If you’re transgender and/or nonbinary and are or have been on Hormone Replacement Therapy (HRT) as a part of your gender-affirming care, chances are you’ve been told that your fertility is ruined, or at the very least greatly diminished, possibly permanently – but what if that’s not true? While fertility preservation through freezing eggs or sperm is still the safest option and the standard of care recommendation, many of us did not choose to do that before starting HRT. I am a part of a large community of transmasculine and transfeminine people who are successfully creating families that include their own biological children, often without assisted reproductive technology and after many years on HRT. My own family is one of them – I am a nonbinary (genderfluid) transmasculine person and I was on testosterone for 9 months before coming off of it to conceive. My first child’s other bio-parent is a transwoman who had been on the testosterone blocker spironolactone (spiro) and estrogen (estradiol) for seven years before coming off them for just 3 months to restore her sperm count and motility and conceive our baby. My second child was conceived while my partner was on their usual dose of estradiol – but they have never taken a T-blocker of any kind. There is very little to no evidence to suggest that the majority of us can’t achieve fertility levels similar to cisgender folks after discontinuing hormones and optimizing wellness. So how is all of this possible? I’ll go over the basics for you, and report on some of the science, but if you would like to discuss how this applies to your body specifically, I would love to see you in our office!
For folks on feminizing HRT who have retained all of their original plumbing, the main things to keep in mind are this: spermatogenesis (the development of sperm in the testes) takes 3 months of continual exposure to testosterone. This is independent of what is going on with estrogen, and as long as estrogen is not suppressing testosterone completely (which it generally does not, especially at the testes where testosterone is being produced locally) it can proceed. I have personally known several folks to conceive babies while on estrogen and not a T-blocker, but it may sometimes be necessary or optimal to come off both for a period of time to restore sperm production. There is also a (smaller than most doctors would lead you to believe) chance that long-term suppression of testosterone may permanently reduce or eliminate the ability to create sperm. You can work with a fertility clinic to get a semenalysis to check where you are at with sperm count and motility now or after adjusting your HRT regimen. I am available to support you by tracking your progress medically, checking hormone levels, helping you mitigate uncomfortable symptoms, optimizing your health, and providing counseling as you navigate the journey toward parenthood.
For folks on masculinizing HRT who retain their original plumbing – your cycle (ovulation and
menstruation) is suppressed by testosterone, but not necessarily completely. Some folks on lower doses of T, have started recently, or sometimes miss doses may still ovulate. I have not found any evidence to suggest that Testosterone therapy reduces egg viability or conception rates in trans folks attempting cryopreservation or natural conception. In fact, I have seen anecdotal evidence that fertility may be increased after discontinuing testosterone, which may be due to a hormonal “bounce back”. However, Testosterone is considered teratogenic – meaning it can cause birth defects in a developing fetus (or miscarriage) if it remains in your system while you are pregnant, although we have limited evidence on this, and many people have perfectly healthy pregnancies after accidentally conceiving while on testosterone and discontinuing it when they discover they are pregnant. The process of going from no cycle/fully testosterone-dominant to having full fertility cycles can range from very simple to complex. The longer you have been on T, the longer it may take your body to return to normal cycles. You can begin to track your fertility by noting what days and how heavily you bleed and any other hormonal symptoms that come up. The next step would be to begin looking for ovulation by using luteinizing hormone (LH) urine test strips, basal body temperature tracking, and other fertility signs. Your body may do things you haven’t ever experienced before, especially if you started HRT in your teens or early 20s (if you went on puberty blockers earlier in life, your journey will be different because you may still need to go through the final stages of puberty before achieving fertility. These changes can be overwhelming and stressful – please seek the support of a medical and/or mental health provider during the process of pre-conception. I am available to support you by tracking your progress medically, checking hormone levels, helping you mitigate uncomfortable symptoms, optimizing your health, and providing counseling as you navigate the journey toward parenthood.
If you would like to see if I might be a good resource for you, please reach out to book a complimentary 15-minute consultation with me (Dr. Justice Erikson) by emailing firstname.lastname@example.org.
References / Recommended Reading:
Reproductive potential and fertility preservation in transgender and nonbinary individuals - PubMed (nih.gov)
Fertility Preservation and Reproductive Potential in Transgender and Gender Fluid Population (nih.gov)
Fertility Options for the Transgender and Gender Nonbinary Patient - PMC (nih.gov)
Similar fertilization rates and preimplantation embryo development among testosterone-treated transgender men and cisgender women - PubMed (nih.gov)