Fertility care and family planning for transgender and gender-diverse people

Starting a family is something we often don't think about until we're really ready. And even though contemplating the options can be stressful, particularly for transgender and gender-diverse people, a little advance planning can go a long way.

It’s important to remember that everyone—regardless of gender identity or expression—deserves access to the same information, resources, and care for family planning and fertility preservation. Here’s what to know about your fertility options, based on your anatomy, gender-affirming hormone use, and surgical history.

How gender-affirming hormone therapy plays a role in fertility

If you haven't started on gender-affirming hormone therapy (GAHT) but are talking about it with your healthcare provider (HCP), you may want to discuss your fertility options, too. Generally speaking, the best time to think about family planning is before starting on GAHT, even if you don’t have current or immediate plans to start a family. (GAHT is sometimes also referred to as hormone replacement therapy, or HRT.)

"It's important to think about: Do you want to have biological children at some point? Would you want to carry a pregnancy?" says Halley Crissman, MD, MPH, an adjunct clinical assistant professor of obstetrics and gynecology at Michigan Medicine specializing in transgender health and gender-affirming care and director of gender-affirming care at Planned Parenthood of Michigan.

Keep in mind that your HCP may not be the one to bring this up and that you may have to be your own advocate.

"Sometimes providers make assumptions that when a patient is coming to them for gender-affirming care that they are sort of rejecting their natal biological capacity," says Dr. Crissman—meaning they are deciding not to have children of their own. "We know that is definitely not always the case,” she says. Many gender-diverse people are interested in making biological contributions to a pregnancy.

The type of hormone therapy you're on or considering taking may have an impact on your family planning options for the future.

Masculinizing hormone therapy is not thought to negatively affect fertility

"We think testosterone probably does not have a long-term negative effect on the uterus or the ovaries," says Crissman. "At the same time, we also know that testosterone is not contraception and that it can affect a developing pregnancy, so if someone is having sex with pregnancy potential while taking testosterone, they are advised to use contraception."

If you've been on GAHT for some time and decide you want to have a child, stopping testosterone therapy for a few months is likely to bring on the menstrual cycle and ovulation. This can allow you to have a pregnancy either with a partner's sperm or donor sperm. Just be sure to have a conversation with your HCP before making any changes to your GAHT, including pausing treatment.

Another option before starting GAHT or while on a break from GAHT is to go through the process of oocyte (or egg) harvesting.

"Essentially, a patient will take high-dose hormones to induce a large number of eggs that can then be harvested either for combination with sperm and implantation of an embryo in that individual or in another partner," explains Crissman.

Feminizing hormone therapy may have negative effects on sperm

"From the limited data we have for people pursuing feminizing hormones, we think that there is a potential long-term negative impact of feminizing hormones on sperm," says Crissman. "For that reason, when somebody thinks about starting gender-affirming hormones from a feminizing perspective, it is important for them to consider whether they want to contribute biological material to a future pregnancy, how important that is to them, and whether sperm banking is desired and/or feasible.”

If you didn't bank (or store) sperm before starting GAHT and later decide you want to provide biological material for a pregnancy, it's still possible to pause hormone therapy for a while and try to get pregnant with a partner that way. While medical intervention isn't necessarily required for this, it’s worth consulting with your HCP to determine the viability of your sperm.

"If you're trying to minimize the amount of time spent off hormones, then you might talk to a provider who may suggest something like doing an analysis of your semen after three months off hormones,” says Crissman. “The goal is to see where things are in terms of function and sperm motility and sperm counts, to set expectations or see if there's anything else we can optimize."

Meanwhile, remember that it is still possible to contribute to a pregnancy while on feminizing hormone therapy, so you should use contraception if you're having sex with pregnancy potential and don’t wish to start a family.

Considerations around gender-affirming surgery

When talking to your HCP about gender-affirming surgery, you should discuss any desire you might have to carry a pregnancy or contribute biological material to one in the future. This conversation doesn’t always happen, however, either because patients or HCPs don’t bring it up.

You may simply not be in this mindset at the time, or you may feel uncomfortable raising the topic in certain medical settings for fear of being denied surgery. "People often worry that they sort of have to stick to that script of rejecting their natal biological reproductive capacity" in order to proceed with gender-affirming procedures, says Crissman.

Given your comfort level and where you are in your process of gender affirmation, thinking about your future fertility options is a good idea. For example, having a hysterectomy would preclude you from carrying a pregnancy, while having an orchiectomy to remove the testicles would prevent you from producing sperm for a pregnancy.

Top surgery (to either augment or remove breast tissue) is another procedure that many people don’t always consider, notes Crissman.

"If a transmasculine person who has had or is planning to have top surgery chooses to carry a pregnancy or is thinking about carrying a pregnancy in the future, that's something they'd ideally discuss with their top surgeon,” she says. “They’ll want to talk about how this will impact chest feeding if that's something they would want to do, without making any assumptions. It’s also important to know that remnant chest tissue can develop further during pregnancy and the postpartum period."

The development of breast tissue may lead to feelings of dysphoria in certain people. (Gender dysphoria refers to the distress someone might experience when they feel their gender identity doesn’t align with their physical or physiological characteristics.)

Seeking affirming, empathetic care can make the process easier

There are many factors that can make family planning a complicated process for transgender and gender-diverse people. These include inadequate insurance coverage, a lack of access to culturally competent providers, and the ways in which undergoing fertility and pregnancy care as a transmasculine person can contribute to dysphoria.

It's important to remember that medical intervention is not always necessary to start a family, depending on your circumstances.

"If we're talking about a transmasculine person who has a uterus, ovaries, and menses that come back within a few months after stopping their testosterone, and has a partner who makes sperm, they can just go about trying to get pregnant," says Crissman. That said, if you would like to optimize your time off hormones or if you'll need to use donor sperm, you'll want to find a knowledgeable and experienced reproductive health specialist who can help with that.

For transfeminine people, you'll likely be seeking out medical options, whether that includes sperm banking, semen analysis after stopping feminizing hormone therapy, and/or assisted reproductive technologies to use your own biological material for a pregnancy.

"This is one of those situations where the local trans and nonbinary or LGBTQIA+ community and their recommendations may play a big role in helping people navigate the healthcare system," says Crissman. She also suggests word of mouth for finding inclusive, empathetic, and competent providers in your area.

Local Planned Parenthood clinics may also be a good place to find affirming care; call to check what services are available before you visit. You can also search the online directories from TransPulse, OutCare, GLMA, or Included Health for options.

Finally, consider seeking out mental health and social support as you go through this process.

"All people are different," says Crissman. While pausing hormone therapy is unlikely to change things like your appearance or your voice, the experience of ovulating, getting your period, and undergoing invasive tests can lead to feelings of dysphoria for some transmasculine people.

To find a mental health provider in your area, ask your HCP for a referral or try online databases such as those from WPATH, GLMA, and Psychology Today, or teletherapy options like Better Help.

"I think having a medical provider—and/or a mental health provider, if that's right for you—as well as social support through that process can be really important," says Crissman.