The Fertility Conversation You'll Be Required to Have#

WPATH Standards of Care Version 8 mandates that healthcare professionals "discuss reproductive options with patients prior to initiation of these medical treatments" (Coleman et al., 2022). Most gender-affirming care providers will raise fertility preservation before prescribing hormones and again before surgery. Some require documented evidence that this conversation occurred.

The stated rationale is patient protection: ensuring no one loses reproductive capacity without understanding that's happening. The guidelines explicitly state that "care should NOT be denied if the patient elects against fertility preservation"—preservation is offered, not required (Coleman et al., 2022).

The intention is reasonable. The experience, for many people, is something else.

If you've already sat through fertility counseling that felt more like interrogation than information-sharing, you're not alone. Many trans people report being asked repeatedly whether they're sure they don't want to preserve gametes, as if their certainty were provisional, as if saying no once weren't enough. For people pursuing surgeries that remove gonads—including vaginoplasty, orchiectomy, oophorectomy, and nulloplasty—the conversation can feel like a final gatekeeping barrier, one more person who doesn't trust you to know your own mind.

When I was preparing for my own surgery, I had the counseling conversation. My providers asked the required questions about fertility preservation. I said no. That was it—they documented my decision and moved forward. I was fortunate to have providers who respected my answer the first time. Not everyone is so lucky.

The counseling mandate exists because some people genuinely don't understand that hormone therapy and surgery affect fertility, and some people do change their minds later and wish they'd preserved options. Both of these are real. But the mandate can also function as institutional skepticism of trans decision-making, a requirement rooted in assumptions that trans people need extra protection from their own choices in ways cisgender people seeking comparable procedures do not.

A 2025 study published in Women's Health Issues surveyed 125 transgender adults who started gender-affirming testosterone by age 18 and found that 47% of participants could not recall receiving counseling about fertility preservation options at all (Boskey et al., 2025). So the system manages to be simultaneously too insistent for some people and completely absent for others—a paradox that speaks to inconsistencies in how trans healthcare is delivered across different settings.

If fertility counseling has felt coercive, condescending, or designed for someone other than you, your frustration is legitimate. You're allowed to go through the motions of a conversation you find meaningless to access the care you need. You're also allowed to advocate for that conversation to be brief and to the point. And you're allowed to give feedback—through patient satisfaction surveys, provider conversations, or advocacy organizations—about how these conversations could be conducted with more respect for the full range of positions people hold.

What Hormones and Surgery Actually Do#

Hormone Effects on AMAB Individuals#

Gender-affirming hormones suppress the body's natural reproductive functions, but the effects are often more reversible than previous generations were told. Understanding what the evidence actually shows—rather than what providers sometimes assume—helps you make informed decisions.

For AMAB individuals on estrogen-based therapy, sperm production declines significantly within three to six months. The mechanism involves suppression of the hypothalamic-pituitary-gonadal axis: estrogen signals the brain to reduce production of the hormones that stimulate the testes, and spermatogenesis slows accordingly. Testicular changes include atrophy, hyalinization (affecting about 28% of specimens in one study), and fibrosis (about 20%). These changes sound alarming, and they're real—but they're not necessarily permanent.

A landmark 2023 Amsterdam study documented complete fertility recovery in all nine trans women who discontinued hormones for reproductive purposes—including three who conceived without any assisted reproductive technology at all (de Nie et al., 2023). This finding challenges previous assumptions that extended estrogen therapy inevitably destroys fertility. A 2019 OHSU study found that 40% of patients maintained some sperm production even after extended estrogen therapy (Schneider et al., 2019). Perhaps most importantly, duration of therapy showed no significant correlation with degree of impairment across multiple studies—meaning someone who's been on hormones for five years isn't necessarily worse off than someone who's been on hormones for one year.

The impact of different anti-androgens varies significantly. Spironolactone shows minimal effect on fertility—53% of patients maintain active spermatogenesis compared to only 8.7% on cyproterone acetate (a more potent anti-androgen used in some countries but not approved for this purpose in the United States). Bicalutamide, uniquely, may preserve testicular function better due to its lack of gonadotropin suppression, though effects depend on concurrent estrogen use. GnRH agonists—puberty blockers used in adolescent care—are considered fully reversible, with normal hormone production resuming approximately one week after cessation.

Hormone Effects on AFAB Individuals#

For AFAB individuals on testosterone, ovulation stops and menstruation typically ceases within three to six months. But anti-Müllerian hormone levels—a key marker of ovarian reserve—remain within normal ranges even after years of testosterone use. Histological studies show 88% of ovarian tissue maintains normal cortical follicle distribution, meaning the eggs are still there, just dormant.

Multiple pregnancies have been documented after up to twelve years of testosterone use, and 80% of individuals resume menstruation within six months of stopping. A survey of 41 transgender men and transmasculine individuals who became pregnant found that most were able to conceive within six months of stopping testosterone—five of these people conceived without having first resumed menstruation at all (Light et al., 2014).

The practical takeaway: hormones suppress fertility during use but don't necessarily destroy it. If you've been on HRT and haven't preserved gametes, options may still exist. If you're starting HRT and don't want to preserve, the reversibility data shouldn't pressure you into procedures you don't want—it just means the door isn't necessarily closed forever.

Surgical Effects#

Surgery creates clearer categories. Procedures that remove gonads—testes or ovaries—end the possibility of producing genetic offspring permanently and irreversibly. This includes bilateral orchiectomy, bilateral oophorectomy, standard vaginoplasty (which incorporates orchiectomy), and nulloplasty.

Once the tissue that produces gametes is gone, it cannot be regenerated. No amount of hormone cessation will restore fertility after gonadal removal. This is the point of no return.

Other surgeries leave options open. Hysterectomy without oophorectomy removes the uterus but leaves ovaries intact—you couldn't carry a pregnancy, but your eggs could theoretically be used with a gestational carrier. Approximately 32% of transgender patients retain one or both ovaries during hysterectomy, representing an important shared decision between patient and surgeon.

Phalloplasty and metoidioplasty don't inherently require removal of reproductive organs; some surgeons offer approaches that preserve the uterus, ovaries, and even vaginal canal. A 2021 Oxford case series documented successful phalloplasty with preservation of vaginal canal and reproductive organs, noting this approach "may allow them the ability to carry a baby to term in the future" (Chen et al., 2021). This option is uncommon though becoming increasingly discussed.

Top surgery—chest masculinization—has no impact on pregnancy capacity, though it typically eliminates or significantly reduces chestfeeding ability. Milk-producing glands are removed during most procedures, and free nipple grafts sever connections to any remaining ducts. Some chest masculinization surgeries maintain the mammary glands while removing breast tissue, potentially preserving some chestfeeding capacity—but this varies by surgical technique and individual anatomy. Of 22 study participants who experienced pregnancy after transition, 4 confirmed inability to chestfeed due to prior surgery, while 5 had deliberately delayed top surgery to preserve this option (MacDonald et al., 2016).

If permanent sterility is part of what you want from surgery—if the removal of reproductive capacity is neutral or actively desirable—then understanding these distinctions matters less for decision-making and more for knowing what to expect from conversations with providers. Some surgeons will emphasize the permanence of sterility as if it were always a tragedy; knowing that you can receive that information without performing grief may help you navigate those conversations.

The Case for Not Preserving#

Medical literature on fertility preservation assumes preservation is the default desirable outcome and non-preservation requires explanation. This framing doesn't fit everyone's reality.

Some people have always known they don't want biological children. The certainty isn't ambivalence waiting to mature into desire—it's self-knowledge that has held steady across years or decades. Being asked to justify that certainty, to consider whether they might change their minds, to spend thousands of dollars preserving capacity they don't want, can feel invalidating rather than protective.

Some people hold ethical positions that make biological reproduction something they would never pursue. Antinatalist philosophy argues that bringing new people into existence causes harm that the person being created cannot consent to in advance—that no life, however good, can justify imposing existence on someone who didn't ask for it. These aren't casual preferences; they're considered ethical positions with philosophical literature spanning centuries. A person holding antinatalist views doesn't need fertility counseling designed to help them think through whether they really want to close the door on reproduction. They closed it deliberately, for reasons they've examined at length.

Some people carry hereditary conditions that inform their choices. Mental illness, chronic pain, genetic disorders, developmental disabilities—these run through families, and some people decide not to pass them on. This choice deserves respect, not challenges dressed as concern.

Some people have experienced trauma that makes the idea of biological parenthood unbearable. The suggestion that they should preserve gametes "just in case" can feel like a demand to keep open doors they've closed for their own protection.

Some people find the entire category of reproductive capability connected to organs causing them profound distress. Being asked to think carefully about preserving the function of body parts they're desperately trying to be rid of—to spend money, time, and emotional energy engaging with anatomy that generates dysphoria—can be genuinely harmful rather than helpful. Research consistently identifies "procedural dysphoria" as a major barrier to fertility preservation uptake: the process itself triggers the very distress people are trying to resolve through transition (Nadgauda & Butts, 2024).

If any of these describe you, this guide affirms your position. You don't owe the medical system a particular emotional response to your own sterility. You don't need to demonstrate adequate grief over lost options you never wanted. You can decline preservation, decline extensive counseling about preservation, and decline to perform conflict about a decision that isn't conflicted for you.

When Preservation Matters#

For people who want biological children, or who aren't sure and want to keep the door open, preservation options exist. The science is better than it was a decade ago, costs are coming down in some areas, and outcomes continue to improve.

Sperm Cryopreservation#

For AMAB individuals, sperm banking before initiating hormone therapy represents the most reliable preservation approach. The process typically requires two to three weeks, with specimens collected every few days to allow sperm counts to recover between samples. Samples are analyzed for viability—including count, motility, and morphology—and frozen in liquid nitrogen, where they can remain indefinitely. Sperm frozen for over forty years have produced healthy children (Szell et al., 2013).

Initial costs range from $1,000 to $2,500 at most facilities, with annual storage fees of $200 to $600. At-home collection services like Legacy offer lower-cost options—sometimes under $500 for collection, analysis, and initial storage—for people without local facilities or those who find clinic collection too difficult to complete. These services ship samples via temperature-controlled kits and provide results within days.

For those already on hormone therapy, options remain but are less certain. UCSF data suggests patients on spironolactone plus estradiol typically have reduced but potentially bankable sperm counts—getting tested to see where you stand costs far less than assuming the worst. Those willing to discontinue hormones may see recovery, though it takes months (typically three to six) and isn't guaranteed—and it means experiencing masculinizing effects that may be intolerable. Some people find this trade-off acceptable; others find it unbearable. Neither response is wrong.

Success rates with frozen sperm are generally good. Intracytoplasmic sperm injection (ICSI), which involves injecting a single sperm directly into an egg, can work with even severely reduced samples. Assisted reproductive outcomes for male cancer survivors—the population with the most comparable long-term cryopreservation data—show pregnancy rates of 40-60% per cycle using frozen sperm, depending on partner factors and technique.

Egg Cryopreservation#

For AFAB individuals, egg freezing requires more intensive intervention. The process involves ovarian stimulation through daily self-administered injections for ten days to two weeks, monitoring through transvaginal ultrasound every few days, and retrieval under sedation—a brief outpatient procedure where eggs are collected via a needle guided through the vaginal wall.

Costs typically total $10,000 to $20,000 per cycle, including medications (which can run $3,000-$5,000 alone), monitoring appointments, retrieval procedure, and initial freezing. Many people complete multiple cycles to bank enough eggs for reasonable chances of eventual pregnancy—eight to fifteen eggs per intended pregnancy is a common target, requiring one to three cycles depending on response.

The traditional protocol requires stopping testosterone months before retrieval to allow ovulation to resume. Depending on individual physiology and duration of testosterone use, this typically takes three to six months—meaning experiencing menstruation returning, breast changes, mood shifts, and other feminizing effects during an already demanding process. For some people, this is manageable. For others, it's unbearable.

Emerging protocols offer alternatives. Random-start ovarian stimulation with letrozole—an aromatase inhibitor that blocks estrogen conversion—allows retrieval without the months-long hormone cessation that traditional protocols require (Amir et al., 2022). Not all clinics offer this approach, and outcomes data are still limited, but it represents meaningful progress for those who find testosterone cessation intolerable.

Boston IVF data shows trans men achieve egg retrieval outcomes comparable to cisgender women, with no correlation between testosterone duration and outcomes (Leung et al., 2019). Testosterone suppresses ovulation but doesn't damage underlying egg supply—the eggs are dormant, not destroyed.

Embryo Cryopreservation#

For those with a partner or willing to use donor sperm, creating and freezing embryos rather than eggs alone offers some advantages. Embryos survive freezing and thawing better than unfertilized eggs—survival rates exceed 95% for embryos compared to 80-90% for eggs. And because embryos can be genetically tested before freezing, you can potentially select the highest-quality embryos and avoid transferring those with chromosomal abnormalities.

The downsides: embryo creation requires either a partner or donor sperm at the time of preservation, and embryos created with a partner can raise complex questions if relationships end. Eggs offer more flexibility for an uncertain future.

The Dysphoria Problem#

Beyond costs and logistics, preservation procedures themselves can trigger significant gender dysphoria. For AFAB individuals, the process involves repeated transvaginal ultrasounds, ovarian stimulation with female hormones, and invasive vaginal procedures. For AMAB individuals, sperm collection via masturbation requires engaging with anatomy that may cause distress.

Research consistently identifies this procedural dysphoria as a major barrier to fertility preservation uptake (Nadgauda & Butts, 2024). Some fertility clinics are developing more trauma-informed approaches—offering sedation for egg retrievals, providing private rooms with gender-affirming options for sperm collection, using inclusive language throughout. But availability varies widely, and many clinics haven't caught up.

If you want to preserve fertility but dread the process, consider seeking clinics that specifically serve transgender patients. Ask about their experience with trans patients, their protocols for managing dysphoria, and what accommodations they offer. You don't have to white-knuckle through a traumatizing experience—though you also don't have to pursue preservation at all if the process itself outweighs the value of the preserved gametes.

Cost Barriers and Insurance Reality#

Preservation costs are genuinely prohibitive for many people. The financial barrier isn't incidental—it shapes who gets to keep reproductive options open and who doesn't.

Only 11% of transgender adults live in states requiring private insurers to cover fertility preservation with storage (RESOLVE, 2024). The remaining 89% are largely on their own. While 15 states now have some form of legislation regarding fertility preservation protection for iatrogenic infertility—infertility caused by medically necessary treatments like chemotherapy—those pursuing gender-affirming hormone therapy are largely excluded from qualifying for this coverage (Nadgauda & Butts, 2024).

States with LGBTQ+-inclusive fertility coverage include California (effective January 2026 for large group plans), Colorado, Connecticut, Delaware, Illinois, Maine, Maryland, New Hampshire, New Jersey, New York, and Rhode Island. But even in these states, coinsurance and copays vary widely, self-funded employer plans often fall outside state mandates, and comprehensive coverage is not guaranteed.

Employer benefits are expanding—42% of U.S. employers covered fertility treatments in 2024, up from 30% in 2020—but 67% of employer plans are self-insured and exempt from state coverage mandates. If your employer offers fertility benefits, check whether they explicitly include coverage for gender-affirming treatment-related preservation or whether they define "infertility" in ways that exclude you.

Racial and economic disparities compound access barriers. One survey found that 8% of LGBTQI+ adults of color reported denial of fertility preservation coverage compared to 3% of white LGBTQI+ adults—a disparity that reflects broader patterns of discrimination in healthcare access.

This isn't a neutral reality to accept; it's an injustice worth naming. People without resources for preservation shouldn't carry additional guilt about a decision economics made for them. And the existence of cost barriers shouldn't be weaponized to pressure people who could afford preservation but don't want it—as if failing to preserve when you can afford it represents irresponsibility.

What the Sterility Mandate Obscures#

The fertility conversation as currently structured assumes reproductive desire is the default human condition and its absence requires explanation, counseling, and verification. This assumption deserves interrogation.

Cisgender people make choices that end their fertility without comparable scrutiny. Tubal ligation and vasectomy are available to adults who want them, often with minimal counseling about potential future regret. Yes, some young cisgender women seeking sterilization face invasive questioning—that's also a problem. But the "are you sure you won't want children later?" question gets layered on top of all the other gatekeeping trans people navigate.

The underlying assumption that everyone should want to reproduce—that permanent sterility is always a loss to be weighed against other considerations—reflects pronatalist cultural values that not everyone shares. If you don't share them, you don't need to pretend you do. If you find the assumption irritating, offensive, or disconnected from your values, your response is reasonable.

The same 2025 survey of transgender adults who started testosterone by age 18 found revealing results: 22% of participants did not wish to have children, 47% wanted children but did not view a genetic relationship as important, only 8% viewed having genetically related children as important, and 17% were unsure (Boskey et al., 2025). In other words, only a small minority of trans adults who transitioned young place high value on genetic parenthood. The medical system's assumption that fertility preservation should be strongly encouraged for everyone doesn't reflect the actual priorities of many trans people.

This isn't to say the counseling mandate is purely malicious or without value. Some people genuinely benefit from conversations that surface considerations they hadn't thought through. But the way these conversations often occur—focused on potential future regret, treating non-desire as the position requiring justification, assuming grief over options closing—serves some people and alienates others.

Pregnancy and Parenthood After Transition#

For AFAB individuals who retain their uterus and ovaries, pregnancy remains possible after transition—including after years of testosterone use. Understanding what this path involves helps people make informed decisions about whether to pursue it.

Becoming Pregnant After Testosterone#

Testosterone must be stopped before attempting conception. This isn't optional—testosterone is teratogenic, meaning it can cause abnormal development in a fetus, particularly affecting the urogenital system of a female fetus. The first trimester is especially critical, when many pregnancies haven't been discovered yet. Continuous testosterone use is contraindicated while attempting to conceive, during pregnancy, and while chestfeeding.

After stopping testosterone, menstrual cycles typically return within three to six months, though timing varies based on how long someone used testosterone and individual physiology. Many trans men who had planned pregnancies were able to conceive within six months of stopping. Some conceive even before menstruation returns.

A survey of 41 transgender men who experienced pregnancy found 61% had previously used testosterone. There were no significant differences in pregnancy, delivery, or birth outcomes between trans men who had versus hadn't used testosterone—suggesting that prior testosterone use doesn't compromise pregnancy outcomes once discontinued (Light et al., 2014).

The Reality of Pregnancy While Trans#

Pregnancy involves months of a body doing something that may feel deeply incongruent with identity. For some trans men and nonbinary people, this is manageable—even meaningful. For others, it triggers severe dysphoria that outweighs any desire for biological parenthood.

The emotional experience varies enormously. Some people find pregnancy surprisingly affirming or at least neutral. Others experience it as months of dissociation, distress, and gender incongruence they're enduring for the sake of a child. Patient responses in research studies ranged from significantly improved to significantly worsened dysphoria during pregnancy. Neither response is more valid; both are real possibilities worth considering honestly before pursuing this path.

Healthcare interactions during pregnancy can compound dysphoria. Medical settings often assume pregnant people are women, use gendered language, and respond awkwardly to trans patients. Fears of stigmatization by healthcare providers are prevalent among trans people considering pregnancy. Seeking care from providers experienced with transgender patients—or at minimum, willing to learn and use affirming language—can make the experience more tolerable.

Chestfeeding Considerations#

Whether and how to feed a newborn is another decision with no single right answer.

For those who haven't had top surgery, chestfeeding is typically physically possible, though testosterone must remain stopped during the chestfeeding period—extending the time without hormones from months of pregnancy to potentially a year or more of nursing. Some people find this extension unbearable; others find the connection to their infant worth the trade-off.

For those who have had chest masculinization surgery, chestfeeding depends on the specific procedure performed. Double-incision mastectomy with free nipple grafts typically eliminates chestfeeding capacity because milk-producing glands are removed and nipples are disconnected from ducts. Some surgeries that maintain more breast tissue and preserve nipple connections may allow partial chestfeeding, though production is often reduced. Supplemental nursing systems allow chest-to-baby bonding without significant milk production, using a tube to deliver formula or donor milk while the baby nurses.

Research on transmasculine experiences with chestfeeding reveals complex emotional terrain. Some participants described intense internal conflict—"He needs to eat!" warring with dysphoria about the activity. Others found chestfeeding unexpectedly meaningful. One participant who bound his chest and took testosterone while chestfeeding found this approach allowed him to present as male and also chestfeed his child into toddlerhood—an unconventional path, but one that worked for him (MacDonald et al., 2016).

Healthcare providers typically recommend not using testosterone while chestfeeding, citing concerns about hormone transfer through milk and suppression of milk production. The evidence base is limited—testosterone has been used to suppress lactation in cisgender women, suggesting it would reduce supply, but data specific to microdosing during lactation is minimal. As one researcher noted, recommendations to pause testosterone "could mean a pause in testosterone therapy for up to two years"—a significant burden that deserves more research attention (Lowik, 2025).

Resuming Transition After Pregnancy#

Once pregnancy and any desired chestfeeding period ends, testosterone can be resumed. Previous testosterone use doesn't prevent restarting, and masculinizing effects typically resume as expected. Some people find returning to testosterone after the hormonal experience of pregnancy and postpartum brings intense relief; others navigate postpartum depression or adjustment challenges that deserve attention.

Contraception planning after pregnancy matters because testosterone is not an effective contraceptive. Even if menstruation has stopped, approximately one-third of amenorrhic trans people taking testosterone still ovulate, which can result in unintended pregnancy. If you don't want to become pregnant again, using reliable contraception alongside testosterone is essential.

Alternatives to Biological Reproduction#

For people who want to parent but haven't preserved gametes, or who actively prefer non-biological pathways, other options exist.

Adoption#

Adoption remains possible for transgender individuals in all 50 states. Same-sex and transgender adoption has been legal nationwide since 2016. However, 14 states have religious exemption laws allowing some private adoption agencies to discriminate—these agencies can refuse to place children with LGBTQ+ individuals based on religious beliefs.

Public agency foster-to-adopt pathways explicitly prohibit discrimination and offer significantly lower costs than private infant adoption—often little to nothing compared to $35,000 to $65,000 for domestic infant adoption. Timelines vary widely but typically range from one to three years for domestic infant adoption.

International adoption has become extremely limited for LGBTQ+ individuals. Most countries with active international adoption programs exclude same-sex couples and/or transgender individuals. Only Colombia, Brazil, and some Mexican states potentially remain open, and policies change frequently.

Surrogacy#

Surrogacy using donor gametes enables parenthood without genetic connection to the child. For trans women who haven't preserved sperm, this would involve using donor sperm with a gestational carrier. For trans men who haven't preserved eggs, this could involve using donor eggs.

Known donation from friends or family can create biological links that don't require your own gamete preservation. A sibling's egg or sperm would make a child genetically related to your family, even if not to you specifically.

Costs are substantial—gestational surrogacy in the United States typically runs $100,000 to $200,000 including agency fees, legal costs, medical expenses, and carrier compensation. International surrogacy may offer lower costs but involves complex legal considerations.

Co-Parenting and Chosen Family#

Co-parenting arrangements—raising children collaboratively with others who contribute genetic material, gestational capacity, or both—represent creative family structures that don't fit neatly into traditional models but meet the needs of people building them. Trans women might co-parent with trans men, each contributing gametes but neither carrying pregnancy; queer friends might raise children together without being romantic partners; chosen family structures might involve multiple adults sharing parenting responsibilities.

These arrangements require careful thought about legal protections, custody arrangements, and expectations—but they represent real options for people who want to parent without the pathways that traditional fertility counseling assumes.

Finding Clarity About What You Want#

Some people find that the question of biological reproduction, once removed from possibility, clarifies desires they didn't know they had—they discover they wanted it more than they realized only after it's no longer an option. Others find that sterility closes a question that was never really open—confirming what they always knew, that biological parenthood wasn't for them.

Both experiences are common; neither is more valid than the other. If you're uncertain, sitting with that uncertainty—rather than rushing to resolve it through preservation or surgery—may be worthwhile. But you don't owe certainty to anyone. Making decisions under uncertainty is a normal part of being human.

Experimental Technologies on the Horizon#

Technologies in development may eventually enable reproduction without traditional gametes. Understanding what's actually possible versus what's speculative helps calibrate expectations.

Testicular Tissue Cryopreservation#

For prepubertal trans girls who haven't yet produced sperm, testicular tissue cryopreservation offers the only current preservation option. This involves extracting tissue containing spermatogonial stem cells for potential future use. Approximately 200 children worldwide have cryopreserved testicular tissue under research protocols—primarily for cancer treatment rather than gender-affirming care (University of Pittsburgh, 2024).

The technology is still experimental with no human pregnancies yet achieved from cryopreserved testicular tissue. Future applications include transplanting stem cells back into testes to restart sperm production (successful in mice, pigs, and primates—potentially three to five years from clinical translation) and in vitro spermatogenesis, growing sperm from stem cells in the lab (five to ten or more years away).

Ovarian Tissue Cryopreservation#

Ovarian tissue cryopreservation is no longer experimental for cisgender women—the American Society for Reproductive Medicine removed its experimental designation in 2019, and over 200 live births have been documented worldwide. The technique offers significant advantages: no hormone stimulation required, no transvaginal ultrasounds, and can be performed at the time of oophorectomy.

Data from transgender individuals on testosterone remains limited, but research from Ghent University shows primordial follicles are not depleted after testosterone treatment, with 38% of cultured oocytes reaching mature stage. This suggests tissue frozen from trans men could potentially be used for future fertility.

Uterus Transplantation#

Uterus transplantation for trans women has moved from theoretical discussion to active planning. Over 60 uterus transplants have been performed globally with 18 or more live births—all in cisgender women who lacked a functioning uterus. A 2021 survey found 99% of trans women believed uterus transplantation would increase their happiness, and 77% would be more likely to cryopreserve sperm if uterus transplantation became a realistic option.

The first trans woman uterus transplant is predicted within two to five years, though significant anatomical challenges remain—including narrower pelvic inlet and the need to connect a transplanted uterus to a surgically constructed vagina rather than a natural one.

In Vitro Gametogenesis#

In vitro gametogenesis—creating eggs or sperm from skin or blood cells via induced pluripotent stem cells—represents the most transformative but distant technology. Complete mouse gametogenesis has been achieved with fertile offspring produced. A 2023 breakthrough demonstrated converting male mouse cells with XY chromosomes into functional eggs with XX chromosomes.

For humans, this could theoretically enable trans women to produce genetically-related eggs and trans men to produce sperm. Timeline estimates range from 10 to 20 years for clinical application, assuming technical and regulatory hurdles can be overcome.

The Problem with Planning for Speculative Futures#

If you're young and making decisions now with an eye toward technologies that might exist in twenty years, that's your prerogative. But building major life decisions around speculative futures carries risks. The technologies may not materialize. They may not be accessible or affordable. They may work less well than hoped.

And orienting your current choices around hypothetical future capacity means living in anticipation rather than in the present reality of your body and your values. You are not obligated to preserve fertility on the off chance that in vitro gametogenesis pans out. You're allowed to make decisions based on what exists now and what you want now.

Making This Decision Without Apology#

Fertility preservation is a personal decision that sits at the intersection of identity, values, resources, and uncertainty about the future. There is no universal right answer.

If you want to preserve fertility and can access preservation services, the technology is better than it's ever been. Start early—ideally before hormone therapy if you have that option—and work with fertility clinics experienced with transgender patients. The information in this guide and discussions with reproductive medicine specialists can help you plan.

If you don't want to preserve fertility—whether from certainty about not wanting children, ethical convictions about reproduction, practical considerations, or simple lack of interest in the option—your position is valid. You don't owe extended justification to providers, family members, or anyone else. You can complete mandated fertility counseling by stating that you understand the information and decline preservation, then move forward with the care you need.

When I went through this process, I said no. I said it once, clearly, without apology. My providers documented my informed refusal and proceeded with my care. That's how it should work for everyone—your decision respected the first time you make it.

If you're uncertain, that's a legitimate place to be. Uncertainty doesn't obligate you to preserve, but it might inform a decision to do so. Only you can weigh how much the possibility of future regret matters against the costs—financial, emotional, physical—of preservation now.

Whatever you decide, the decision is yours. The medical system's job is to provide information and access; it is not to determine what choices are correct for you. You are the expert on your own life, your own values, your own relationship to reproduction and family. Trust that expertise.

Reflection Questions#

  1. Before reading this guide, what assumptions did you hold about what trans people are "supposed to" feel about fertility and reproduction? Where did those assumptions come from?

  2. If you've experienced fertility counseling as part of transition-related care, how did that conversation feel? Was it helpful, neutral, or something more frustrating? What would have made it better?

  3. What is your relationship to the concept of biological parenthood? Not what you think you should feel, but what you actually feel when you imagine it.

  4. For those who don't want biological children: How do you typically respond when that choice is questioned? How would you like to respond? What would it feel like to simply state your position without defending it?

  5. For those who want biological children or are uncertain: What would you need to feel confident in a decision about preservation? What information, support, or resources are you missing? What barriers—financial, logistical, emotional—stand in your way?

  6. How do you feel about the permanent, irreversible nature of sterility after gonadal removal? Is that aspect of surgery neutral, frightening, relieving, or something more complicated?

  7. If you imagine your life in ten years without biological children—whether by choice, circumstance, or surgical outcome—what does that life look like? What does it contain? Is that vision acceptable, desirable, or something else?

References#

Amir, H., Yaish, I., Oren, A., Groutz, A., Greenman, Y., & Azem, F. (2022). Oocyte retrieval outcomes among transgender men compared with fertile cisgender women. Journal of Assisted Reproduction and Genetics, 39(9), 2193–2199. https://doi.org/10.1007/s10815-022-02599-4

American Society for Reproductive Medicine Ethics Committee. (2021). Access to fertility services by transgender and nonbinary persons: An Ethics Committee opinion. Fertility and Sterility, 115(4), 874–878. https://doi.org/10.1016/j.fertnstert.2021.01.049

Boskey, E. R., Redwood, E., Parsa, T., & Grimstad, F. W. (2025). Fertility intentions and histories among transgender adults who started gender-affirming testosterone before adulthood. Women's Health Issues. Advance online publication. https://doi.org/10.1016/j.whi.2025.02.001

Chen, M. L., Reyblat, P., Poh, M. M., & Chi, A. C. (2021). Overview of surgical techniques in gender-affirming genital surgery. Translational Andrology and Urology, 8(3), 191–208. https://doi.org/10.21037/tau.2019.06.19

Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., de Vries, A. L. C., Deutsch, M. B., ... & Arcelus, J. (2022). Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health, 23(S1), S1–S259. https://doi.org/10.1080/26895269.2022.2100644

de Nie, I., de Blok, C. J. M., van der Sluis, T. M., Meißner, A., Wiepjes, C. M., Carrie, C. J., ... & den Heijer, M. (2023). Successful restoration of spermatogenesis following gender-affirming hormone therapy in transgender women. Cell Reports Medicine, 4(9), 101059. https://doi.org/10.1016/j.xcrm.2023.101059

De Roo, C., Tilleman, K., T'Sjoen, G., & De Sutter, P. (2017). Fertility options in transgender people. International Review of Psychiatry, 28(1), 112–119. https://doi.org/10.3109/09540261.2015.1084275

Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., ... & T'Sjoen, G. G. (2017). Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism, 102(11), 3869–3903. https://doi.org/10.1210/jc.2017-01658

Leung, A., Sakkas, D., Pang, S., Thornton, K., & Resetkova, N. (2019). Assisted reproductive technology outcomes in female-to-male transgender patients compared with cisgender patients: A new frontier in reproductive medicine. Fertility and Sterility, 112(5), 858–865. https://doi.org/10.1016/j.fertnstert.2019.07.014

Light, A. D., Obedin-Maliver, J., Sevelius, J. M., & Kerns, J. L. (2014). Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstetrics & Gynecology, 124(6), 1120–1127. https://doi.org/10.1097/AOG.0000000000000540

Lowik, A. J. (2025, February 12). Transgender men and nonbinary people are asked to stop testosterone therapy during pregnancy—but the evidence for this guidance is still murky. The Conversation. https://theconversation.com/transgender-men-and-nonbinary-people-are-asked-to-stop-testosterone-therapy-during-pregnancy-but-the-evidence-for-this-guidance-is-still-murky-187672

MacDonald, T., Noel-Weiss, J., West, D., Walks, M., Biener, M., Kibbe, A., & Myler, E. (2016). Transmasculine individuals' experiences with lactation, chestfeeding, and gender identity: A qualitative study. BMC Pregnancy and Childbirth, 16, 106. https://doi.org/10.1186/s12884-016-0907-y

Nadgauda, A. S., & Butts, S. (2024). Barriers to fertility preservation access in transgender and gender diverse adolescents: A narrative review. Therapeutic Advances in Reproductive Health, 18. https://doi.org/10.1177/26334941231222120

RESOLVE: The National Infertility Association. (2024). Insurance coverage by state. https://resolve.org/learn/financial-resources-for-family-building/insurance-coverage/insurance-coverage-by-state/

Schneider, F., Neuhaus, N., Wistuba, J., Zitzmann, M., Heber-Katz, E., Kliesch, S., & Schlatt, S. (2019). Testicular functions and clinical characterization of patients with gender dysphoria undergoing sex reassignment surgery. Journal of Sexual Medicine, 12(11), 2190–2200. https://doi.org/10.1016/j.jsxm.2015.09.003

Szell, A. Z., Biber, R. C., Engmann, L. L., Thomas, M. R., Nulsen, J. C., & Benadiva, C. A. (2013). Live births from frozen human semen stored for 40 years. Journal of Assisted Reproduction and Genetics, 30(6), 743–744. https://doi.org/10.1007/s10815-013-9998-9

UCSF Transgender Care. (2016). Fertility options for transgender persons. https://transcare.ucsf.edu/guidelines/fertility

Continue exploring#