by Wendy B. Shelly, MD
Dr. Wendy Shelly shares her knowledge of reproductive options for those of trans experience, history/herstory/theirstory, and/or identity. I, Dr. Abigail Weissman, often share Dr. Shelly’s article with people who are beginning medical transition and have some hesitancy around reproductive issues. Dr. Shelly wrote this guest blog back in 2017 and I am excited to be able to share it with you in 2019! Please contact her should you have any questions about its content, as she is the medical doctor, not me. She is a caring and thoughtful person and I am honored that she contributed this wonderful piece to this blog. Without further ado, here is Wendy Shelly, MD, FACOG and A Family in Transition: Reproduction and the Transgender Individual.
A Family in Transition: Reproduction and the Transgender Individual
by Wendy Shelly, MD, FACOG
Many transgender individuals are of reproductive age at the time of transition, so it is imperative that family-building goals are part of the conversation. Though not exhaustive, this post is designed to help transgender individuals understand their fertility options and barriers they may encounter at different points in transition. Regardless, transgender individuals should speak to a fertility specialist (called a Reproductive Endocrinologist) to discuss the impact of hormonal and/or surgical treatment on their fertility, as well as options for fertility preservation. They should also speak with an experienced counselor to help address the potential impact of fertility treatments on any gender dysphoria, the impact of temporary discontinuation of hormonal therapy and the need for emotional support.
* For the purposes of this article, to avoid confusion, transitioning males will be referred to as FTM individuals and transitioning females will be referred to as MTF individuals.
Prior to Hormone Therapy and/or Surgery
For FTM individuals, improvements in cryopreservation (freezing) technology have made freezing eggs a realistic option for many. To do so, a series of injections of ovarian stimulating hormones are given for ~10-12 days, with frequent monitoring with ultrasound and estrogen levels. When the eggs are ready for retrieval, a transvaginal egg retrieval is performed under light anesthesia, using a small needle that punctures through the vaginal wall and into each ovary. Risks related to the medications and the egg retrieval procedure are minimal. Recovery is quick, with most people able to return to work or school the next day. Eggs are frozen on the day of retrieval and remain in cryopreservation until ready for use. Long-term viability and utility of eggs is still unknown as the freezing technology is still relatively new. The number and quality of eggs available for retrieval is best in younger individuals, optimally ≤ 30 years old. Prior to treatment, an assessment of quantity can be made to tailor expectations for egg retrieval. Though still experimental, cryopreservation of ovarian tissue at the time of hysterectomy can also be considered. This is currently only performed at specifically designated research sites under institutional review board (IRB) approval.
For MTF individuals, sperm tend to be very robust and survive freezing for extended periods of time. For this reason, sperm cryopreservation is an excellent option for potential use in the future, either for inseminations (IUI) or with more advanced technology like in-vitro fertilization (IVF). A number of collections (usually 4-6) is recommended to increase options for use.
After Hormone Therapy
Reproduction for transgender individuals who have initiated transition with hormones will typically involve temporary discontinuation. This can cause difficult physical and emotional changes that are best addressed actively with a qualified mental health professional as part of the treatment process.
The impact of long-term hormone exposure on eggs, sperm and offspring is essential unknown. It is imperative that individuals who choose to pursue treatment understand the limitations of our current knowledge.
For FTM individuals, several options exist. For individuals wishing to carry a child, case reports1 have shown spontaneous resumption of menses after discontinuation of testosterone therapy, even in situations of use for many years. In another study2, 57% of individuals had been on hormone therapy for an average of 3.7 years. However, 23% required the assistance of a fertility specialist to conceive, suggesting that the previous testosterone exposure may have affected the function of the ovary. For individuals wishing to preserve eggs, case reports3 also exist showing successful egg retrieval. Protocols were even used to minimize negative impact of estrogen exposure, improving patient compliance.
For MTF individuals, most data regarding resumption of sperm production after sex steroid suppression comes from short-term male contraception studies; this means the data is not necessarily applicable to the transgender population who are using estrogen, particularly for long periods of time. 4 The data we do have would suggest that return of sperm production is slow (many months), and sometimes not at all. Therapies are available to promote resumption of sperm production; these can be discussed with a Urologist who specializes in fertility or a Reproductive Endocrinologist.
For transgender individuals who have had surgery or do not wish to disrupt their hormone therapy, many options still exist for family building. Egg and sperm donors (from known or anonymous sources) as well as gestational carriers can be part of a family building plan.
For transgender individuals interested in family planning, it is critical that they are informed of their options. Because there are currently no formal practice guidelines for physicians providing fertility guidance and care to transgender individuals, it is important to make sure you seek advice from experts in the field of Reproductive Endocrinology and/or Urology. These specialists can help guide you through options, risks, and outcomes to optimize your care.
Best Wishes in Reproductive Health!
Wendy B. Shelly, MD, FACOG
Board Certified, Obstetrics/Gynecology and Reproductive Endocrinology Fertility Specialists Medical Group
1 Gidoni YS, Raziel A, Strassburger D, Kasterstein E, Ben-Ami I, Ron-El R. Can we preserve fertility in a female to male transgender after a long term testosterone treatment – case report. Fertil Steril 2013;100:P-77.
2 Light AD, Sevelius J, Obedin-Maliver J, Kerns J. Pregnancy after transitioning: the male-gendered experience with fertility, pregnancy, and birth outcomes. Fertil Steril 2013;100:P-895.
3 Rodriquez-Wallberg KA, Dhejne C, Stefenson M, Degerblad M, Olofsson JI. Preserving eggs for men’s fertility. A pilot experience with fertility preservation for female-to-male transsexuals in Sweden. Fertil Steril 2014;102:P-65. 4 Stahl P. Recovery of spermatogenesis after hormone therapy: what to expect and when to expect it. Fertil Steril 2017;107:338-339.