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Fertility Referral Session to explore your options. You can ask any questions you have and learn more about private (non-NHS) clinics in your area that suit your needs.
Introduction
An important risk to consider when deciding whether to commence gender affirming treatment is the potential loss of fertility. This is especially relevant for young people who have not yet completed puberty. Puberty is usually a crucial stage for fertility, because this is when maturation of sperm or eggs usually occurs. However, in young people who take puberty suppressing medication or commence gender affirming hormone treatment before the completion of puberty, this maturation of sperm or eggs may not yet have occurred. While fertility preservation may be more straightforward for adults whose gametes are already producing mature sperm or eggs, the options for fertility preservation are much more limited for young people, because young people may not have mature sperm or eggs to preserve. This article covers some of the options, evidence, and ethical considerations pertaining to fertility preservation for young people.
Effects of gender affirming treatment on fertility in young people
While you are taking puberty suppressing medication, your ovaries or testes may not produce eggs or sperm that are required for fertility. Although the effect of puberty suppressing medication on fertility is itself reversible, it is important to note that subsequent gender affirming hormone treatment may have a more prolonged impact on fertility.
If you commence puberty suppressing medication in early puberty (Tanner stages 2–3) but later stop taking the puberty suppressing medication without commencing gender affirming hormone treatment, then it is likely that your ovaries or testes will go on to produce eggs or sperm, which would allow you to have children (Krishna et al., 2019). However, the process of stopping puberty suppressing medication would also result in other secondary sexual characteristics developing, which may not desirable for gender affirmation.
If you commence puberty suppressing medication in early puberty (Tanner stages 2–3) and then begin gender affirming hormone treatment either at the same time or later, then there is a possibility that your fertility may not even recover after stopping the puberty suppressing medication. This is because your ovaries or testes may not have developed the capacity for mature egg or sperm production by the time you begin the gender affirming hormone treatment (Cheng et al., 2019).
If you commence puberty suppressing medication in late puberty (Tanner stages 4–5) and then begin gender affirming hormone treatment either at the same time or later, then there is a possibility that your fertility may recover after stopping the puberty suppressing medication and gender affirming hormone treatment. This is because your ovaries or testes may have already developed the capacity for mature egg or sperm production. However, the exact effect of the gender affirming hormone treatment on fertility cannot be predicted, and so it is best to consider the possibility that your fertility might be affected by the gender affirming hormone treatment.
Options for fertility preservation in young people
The following table summarises the currently available methods of fertility preservation for prepubertal youth and peripubertal or postpubertal adolescents and adults. Prepubertal means that the person has not commenced puberty. Peripubertal means that the person has commenced but has not completed puberty. Postpubertal means that the person has completed puberty.
| Prepubertal | Peripubertal and postpubertal |
Transfeminine people with testes | - Testicular tissue cryopreservation
| - Sperm cryopreservation
- Testicular tissue cryopreservation
|
Transmasculine people with ovaries | - Ovarian tissue cryopreservation
| - Oocyte cryopreservation
- Ovarian tissue cryopreservation
|
Prepubertal youth
As noted above, there are fewer fertility preservation options for prepubertal youth than for peripubertal or postpubertal adolescents and adults, because prepubertal youth may not yet be producing mature sperm or eggs. Hence, the main options for prepubertal adolescents are testicular tissue cryopreservation and ovarian tissue cryopreservation (Baram et al., 2019). These involve surgical procedures to remove tissue from the testes or ovaries for preservation through freezing. The testicular or ovarian tissue can then be matured in the laboratory and used to produce sperm or eggs.
It is important to note that testicular tissue cryopreservation and ovarian tissue cryopreservation are currently considered experimental procedures (Johnson et al., 2017). Hence, it is currently not well established precisely how effective these procedures are at preserving fertility. Nonetheless, several successful pregnancies have been reported following ovarian tissue cryopreservation in cancer survivors, and so there is evidence that it is effective (Leonel et al., 2019).
Given the experimental status of testicular tissue cryopreservation and ovarian tissue cryopreservation, the availability of these procedures may vary from region to region, and so there may be a need to look for a provider outside of your region if there are none within your geographical region.
Peripubertal and postpubertal adolescents and adults
For individuals who have already commenced puberty, there are more options for fertility preservation. However, the effectiveness of these will depend on how far along in puberty the individual is. These options are likely to be more effective in later puberty, when the individual is more likely to be producing mature sperm or eggs.
For transfeminine people with testes, sperm cryopreservation is an option. Sperm can be collected with a semen sample obtained through masturbation. Alternatively, surgical sperm removal can be performed, although this is more invasive. For transmasculine people with ovaries, oocyte cryopreservation involves surgical removal of eggs from the ovaries, with or without hormonal stimulation of the ovaries.
Ethical considerations
Given that loss of fertility is a significant risk to consider when deciding whether to commence gender affirming treatment, it is important that all trans individuals are fully informed of the risk of infertility as part of the process of establishing informed consent to treatment. Furthermore, the World Professional Association for Transgender Health (2022) recommend that all trans individuals must be counselled about the options for fertility preservation before commencing gender affirming treatment.
Trans people have the same rights to access fertility preservation as any other people. Hence, trans adolescents should not be refused access to fertility preservation because of their gender identities. Moreover, clinicians who have conscientious objections to fertility preservation are still obligated to refer the individuals to services who can provide fertility preservation (Warton and McDougall, 2022).
As with any other healthcare decision, the young person's right to autonomy should be respected (Clark and Virani, 2019). The young person should be fully informed of the benefits and risks of gender affirming treatment, and also of the benefits and risks of the different fertility preservation options. Sufficient support must be provided to enable the young person to make informed decisions about the gender affirming treatment and fertility preservation.
References
- Baram, S., Myers, S. A., Yee, S., and Librach, C. L. (2019). "Fertility preservation for transgender adolescents and young adults: A systematic review". Human Reproduction Update, 25: 694–716.
- Cheng, P. J., Pastuszak, A. W., Myers, J. B., Goodwin, I. A., and Hotaling, J. M. (2019). "Fertility concerns of the transgender patient". Translational Andrology and Urology, 8: 209–218.
- Clark, B. A., and Virani, A. (2019). "Letter: Words matter in the lives of transgender youth: Response to 'Family discordance regarding fertility preservation for a transgender teen: An ethical case study'". Journal of Clinical Ethics, 30 :297–299.
- Johnson, E. K., Finlayson, C., Rowell, E. E., Gosiengfiao, Y., Pavone, M. E., Lockart, B., Orwig, K. E., Brannigan, R. E., and Woodruff, T. K. (2017). "Fertility preservation for pediatric patients: Current state and future possibilities". Journal of Urology, 198: 186–194.
- Krishna, K. B., Fuqua, J. S., Rogol, A. D., Klein, K. O., Popovic, J., Houk, C. P., Charmandari, E., and Lee, P. A. (2019). "Use of gonadotropin-releasing hormone analogs in children: Update by an international consortium". Hormone Research in Paediatrics, 91: 357–372.
- Leonel, E. C. R., Lucci, C. M., and Amorim, C. A. (2019). "Cryopreservation of human ovarian tissue: A review". Transfusion Medicine and Hemotherapy, 46: 173–181.
- Warton, C., and McDougall, R. J. (2022). "Fertility preservation for transgender children and young people in paediatric healthcare: a systematic review of ethical consideration". Journal of Medical Ethics, 48: 1076–1082.
- World Professional Association of Transgender Health (2022). "Standards of care for the health of transgender and gender diverse people, version 8". International Journal of Transgender Health, 23: S1–S258.