The Endocrine Society's 97th Annual Meeting & Expo:

Fertility Options for Transgender Persons

At her presentation during The Endocrine Society Annual Meeting in San Diego, CA, Paula Amato, MD addressed four issues related to the fertility options of transgender individuals:

  1. The impact of transition on fertility
  2. Fertility preservation options
  3. Reproductive options
  4. Ethical and legal issues related to transgender parenting

Dr. Amato is Associate Professor of Obstetrics and Gynecology at Oregon Health & Science University, Portland, OR.

Definition of Central Terms in Transgender Medicine
Three terms are central to transgender medicine:

  • Gender identity: A person’s intrinsic sense of being male, female, or an alternative gender
  • Gender dysphoria: Distress caused by a discrepancy between a person’s gender identity and assigned sex at birth
  • Sexual orientation: Patterns of emotional, romantic, and/or sexual attraction to men and women

Key Underlying Factors
Though the prevalence of transexualism is unknown, the majority of  transgender persons are of reproductive age at the time of transition and experience relationships after transition. Many desire children; in fact, 62% of transmen (female to male) reported wishing to have children in a 2012 study (Wierckx et al). Of concern to the effort to have children is the fact that cross-hormone therapy and sex-reassignment surgery can result in loss of fertility.

Fertility Preservation Options
Prior to donating sperm or eggs, the US Food and Drug Administration (FDA) and the American Society of Reproductive Medicine guidelines recommend a medical history and physical exam, testing for sexually transmitted disease, a questionnaire about risk factors for sexually transmitted disease, and psychological counseling. The World Professional Association for Transgender Health and The Endocrine Society recommend counseling on fertility preservation options. Information is limited on fertility preservation in the transgender population.

For transwomen (male to female) the options for preservation of fertility are:

  • Sperm cryopreservation
  • Testicular sperm extraction
  • Testicular tissue preservation

Transwomen may undergo intrauterine insemination of the female partner, in vitro fertilization using partner or donor eggs or sperm and/or the partner’s uterus or gestational carrier, or, in future, uterine transplantation.

For transmen (female to male), the options are:

  • Oocyte and/or embryo cryopreservation/vitrification using partner or donor sperm (the success rate is age-dependent)
  • (Experimental) ovarian tissue cryopreservation (about 20 live births worldwide)
  • (Experimental) in vitro oocyte maturation

Transmen may undergo intrauterine insemination using partner or donor sperm or in vitro fertilization using his own or partner eggs or his own or his partner’s uterus or gestational surrogate.

In a 2014 Web-based survey of 41 transmen who experienced pregnancy after transition (Light et al), 61% had taken testosterone, 80% resumed menses within 6 months of stopping testosterone, and 88% used their own eggs. Two-thirds of pregnancies were planned, and 7% involved fertility medications. Similar obstetric outcomes occurred in testosterone and non-testosterone users. The men expressed a desire for supportive resources and reported a lack of provider awareness and knowledge.

All transgender persons must discontinue exogenous hormones before embarking on reproduction, though how long before is not known. After discontinuing these hormones, the time needed to return to fertility is variable, and may be irreversible. In fact, the impact of long-term exogenous hormone exposure on sperm and eggs, and on resulting offspring, is unknown.

Access to Fertility Services
No data are available on transgender persons’ access to fertility services, though about 70% of adult reproductive clinics treat lesbian couples, and about 90% treat single women. Some clinics, however, refuse to treat single or gay men. Nondiscrimination laws vary by jurisdiction.

Legal Considerations
Patients should consult a legal expert regarding donor and coparenting agreements and adoption. Same-sex marriage is legal in over 30 states.

Cost

  • Donor sperm: $500 per vial
  • Sperm banking and FDA testing: $1000
  • Intrauterine insemination: $400
  • In vitro fertilization: $15,000 per cycle
  • In vitro fertilization with egg donation: $25,00 per cycle
  • Oocyte/embryo cryopreservation: $10,000
  • Gestational surrogacy: $50,000 - $100,000

Conclusion
Though data are scarce, no compelling evidence exists of harm to the children of transgender persons, so there are no reasons to deny fertility services to these patients based solely on their gender identity. Research into transgender medicine is needed, and since many transgender persons desire children and are of reproductive age at the time of transition, they should have legal access to fertility services and be offered fertility preservation prior to cross-sex hormone therapy and sex reassignment surgery. A multidisciplinary, team approach goes a long way toward ensuring optimal outcomes in transgender fertility treatment.

March 17, 2015

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