Fertility Preservation for Transgender Individuals

Transgender individuals represent a small, albeit growing, patient population that is encountered more frequently in clinical care due to improved insurance coverage and increasing awareness. Gender-affirming treatments, including both gender-affirming hormone therapy and gender-affirming surgery, pose significant risks to fertility potential and outcomes, ranging from potentially impaired fertility rates to full elimination of reproductive potential depending on the type of treatment pursued. However, there are relatively limited data specific to fertility preservation for transgender individuals. Current approaches to treatment are extrapolated from options for fertility preservation after oncologic diagnoses. In this review, we aim to summarize current clinical approaches, fertility preservation options, and patient experiences in fertility preservation for transgender individuals. Several forms of fertility preservation options are available depending on the pubertal status of a transgender individual. Despite the multiple options for fertility preservation, major barriers exist to patient care and there are reports of mixed patient experiences. Further awareness of this clinical situation and understanding of these processes will allow for comprehensive and specialized care for transgender individuals who may otherwise miss opportunities for adequate counseling or treatment options regarding fertility preservation.

Transgender individuals represent a small but growing patient population in reproductive medicine. Although the number of transgender individuals is not necessarily increasing, the increase in clinical care likely results from improved recognition of transgender individuals and improved insurance coverage. In the United States, Medicare now covers hormonal treatments and does not exclude coverage for surgical gender-affirming therapy. The number of transgender individuals worldwide is underestimated due to limitations of previous population surveys, differences in methodology, and variations in the definition of transgender.¹ A recent meta-analysis attempted to estimate this prevalence and reported rates of 521 transwomen and 256 transmen per 100,000 individuals.² In the United States, a meta-regression of population-based probability samples reported 390 transgender adults per 100,000 individuals.³

Many transgender individuals report recognition of gender identity differing from sex assigned at birth during pre-pubescence, although the mean age of presentation is 27 to 32 years.^4,5 There is a growing number of patients presenting for gender-affirming treatment and a trend toward decreasing age at time of presentation.⁶ In the United States, 0.7% of individuals aged 13 to 24 years identify as transgender.⁷ Gender-affirming treatments, including both gender-affirming hormone therapy and surgery, have significant impacts on fertility potential and outcomes. For example, current use of gender-affirming hormone therapy may make fertility outcomes substantially lower whereas gender-affirming surgical treatments may make autologous fertility options impossible.

There are strong arguments for counseling transgender patients about fertility and fertility preservation. Reproductive desire is high among transgender individuals, but the use of reproductive options is surprisingly low. A recent Australian study surveyed 409 transgender and non-binary adults and found that, of participants who were not already parents, 33% hoped to have children in the future.⁸ Nearly all respondents (94.6%) responded that fertility preservation should be offered to all transgender and non-binary people. Public opinion in the United States also shows support for fertility treatment and preservation for transgender individuals. In a 2017 survey, 76.2% of respondents agreed that transgender individuals should be offered assistance to have biological children. However, only 60% of respondents supported fertility preservation in transgender minors or aiding transgender men in carrying a pregnancy.⁹ Other data describes a significantly higher desire for children in transmen compared with transwomen (P=.016) before gender-affirming treatment. In contrast, in those who had already started gender-affirming treatment, a current desire to have children was equally present in approximately one-fourth of participants of both genders, whereas the interest in having children in the future was significantly higher in transwomen (69.9%) than in transmen (46.9%; P=.034).¹⁰

Support for reproductive options for transgender individuals is formally recognized by multiple national and international organizations. The American Society for Reproductive Medicine states that it opposes restrictions on the use of reproductive technology in transgender individuals.¹¹ The World Professional Association of Transgender Health, American Society for Reproductive Medicine, and the Endocrine Society recommend that all transgender patients be counseled on the effect of their treatments; both gender-affirming surgeries and hormonal transition, on fertility and offered options for fertility preservation before transition.^11, 12, 13 A task force by the European Society of Human Reproductive Endocrinology published an opinion on the ethical principles involved in transgender fertility care and added that physicians caring for this population have moral obligations to invest in follow-up studies, as current data are limited.¹⁴

Nevertheless, many providers may be less familiar with the clinical options available for these patients. A recent survey of providers from nine different countries identified a need for additional information and resources to summarize available options for transgender fertility preservation.¹⁵ There is relatively limited data specific to fertility preservation for transgender individuals and current approaches are extrapolated from options for fertility preservation after oncologic diagnoses. In this review, we summarize current clinical approaches and patient experiences in fertility preservation for transgender individuals.