In the past, gender affirming transitions were achieved at the expense of reproductive function. Today, advances in assisted reproductive technology provide paths to genetic parenthood for transgender individuals without having to sacrifice their gender affirming transition.

More than half of transgender individuals wish to become parents to biological children.  Somewhere between 25-50% of transgender individuals are already parents.  Transpeople want to become parents for the same reasons cisgender people do: desire to parent a child, to have their own family, to pass on their genetics, and love.

This article provides an overview of the reproductive options and arrangements available to transgender people at all points during their transition.  

Pre-Transition Fertility Preservation

Freezing sperm or eggs prior to beginning hormone therapy remains the best way to preserve your reproductive options.  The World Professional Association of Transgender Health (WPATH) recommends health care professionals discuss preservation of sperm or eggs with transgender patients prior to commencing hormone therapy.  Although a suitable proposal in theory, it is difficult to implement in practice.  

Most people begin their transition at a young age.  It can be overwhelming to add the stress of considering fertility preservation and future family building at a time when a person is on the brink of their long-awaited gender affirming transition.  With the focus on their transition, adequate attention is not always given to the decision regarding future fertility.  The thought of delaying their transition for any reason or for any length of time can be agonizing.  Some may find the invasiveness of an egg retrieval too much to handle.  Others may have body dysphoria such that producing sperm for preservation would be traumatic.  These are all considerations when deciding if fertility preservation is right for you.  If you are considering your transition now, it is worth having a discussion with your healthcare practitioner about preserving your fertility so you may make an informed decision.

Post-Transition Egg and Sperm Retrieval
Already undergoing hormone therapy as part of your transition?  Dr. Ben Lannon of Boston IVF has positive news: “My advice is to always assume it is still possible to retrieve sperm or eggs.  Depending on an individual’s current age, age at transition, time on hormones, and other biological factors, the success rates can vary widely.” 

When it comes to trans men, Dr. Lannon explains, “ the option of egg retrieval in trans men can be successful before or after the onset of hormone therapy.  This is particularly true for trans men that undergo transition after puberty.  It generally requires 3-4 months off of the hormone therapy for the ovary to resume function.”  Discontinuation of hormone therapy combined with ovarian stimulation can result in high quality oocytes and high quality embryos.  This data makes it highly probable that trans men are able to create viable embryos using their own eggs with the potential of having genetic children.

For trans women, it isn’t quite at easy, but it is still possible.  Dr. Lannon clarifies: “For trans-women, it has traditionally been preferable to cryopreserve sperm prior to starting hormone therapy.  It is possible to obtain sperm after therapy, however, it can take often longer for sperm production to resume.  This is due to a delayed recovery of the brain hormones involved in sperm production, as well as the natural time course it takes for sperm to develop.”  A 2019 study reported semen samples collected after hormone therapy was discontinued for 4.4 months were comparable to those from individuals who had yet to begin hormone therapy. 

The possibility of retrieving sperm or eggs does not necessarily mean you will be comfortable with moving forward with the process.  Transgender individuals have gone through so much to achieve their gender-identity the thought of pausing hormones and the bodily changes it may cause can be understandably intolerable.  Decide whether or not you are willing to stop hormone therapy for the length of time suggested by your physician for retrieving eggs or sperm and know there are still options for family building outside of reproductive function.

Donor Eggs and Donor Sperm

Whether you decide not to pause your hormone therapy, or are unable to retrieve sperm or eggs medically, you may require the assistance of a donor.  Even if you are able to reproduce with your own genetic material, your relationship situation may also necessitate the involvement of an egg donor or sperm donor.  Someone with a uterus and eggs desiring to gestate a pregnancy may still require assistance from a sperm donor to have a baby.  Same-sex male couples or individuals who make sperm will require the assistance of both an egg donor, and a surrogate or gestational carrier.  A gestational carrier is a woman who agrees to carry and birth a child with the intention that the child be the legal and physical child of the intended parents.  We will discuss more on this topic below.

When working with a donor it is imperative to sign a contract clearly stating the intention of all parties that the donor not be a legal parent, and that the intended parents be the legal parents of any resulting child(ren).  Please consult with a lawyer before you begin the process of sperm donation or egg donation to ensure legal parentage is properly secured and the rights of all parties are protected.

Gestating a Pregnancy and Surrogacy 

For bodies that have a uterus, you may or may not decide to gestate a pregnancy and give birth.  For same-sex couples who produce eggs, reciprocal IVF is an increasingly popular option to achieve parenthood.  Reciprocal IVF refers to the situation where one partner carries a baby created from the eggs of the other partner.  Founder of connecting rainbows, Gena Jaffe, and her partner chose this path to parenthood.  You can read more about her journey here.

Trans men also have the option of gestating a pregnancy if their transition included keeping their uterus.  In the cisnormative society in which we live, the concept of a trans man desiring to gestate a pregnancy and experience giving birth can be met with misunderstanding.  Trans individuals including Trystan Reese, Myles Brady Davis, Freddy McConnell and Reuben Sharpe are inspiring tales of trans men carrying and delivering their own children.  Their stories can be found all over the internet, and serve as a reminder that this option is absolutely possible.  Keep in mind carrying a pregnancy necessitates pausing hormone therapy for the length of the pregnancy and for a period of time postpartum.

Whether or not you have a uterus, you may decide you’d prefer another person to carry your baby.  This person could be your partner, or could be a gestational carrier as part of a surrogacy arrangement.  As with any third party reproductive situation, all surrogacy arrangements require a detailed contract addressing a multitude of legalities and adhering to state law.  Without a signed contract in place before starting medication in anticipation of an embryo transfer you risk being unable to secure legal parental rights to your child.  

Learn Your Options

As each transition is unique to the individual, it is necessary to discuss your personal journey with your medical provider to fully understand the options available to you.  If your parenthood journey includes an intimate partner who intends to contribute an egg, sperm, gestate a pregnancy, and/or co-parent, including your partner in this discussion is advisable.  If you want to explore your reproductive options or preserve your sperm or eggs until you are ready to make a decision, please consult with a reproductive endocrinologist.  

Ready to start on your path to parenthood today?  Match with a sperm donor, egg donor, or gestational carrier and call an assisted reproductive technology attorney licensed in your state.  Attorneys who specialize in assisted reproduction and family formation can explain the legal process to you and help you avoid putting yourself in a precarious situation.  Initial consults to discuss your options should be free of charge.  Knowledge about your reproductive options can only serve to empower your decision-making process.

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[1] Dunne P. Transgender sterilisation requirements in Europe. Med Law Rev 2017;25:554-81. 10.1093/medlaw/fwx028; Light A, Wang LF, Zeymo A, et al. Family planning and contraception use in transgender men.Contraception 2018;98:266-9. 10.1016/j.contraception.2018.06.006; Light AD, Obedin-Maliver J, Sevelius JM, et al. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol 2014;124:1120-7. 10.1097/AOG.0000000000000540; Hoffkling A, Obedin-Maliver J, Sevelius J. From erasure to opportunity: a qualitative study of the experiences of transgender men around pregnancy and recommendations for providers. BMC Pregnancy Childbirth 2017;17:332. 10.1186/s12884-017-1491-5; Tornello SL, Bos H. Parenting intentions among transgender individuals. LGBT Health 2017;4:115-20. 10.1089/lgbt.2016.0153

[2] Stotzer RL, Herman JL, Hasenbush A. Transgender parenting: a review of existing research. In: Institute TW, editor. Los Angeles, CA, 2014.

[3] https://www.wpath.org/media/cms/Documents/SOC%20v7/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf?_t=1605186324

[4] Resende SS, Kussumoto VH, Arima FHC, Krul PC, Rodovalho NCM, Sampaio MRJ, Alves MM. A transgender man, a cisgender woman, and assisted reproductive technologies: a Brazilian case report. JBRA Assist Reprod. 2020 Oct 6;24(4):513-516. doi: 10.5935/1518-0557.20200024. PMID: 32469193; PMCID: PMC7558884.

[5] Adeleye AJ, Reid G, Kao CN, et al. Semen Parameters Among Transgender Women With a History of Hormonal Treatment. Urology 2019;124:136-41

Janene Oleaga, Esq. founded Oleaga Law LLC to assist LGBTQ+ individuals and those struggling with infertility to grow their families through assisted reproductive technology, third-party reproduction, surrogacy, and adoption. She represents individuals and couples in every phase of surrogacy, embryo donation, egg donation, sperm donation, and securing legal parentage. Janene is a member of RESOLVE New England, the American Bar Association’s ART & Adoption Law Committee, Human Rights Campaign, and is a former board member of MaineShare. She is licensed in New York and Maine.