation counseling is an essential aspect of comprehensive health care for lgbtq+ individuals, including trans men, as gender-affirming treatments might impact their ability to have biological children in the future.
When trans men are considering things such as hormone therapy or gender-affirming surgery, fertility preservation counseling should be a part of that decision. Transgender individuals should be fully informed about how these treatments can affect their ability to have biological children in the future.
While fertility preservation counseling is becoming a standard practice in comprehensive health care for transgender patients, there is more to be done.
Future family building and fertility services are critical aspects of transition for transgender and gender non-conforming individuals mainly because things like hormonal therapy and surgery can make it challenging to have biological children later on.
Testosterone therapy, which trans men commonly use during the female-to-male (FTM) process, can suppress ovulation and cause changes in the ovaries. While some studies have found that some of the impacts of gender-affirming hormone therapy on fertility may be reversible once the treatment is stopped, there is still a risk of permanent infertility.
Alternatively, gender-transitioning surgeries typically result in permanent infertility. Many trans men undergo surgeries such as hysterectomy (removal of the uterus) or oophorectomy (removal of the ovaries). These treatments often lead to irreversible infertility. Therefore, it is crucial to consider fertility preservation options before these procedures.
Several FTM fertility preservation options are available, each with benefits, challenges, and considerations. Choosing which to pursue depends on various factors, including age, health, and family planning goals.
Oocyte cryopreservation, known as egg freezing, has become established in assisted reproductive technology (ART). It involves stimulating the ovaries with hormones to produce multiple eggs, which are then retrieved and frozen for future use.
Ovarian stimulation and egg retrieval allow transmasculine individuals to preserve their eggs before starting testosterone therapy or undergoing surgery. This way, the frozen eggs can later be used for in vitro fertilization (IVF) or with a gestational carrier, offering the possibility of biological children.
Embryo cryopreservation involves fertilizing retrieved eggs with sperm (from a partner or donor) to create embryos. They are then frozen for future implantation with a partner or through surrogacy.
This fertility treatment has a higher success rate than egg freezing, as embryos are more likely to survive the thawing process and result in successful pregnancies and live births. But like egg freezing, it must also be completed before testosterone treatment or other interventions.
Ovarian tissue cryopreservation is an emerging reproductive technology where a portion of the ovarian tissue is surgically removed and frozen. This tissue can potentially be reimplanted in the future to restore fertility or used to mature eggs in the laboratory.
Ovarian tissue cryopreservation is particularly useful for trans men who wish to begin testosterone use before reproductive maturation and the start of their menstrual cycles. Unlike egg or embryo freezing, there is no need for hormonal therapy to stimulate the ovaries.
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While fertility preservation that makes future family building possible offers valuable options for transgender men, it is vital to acknowledge the challenges and considerations involved in this process.
Fertility preservation can be emotionally challenging for a few reasons. Both egg and embryo cryopreservation involve hormone stimulation, which can cause emotional distress and temporary discomfort.
Additionally, in the case of embryo cryopreservation, the decision to create embryos involves considering legal and ethical implications, especially regarding the use of donor sperm. Ovarian tissue cryopreservation is still regarded as experimental, and the success rates are not yet well established, which can also result in conflicting emotions.
All of the fertility preservation options naturally come with a focus on reproductive organs, which can exacerbate gender dysphoria for some trans men. Trans men may experience conflict between the desire to preserve fertility and the urgency to begin hormone treatment or undergo surgery. Fertility preservation counseling and mental health support can provide a space to explore these feelings, prioritize personal goals, and make informed decisions.
The costs associated with fertility preservation can be significant. Unfortunately, insurance coverage usually does not apply to these procedures, leading to financial strain for some individuals.
Finding healthcare providers who are knowledgeable about transgender health, gender identity, and fertility preservation can also be challenging. Trans men may need to travel to access these services, which can add to the emotional and financial burden.
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Dr. Speideh Saber is a renowned plastic surgeon based in Los Angeles. She specializes in gender-affirming surgeries and cosmetic procedures. She believes in empowering her patients through knowledge, empathy, and expert care.
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Because testosterone suppresses egg maturation, transgender men taking testosterone will need to stop hormone therapy and begin menstrual cycles before the egg-freezing process.
Transgender men are unable to produce sperm, but there may still be ways to achieve gender-affirming goals, such as ejaculation or natural family building.
While hormone therapy usually makes an individual infertile, studies have shown that breakthrough ovulation is still possible while on testosterone. Because individuals on HRT can still become pregnant, contraception should be considered.
Sources:
Katrien Wierckx, Eva Van Caenegem, Guido Pennings, Els Elaut, David Dedecker, Fleur Van de Peer, Steven Weyers, Petra De Sutter, Guy T’Sjoen, Reproductive wish in transsexual men, Human Reproduction, Volume 27, Issue 2, 1 February 2012, Pages 483–487, https://doi.org/10.1093/humrep/der406
Wallace, S. A., Blough, K. L., & Kondapalli, L. A. (2014). Fertility preservation in the transgender patient: expanding oncofertility care beyond cancer. Gynecological Endocrinology, 30(12), 868–871. https://doi.org/10.3109/09513590.2014.920005
Warton C, McDougall RJ. Fertility preservation for transgender children and young people in pediatric healthcare: a systematic review of ethical considerations. J Med Ethics. 2022 Dec;48(12):1076-1082. doi: 10.1136/medethics-2021-107702. Epub 2022 Jan 3. PMID: 34980674; PMCID: PMC9726968.
von Vaupel-Klein AM, Walsh RJ. Considerations in genetic counseling of transgender patients: Cultural competencies and altered disease risk profiles. J Genet Couns. 2021 Feb;30(1):98-109. doi: 10.1002/jgc4.1372. Epub 2020 Dec 26. PMID: 33368789; PMCID: PMC7898523.
X, S. & Rutgers University. (2022, September 6). Fertility preservation counseling needed for transgender men. Medical Xpress.https://medicalxpress.com/news/2022-09-fertility-transgender-men.html