Reproductive Options

Dr. Luikenaar has long experience with helping to preserve and enhance fertility options for her transgender patients.

She recently presented this paper at the ACOG annual scientific and clinical meeting : Reproductive Options for Transgender Patients (PDF)
by Rixt Luikenaar

Thank you to the Center of Excellence in Transgender Health for the following general information

Primary author: Paula Amato, MD

Introduction

Transgender people have the same range of reproductive desires as do non-transgender people. Although data are limited, there is no evidence that children of transgender parents are harmed in any unique way.[1] It is recommended that prior to transition all transgender persons be counseled on the effects of transition on their fertility as well as regarding options for fertility preservation and reproduction (Grading: T O S).[2,3]

Exogenous hormones and gonadectomy (removal of testes or ovaries) have clear impacts on fertility. Reproduction in transgender persons who have initiated transition and retain their gonads generally involves discontinuation of exogenous hormones, though ovulation and spermatogenesis may continue in the presence of hormone therapy. If an individual has not undergone gonadectomy, and if an initial evaluation demonstrates an absence of ovulation or spermatogenesis, return of fertility may be possible after discontinuing hormone therapy for a period of time. Anecdotally the time to return of fertility can range from 3-6 months, though some may experience permanent loss of fertility, or require assisted technologies as described below.

Because infertility is not absolute or universal in transgender people undergoing hormone therapy, all transgender people who have gonads and engage in sexual activity that could result in pregnancy should be counseled on the need for contraception. Gender affirming hormone therapy alone is not a reliable form of contraception, and testosterone is a teratogen that is contraindicated in pregnancy. It is unknown how long of a testosterone washout period is appropriate in transgender men prior to pregnancy (Grading: X C S).

Fertility preservation options may include sperm, oocyte, embryo, ovarian tissue or testicular tissue cryopreservation.[4] These are similar to options available to men and women undergoing gonadotoxic cancer therapies or elective fertility preservation for social reasons.

Assisted reproduction may include the full range of fertility services. Whether long-term hormone exposure confers any unique medical risks to the patient undergoing assisted reproduction procedures or any long-term impact on gametes and to future offspring is currently unknown. Transgender patients who undergo fertility preservation or assisted reproduction should be informed of the lack of data on outcomes.

Reproductive options for transgender women

In transgender women, research suggests that prolonged estrogen exposure of the testes has been associated with testicular damage.[2] Restoration of spermatogenesis following extended estrogen treatment, however, has not been well studied.[2] The most successful option for fertility preservation for transgender women is cryopreservation of sperm prior to initiation of hormone therapy. Clomiphene citrate or hCG injections are sometimes used to stimulate spermatogenesis. Several recently reported cases of uterine transplantation into non-transgender women represent a potential future option; however this technology is still in infancy.

Reproductive options for transgender men

The effect of prolonged treatment with exogenous testosterone on ovarian function is unclear. Testosterone therapy usually leads to anovulatory state and amenorrhea. This is usually reversible upon discontinuation of testosterone therapy, and pregnancies have been reported in transmen following prolonged testosterone treatment.

Fertility preservation options for transgender men include oocyte cryopreservation, embryo cryopreservation, and ovarian tissue cryopreservation. The frozen-thawed oocytes or embryos can then be later used for establishing a pregnancy using the patient’s uterus or by transfer into a female partner or gestational carrier. While solid data are lacking, transgender men who have initiated transition have been able to discontinue testosterone treatment and undergo insemination of sperm or IVF with embryo transfer to the patient’s uterus, a female partner or gestational carrier.

A recently published report surveyed transgender men who experienced pregnancy after initiation of testosterone.[5] Eighty percent resumed menses within 6 months of stopping testosterone. Seven percent used fertility medications. Obstetrical outcomes were similar in the testosterone and non-testosterone users, however it is not clear if participants reporting testosterone use were receiving testosterone at the time of conception and during pregnancy. The men in the study also expressed a desire for more supportive resources and reported a lack of provider awareness and knowledge regarding fertility in transgender patients. One third of the pregnancies were unplanned, though it is not clear how many of these unplanned pregnancies occurred in the setting of current testosterone use. Nevertheless, such findings highlight the need for contraception in some patients.

Ovarian tissue cryopreservation is currently still considered experimental. There have been several live births reported worldwide resulting after autotransplantation of cryopreserved ovarian tissue.[6,7] However, there have yet to be any live births resulting from in-vitro maturation of oocytes derived from frozen-thawed ovarian tissue fragments. Research to create gametes through stem cell techniques is also ongoing.

All patients should also be informed that these assisted reproductive options are expensive and often not covered by insurance. Mental health counseling and support should be made available for those transgender people pursuing reproductive options who request or require such services.

Fertility preservation for children and adolescents

It is recommended that transgender children and adolescents, and their guardians, also be informed and counseled regarding options for fertility preservation prior to the initiation of pubertal suppression and treatment with gender affirming hormones. In children who have initiated natal puberty, fertility preservation options include sperm, oocyte, and embryo cryopreservation. Currently it is not possible for children who have not undergone natal puberty (and who may have used gender affirming hormones) to preserve gametes.

Prolonged pubertal suppression using gonadotropin releasing hormone (GnRH) analogs is usually reversible and should not impair resumption of puberty upon cessation, though most children who undergo pubertal suppression go on to begin gender affirming hormone therapy without undergoing natal puberty.

Further discussion of pubertal suppression, and the decision to undergo gonadectomy prior to the legal age of majority, is included in the guidelines for transgender children and adolescents.

References

  1. Ethics Committee of the American Society for Reproductive Medicine. Access to fertility services by transgender persons: an Ethics Committee opinion. Fertil Steril. 2015 Nov;104(5):1111-5.
  2. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer WJ 3rd, Spack NP, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
  3. Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th Version. World Professional Association for Transgender Health (WPATH). WPATH; 2012 [cited 2016 Mar 10]
  4. T’Sjoen G, Van Caenegem E, Wierckx K. Transgenderism and reproduction. Curr Opin Endocrinol Diabetes Obes. 2013 Dec;20(6):575-9.
  5. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014 Dec;124(6):1120-7.
  6. Donnez J, Silber S, Andersen CY, Demeestere I, Piver P, Meirow D, et al. Children born after autotransplantation of cryopreserved ovarian tissue. a review of 13 live births. Ann Med. 2011;43(6):437-50.
  7. Dittrich R, Hackl J, Lotz L, Hoffmann I, Beckmann MW. Pregnancies and live births after 20 transplantations of cryopreserved ovarian tissue in a single center. Fertil Steril. 2015 Feb;103(2):462-8.