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Transgender Fertility: Exploring Options Before and During Transitioning

July 19, 2018
Katie Visco

With increasing public awareness and understanding for transgenderism, many children and teens are liberated to express their own gender and sexual identifications. For these children and adolescents working towards self-identification and acceptance, future fertility is often the last thing on their minds.

For many years, transgender people were forced to accept the potential loss of their fertility after transitioning. However, thanks to recent advancements in assisted reproductive technology, transgender patients may be able to preserve their fertility early on in their treatments.

  • Fertility counseling for transgender patients
  • Implications of preserving sperm and eggs before and after transitioning
  • The future of transgender fertility

Fertility counseling for transgender patients

Several years ago, Ann & Robert H. Lurie Children’s Hospital began incorporating discussions regarding fertility and family planning into counseling sessions for transgender and gender nonconforming youth. The hospital drew its counseling strategies from its fertility preservation program for pediatric cancer patients. However, out of 105 transgender adolescents who went to Lurie Children’s Hospital, only 13 chose to see a fertility specialist for a formal consultation. Out of those 13, only five had their sperm or eggs frozen.

The ethics committee of the American Society for Reproductive Medicine recommends that all patients should be offered options for fertility preservations before transitioning. Despite counseling, however, many transitioning adolescents choose not to undergo fertility-preserving treatments.

Considerations during counseling

For many transgender youth, the decision to transition is an emotional process. Counseling for fertility preservation is important but happens during a period of change that many youth would like to focus on. This may explain why many transgender youth do not choose to consider the possibility of biological children in the future.

Potential factors that influence these decisions are barriers such as cost, invasiveness of fertility preservation treatments, and wanting to begin therapy as soon as possible.

Looking into fertility treatments a decade or more before actually conceiving can be difficult for transgender patients even with the help of counseling. Fertility procedures and storage fees can cost thousands of dollars and are not usually covered by insurance. The invasive and intimate aspects of the procedure in which the sperm and eggs are retrieved can magnify patients’ feelings of gender dysphoria. This is a condition in which a person is in conflict with their physically assigned gender and that they identify with.

Kacey Cabanban, a junior at Michigan State University, recalled that retrieving his eggs was one of the most uncomfortable moments of his life. However, now that they are no longer inside him, he only sees them as a tool for reproduction.

Implications of preserving sperm and eggs before and after transitioning

Transgender individuals can transition in a variety of ways. In many discourses, transitions are considered as either social or medical. While it has historically been assumed that medical transitioning results in an automatic loss of fertility, there are now options for preserving or regaining fertility in certain circumstances.

Preserving Fertility Before Transitioning

The most convenient and reliable way to maintain fertility is by making a decision to preserve fertility before any medical transitioning. Some types of fertility preservation procedures are sperm, oocyte, embryo, ovarian tissue or testicular tissue cryopreservation.

Cryopreservation is a medical practice that involves storing live matter at low temperatures in order to preserve them for future use. For example, since the 1960s, sperm freezing has been an option for preserving fertility. Sperm is collected and mixed with a freezing medium that contains cryoprotectants. The mixture is then frozen using liquid nitrogen, labeled, and stored for future use (the current permitted storage time is ten years).

If there is any desire to have children in the future, the sperm will be thawed and can be used for artificial insemination, in vitro fertilization (IVF), or intracytoplasmic sperm injection (ICSI).

What if I’ve already started transitioning?

If you already started treatment but wish to preserve your fertility, talk to your doctor about your options. While some medical procedures, such as a gonadectomy, results in permanent infertility, transgender individuals who have undergone other transitional procedures may have a chance of regaining fertility.

For transgender women, restoring sperm production after prolonged exposure to estrogen is complicated due to potential damage to testes. It is recommended that you stop treatment for at least 90 days before attempting to bank your sperm. This gives your body time to resume normal sperm production.

The sooner treatment is paused, the greater the chance of regaining fertility. Sometimes, hCG injections can be used to stimulate sperm production if ceasing hormone therapy is not effective.

For transgender men, prolonged exposure to testosterone usually results in a lack of ovulation but no reported damage to the ovaries. Studies show that discontinuing testosterone therapy has successfully restarted ovulation and resulted in pregnancy.

If a transgender individual has gonads and is engaging in sexual activity, there is still a chance of pregnancy, although there is a decrease in fertility due to hormone treatments. Proper contraception should be used if pregnancy is not desirable at the time, even during transitional hormone replacement therapies.

For transgender individuals interested in pregnancy after transitioning, speak to a doctor about your options.

The Future of Transgender Fertility

New advancements are making it easier for transgender individuals to discuss and manage their fertility, both from social and medical perspectives.

Making conversations easier

Researchers at Children’s National Health System have developed a new tool – the Transgender Youth Fertility Attitudes Questionnaire – to begin the conversation with transgender youth about their fertility options.

Here’s what the tool does:

·      Evaluates child and parents’ knowledge of fertility risks from gender transitioning treatments

·      Gauges potential future interest on having their own biological children

·      Introduces options for fertility preservation

The Transgender Youth Fertility Attitudes Questionnaire is the first tool of its kind, and is designed to keep transgender youth engaged and informed on transitioning options and their effects on future fertility. "Gender-related medical approaches may impact fertility for a lifetime,” John Strang, Psy. D., a neuropsychologist at Children’s National Health System and lead author of the study says, “and while it may not matter to someone now, it might in the future. This new tool will help us understand how our youth feel about these issues and questions, so we know when it is appropriate to discuss choices." With the knowledge gained from the newly developed tool, clinicians can better support transgender teens.

Although there are currently approaches for assessing fertility attitudes in youth with at-risk fertility, the Transgender Youth Fertility Attitudes Questionnaire is the first with questions specifically designed for transgender youth. With special sets of needs for the transgender population – as well as the large autistic population that exists within the transgender youth population – the new tool is specifically geared to ask the right questions while respecting language preferences and other topics sensitive to transgender youth. Best of all: the tool is completely free and available on the Children’s National Website.

The pilot study feature in the journal article found that a majority of transgender youth expressed a desire to have children someday, and 24% hoped that there was a way to make sure that these children were biologically their own. The tool found that many transgender youth are unsure about their feelings of having biological children in the future, which reinforces the importance of the tool. With the ability to trigger conversations about future fertility, transgender youth can begin thinking about the future fertility options before undergoing transitioning or hormone treatments.

Evolving fertility technology

Some transgender youths freeze tissue from their ovaries or testes for later use. This method is still considered experimental but can emerge soon as a viable option for the transgender population.

Scientists at Northwestern University Feinberg School of Medicine also recently created 3-D printed bio-prosthetic ovaries that allow mice to ovulate, give birth, and nurse their offspring. The technology originally was intended for restoring fertility in cancer survivors but has implications for any community struggling with infertility.

Of course, it is important to remember that there are different forms of parenthood available to patients such as adoption and surrogacy. If biological parenthood is something you are interested in, however, it is vital to seek out care from medical professionals who are qualified to work with transgender individuals. Organizations such as the Gay and Lesbian Medical Association provide directories and resources to point you towards professionals who have actively and positively contributed to transgender health.

If you are emotionally struggling during this time, realize that you are not alone. Talking to a professional or seeking out a medical opinion could help you get through this period. Remember, by staying educated about all of your options you are already ahead of the curve.

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