Trans women may still be able to produce sperm. But anyone who takes hormone therapy can experience a reduction in their fertility — or infertility — that could be either temporary or long-lasting. Let’s take a look at what the science says about whether transgender women can produce sperm, and the most recent expert advice about fertility preservation for trans women, trans femme people, and non-binary people with testes.
Key takeaways
- Many trans women take gender-affirming hormone therapy such as estrogen or testosterone blockers, which is likely to reduce or curtail their sperm production, affecting their fertility.
- For those who have not had “bottom surgery,” it may be possible to restart sperm production by pausing gender-affirming medication for 3–6 months or more. However, it’s not guaranteed that a trans woman will be able to recover fertility, and stopping hormone therapy can come with unwanted side effects.
- Experts encourage trans women to preserve their fertility by freezing their sperm (AKA sperm cryopreservation) before beginning hormone therapy.
First, a few definitions. A transgender woman is a person who was assigned male at birth, but whose gender identity is female. Trans women may take medication or undergo medical procedures, such as surgery, to change their physical appearance to align with their gender identity.
Transgender women often take gender-affirming hormone therapy, or GAHT (also called hormone replacement therapy or “HRT”). GAHT for trans women typically aims to do two things:
- Increase the body’s level of estrogen
- Lower levels of androgens, including testosterone (T)
This is known as “feminizing” hormone therapy. Estrogen and T-blockers can help trans women achieve a physical appearance that’s more in line with their gender identity, including changing body composition, reducing facial and body hair, and changing their voice.
Here, we’re also discussing transfemme and nonbinary people — anyone gender-diverse people who were assigned male at birth and take feminizing hormones or T-blockers.
Can transgender females produce sperm?
Most trans women taking GAHT will experience a decline in sperm production while taking estrogen or T-blockers. Some may find their sperm production stops completely. “Bottom surgery” — in which the penis and/or testicles are removed (orchiectomy and penectomy) and a vagina may be constructed (vaginoplasty) — also permanently curtails sperm production.
A 1992 study found that typical estrogen protocols are likely to impact sperm motility in as little as a few days, and sperm count in as little as 2 weeks.1 The same research also found that estrogen’s impact on sperm appears to be dose dependent. That means that the higher the dose you’re taking, the more likely you are to see an impact on your sperm production.
Trans women taking T-blockers are typically aiming for testosterone levels under 70 ng/dL. Research has found that testosterone levels under 264 ng/ml are associated with poorer semen parameters.2
More recent research has also found a similar impact. A 2018 paper found that, of 173 trans women undergoing bottom surgery, only 11% had normal sperm production at the time of surgery.3 A 2019 study of 28 trans women found that those on GAHT had, on average, very low sperm count and sperm motility.4 A 2021 paper found that, of 97 trans women in the study, 92% had suppressed testosterone levels, and zero participants were producing mature sperm.5
(Remember — hormone therapy isn’t birth control! There’s no guarantee your sperm count will drop significantly.)
Are transgender women infertile long-term?
The conventional medical view has been that taking gender-affirming medication could make a transgender person permanently infertile. And research from 1987 found that estrogen may cause atrophy of the seminiferous tubules, the structures in the testes that produce sperm — meaning there’s a possibility that sperm production could be permanently impacted after estrogen therapy.6
However, recent research has found that fertility restoration for transgender women may be possible, so long as they retain a penis and testicles. A 2023 study published in Cell Reports Medicine looked at 9 transgender women who stopped hormone replacement therapy (HRT) after taking it for an average of 36 months (3 years). Researchers found that 8 of the 9 were able to produce viable sperm samples within ten months of stopping therapy. Of those 8, 4 had normal semen parameters, while the remaining 4 had low sperm counts and/or motility.7
Another study from 2019 found that trans women who had previously used GAHT, but had paused therapy, had lower semen parameters than trans women who had never used GAHT, but higher than trans women currently on GAHT, indicating that their fertility was able to recover somewhat.4
| Trans women who had not yet started GAHT | Trans women who were on GAHT, but paused therapy | Trans women who were on GAHT when they gave their sample | |
| Sperm concentration Normal sperm count is at least 15 million sperm/mL of semen | 63.6 million/mL | 39 million/mL | 2.4 million/mL |
| Sperm motility Normal sperm motility is at least 40% | 51.5% | 34.3% | 15.6% |
| Semen volume Normal semen volume is at least 1.5mL | 2.7 mL | 2.1 mL | 0.9 mL |
| Total motile sperm count Normal TMSC is at least 20 million | 63.2 million | 39.1 million | 0.2 million |
Can a transgender woman get another woman pregnant?
It is possible that a trans woman with a cis female partner can create a pregnancy. In the aforementioned study, 4 participants tried to conceive naturally with their partners after stopping therapy, and 3 were able to do so.7 It took an average of 15 months to achieve pregnancy, during which these women had stopped gender-affirming hormone therapy.
However, this was also a very small study, and should not be taken as a scientific consensus. For those who do resume sperm production, sperm concentration or motility may be low and require assisted reproductive technology, like in vitro fertilization (IVF) or intrauterine insemination (IUI).
Another option for having a biological child as a trans woman is to use sperm frozen before medical transition. More on that below.
How long does it take for a trans woman to produce sperm again?
In the aforementioned study, semen analyses were performed after GAHT was paused.7 At 3–6 months post-therapy, a majority of women in the study were producing sperm, but only 1 in 4 had healthy sperm counts and motility. About 89% of women in the study were able to achieve sperm production within 10 months, with 44% achieving normal semen parameters.
Based on this limited data, we can estimate that most trans women will be able to produce sperm again within 1 year of pausing therapy. However, there is no guarantee that sperm production will resume within 1 year, if at all.
The mental-health effects of pausing hormone therapy can complicate the process. Trans women have to supplement with estrogen continuously to maintain the feminizing effects of the therapy. Pausing GAHT can result in some unwanted and dysphoric side effects, such as changes to body hair and composition.
A 2019 study looked at 2 transgender women who attempted to recover their fertility.8 One woman was able to produce viable sperm after stopping puberty-halting medication, while the other patient was unable to tolerate the psychological effects of pausing their gender-affirming medication and discontinued their attempt to produce sperm.
Therefore, the question should be not only can transgender women produce sperm if they pause hormones — but also what that interruption might mean for them, psychologically and socially.
What can trans women do to protect their fertility?
The World Professional Association for Transgender Health (WPATH) recommends that healthcare providers advise their patients that gender-affirming hormone therapy may reduce their fertility before a medication regimen is begun.9
That doesn’t always happen. According to The Sperm Report, a 2023 survey by Legacy and the fertility benefits provider Carrot, 71% of people taking gender-affirming hormone therapy weren’t aware of its potential effect on their fertility.
For those that do get this counseling, sperm freezing can be a simple way of preserving the option to have a genetic child in the future.
Sperm freezing for trans women
To keep major life options open, experts encourage people who are considering estrogen therapy to preserve their fertility by freezing their sperm (AKA sperm cryopreservation) before beginning gender-affirming medication. This preserves the healthiest reproductive material and can enable trans women to have a genetic child with a partner or surrogate if they so choose.
Learn more about sperm freezing for trans women.
References
3. Jindarak et al, “Spermatogenesis Abnormalities following Hormonal Therapy in Transwomen.” 2018.
4. Adeleye et al, “Semen Parameters Among Transgender Women With a History of Hormonal Treatment.” 2019.
9. Cheng et al. “Fertility concerns of the transgender patient,” 2019.
