Trans Fertility in Conversation

In January of 2019, Japan’s Supreme Court upheld a law requiring trans people to be sterilized in order to legally change their gender. After the ruling, I remember seeing a tweet by the Economist sharing the article,“Should transgender people be sterilised before they are recognised?”. Posing this as a question legitimizes the idea that individual reproductive rights are up for debate. They are not. 

I was infuriated, and deeply hurt. The right to reproduce is fundamental. To be told by the state that you must trade your right to have biological children to have your gender legally recognized is a chilling violation of human dignity. 

It also got me thinking about how, reproductive rights violations aside, trans people’s fertility options are often overlooked, discounted or stigmatized. Oftentimes, conversations about fertility are glossed over by practitioners with trans clients seeking gender-affirming care. Maybe it’s difficult to think about having a biological child if you’re young, if you are just at the beginning of your medical transition or for any number of other reasons. But you should at least know about your fertility options. 

To bring more awareness of fertility options for trans people, I recently organized a panel discussion with two reproductive health specialists who specialize in providing services to trans people: Evelyn Mok-Lin, MD, medical director of UCSF Center for Reproductive Health, and Pratima Gupta, MD, medical director of St. James Infirmary and board member of San Francisco AIDS Foundation. They answered questions about the effect of hormones on fertility, pregnancy options for trans people, and more. Here’s what we learned. 

Do you get many trans clients who initiate conversations about their fertility?

Pratima Gupta, MD: It’s a very small percentage of my patients that ask. Anecdotally, I would say that this is just not something that’s on their radar. When people are initiating hormones, that is usually their priority. Fertility isn’t something that they are considering. They’re thinking about gender-affirming care, so it is important for us, as providers, to discuss it. 

Why is it important for trans people to start conversations about their fertility with their health care provider?

Evelyn Mok-Lin, MD: The ideal right now is to try to conceive or try to preserve one’s fertility before starting hormone therapy. We know that people that have transitioned can still conceive. We also know that people who have not started hormones are more likely to conceive. So that’s why it’s important to have a discussion with your doctor about your future fertility plans and family plans before starting hormone therapy or having surgery.

Gupta: It’s really important for health care providers to have thorough discussions about options, planning and cost with their trans clients. It’s so much more than just ticking a box and asking trans clients if they want to get pregnant or get someone else pregnant. Although there are these recommendations for health care providers, it’s also good for people to advocate for themselves. It’s a good conversation to start, even if your provider doesn’t initiate it.

What are options for trans people to have a baby?

Mok-Lin: Of course adoption is always an option, but here I’ll discuss options for having a genetically related child. To have a genetically-related child, you need an egg, a sperm and a uterus. That’s the foundation of it. It depends on which of these you have, and which your partner (if you have one) has.

If between you and a partner, you have eggs, a uterus and sperm, spontaneous conception (getting pregnant “naturally”) may be an option.

Intrauterine insemination (IUI) may also be an option. This is when your sperm, a partner’s sperm, donor sperm or frozen sperm is put into the uterus.

In vitro fertilization (IVF) may also be an option. We can use frozen eggs from someone who may have frozen them prior to having ovaries removed or before starting hormone treatment. Or you can use donor eggs or a partner’s eggs and combine them with a partner’s sperm, donor sperm, or frozen sperm. If you have a uterus, the embryo could be transferred there, or it could be put into the uterus of a surrogate. There are a lot of ways to make it happen.

What are the costs associated with these procedures?

Mok-Lin: It depends on your insurance. We live in a unique place where a lot of people who work in Silicon Valley have coverage for fertility treatments. But not everyone does.

If you don’t have coverage, intrauterine insemination can cost about $1,000. That doesn’t include the cost of sperm. If the sperm comes from the couple, then there’s little to no cost. If you get donor sperm, the cost may be another $700. IVF can cost around $15,000 to $20,000 per cycle. If you use a surrogate, that can be on the order of $150,000.

There are a lot of options, but it can be extremely cost-prohibitive, unfortunately. Some people who need fertility coverage switch companies to get the right insurance coverage. They may move to another state (such as Massachusetts), or look for jobs that are local but at a company based in Massachusetts.

Gupta: I recently had a client who did that: She took a position at a company that was, job-wise, a bit of a demotion in terms of her career. But the company offered fertility coverage, and she did the math.

Can you get pregnant, or can you get a partner pregnant, if you’re taking hormones?

Mok-Lin: This is one of the things I always talk to teenagers about before they start testosterone. T (testosterone) is not a form of contraception! We know that people have gotten pregnant on testosterone. If you don’t want to get pregnant, and are having intercourse with someone who has sperm, you need another form of protection.

That said, there aren’t that many people who have gotten pregnant when on T, because T can prevent ovulation and the thickening of the uterus. When the lining of the uterus is thin, an egg—if one is released—isn’t able to implant properly.

There was one study by Alexis Light of trans men who had pregnancies. The group of men included those who had never taken T and those who had taken T and come off of it. This study concluded that men who had never taken T were three times more likely than those who took T to get pregnant. But the number of people in the study was so small, it’s hard to know for sure.

Gupta: The same is true for people on estrogen. Feminizing hormones, similarly, do not cease sperm production. You can’t rely on estrogen as contraception.

What about for trans people who do want to become pregnant or get someone else pregnant? What are the effects of hormones?

Mok-Lin: It’s more difficult to conceive naturally on hormones, but we know it’s not impossible. The recommendation now is to come off of hormones three to six months before trying to conceive. Time off of hormones allows the lining of the uterus to thicken, which allows the egg to implant properly. The life cycle of sperm is about 70 days so it takes between two and three months to resume spermatogenesis.

There is one study from our center comparing sperm samples from people who had never taken estrogen, who had taken estrogen but stopped and who were currently on estrogen.

The people who had never taken estrogen had the highest sperm counts. People who took hormones but stopped had relatively normal sperm counts, but had lower sperm counts than people who had never started hormones. The folks who stayed on hormones had really low sperm counts. This shows us that the decreased sperm count is reversible. That’s reassuring. Sperm seems relatively hardy.

Testosterone doesn’t make someone completely infertile. We know that people who have never taken testosterone are three times more likely to conceive naturally than people who have taken testosterone, even if the testosterone is stopped.

From the data we have on pregnancies that happened when people were on hormones, we know that there were no higher risk of birth defects or other issues.

How can the intersection of being trans and a person of color impact someone’s reproductive journey?

Gupta: I think it’s very complicated – this issue of being black or brown, being trans, and seeking pregnancy. We know that structural and institutional racism contribute to maternal mortality rates that are three to four times higher for African American women than white women. On top of that, you have challenges to health because you are trans. It’s not necessarily true that all providers are aware of and support trans health. There’s higher risk pregnancy and delivery. There’s postpartum depression. There may be complications. It’s something we need to be aware of and supportive of our trans brothers and sisters who are seeking pregnancy.

What are the options for trans people to breastfeed or chestfeed a baby?

Gupta: If a trans man who has had top surgery wants to breast or chest feed, it can be difficult. This is something to discuss before initiating gender-affirming care. If there isn’t any breast tissue left after a mastectomy, there aren’t any mammary glands to produce milk. That being said, there are options to use donor milk or formula.

For trans women, induction is an option. We can stimulate breast milk production—it’s similar to if a cis-woman adopts a baby and wants to breast feed. It does take a lot—it’s a lot of work. 

What would you say to someone who says that trying to have a baby makes you less authentically trans?

Gupta: That’s horrible. And completely untrue! Everyone has their own journey. There’s no one way to be a trans person. Wanting to have a baby doesn’t make a person more or less trans.

Mok-Lin: Agree. Reproduction is a completely separate thing from gender identity. It’s like saying to a cis-woman who chooses not to have children that they are somehow less of a woman.