International Journal of Transgenderism

ISSN: 1553-2739 (Print) 1434-4599 (Online) Journal homepage: https://www.tandfonline.com/loi/wijt20

Fertility preservation in transgender patients

C. A. Jones, L. Reiter & E. Greenblatt

To cite this article: C. A. Jones, L. Reiter & E. Greenblatt (2016) Fertility preservation
in transgender patients, International Journal of Transgenderism, 17:2, 76-82, DOI:
10.1080/15532739.2016.1153992

To link to this article: https://doi.org/10.1080/15532739.2016.1153992

Published online: 07 Jun 2016.

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INTERNATIONAL JOURNAL OF TRANSGENDERISM
2016, VOL. 17, NO. 2, 76–82
http://dx.doi.org/10.1080/15532739.2016.1153992

Fertility preservation in transgender patients

C. A. Jonesa,b, L. Reiterc, and E. Greenblatta,b
a
Centre for Fertility and Reproductive Health, Mount Sinai Hospital, Toronto, Canada; bDepartment of Obstetrics and Gynaecology, University of
Toronto, Toronto, Canada; cDepartment of Medicine, University of Toronto, Toronto, Canada

ABSTRACT KEYWORDS
Fertility preservation is an important consideration for transgender people prior to initiating cross- Fertility preferences; fertility;
sex hormones or undergoing sex reassignment surgery. We performed a retrospective chart review in vitro fertilization;
identifying all transgender patients referred for fertility preservation at one university-affiliated transgender persons
fertility clinic from November 2011 to March 2014. Eleven male-to-female (MtF) transgender
patients and 3 female-to-male (FtM) transgender patients were seen for sperm banking or fertility
preservation consultation. FtM transgender patients were referred for fertility preservation at a later
age and after being on a longer duration of cross-sex hormone therapy than MtF transgender
patients. Nine of eleven MtF patients cryopreserved sperm resulting in 1 pregnancy following IVF-
ICSI. None of the FtM patients underwent any cryopreservation techniques. This study highlights
the need to increase awareness on the effects of age on fertility for FtM patients, and to improve
awareness of and access to fertility preservation technologies for all transgender people early on in
their transition.

Background
Cross-sex hormone therapy is well established as
effective management for sex reassignment in trans-
gender people who desire to live and be accepted as
members of the opposite gender. Despite the many
positive outcomes associated with hormone therapy,
variable effects have been seen on fertility ranging
from no effect to total impairment of spermatogenesis
(Lubbert, Leo-Rossberg, & Hammerstein, 1992;
Murad et al., 2010; Payer, Meyer, & Walker, 1979;
Schulze, 1988; Thiagaraj et al., 1987; Venizelos &
Paradinas, 1988). Furthermore, the negative impact
on fertility of sex-reassignment surgery is well recog-
nized (Murad et al., 2010). Historically, a decline of
reproductive potential was deemed a necessary sacri-
fice for individuals who transitioned to the opposite
gender (De Sutter, 2001). As a result, the reproductive
needs of transgender patients have been largely
ignored by modern medicine (Hunger, 2012).
Nevertheless, the desire to have children is com-
mon among transgender people. A survey of 121
male-to-female (MtF) transgender people in Belgium
found that 40% of respondents wanted to have
children and over half of those respondents wished for
their children to be biologically their own (De Sutter
et al., 2002). Similar desires have been found in
female-to-male (FtM) transgender people, in which
over 50% of survey respondents in Belgium stated
wanting to have children (Wierckx et al., 2012).
Only recently have the reproductive needs of trans-
gender patients begun to be recognized as an issue of
importance. In 2001, the WPATH Standards of Care
introduced a paragraph addressing the need to discuss
fertility issues with transgender patients before initiat-
ing hormone therapy (Meyer et al., 2001). These rec-
ommendations were expanded in 2011, with the new
WPATH Standards of Care containing an entire chap-
ter dedicated to the reproductive health needs of trans-
gender people (Coleman et al., 2012). Rather than
dismissing the reproductive needs of the transgender
community, current fertility preservation technologies
can now offer transgender patients the possibility of
having children that are biologically their own.
In MtF patients, sperm cryopreservation can be
achieved after masturbation, without the need for an
invasive procedure, and is readily available at many

CONTACT C. A. Jones cjones2@mtsinai.on.ca Centre for Fertility and Reproductive Health, Mount Sinai Hospital, 250 Dundas Street West, Suite 700
Toronto, ON, M5T 2Z5, Canada.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wijt.
© 2016 Taylor & Francis Group, LLC
 INTERNATIONAL JOURNAL OF TRANSGENDERISM 77

fertility clinics. Costs of sperm cryopreservation are affiliated fertility clinic for fertility preservation. By
similar at various fertility clinics in Canada and range identifying the characteristics of this patient popula-
from CAD$500 to CAD$800 or more depending on tion and the barriers to successful gamete banking, we
the number of samples cryopreserved with annual fees hope to improve access to reproductive technologies
of approximately CAD$250 to keep samples frozen and ultimately to enhance the reproductive outcomes
over time. Sperm cryopreservation can also be of all transgender patients.
achieved by vibratory stimulation for those with an
ejaculation, or surgical extraction procedures such as
Materials and methods
percutaneous epididymal sperm aspiration (PESA) or
microsurgical testicular sperm extraction (micro- Approval to complete this study was obtained from
TESE), which is usually reserved for those patients the Health Research Ethics Board at Mount Sinai Hos-
with azospermia due to reduced sperm quantity and pital, Toronto, Canada. All charts of self-identified
maturity compared with ejaculated sperm (Wallace, transgender patients who were seen for a fertility con-
Blough, & Kondapalli, 2014). Traditionally, patients sultation or sperm banking between January 2010 and
have been advised to cryopreserve sperm prior to May 2014 at one Canadian university-affiliated fertil-
starting cross-sex hormone therapy as there is a ity clinic were identified and reviewed. Clinical data
potential for a decline in sperm motility with high- retrieved and recorded from the identified charts
dose estrogen therapy over time (Lubbert et al., 1992). included age, number of children, length of time on
However, this decline in fertility due to estrogen ther- hormone therapy, source of referral, amount of game-
apy is controversial due to limited studies. A recent tes preserved, and subsequent use of cryopreserved
study demonstrated normal spermatogenesis in testic- gametes for reproduction. Specialties of the referring
ular biopsies performed at the time of sex reassign- health care professionals were found by searching the
ment surgery for patients on long-term estrogen public register of the College of Physicians and Sur-
therapy (Schneider et al., 2015). Pregnancy may also geons of Ontario and the College of Nurses of Ontario.
be achieved if only poor-quality sperm is obtained
while on estrogen therapy with the use of assisted
Results
reproductive technologies (ART), specifically, intracy-
toplasmic sperm injection (ICSI). From January 2010 to May 2014, a total of 14 self-
Oocyte or embryo cryopreservation following ovar- identified transgender patients were seen in consulta-
ian hyperstimulation and oocyte retrieval can be used tion. Of those, 11 patients (78.6%) identified as MtF
as a fertility preservation strategy for FtM patients transgender patients and three patients (21.4%) identi-
(Wallace et al., 2014; Wallace, Blough, & Kondapalli, fied as FtM transgender patients. Age and length of
2014). Costs for oocyte preservation in Canada range time on hormone therapy at the time of initial presen-
from CAD$8,000 to CAD$13,000 depending on a tation differed between MtF and FtM patients
number of factors including the dose of medications. (Table 1). The mean age of first visit for the MtF
While androgen therapy is not believed to interfere
with the quality and development of the primordial
Table 1. Demographic and clinical characteristics of MtF and FtM
follicles, it is recommended that hormone therapy be patients.
stopped prior to ovarian stimulation for oocyte
Male-to- Female-to-
retrieval to maximize the response to gonadotropins female male Overall
(Coleman et al., 2012; Van Den Broecke et al., 2001). Number of patients (%) 11 (78.6) 3 (21.4) 14
With fertility preservation now being recognized as Mean (range) age at first visit 26.4 (20–40) 36.3 (33–39) 28.5 (20–40)
(years)
a viable option to address the reproductive wishes of Mean (range) length of time 0.33 (0–2) 35.3 (15.6–66) 11.95 (0–66)
the transgender community, an increasing number of on hormone therapy
before first visit (months)
transgender patients are being referred for consider- Referring physician type
ation of fertility preservation, although little is known Family medicine 8 0 8
Primary care nurse 1 0 1
about this patient population. The goal of this retro- practitioner
spective case series is to define the population of trans- Endocrinology 2 0 2
Obstetrics and gynecology 0 3 3
gender patients who were referred to a university-
78 C. A. JONES ET AL.
Figure 1. Number of patients seen by date of first visit.
patients was 26.4 years compared with 36.3 years for
FtM patients. The length of time on hormone therapy
was recorded in six of the 11 MtF patients’ charts. Of
these six patients, the mean length of time on hor-
mones prior to visiting the clinic was 0.33 months
compared with 35.2 months for the three FtM
patients. Differences in referring physician specialty
were noted ( Table 1). There has been an increase in
the number of transgender patients seen for a first visit
for fertility preservation over the last year of collected
data (Figure 1).
Differences in use of cryopreserved gametes and
fertility treatment outcomes were found between the
MtF and FtM patients (Figure 2). Nine of the 11 MtF
patients (81.8%) banked sperm, all of which were
obtained from fresh ejaculate after masturbation, with
a median number of banking events of two per patient,
most of which were performed within 2 weeks of
Figure 2. Use of fertility preservation techniques and pregnancy
outcomes.
referral. The mean number of straws banked was 27.1.
Table 2 contains average semen parameters at first and
second visits. Only one patient used cryopreserved
sperm for fertility treatment resulting in a viable intra-
uterine pregnancy after frozen embryo transfer of a
cryopreserved embryo following an intracytoplasmic
sperm injection (ICSI) cycle.
Fertility preservation techniques discussed with all
FtM patients included controlled ovarian hyperstimu-
lation with transvaginal ultrasound–guided oocyte
retrieval with oocyte or embryo cryopreservation. The
following experimental techniques were also offered
to all FtM patients, despite a lack of success with this
approach at our institution: immature oocyte aspira-
tion with in vitro maturation and oocyte cryopreserva-
tion at the time of hysterectomy and bilateral
salpingoopherectomy (Chian, Uzelac, & Nargund,
2013; Huang et al., 2008a; Huang et al., 2008b; Lau
et al., 2009; Whyte, Hawkins, & Rausch, 2014) and
ovarian tissue cryopreservation (Gamzatova et al.,
2014; Huang et al., 2008). Surgical retrieval with sub-
sequent cryopreservation of sperm was not discussed
with any patients since they were all able to provide
ejaculated sperm. Alternative options for having a
family were discussed with all patients including the
use of donor gametes, gestational carriers, and
adoption.
The usual cycle monitoring protocol for patients
undergoing controlled ovarian hyperstimulation for
oocyte retrieval at our institution involves changing
into a hospital gown in a women’s-only change room,
then sitting in a hallway with many other gowned
patients before having a transvaginal ultrasound. Since
these steps were perceived to be uncomfortable by our
 INTERNATIONAL JOURNAL OF TRANSGENDERISM 79

Table 2. Semen parameters at sperm banking visits. patients. While 82% of MtF patients referred for
Median (range) semen Median percentage decrease sperm banking underwent sperm cryopreservation,
Semen analysis parameters in semen parameters between
analysis at banking (n D 11) first and second visit (n D 8) none of the three FtM patients underwent any form
of fertility preservation. This is due to many factors
Concentration 30 (1.18–108) 17.40%
(million/mL) including financial constraints, a low likelihood of
Motility (%) 46 (14–86) 6.70% successful pregnancy outcomes due to advanced
Morphology (%) 14 (1–36) 7.10%
reproductive age and diminished ovarian reserve, and
psychosocial barriers to traditional fertility preserva-
FtM patients, we involved a multidisciplinary team tion techniques. However, our sample size of FtM
that included physicians, nurses, laboratory staff, hos- patients is very small and, therefore, it is difficult to
pital bioethicists, and our LGBT hospital coordinator draw conclusions about why they did not pursue fer-
to plan a sensitive patient-friendly approach to cycle tility preservation. These factors are very different for
monitoring for our FtM patients. However, none of MtF patients, in whom successful sperm cryopreser-
our FtM patients chose to undergo oocyte cryopreser- vation is far less expensive and is commonly achieved
vation. Age, anti-M€ ullerian hormone level, and rea- by masturbation, rarely requiring an invasive surgical
sons for not pursuing fertility preservation are listed extraction procedure such as PESA or micro-TESE
per patient in Table 3. (Selk et al., 2009).
Our FtM patients were much older and on hor-
mone therapy for a longer period of time than our
Discussion MtF patients, demonstrating that they sought fertility
We have seen an increase in the number of referrals preservation later in their sex reassignment transition.
for fertility preservation in transgender patients at This discrepancy between the two groups did not
our institution over the last year. This may be due to reflect a difference in the age of presenting with gen-
increasing awareness of fertility preservation options der dysphoria, as FtM patients generally present in a
among patients and/or physicians, although our health care setting at a younger age (De Cuypere et al.,
study was not designed to identify who initiated the 2007; Zucker & Lawrence, 2009). Instead, this differ-
referral for fertility preservation. However, the num- ence demonstrated that our FtM patients were consid-
ber of referrals for fertility preservation still remains ering their reproductive options later in their gender
low, suggesting multiple barriers to access including reassignment transition than our MtF patients. It is
cost and awareness, especially for FtM transgender unclear whether this is due to a lack of knowledge of
the effects of cross-sex hormones on fertility and the
Table 3. Reasons FtM patients did not cryopreserve oocytes and options for fertility preservation or whether the sub-
future plans. ject had previously been discussed with health care
Patient 1 Patient 2 Patient 3 providers and dismissed as an unrealistic option. In a
study of 41 FtM people who experienced pregnancy
Age (years)
37 33 39 after transitioning, the majority conceived spontane-
Antimullerian ously after stopping androgens, with very few making
hormone (pmol/L)
12.1 12 2.2 use of assisted reproductive technologies (Light et al.,
Barriers to oocyte 2014). In all three FtM cases in our study, the patients
cryopreservation
Financial Financial Financial were referred by an obstetrician-gynecologist who
Stopping androgen Stopping androgen
therapy therapy
suggested fertility preservation prior to planned hys-
Prognosis due to age Prognosis due to age terectomy and bilateral salpingo-oopherectom. Fertil-
Vaginal ultrasounds
and transvaginal ity preservation had not been discussed previously
oocyte retrieval with their primary care physicians, which is likely
Decisions and future
plans why we had so few FtM patients referred to our insti-
Still considering oocyte Postponed definitive Decided not to tution for fertility preservation or ART.
cryopreservation— surgery to save money pursue fertility
sought second for oocyte preservation or The WPATH Standards of Care recommend that
opinion at other cryopreservation in definitive surgery all transgender patients make decisions regarding
fertility clinic the future
their fertility before starting hormone therapy
80 C. A. JONES ET AL.
(Coleman et al., 2012). These recommendations are
significant for both MtF and FtM individuals, as it
would be preferable to undergo fertility preservation
prior to starting long-term hormone treatment, and
these therapies, when already started, ideally should
be stopped prior to gamete banking, due to the
potential negative effects of hormone therapy on
ovarian reserve and the response to gonadotropins
for ovarian hyperstimulation (Caanen et al., 2015;
Coleman et al., 2012; Hembree et al., 2009) The
majority of our MtF patients came for sperm banking
prior to initiating hormone therapy, compared with
all FtM patients who had been on hormone therapy
for several years before their first clinic visit, which
had a negative impact on the decision to undergo fer-
tility preservation.
At first consultation, our FtM patients were
advised to stop taking androgens to allow for sponta-
neous resumptions of menses prior to starting gona-
dotropins for an oocyte cryopreservation cycle. This
option was evidently unappealing to all of our FtM
patients, since stopping hormone treatment could
result in the reversal of many androgen-induced
changes and the possible return of female physical
characteristics. Thus, not discussing reproductive
options before initiating hormone therapy repre-
sented a significant psychosocial barrier to fertility
preservation for our FtM patients. Only one of our
three patients was willing to come off androgens in
order to plan an oocyte cryopreservation cycle; that
patient had delayed starting a cycle due to financial
constraints and career changes.
Cost and the invasiveness of transvaginal ultra-
sound monitoring and oocyte retrieval were identified
as major barriers to oocyte cryopreservation in our
FtM patients. Other experimental options were dis-
cussed with all of our FtM patients including imma-
ture oocyte aspiration with in vitro maturation and
cryopreservation or ovarian tissue cryopreservation
performed at the time of hysterectomy and bilateral
salpingoopherectomy (Chian et al., 2013; Gamzatova
et al., 2014; Huang et al., 2008; Huang et al., 2008;
Imbert et al., 2014 ;Lau et al., 2009; Whyte et al.,
2014). Given the paucity of data on successful preg-
nancies for these experimental strategies, particularly
in the transgender patient population, none of our
patients decided to pursue these techniques. Other
options discussed with all FtM patients included the
use of donor gametes, gestational carriers, and
adoption.
The effect of age on fertility is more significant for
FtM patients than for MtF patients, as it has been well
established that the success of oocyte banking declines
significantly with increasing reproductive age (Cil,
Bang, & Oktay, 2013). The mean age of first consulta-
tion for our FtM patients was 36 years. Using age-spe-
cific–live-birth-probability calculations, the chance of
having a successful live birth using six frozen-thawed
oocytes by vitrification at age 36 is 17.1% in nontrans-
gender patients (Cil et al., 2013). In contrast, the aver-
age age when MtF patients first visited the clinic was
26 years. Assuming a similar age-related success rate
in transgender patients as in nontransgender patients,
our FtM patients could have doubled their potential
success rate using frozen-thawed oocytes by vitrifica-
tion if they had sought fertility preservation at the
same age as our MtF patients (Cil et al., 2013). Thus,
by not banking their oocytes at a younger age, our
FtM patients had decreased the likelihood of repro-
ductive success through fertility preservation.
Oocyte cryopreservation is a newer fertility preser-
vation strategy that is more complicated, more
expensive, and less effective than sperm banking. The
first case of oocyte cryopreservation prior to initia-
tion of androgen therapy in a transgender person
was only reported in 2014 (Wallace et al., 2014).
Thus, hormone-prescribing physicians may be less
inclined to discuss oocyte cryopreservation as a
reproductive option with their FtM patients, although
with advances in technology, including oocyte vitrifi-
cation, success rates have improved drastically, with
some fertility units showing similar pregnancy rates
to fresh IVF cycles (Oktay, Cil, & Bang, 2006; Potdar,
Gelbaya, & Nardo, 2014; Levi Setti et al., 2014; Sole
et al., 2013; Goldman et al., 2013; Chang et al., 2013;
Nagy et al., 2009). However, by not having these
early discussions, physicians are hindering their
patients’ ability to have children that are biologically
their own. Therefore, it is important that all health
care providers serving the transgender community
understand the impact of hormone therapy on fertil-
ity as well as the fertility preservation options for
both MtF and FtM patients. Education needs to be
available for hormone-prescribing physicians to
ensure informed discussions about reproductive
health occur early in the patients’ transition. Future

studies should assess the knowledge of this physician
population to identify areas of improvement.
While the majority of MtF patients referred to our
clinic were successful in preserving sperm, it is of note
that only one patient returned to use cryopreserved
sperm for reproduction during the study time frame.
The lack of pregnancies using banked sperm may be
an age-related factor, as the mean age of the MtF
patients banking their sperm at the clinic was
26.4 years, and many of them may not yet be ready to
start a family. Future studies are needed to explore the
perceptions and attitudes of transgender patients to
fertility preservation to better understand why they
may not choose to bank their gametes or come back
to use previously cryopreserved gametes.
In conclusion, this retrospective case series identi-
fied major barriers to fertility preservation for trans-
gender patients including finances, invasiveness of
procedures, a lack of knowledge of fertility preserva-
tion options, and poor prognoses due to advanced
reproductive age and long-term use of cross-sex hor-
mones. This study identifies a need to improve patient
and physician awareness of the negative effects of age
and long-term hormone therapy on reproductive out-
comes and of the potential options for fertility preser-
vation in transgender patients. In doing so, we strive
to provide all transgender patients the opportunity to
preserve their reproductive potential before it is too
late.
Acknowledgments
The authors would like to thank Nicole Heiss for helping to
identify patient charts.
Conflict of interest
The authors have no conflicts of interest to declare.
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