Fertility preservation

Fertility preservation, in the context of the trans and nonbinary community, means any steps taken by individuals to medically transition but also retain the option of having children who are biologically related to them. There is often an assumption that all trans people are unable to have or do not want to have biological children, but this is untrue.

Some types of hormone therapy or surgery will reduce or eliminate fertility either reversibly or irreversibly. Physicians often do not inform their patients about this, especially younger patients, although discussing it is recommended to be always done.

Some countries and states require transgender people to be sterilized (have their ovaries or testicles removed) in order to be legally recognised as their self-identified gender.

In some cases, individuals who take puberty blockers and then seamlessly move to taking adult hormone therapy may not have their bodies develop sufficient "reproductive material", leaving them permanently infertile.

Fertility preservation for people born with ovaries
Masculinizing hormone therapy decreases ovulation and stops menstrual bleeding. However, people on masculinizing HRT may still become pregnant.

In patients who have at least begun puberty and who still have their ovaries, oocytes (egg cells) can be cryopreserved for use at a later time. This process can take two or three weeks and requires multiple injections of synthetic hormones which induce oocyte production. During this process, the ovarian cycle is monitored by blood tests and ultrasounds, and eventually the mature oocytes are collected while the patient is sedated. This procedure can be done even if the patient has been on testosterone, but it requires quitting testosterone for a while, at least until menstruation resumes, which may cause dysphoria.

Another option is to simply cryopreserve ("freeze") a sample of ovarian tissue. It can be done with patients of any age who have undergone or not undergone puberty, and it can be done at the same time as an oophorectomy (surgical removal of ovaries). However, this is considered experimental. A 2019 study, which was based on eight years of patient data, "found that transgender men who underwent egg freezing for fertility preservation had similar egg yields as cisgender women".

Fertility preservation for people born with testicles
In patients who have at least begun puberty and who still have their testicles, sperm can be cryopreserved for use at a later time. The sperm can be collected manually or can be extracted by a doctor. The process only takes a day. Sperm collection for preservation can also be done by a testicular biopsy when the patient undergoes orchiectomy (surgical removal of testicles).

There is a difference between sperm collected from ejaculate and sperm collected directly from the testicles. Ejaculated sperm can be placed in someone's vagina (artificial insemination) and "swim up" to fertilize an egg. However, when sperm is collected directly from the testicles, it is unable to "swim", and thus can only be used via in vitro fertilization, which is more expensive and time-consuming than artificial insemination.

Note that many patients will have a zero sperm count after just one month of feminizing hormone therapy, so it is often better to preserve sperm before starting HRT.

Cost
Insurance companies generally consider fertility preservation as "not medically necessary", and thus do not cover these procedures, even when covering other transition-related healthcare.