Fertility preservation for transgender men and women

Transgender Awareness Week sheds light on issues faced by the transgender community. This year, it takes place between 13^th – 19^th November before the Transgender Day of Remembrance on Saturday 20^th November.

When it comes to fertility, transgender people face a very complex and often painful situation. Gender-affirming treatment can ease the distress of living in a body that doesn’t express your identity, and can be lifesaving. However, many of these treatments involve medical or surgical intervention, which change the reproductive system and can cause permanent infertility.

This means that without preserving fertility prior to gender-affirming treatment, it might not be possible for you to have a biological family.

At IVI, we offer transgender men and women the option to preserve their fertility. Every person, regardless of gender, should be able to build a family and we are proud to help further and promote the basic reproductive rights that all transgender people deserve.

What happens to fertility during gender reassignment?

The biological reproductive system changes during medical treatment for gender dysphoria. This medical treatment might involve:

• Hormone replacement therapy (HRT), such as feminising hormone therapy or masculinising hormone therapy
• Sex reassignment surgery (SRS) or gender reassignment surgery (GRS)

During feminising hormone therapy, the female hormone oestrogen is taken (usually as a tablet, patch or gel) as well as medication which blocks the effects of testosterone (known as testosterone blockers). This creates physical changes in the body, triggered by female hormones. These physical changes include the appearance of conventionally defined female secondary sex characteristics, such as a lack of body hair, breasts, a change in the composition of body fat and rounder hips.

The effects of oestrogen therapy also take place inside the body, within the reproductive system. The suppression of gonadotropin, which helps to reduce testosterone, affects the ability to produce sperm (spermatogenesis). Although normal spermatogenesis has been restored in a small number of cases after ceasing oestrogen therapy, there is no way this can be guaranteed. There is a chance of permanent infertility, which should be considered before commencing treatment.

During masculinising hormone therapy, testosterone is given by an injection or a patch or gel that is applied to the skin. Testosterone produces the prominence of conventionally defined male secondary sex characteristics, such as oilier skin, deepening of voice and facial hair growth. If you menstruate, this will stop within two to six months after beginning masculinising hormone therapy.

There are also changes which take place inside the reproductive system as a result of testosterone therapy. Testosterone suppresses ovulation. It induces amenorrhea (cessation of periods) and reduces the ovarian and uterine function. Although the long-term effects of testosterone therapy on fertility are not fully understood, it could make it more difficult for you to get pregnant.

Both feminising hormone therapy and masculinising hormone therapy are normally long-term treatments. You will need to take medication for the rest of your life. This is due in part to the side effects of stopping hormone therapy, especially after years of use. This can be psychologically devastating for many transgender men and women. The physiological changes they have already achieved can revert, and trigger the dysphoria to return. Your gender dysphoria clinic can provide all the information you need about hormone therapy, what it involves and its implications.

It is also important to remember that even that if you decide to have sex reassignment surgery, you will still need to continue using hormone therapy.

Sex reassignment surgery, or gender reassignment surgery, is the physical alteration of the genitals through genital reconstructive surgery. There are different types of procedures, ranging from cosmetic to functional, depending on the desired outcome of the patient. This also means the impact on fertility varies depending on the procedure. If you choose to undergo an orchidectomy (removal of one or both testicles) or a hysterectomy (removal of the uterus), these are major surgeries which cause permanent infertility. You will not be able to conceive naturally after these operations.

It is recommended that you think about preserving your fertility before undergoing any medical treatment for gender dysphoria. If you have already begun gender-affirming treatment, it might still be possible to preserve your fertility. Your consultant can talk through your options depending on your situation.

Male-to-female fertility preservation

Before male-to-female gender reassignment, fertility can be preserved by freezing sperm (cryopreservation).

Some transwomen find the process of masturbation uncomfortable, foreign or sometimes impossible. In these cases, semen can be extracted from the body using a simple surgical semen retrieval (SSR) procedure. By freezing these genetic materials, you have the option of undergoing fertility treatments, such as IVF, with a partner’s eggs or eggs from a donor.

You can also freeze embryos which have been fertilised using your sperm. This would require an egg from a partner or a donor.

In both cases, you should consider that you might need to use a surrogate if you plan on having fertility treatment later in life.

The medical field of uterus transplantation is relatively new, but it is progressing rapidly. Since the first successful birth after uterus transplantation in 2014, there have been many successful procedures and live births reported. Despite the fact that there has not yet been a uterus transplantation performed in a transgender woman, this could a fertility treatment from which the transgender community could benefit in the future.

Female-to-male fertility preservation

Before female-to-male gender reassignment, fertility can be preserved by freezing eggs (oocytes) or embryos.

In order to freeze eggs, you will need to undergo ovulation induction and an egg retrieval procedure. This requires taking synthetic hormones for 1 – 2 weeks to stimulate your ovaries to produce multiple eggs. The mature eggs are then collected using a small needle. This is called an egg retrieval procedure. The procedure should not last longer than 20 minutes. It is carried out under sedation. Any pain medication you need will be provided. After the procedure, it is normal to feel cramping but there are no serious side effects.

Your collected eggs are frozen and stored for later use. Their quality, on the day of freezing, will be retained. They will not deteriorate over time. By freezing eggs, you have the option of undergoing fertility treatments, such as IVF, with a partner’s sperm or sperm from a donor in the future.

You also have the option of freezing embryos. The same egg retrieval procedure is carried out; however, the eggs are then inseminated using in vitro fertilisation (IVF) or an intracytoplasmic sperm injection (ICSI) and cultivated to develop into embryos. The embryos will then be frozen and ready for transfer in the future. This procedure would require sperm from a partner or a donor.

Similarly, if you plan to have fertility treatment in the future, you should consider that you might need to use a surrogate if you or your partner cannot gestate.

Support for transgender people

If you or a friend or family member ever needs help, there are many local and national organisations where you can access free resources, information and emotional support.

• Mermaids: Mermaids is a leading UK charity and support group for gender variant youth, and their families.
• Stonewall: Stonewall is a UK LGBT+ rights charity and lobbying organisation which protects the rights of transgender people.
• Galop: Galop is a UK LGBT+ anti-violence and abuse charity, providing support for people who have experienced transphobia or have been victims of targeted violence.
• Mindline Trans+: Mindline Trans+ is a free helpline for trans, non-binary and genderfluid individuals, providing emotional support and signposting helpful information.
• The Angels: The Angels UK is an online forum and support group, designed to promote the positive side of being transgender.
• Find an NHS gender dysphoria clinic: Find your closest GDC and the kind of support offered at these facilities.

If you are thinking about preserving your fertility, you will need to take some basic fertility tests beforehand. We can guide through every step of this process. Get in touch with our London clinic to book a consultation with one of our fertility preservation specialists.