BuzzFeed Life recently reported Part 1 of a story about things that people should know about their fertility.
And it covered a lot of ground, like how smoking cigarettes can hurt your egg quality, and how fertility issues can impact both men and women. That said, it focused on fertility issues that applied most specifically to cisgender individuals — people who identify as the gender that they were assigned at birth. The issues covered in part 1 can and do affect transgender individuals, of course, but certain tips and facts covered in the first piece are less broadly applicable in the context of transitioning.
So this is part 2 of that story. This piece focuses on numerous things that transgender individuals specifically should be aware of when it comes to fertility, pregnancy, and having genetically related kids.
Worth noting before we get going: This article will refer to three general types of transitioning, based on expert feedback:
1. Social — where you transition socially, in how you present yourself
2. Medical — where you take hormones and other medications to bring your body in greater alignment with your self-identified gender
3. Surgical — where you undergo any number of a wide range of surgical procedures, also meant to bring your body into greater alignment with your identity
For this story, BuzzFeed Life spoke with three experts with a range of experiences:
Juno Obedin-Maliver, M.D., M.P.H., an OB-GYN at the San Francisco VA and researcher at the University of California San Francisco, and founding member of the Stanford Lesbian, Gay, Bisexual, and Transgender Medical Education Research Group (LGBT MERG)
Dane Menkin, M.S.N., C.R.N.P., a family nurse practitioner and clinical operations manager at Mazzoni Family and Community Medicine in Philadelphia, Pennsylvania. Menkin estimates that he has performed over 50 intrauterine inseminations (IUIs) for transgender individuals and their partners trying to have babies
Courtney Finlayson, M.D., a pediatric endocrinologist at the Ann & Robert H. Lurie Children's Hospital of Chicago
Here's some of what they had to say.
1. To keep it simple: In order to make a baby, you need sperm, an egg, and a uterus for the embryo to grow in.
Any one of those can be your own, your partner's, or a donor's. All that matters is that the sperm meets the egg, and the fertilized embryo implants and then grows inside the uterus. How and where the magic happens is ultimately a matter of logistics and planning.
2. The same issues that can impact a cisgender person's fertility can impact a transgender person's fertility.
If you have ovaries, you will have fewer eggs and fewer healthy eggs as you get older, just as cis women do. Smoking will seriously hurt your egg quality. Being overweight, obese, or underweight can also adversely impact your fertility, and a history of sexually transmitted infections can potentially mean that your fallopian tubes may be scarred, increasing your risks of miscarriage or ectopic pregnancy. Smoking marijuana can hurt your sperm quality, and varicoceles in your testicles can render you (temporarily) infertile. And more. Read 22 things people should know about their fertility and 22 things you should know about STDs and your fertility to get some basic facts about infertility issues.
3. Even if you've medically or surgically transitioned, you may still be able to have genetically related kids. And it might even happen by accident, if you don't take certain precautions.
"Most transgender people do not have surgical procedures that make them incapable of having genetically related children," Obedin-Maliver says. Sure, certain surgical transitions can mean that you no longer have access to your own eggs or sperm or uterus, and some medical transitions can have potential negative effects on the quality or viability of your eggs or sperm. But otherwise... you may still be able to make a baby (intentionally or accidentally). And because of that, it might be helpful to learn about what goes into it, so that you can have greater control over your reproductive choices.
"I think fertility is something that every person should think about, whether they want to have children or not, and whether they want to have genetically related children or not," Obedin-Maliver says. "And trans people are no different in that."
4. Not to put TOO fine a point on it, but if you still have a uterus, fallopian tubes, and ovaries, you might still be able to get pregnant EVEN IF you're taking hormones.
It's not common, but it happens. "You will not be the first guy to get pregnant not expecting it," Menkin says. "If you're having the kind of sex that could potentially get you pregnant, you should think about an additional method [of birth control] that could prevent that." Just in case!
5. And along those lines, just because you or your partner are trans doesn't necessarily mean that you will have issues with infertility, or that you'll need any help from advanced reproductive technology in order to have a baby.
Advanced reproductive technology, like in-vitro fertilization, for instance, can be prohibitively expensive. And it often isn't even necessary. "In my experience, the folks that I work with don't have infertility problems," Menkin says. "The issue more often has to do with a lack of access to sperm, or a lack of access to uterus and eggs. Not infertility."
6. There are resources that can help you find good trans-care.
Obedin-Maliver recommends Trans Birth (From the website: "Trans Birth is a directory created to connect trans* and gender non-conforming people and their families to midwives, OBGYNs, and doulas who provide welcoming care to our communities"). She also suggests the World Professional Association for Transgender Health as another potential resource.
Menkin says the Gay and Lesbian Medical Association offers a searchable database of providers, organized by location, for instance. And if that doesn't work, he suggests reaching out to some of the big LGBT healthcare centers across the country, and asking them to connect you with trans-care providers in your region.
Some major centers include:
7. Before you start a medical transition, doctors recommend that you do what you can to preserve your future fertility, just in case.
Of course you know best what you want for now and for later, but if you have even a glimmer of an idea of wanting genetically related kids this means banking sperm and freezing eggs before you begin a medical transition (taking hormones). "Every medical body that looks at this basically recommends that any consideration of fertility is undertaken prior to initiating cross-sex hormones," Obedin-Maliver says. "The rationale for that is that we just don't know what long-term effects testosterone would have, say, on egg production and ovarian function over the long-term." It certainly has happened that trans people have gotten pregnant after years of taking hormones, Obedin-Maliver says, "but I would never counsel someone that if they knew they wanted to have children that that was a surefire bet."
"For trans women, similarly, estrogen does effect spermatogenesis," she says. "Have there been trans women who have been on long-term estrogen and have come off of it and been able to produce sperm? Yes. But it takes a long time for the testes to recover, and we're not sure that they will. It's not guaranteed."
Menkin agrees: "For trans women I think it's incredibly important that they really think about banking sperm before they start this process," he says. This might not be something that you want to think about at the time, he warns, and it is something that might stir up discomfort and other negative feelings. "It can be really hard by the time they get in front of a clinician, or in front of me — they are so excited and so ready to start hormones and blocking agents, the last thing they want to hear from me is, why don't we put this off for two weeks so you can go [bank] sperm. It's a really hard sell and it's very hard for young people [...] It's just not on their radar at all. But you kind of get one shot at it. Once you start on blocking agents and estrogen, it might end up being pretty different sperm."
8. If you are interested in one day having genetically related children, the biggest barrier you may face is actually social, rather than medical or surgical.
"It takes a lot of time and effort to work with your family and your loved ones, to figure out what it means to have a partner, if that's relevant to someone with their affirmed gender," Obedin-Maliver says. "Even without any of the hormones, those processes take time, and they take a lot of energy. So the kind of trajectory of finding a partner, having a supportive family, it's all delayed. So people may run up against age-related fertility barriers because they have other stuff going on in their lives. It's a Maslow's hierarchy of needs issue — if you're dealing with [needing to secure] safety, food, shelter, intentionally planning children may not be on the top of the list. Age-related fertility is a reality, and that's a reality for every human being. But there's a way in which transitioning may dovetail with that to make it more challenging."
Age-related fertility refers to the fact that a person's egg quantity and quality tends to decline with age — for some perspective a cisgender heterosexual woman at age 30 has a 20% chance of conceiving each month; by 40, her odds are at roughly 5%. Fertility experts point to 35 as the year where the decline becomes steeper.
9. Along those lines, the mainstream medical establishment isn't always super easy to navigate.
"We unfortunately now know that transgender people experience a lot of discrimination in medical settings," Obedin-Maliver says. "So around getting pregnant, understanding your options, around those types of questions, you may experience a lot more boundaries and barriers than a cisgender person, which could delay things. Even getting routine labs. If you're being a responsible person and want to do your pre-conception counseling and find out if there's anything you should do to optimize carrying a pregnancy or whatnot and the person at the front desk misgenders you, uses the wrong pronoun, someone in the waiting room says something disparaging, and you leave the office before seeing the doctor, that's a delay in care. That's without even hormones and surgery. That's a lived experience of being a gender nonconforming or gender-expansive person on the planet."
10. For trans kids and teens, if you go from taking puberty-suppressing medication directly to hormone replacement therapy, that can render you infertile down the line.
First, a few words about a typical scenario that a trans kid might face:
Typically a child who is gender-nonconforming will begin talking about it at age three or four, Finlayson says. "They start saying it very young, and they're very persistent and insistent, and they're very upset by the idea that they're in the wrong body," she says.
When a gender non-conforming child reaches puberty, they may develop gender dysphoria — this is when "the individual becomes very upset and traumatized by the changes they're seeing in their body," Finlayson says. Not all gender-nonconforming adolescents will experience dysphoria, but some might. Finlayson says that the Endocrine Society guidelines for care recommend that the child take puberty-suppressing medications at this stage.
"[Puberty-suppressing medication] is a medication that is generally speaking very safe, and can be used to just pause puberty," Finlayson says. "If a year later they think they want to go through with their natural puberty, that's fine — it's reversible, and we think it doesn't have any long-term harm." The reason doctors recommend the puberty-suppressing medication at this stage is because it can help kids take some more time to figure out what they want, without the potential trauma or stress of being in a rapidly changing body that is becoming something even farther from what they identify with. But another important reason is because it can potentially help them avoid future surgical operations down the line — thanks to puberty-suppressing medication, trans boys will never develop breasts, for example, which would make a future double mastectomy unnecessary.
After a few years of taking puberty-suppressing medication, with the help of a mental health team, the teenager may then choose to start using hormone replacement medication if they decide that's the right path for them, Finlayson says.
Here's where the fertility issues come in:
"When an individual goes through puberty, the germ cells — what becomes eggs or sperm — mature," Finlayson says. "You have to have puberty for those cells to mature. So if we prevent puberty from occurring, the germ cells in those gonads, whether they're ovaries or testicles, are not going to mature. So in that situation, those individuals who have never gone through a natural puberty in their body — they're not going to have germ cells to use."
In other words: If a trans teen goes directly from using puberty-suppressing medication to hormone-replacement medications, they have not ever undergone puberty, and it may render them infertile in the future.
11. If trans adolescents want to preserve their fertility, they'll have to stop the puberty-suppressing medication for long enough to go through puberty, and then bank sperm or eggs through cryopreservation. But that's much easier said than done.
The key to preserving potential future fertility is to go through puberty, do cryopreservation (sperm- or egg-freezing), and THEN start the medical transition. But this is often a very tough sell, and not something that many trans children want to think about at the time, Finlayson says. "When we see kids who are [potentially] gender dysphoric, who are 10, 11, 12, who are starting puberty, and they're coming in and they're distraught about these changes in their body and they want to start pubertal suppression as quickly as possible, having these conversations at that time, plus talking about fertility with a 10-year-old, and it's hard to have these children understand and consider these things," Finlayson. She says parents tend to be more thoughtful about it, but also that even the act of banking sperm if you're a young trans woman can be incredibly traumatic, especially at this stage.
12. If you personally want to get pregnant, you should stop taking hormones before you start trying.
You need to ovulate in order to have a chance at getting pregnant. If you're a trans man and have decided that you want to carry a baby in your own uterus, you would have a higher chance of conceiving by going off hormones.
Again, doctors recommend that you bank eggs before initiating medical transition — but that doesn't mean that you won't be able to get pregnant "naturally" and without reproductive technology, even after years of being on hormones.
13. If you're trying to get pregnant, it definitely helps if you know how to track your ovulation.
This means tracking your basal temperature in the morning, looking at your cervical mucus, and understanding this process for a few months so you have some retrospective data to look at and so you can know what's normal for you, Menkin says. The reason this is important is because if you're using donor sperm, you're going to want to know the absolute ideal time to use it, to increase your odds of success.
Menkin recommends the book Taking Charge of Your Fertility as a great guide to learning how to track your ovulation. "It's not a queer book," he warns. "It can be difficult for trans men in particular, and I know the literature and the language is complicated."
14. If you're pregnant and trans, it helps a LOT to have healthcare providers who are familiar with trans-care — and it'll be easiest and probably best to find good medical care well in advance of when you give birth.
Menkin says many trans men he knows prefer the idea of a home birth over a hospital birth, because of fear of being judged or getting poor quality care in the hospital due to bigotry. But Menkin advises against home births, for exactly that reason. "The big reason not to do it at home is because [if something goes wrong and you need to go to the hospital], you're really at the mercy of whatever jerk emergency room doctors you might be dealing with. One of the guys I worked with did that, and it was really hard and he really struggled, and had to deal with a lot of ignorance."
Menkin suggests finding a midwife or doula early in your pregnancy, so that you have an advocate by your side throughout the pregnancy and also the birth (midwives and doulas tend to be known for being more "culturally competent," which could help make the whole experience much easier for you). If you can't find a midwife or doula or can't afford one, talk to your doctor who is providing you with trans-care. "The person doing your trans-care can be a resource and an advocate," Menkin says. They may need to call around to find out what resources are available, but it's not unreasonable to ask them for help.
15. If you're using donor sperm, you should know that fresh sperm has higher success rates than frozen sperm.
Statistics from frozen sperm tend to be lower for each attempt at conception, Menkin says.
16. If there's a donor involved at all, filling out some paperwork before you get started can help protect you legally.
You want to have a solid contract worked out in advance, Menkin says, so it's clear (and in writing!) to everyone involved what roles each person is going to be playing in any potential child's life. Whether that means financial obligations, or visitation agreement, child custody, or more, you want to make sure to get it in writing to protect yourself.
17. There are different types of donor sperm you can use, if you plan to buy it.
There's intra-uterine insemination, or IUI, sperm. This is a bit complicated: Semen can't go directly into the uterus as-is, because the uterus is a sterile environment and semen is decidedly not sterile. So it needs to be "washed," Menkin says, and then a doctor will have to perform the IUI with the washed semen using a catheter at exactly the right time of month. It's an out-patient procedure. "Sperm goes in, person hangs out for five to ten minutes, and off they go with their day," he says. Menkin, a nurse practitioner, performs IUIs for couples who want to conceive this way.
And then there's intra-cervical insemination, or ICI, sperm. This is using unwashed sperm. "A syringe will deposit the [ICI sperm]. You put the syringe inside, and you push it in, and then you lay down for a while," Menkin says. This is an attractive option for some couples because it's something that they can do in the privacy and comfort of their own home.
Now here's the thing: "ICI sperm is much cheaper [than IUI sperm], because it hasn't been washed. But frozen sperm that thaws doesn't swim well at all. So I urge people not to do ICIs with frozen sperm," Menkin says. That's because it's a low chance of conception with each cycle, and you may be paying somewhere between $800 and $1,000 for that frozen ICI sperm. It might end up being a huge amount of money spent for a lot of heartbreak. "I urge people to give up the romance and the good feeling that might come with this, because it kind of sucks practically," he says. If you're going to use frozen sperm, you should opt for an IUI instead.
18. If a friend or your partner's family member is going to donate fresh sperm, that works in pretty much the exact way you might expect.
First step is to make sure you (or your partner) are ovulating. When you're ovulating, that's when they need to make the donation. "[When I'm working with couples,] I give them a 3 mL syringe, and say, here's a plastic sterile urine cup (it can be a small bowl from your dishwasher)," Menkin says. "Sex is not a clean process. So he ejaculates into the cup, you pull [the ejaculate] up [into the syringe], you put the syringe inside of you, push the ejaculate in, and then maybe lay down. And then try to do it again about 24 hours later so you really have a big window of covering your ovulation." Then you wait two weeks to see if the results come back positive.
19. If you and your partner are relying on a friend or family member for donor sperm, Menkin suggests that the friend or family member talk to a specialist first.
Beyond just getting tested for sexually transmitted infections, Menkin says this can help the donor really truly understand what they're getting themselves into. "I think that it's a good idea that someone besides the couple talks to the donor about their risk, talk to them about their role, make sure they understand their role," he says.
20. If you have been trying unsuccessfully to get pregnant for a year (or 6 months if the person supplying the eggs is over 35), you should see a fertility specialist — and make sure that both the eggs and the sperm are tested.
Making babies isn't actually as easy as you might expect. As we mentioned above, typical cisgender heterosexual couples where the woman is 30 years old have about a 20% chance of conceiving each month. So it's totally normal for anyone to try for a few months without success. Doctors recommend that couples try for a year if the person supplying the eggs is under 35; over 35, and you should try for 6 months before going to a specialist. Menkin says that when he works with couples, his limit is six IUIs before he recommends that they visit a fertility specialist for testing.
If you do decide to go to a fertility specialist, you should know that infertility issues are often about one (or some combination) of three different potential factors: problems with the eggs, problems with the fallopian tubes, or problems with the sperm. If you're having trouble conceiving, don't assume that it's definitely an egg-related or ovulation-related issue — you'll potentially save yourself a lot of time and money by getting the sperm checked first, Menkin says.
Dr. Courtney Finlayson works at the Ann & Robert H. Lurie Children's Hospital of Chicago. An earlier version of this story misnamed the hospital.