Skip to main content

Advertisement

SpringerLink
Log in

Fertility Preservation for the Transgender Individual

  • Care for the Transgender Patients (C Ferrando, Section Editor)
  • Published:
Current Obstetrics and Gynecology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This review aims to update readers on recent evidence in order to counsel and guide clinical management of individuals with gender dysphoria seeking fertility preservation (FP).

Recent Findings

Relevant topics include a discussion of the consistent desire for children in transgender people despite a low utilization rate of FP services, animal models, and human histology depicting the effect of gender-affirming treatment (GAT) on the gonads, varied time for resumption of menses, and start of ovarian stimulation upon discontinuing testosterone (T) in transmen, feasible clinical and experimental options for FP in transgender males and females, worsening dysphoria, and recommended methods to mitigate symptoms, and lastly a short discussion of changes in legislation providing increased insurance coverage of medically indicated FP for transpatients.

Summary

FP is an important option for transgender patients who desire to retain the ability to become genetic parents. While controlled ovarian stimulation for oocyte or embryo cryopreservation is the standard-of-care for transmen, unique considerations must be made in this population. Recent literature has highlighted the ability of transmen to have viable oocytes and pregnancies despite a history of T use, suggesting that the window of genetic parentage does not close with the start of GAT. FP for transwomen requires ejaculation or extraction with sperm cryopreservation; options for prepubertal transwomen are only in nascent phases. Research is rapidly evolving though many questions remain unanswered. The harmonization of advances in assisted reproduction with legislation advocating for transgender rights will continue to reach new peaks in the coming years.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Diagnostic & Statistical Manual of Mental Disorders. In Arlington, VA: American Psychiatric Publishing; 2013.

  2. Report of the Task Force on Gender Identity and Gender Variance. In: APA Task Force on Gender Identity and Gender Variance [Internet]. Washington DC; 2008 [cited 2020 Apr 17]. Available from: http://www.apa.org/pi/lgbt/resources/policy/gender-identity-report.pdf

  3. Wiepjes CM, Nota NM, de Blok CJM, Klaver M, de Vries ALC, Wensing-Kruger SA, et al. The Amsterdam cohort of gender dysphoria study (1972–2015): trends in prevalence, treatment, and regrets. J Sex Med. 2018 Apr;15(4):582–90.

    PubMed  Google Scholar 

  4. Zucker KJ. Epidemiology of gender dysphoria and transgender identity. Sex Health. 2017;14(5):404.

    PubMed  Google Scholar 

  5. Fielding J, Bass C. Individuals seeking gender reassignment: marked increase in demand for services. BJPsych Bull. 2018 Oct;42(5):206–10.

    PubMed  PubMed Central  Google Scholar 

  6. Access to fertility services by transgender persons: an Ethics Committee opinion. Fertil Steril. 2015 Nov;104(5):1111–5.

  7. Condat A, Mendes N, Drouineaud V, Gründler N, Lagrange C, Chiland C, et al. Biotechnologies that empower transgender persons to self-actualize as individuals, partners, spouses, and parents are defining new ways to conceive a child: psychological considerations and ethical issues. Philos Ethics Humanit Med. 2018;13(1):1.

    PubMed  PubMed Central  Google Scholar 

  8. Mattawanon N, Spencer JB, Schirmer DA, Tangpricha V. Fertility preservation options in transgender people: a review. Rev Endocr Metab Disord. 2018;19(3):231–42.

    PubMed  Google Scholar 

  9. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 2012;13(4):165–232.

    Google Scholar 

  10. Moravek MB, Kinnear HM, George J, Batchelor J, Shikanov A, Padmanabhan V, et al. Impact of exogenous testosterone on reproduction in transgender men. Endocrinology. 2020;161(3):bqaa014.

    PubMed  Google Scholar 

  11. Neblett MF, Hipp HS. Fertility considerations in transgender persons. Endocrinol Metab Clin N Am. 2019;48(2):391–402.

    Google Scholar 

  12. Wierckx K, Van Caenegem E, Pennings G, Elaut E, Dedecker D, Van de Peer F, et al. Reproductive wish in transsexual men. Hum Reprod. 2012;27(2):483–7.

    PubMed  Google Scholar 

  13. • Auer MK, Fuss J, Nieder TO, Briken P, Biedermann SV, Stalla GK, et al. Desire to have children among transgender people in Germany: a cross-sectional multi-center study. J Sex Med. 2018;15(5):757–67 Multicenter study evaluating both transmen and women before and after start of GAT and their respective desires to have children.

    PubMed  Google Scholar 

  14. De Sutter P, Kira K, Verschoor A, Hotimsky A. The desire to have children and the preservation of fertility in transsexual women: a survey. Int J of Transgenderism [Internet]. 2002;6(3) Available from: http://www.symposion.com/ijt/ijtvo06no03_02.htm.

  15. Jones CA, Reiter L, Greenblatt E. Fertility preservation in transgender patients. Int J Transgenderism. 2016;17(2):76–82.

    CAS  Google Scholar 

  16. Wakefield BW, Boguszewski K, Cheney D, Taylor J. Trends in fertility preservation for transgender adolescents and young adults at an academic referral center. J Adolesc Health. 2018;62(2):S41.

    Google Scholar 

  17. Chen D, Simons L, Johnson EK, Lockart BA, Finlayson C. Fertility preservation for transgender adolescents. J Adolesc Health. 2017;61(1):120–3.

    PubMed  PubMed Central  Google Scholar 

  18. Nahata L, Tishelman AC, Caltabellotta NM, Quinn GP. Low fertility preservation utilization among transgender youth. J Adolesc Health. 2017;61(1):40–4.

    PubMed  Google Scholar 

  19. Chen B, Zhang Z, Sun X, Kuang Y, Mao X, Wang X, et al. Biallelic mutations in PATL2 cause female infertility characterized by oocyte maturation arrest. Am J Hum Genet. 2017;101(4):609–15.

    CAS  PubMed  PubMed Central  Google Scholar 

  20. Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869–903.

    PubMed  Google Scholar 

  21. Moravek MB. Fertility preservation options for transgender and gender-nonconforming individuals. Curr Opin Obstet Gynecol. 2019;31(3):170–6.

    PubMed  Google Scholar 

  22. De Roo C, Tilleman K, T’Sjoen G, De Sutter P. Fertility options in transgender people. Int Rev Psychiatry. 2016;28(1):112–9.

    PubMed  Google Scholar 

  23. Padmanabhan V, Veiga-Lopez A. Animal models of the polycystic ovary syndrome phenotype. Steroids. 2013;78(8):734–40.

    CAS  PubMed  PubMed Central  Google Scholar 

  24. Shi D, Vine DF, et al. Fertil Steril. 2012;98(1):185–193.e2.

    PubMed  Google Scholar 

  25. •• Kinnear HM, Constance ES, David A, Marsh EE, Padmanabhan V, Shikanov A, et al. A mouse model to investigate the impact of testosterone therapy on reproduction in transgender men. Hum Reprod. 2019;34(10):2009–17 Study evaluating effect of postpubertal T exposure on mice models to replicate GAT and fertility in transmale patients.

    CAS  PubMed  Google Scholar 

  26. Ikeda K, Baba T, Noguchi H, Nagasawa K, Endo T, Kiya T, et al. Excessive androgen exposure in female-to-male transsexual persons of reproductive age induces hyperplasia of the ovarian cortex and stroma but not polycystic ovary morphology. Hum Reprod. 2013;28(2):453–61.

    CAS  PubMed  Google Scholar 

  27. Futterweit W, Deligdisch L. Histopathological effects of exogenously administered testosterone in 19 female to male transsexuals. J Clin Endocrinol Metab. 1986;62(1):16–21.

    CAS  PubMed  Google Scholar 

  28. Chadha S, Pache TD, Huikeshoven FJM, Brinkmann AO, Van der Kwast TH. Androgen receptor expression in human ovarian and uterine tissue of long term androgen-treated transsexual women. Hum Pathol. 1994;25(11):1198–204.

    CAS  PubMed  Google Scholar 

  29. Grynberg M, Fanchin R, Dubost G, Colau J-C, Brémont-Weil C, Frydman R, et al. Histology of genital tract and breast tissue after long-term testosterone administration in a female-to-male transsexual population. Reprod BioMed Online. 2010;20(4):553–8.

    CAS  PubMed  Google Scholar 

  30. Nakamura A, Watanabe M, Sugimoto M, Sako T, Mahmood S, Kaku H, et al. Dose-response analysis of testosterone replacement therapy in patients with female to male gender identity disorder. Endocr J. 2013;60(3):275–81.

    CAS  PubMed  Google Scholar 

  31. Steinle K. Hormonal management of the female-to-male transgender patient. J Midwifery Womens Health. 2011;56(3):293–302.

    PubMed  Google Scholar 

  32. T’Sjoen G, Van Caenegem E, Wierckx K. Transgenderism and Reproduction. Curr Opin Endocrinol Diabetes Obes. 2013;20(6):575–9.

    PubMed  Google Scholar 

  33. • Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120–7 Study detailing the effect of T exposure on pregnancy outcomes in transmales.

    CAS  PubMed  Google Scholar 

  34. Obedin-Maliver J, Makadon HJ. Transgender men and pregnancy. Obstet Med. 2016;9(1):4–8.

    PubMed  Google Scholar 

  35. Light A, Wang L-F, Zeymo A, Gomez-Lobo V. Family planning and contraception use in transgender men. Contraception. 2018;98(4):266–9.

    PubMed  Google Scholar 

  36. Matoso A, Khandakar B, Yuan S, Wu T, Wang LJ, Lombardo KA, et al. Spectrum of findings in orchiectomy specimens of persons undergoing gender confirmation surgery. Hum Pathol. 2018 Jun;76:91–9.

    PubMed  Google Scholar 

  37. Schneider F, Kliesch S, Schlatt S, Neuhaus N. Andrology of male-to-female transsexuals: influence of cross-sex hormone therapy on testicular function. Andrology. 2017;5(5):873–80.

    CAS  PubMed  Google Scholar 

  38. Hamada A, Kingsberg S, Wierckx K, T’Sjoen G, De Sutter P, Knudson G, et al. Semen characteristics of transwomen referred for sperm banking before sex transition: a case series. Andrologia. 2015;47(7):832–8.

    CAS  PubMed  Google Scholar 

  39. Adeleye AJ, Reid G, Kao C-N, Mok-Lin E, Smith JF. Semen parameters among transgender women with a history of hormonal treatment. Urology. 2019 Feb;124:136–41.

    PubMed  Google Scholar 

  40. Cooper TG, Noonan E, von Eckardstein S, Auger J, Baker HWG, Behre HM, et al. World Health Organization reference values for human semen characteristics*‡. Hum Reprod Update. 2010 Jan 1;16(3):231–45.

    PubMed  Google Scholar 

  41. Kim S-Y, Kim SK, Lee JR, Woodruff TK. Toward precision medicine for preserving fertility in cancer patients: existing and emerging fertility preservation options for women. J Gynecol Oncol. 2016;27(2):e22.

    PubMed  Google Scholar 

  42. Daar J, Benward J, Collins L, Davis J, Davis O, Francis L, et al. Planned oocyte cryopreservation for women seeking to preserve future reproductive potential: an Ethics Committee opinion. Fertil Steril. 2018;110(6):1022–8.

    Google Scholar 

  43. De Sutter P. Gender reassignment and assisted reproduction. Hum Reprod. 2001;16(4):612–4.

    PubMed  Google Scholar 

  44. Wallace SA, Blough KL, Kondapalli LA. Fertility preservation in the transgender patient: expanding oncofertility care beyond cancer. Gynecol Endocrinol. 2014;30(12):868–71.

    PubMed  Google Scholar 

  45. Maxwell S, Noyes N, Keefe D, Berkeley AS, Goldman KN, et al. Obstet Gynecol. 2017;129(6):1031–4.

    PubMed  Google Scholar 

  46. Chen D, Bernardi LA, Pavone ME, Feinberg EC, Moravek MB. Oocyte cryopreservation among transmasculine youth: a case series. J Assist Reprod Genet. 2018;35(11):2057–61.

    PubMed  PubMed Central  Google Scholar 

  47. Armuand G, Dhejne C, Olofsson JI, Rodriguez-Wallberg KA. Transgender men’s experiences of fertility preservation: a qualitative study. Hum Reprod. 2017 Feb;32(2):383–90.

    CAS  PubMed  Google Scholar 

  48. •• Adeleye AJ, Cedars MI, Smith J, Mok-Lin E. Ovarian stimulation for fertility preservation or family building in a cohort of transgender men. J Assist Reprod Genet. 2019;36(10):2155–61 Effect of T exposure on ovarian stimulation outcomes in transmen vs cisgender women.

    PubMed  Google Scholar 

  49. Broughton D, Omurtag K. Care of the transgender or gender-nonconforming patient undergoing in vitro fertilization. Int J Transgenderism. 2017;18(4):372–5.

    Google Scholar 

  50. •• Leung A, Sakkas D, Pang S, Thornton K, Resetkova N. Assisted reproductive technology outcomes in female-to-male transgender patients compared with cisgender patients: a new frontier in reproductive medicine. Fertil Steril. 2019;112(5):858–65 Effect of T exposure on ovarian stimulation outcomes in transmen vs cisgender women.

    CAS  PubMed  Google Scholar 

  51. Cobo A, Garcia-Velasco JA, Domingo J, Remohí J, Pellicer A. Is vitrification of oocytes useful for fertility preservation for age-related fertility decline and in cancer patients? Fertil Steril. 2013;99(6):1485–95.

    PubMed  Google Scholar 

  52. Wierckx K, Elaut E, Van Hoorde B, Heylens G, De Cuypere G, Monstrey S, et al. Sexual desire in trans persons: associations with sex reassignment treatment. J Sex Med. 2014;11(1):107–18.

    PubMed  Google Scholar 

  53. Lee DE, Park SY, Lee SR, Jeong K, Chung HW. Diagnostic usefulness of transrectal ultrasound compared with transvaginal ultrasound assessment in young Korean women with polycystic ovary syndrome. J Menopausal Med. 2015;21(3):149–54.

    PubMed  PubMed Central  Google Scholar 

  54. Timor-Tritsch IE, Monteagudo A, Rebarber A, Goldstein SR, Tsymbal T. Transrectal scanning: an alternative when transvaginal scanning is not feasible: transrectal scanning. Ultrasound Obstet Gynecol. 2003;21(5):473–9.

    CAS  PubMed  Google Scholar 

  55. Oktay K, Turan V, Bedoschi G, Pacheco FS, Moy F. Fertility preservation success subsequent to concurrent aromatase inhibitor treatment and ovarian stimulation in women with breast cancer. J Clin Oncol. 2015;33(22):2424–9.

    PubMed  PubMed Central  Google Scholar 

  56. Katz DJ, Kolon TF, Feldman DR, Mulhall JP. Fertility preservation strategies for male patients with cancer. Nat Rev Urol. 2013;10(8):463–72.

    PubMed  Google Scholar 

  57. Kafetsoulis A, Brackett N, Ibrahim E, Attia G, Lynne C. Current trends in the treatment of infertility in men with spinal cord injury. Fertil Steril. 2006;86(4):781–9.

    PubMed  Google Scholar 

  58. Furuhashi K, Ishikawa T, Hashimoto H, Yamada S, Ogata S, Mizusawa Y, et al. Onco-testicular sperm extraction: testicular sperm extraction in azoospermic and very severely oligozoospermic cancer patients. Andrologia. 2013;45(2):107–10.

    CAS  PubMed  Google Scholar 

  59. Heger S, Müller M, Ranke M, Schwarz H-P, Waldhauser F, Partsch C-J, et al. Long-term GnRH agonist treatment for female central precocious puberty does not impair reproductive function. Mol Cell Endocrinol. 2006;254–255:217–20.

    PubMed  Google Scholar 

  60. Linde R, Doelle GC, Alexander N, Kirchner F, Vale W, Rivier J, et al. Reversible inhibition of testicular Steroidogenesis and spermatogenesis by a potent gonadotropin-releasing hormone agonist in normal men: an approach toward the development of a male contraceptive. N Engl J Med. 1981;305(12):663–7.

    CAS  PubMed  Google Scholar 

  61. Rothenberg SS, Witchel SF, Menke MN. Oocyte cryopreservation in a transgender male adolescent. N Engl J Med. 2019;380(9):886–7.

    PubMed  Google Scholar 

  62. Insogna IG, Ginsburg E, Srouji S. Fertility preservation for adolescent transgender male patients: a case series. J Adolesc Health. 2020;66:750 S1054139X19309255.

    PubMed  Google Scholar 

  63. Har-Toov J, Brenner SH, Jaffa A, Yavetz H, Peyser MR, Lessing JB. Pregnancy during long-term gonadotropin-releasing hormone agonist therapy associated with clinical pseudomenopause. Fertil Steril. 1993;59(2):446–7.

    CAS  PubMed  Google Scholar 

  64. Fatima P, Hossain MM, Rahman D, Suman GM. Outcome of pregnancies after inadvertent exposure to GnRH agonist in early pregnancy. Mymensingh Med J MMJ. 2011;20(2):303–7.

    CAS  PubMed  Google Scholar 

  65. Donnez J, Dolmans M, Demylle D, Jadoul P, Pirard C, Squifflet J, et al. Livebirth after orthotopic transplantation of cryopreserved ovarian tissue. Lancet. 2004;364(9443):1405–10.

    CAS  PubMed  Google Scholar 

  66. De Roo C, Lierman S, Tilleman K, Peynshaert K, Braeckmans K, Caanen M, et al. Ovarian tissue cryopreservation in female-to-male transgender people: insights into ovarian histology and physiology after prolonged androgen treatment. Reprod BioMed Online. 2017;34(6):557–66.

    PubMed  Google Scholar 

  67. Fasano G, Moffa F, Dechène J, Englert Y, Demeestere I. Vitrification of in vitro matured oocytes collected from antral follicles at the time of ovarian tissue cryopreservation. Reprod Biol Endocrinol. 2011;9(1):150.

    CAS  PubMed  PubMed Central  Google Scholar 

  68. Segers I, Mateizel I, Van Moer E, Smitz J, Tournaye H, Verheyen G, et al. In vitro maturation (IVM) of oocytes recovered from ovariectomy specimens in the laboratory: a promising “ex vivo” method of oocyte cryopreservation resulting in the first report of an ongoing pregnancy in Europe. J Assist Reprod Genet. 2015 Aug;32(8):1221–31.

    PubMed  PubMed Central  Google Scholar 

  69. Lierman S, Tilleman K, Braeckmans K, Peynshaert K, Weyers S, T’Sjoen G, et al. Fertility preservation for trans men: frozen-thawed in vitro matured oocytes collected at the time of ovarian tissue processing exhibit normal meiotic spindles. J Assist Reprod Genet. 2017;34(11):1449–56.

    CAS  PubMed  PubMed Central  Google Scholar 

  70. Telfer EE. Future developments: in vitro growth ( IVG ) of human ovarian follicles. Acta Obstet Gynecol Scand. 2019;98(5):653–8.

    PubMed  Google Scholar 

  71. Bertelloni S, Baroncelli GI, Ferdeghini M, Menchini-Fabris F, Saggese G. Final height, gonadal function and bone mineral density of adolescent males with central precocious puberty after therapy with gonadotropin-releasing hormone analogues. Eur J Pediatr. 2000;159(5):369–74.

    CAS  PubMed  Google Scholar 

  72. Liu PY, Turner L, Rushford D, McDonald J, Baker HWG, Conway AJ, et al. Efficacy and safety of recombinant human follicle stimulating hormone (Gonal-F) with urinary human chorionic gonadotrophin for induction of spermatogenesis and fertility in gonadotrophin-deficient men. Hum Reprod. 1999;14(6):1540–5.

    CAS  PubMed  Google Scholar 

  73. Picton HM, Wyns C, Anderson RA, Goossens E, Jahnukainen K, Kliesch S, et al. A European perspective on testicular tissue cryopreservation for fertility preservation in prepubertal and adolescent boys. Hum Reprod. 2015;30(11):2463–75.

    PubMed  Google Scholar 

  74. Chen D, Simons L. Ethical considerations in fertility preservation for transgender youth: a case illustration. Clin Pract Pediatr Psychol. 2018;6(1):93–100.

    PubMed  PubMed Central  Google Scholar 

  75. Hudson J, Nahata L, Dietz E, Quinn GP. Fertility counseling for transgender AYAs. Clin Pract Pediatr Psychol. 2018;6(1):84–92.

    PubMed  Google Scholar 

  76. Lyttle Schumacher B, Grover N, Mesen T, Steiner A, Mersereau J. Modeling of live-birth rates and cost-effectiveness of oocyte cryopreservation for cancer patients prior to high- and low-risk gonadotoxic chemotherapy. Hum Reprod. 2017;32(10):2049–55.

    CAS  PubMed  PubMed Central  Google Scholar 

  77. Kyweluk MA, Reinecke J, Chen D. Fertility preservation legislation in the United States: potential implications for transgender individuals. LGBT Health. 2019;6(7):331–4.

    PubMed  PubMed Central  Google Scholar 

  78. Gilbert K, Nangia AK, Dupree JM, Smith JF, Mehta A. Fertility preservation for men with testicular cancer: is sperm cryopreservation cost effective in the era of assisted reproductive technology? Urol Oncol Semin Orig Investig. 2018;36(3):92.e1–9.

    Google Scholar 

  79. Infertility Coverage by State [Internet]. [cited 2020 Apr 24]. Available from: https://resolve.org/what-are-my-options/insurance-coverage/infertility-coverage-state/

  80. RESOLVE: Covering Fertility Preservation [Internet]. [cited 2020 Apr 24]. Available from: https://resolve.org/get-involved/advocate-for-access/our-issues/covering-fertility-preservation/

Download references

Author information

Authors and Affiliations

  1. University of California, San Francisco, 499 Illinois St, San Francisco, CA, 94158, USA

    Viji Sundaram & Evelyn Mok-Lin

Authors
  1. Viji Sundaram
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Evelyn Mok-Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Viji Sundaram.

Ethics declarations

Conflict of Interest

Dr. Sundaram has nothing to disclose. Dr. Mok-Lin has nothing to disclose.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Care for the Transgender Patients.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sundaram, V., Mok-Lin, E. Fertility Preservation for the Transgender Individual. Curr Obstet Gynecol Rep 9, 129–137 (2020). https://doi.org/10.1007/s13669-020-00291-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13669-020-00291-z

Keywords

Search

Navigation