For those whose gender identity doesn’t align with their biological sex, proactive fertility considerations are especially important. Gender-affirming hormone therapy and other aspects of gender transition can have a significant impact on a person’s ability to produce healthy sperm and create a pregnancy later in life. Read on to understand more about fertility and sperm freezing for trans women.
While we’ll be using the phrases “trans women” and “transgender women” here, this guide applies to any sperm-producing person considering gender transition, regardless of identity.
Photos courtesy of The Gender Spectrum Collection.
The process of gender transition may affect fertility in several different ways.
Testosterone is essential to the production of sperm; it plays a role in initiating several key processes in spermatogenesis, including the division and maturation of sperm cells. The goal of hormone therapy for transgender women is to decrease testosterone and increase estrogen levels to create a more typically feminine appearance. Estrogen therapy helps decrease testosterone levels in the body. Many trans women also use anti-androgens to further decrease their testosterone to typical female levels (around 70 ng/ml).
Testosterone levels under 264 ng/ml are associated with poorer semen parameters. And, as we would expect, use of estrogen and androgen-blockers is associated in research with poor sperm quality and lower sperm count. A 2017 review looked at nearly 40 years of research on the impact of cross-sex hormones on the sperm quality and testicular function of trans women. The review found that, in the majority of cases, estrogen and/or anti-androgen treatment caused reduced or halted spermatogenesis, as well as physical changes to the testicles.
How long does it take for hormone replacement therapy (HRT) to impair fertility? The effect seems to be dose-dependent. In one study, a low-dose estrogen therapy had no impact on sperm concentration or motility, while a higher-dose regimen resulted in reduced sperm motility after just a few days and reduced sperm concentration after 2 weeks.
Is infertility caused by gender-affirming hormones reversible? In some cases, it appears to be. One study suggested that, within 6 months of stopping estrogen therapy, 67% of subjects recovered a normal sperm count. However, the impact of medical gender transition on fertility, as well as the capacity for spermatogenesis to recover if estrogen treatment is paused, seem to be variable and individual. Case studies demonstrate that, while some patients continued spermatogenesis through gender-affirming hormone treatment, others stopped producing sperm altogether, and several experienced azoospermia for 4–5 months after pausing therapy.
Sperm is produced in the testicles, and gender-affirming bottom surgery for trans women involves the removal of the testicles. Therefore, while most people who opt for bottom surgery retain sexual function, it’s not possible to recover sperm production or “natural” fertility after bottom surgery. That’s why many trans women freeze sperm before surgical transition or have a testicular sperm extraction (TESE) at the time of bottom surgery.
The primary fertility preservation option for assigned-male-at-birth trans people is sperm freezing or cryopreservation. Sperm freezing is the process of freezing one or more semen “samples,” or ejaculations, for potential use to attempt to conceive later on.
The process of sperm freezing is as follows: A person will produce a semen sample via masturbation. That sample is then brought into a lab, processed, and analyzed to determine that it’s healthy enough for freezing. If it is, it’s plunged into liquid nitrogen to quickly bring it to a temperature of -196ºC, at which point all biological processes stop. Then it can stay cryogenically stored indefinitely.
Learn more about sperm freezing.
In the past, the process of sperm freezing required you to visit a fertility clinic or sperm bank to produce a semen sample in a “collection room” on-site. This can be an uncomfortable experience for many people, including trans women. Legacy offers an at-home sperm analysis and freezing kit that allows you to mail your sample to our labs for clinic-grade analysis and cryogenic storage.
Estrogen and anti-androgen medications may significantly impair sperm production. Cryopreserving sperm prior to beginning medical transition will typically offer the best results. Trans women and girls can freeze sperm as soon as they hit puberty and are able to produce a semen sample.
However, if you started HRT without preserving your fertility, you still have options. It may be a good idea to start with a semen analysis, to determine whether your hormone protocol has impacted your fertility. If it has, you can take a 3–5 months off of gender-affirming hormone therapy to allow spermatogenesis to resume and sperm quality to improve.
Most of the changes to a trans woman’s physical appearance that happen as a result of hormone therapy are not permanent, and stopping cross-sex hormones will lead to reversal. Therefore, taking a pause in feminizing hormones can trigger a trans person’s gender dysphoria and be difficult physically, socially, and emotionally. It may be helpful to work with the support of a gender-affirming counselor or therapist throughout this process.
According to LIVESTRONG, the average cost of sperm freezing is $1,000, plus $300–$500 per year for ongoing cryogenic storage. In some states, and under some insurance plans, this may be covered for trans women; for many people, though, it’s an out-of-pocket cost.
Part of Legacy’s mission is to increase the accessibility of fertility care. We offer a few different packages — an analysis package and two options for sperm freezing — that start at $195, with storage that’s less than $200 per year. See Legacy packages.
Options for those who have a penis and testicles and haven’t frozen their sperm:
First, you can do a semen analysis to determine how significantly your hormone therapy has affected your fertility.
If the semen analysis determines you are still producing some healthy sperm, you can attempt to conceive with your partner naturally (via sexual intercourse). Alternatively, you could do an IUI if you want to increase the chances of pregnancy or are not comfortable with penis-in-vagina sex.
If your semen analysis determines you’re not producing healthy sperm, you may be able to recover fertility by stopping hormone therapy for 3–5 months. You could also try IVF with ICSI, which requires only a single healthy sperm and can help achieve pregnancy even when sperm are very few, or motility/morphology is poor.
Options for trans women who have frozen their sperm:
If you have frozen sperm available, you can attempt pregnancy with your partner without stopping your hormone therapy. Frozen sperm can be used in IUI, IVF, or IVF with ICSI, depending on the quantity and quality of the sample once thawed.
Surrogacy (gestational or traditional) is an option for you. You can attempt to use a “fresh” semen sample from yourself or your partner— again, you will want to do a semen analysis first to determine if you are producing healthy sperm. Or, if you have frozen your sperm first, you can use it in IUI, IVF, or IVF with ICSI to create a pregnancy with your surrogate’s egg or an egg donor.
Considering fertility preservation as a trans person can be an emotional process. It can be difficult to think about all of the options you may want to have in the future, especially if you are starting your transition in your teens or early 20s, when family-building is often not top of mind. It’s also expensive to preserve fertility, and to access fertility care such as IUI or IVF later on.
It may be helpful to seek guidance and support throughout the fertility preservation or treatment process from a trans-affirming therapist or organization.
Euphoria offers a suite of digital apps specifically designed for trans people. Apps include Solace, which gives virtual guidance and information for every step of transition; Bliss, a money management app for those saving for medical transition; and Catharsis, a mental health support platform for the trans community, by the trans community.
Gay Parents to Be is an informational resource for LGBTQ family-building and parenting, including trans parents. This organization offers guidance for those considering fertility preservation pre-transition or hoping to start a family, including mental health support and financial guidance, such as a list of fertility grants and assistance in understanding insurance coverage.
A digital healthcare platform for trans people who want to access hormone replacement therapy and other medications, Folx Health also offers invaluable resources and guidance to patients.