Amy Clifton has known she wanted children since she was ten years old. "So when it came to transition and going to the gender identity clinic and starting hormones," she said, "the first thing I asked was, 'How do I ensure that I will be able to have my own progeny someday?'"
Amy is a transgender woman living in Belfast, Ireland. Born with male genitalia, she was capable of producing healthy sperm prior to beginning her gender transition. After starting female hormone therapy in her late 20s, however, the ability of her sperm to produce an embryo via in vitro fertilization would decrease significantly.
Having her own biological children was important enough to Amy that she'd have delayed hormone therapy if necessary in order to bank sperm, she said. Luckily, she didn't have to; at Northern Ireland's National Health Service gender identity clinics, waiting lists are relatively short, and most services—including sperm collection and banking for 10 years—are free.
Amy is one of many transgender people who want to have families of their own. And while the assisted reproductive technology available to people like her isn't particularly novel, there is minimal data and no clinical practice guidelines to help doctors best apply that technology to the care of transgender patients.
The hormones and reproductive organs present in a transgender person differ depending on the types of treatment the person has had. Reproductive organs present at birth, also referred to as the natal organs, may be removed if they do not align with gender identity, although many transgender people do not have this surgery for reasons including cost and surgical risk. As a result, many transgender men have a uterus and ovaries, while many transgender women have testes.
However, many transgender people take hormone therapy that not only produces secondary sex characteristics, but also suppresses the activity of the natal organs, if they are still present. A transgender person taking hormones would need to stop hormone therapy for several months before trying to use the eggs or sperm produced by their natal organs.
How well those eggs or sperm work after stopping hormones is one of the biggest questions facing reproductive specialists, said Dr. Paula Amato, a reproductive endocrinologist at Oregon Health and Science University. Amato was also a lead author of an opinion published last November by the Ethics Committee of the American Society for Reproductive Medicine (ASRM), which concluded transgender people should have equal access to fertility services.
We don't have the data yet to answer many of the most important questions about transgender fertility, said Amato, including "how long do you have to be off hormones before your fertility recovers? How often does it recover? Does it sometimes not recover? Are there any long-term effects of exposure to these exogenous hormones on eggs or sperm or potential children?"
Although there's a lot we don't know about the impact of transgender hormone therapy on reproductive potential, that impact does seem to be different between transgender men and transgender women. Testes become much smaller in volume after long-term estrogen therapy, which may reduce sperm production and function. However, ovaries and egg follicles often regain full function after testosterone therapy is stopped, even after years of exposure to high levels of the hormone.
Dr. Jessica Spencer, a reproductive endocrinologist in Atlanta, Georgia, is an expert in fertility issues related to both gender transition and cancer chemotherapy. For the treatment of transgender people seeking fertility preservation or ready to start a family, she said, she and her colleagues "make inferences from other populations who have similar but not identical experiences."
Because people treated with chemotherapy may have reduced egg or sperm function as a result, those who think they might someday want children sometimes opt for fertility preservation—banking eggs or sperm—before treatment. For similar reasons, transgender people are more frequently being offered fertility preservation prior to starting hormone therapy.
Referral to a specialist to discuss fertility preservation prior to transition should be the standard of care, said Amato. But as transgender people are self-identifying earlier and earlier, questions about how to treat younger patients are arising.
When children identify as transgender while still relatively young, they are sometimes started on puberty-blocking hormones when they start showing early signs of sexual maturation. They may stay on these hormones in a prepubertal state until their mid-teens, or until they are ready to decide whether they want to transition. This prevents the development of unwanted secondary sexual characteristics associated with the gender assigned to the child at birth—breast development, hair growth, and voice changes that may be difficult to reverse, as well as tremendously distressing to the child.
The challenge, said Amato, is that eggs and sperm don't mature into viable, bankable sex cells until after puberty. "It's hard to know what to offer those patients," she said, "because in order to freeze eggs or sperm, they would have to go through puberty in their natal sex, which would often be discordant with their identity."
Beyond the biological challenges, not all adolescents may have the maturity to contemplate the importance of having a biological child, said Spencer, or a reasonable comfort level with the procedures needed to obtain eggs and sperm. Those procedures are particularly invasive for egg banking, which involves daily injections for two weeks, multiple transvaginal ultrasounds, and egg harvesting, an outpatient surgery.
Costs are an additional challenge—sperm banking costs about $400 annually, while it can cost between $8,000 and $12,000 to freeze eggs or embryos. Although private insurers often cover the physician consultation and diagnostic testing, they rarely cover egg or sperm banking without a diagnosis of infertility, said Spencer. And after all the expenditure and effort, there's no guarantee a healthy live birth will result.
There is strong support among reproductive endocrinologists for the rights of transgender people to have families of their own. Several studies have demonstrated good psychological health and secure attachment to parents by children of transgender parents. And while counseling the growing population of transgender adolescents about fertility preservation may not be straightforward, it may have an important impact on family dynamics.
"Some of the parents of the teens have a great sense of relief after the consultation," Spencer wrote in an email. "They can start to imagine their child building their own family one day, something that may have been quite stressful for them to think about before."