We Asked Doctors Every Question This Queer Couple Had About Getting Pregnant
Here's the advice they won't find on Tumblr and Reddit.
“I love this concept that babies can accidentally happen,” Georgia tells BuzzFeed News.
The 33-year-old Sydney woman wants to start a family with her partner Max, a 31-year-old trans guy.
The couple, both using pseudonyms to protect their privacy, want to conceive over the next few years but have found very little information online to help them in their decision-making process.
“At the moment it is a pretty intense process and having healthcare professionals that you trust is important.”
Their ideal scenario is that Georgia would carry an embryo created with Max’s egg and sperm donated by a known donor.
The couple aren’t sure where to find trans-friendly doctors to help them with their reproductive health decisions, particularly around the process of harvesting Max’s eggs for IVF.
“I feel very blind when it comes to fertility,” Max says.
“I can search on Tumblr or Reddit and see if anyone has gone through this before but that’s about it.”
BuzzFeed News spoke to three specialists to help answer the couple’s questions.
Max: “I’ve been on testosterone for nearly five years. How is going off that and going on estrogen going to affect my body?”
Dr Kate Stern is a senior fertility specialist at Melbourne IVF, and head of endocrine and metabolic service at Melbourne’s Royal Women’s Hospital.
The first thing Stern always does with trans patients wishing to harvest eggs is to warn them about how hard going off hormones can be physically and psychologically.
“I wouldn’t go ahead until I know they have contingency plans and they are going to be supported, as it is really tough,” Stern, who specialises in reproductive endocrinology, tells BuzzFeed News.
“It makes you feel somewhat bloated and sometimes a bit estrogenic, which is not what you want to feel as a trans male.
“My trans patients will sometimes feel some chest discomfort, so binding their chest might hurt a bit more if they haven’t had top surgery and often they feel a bit emotionally fragile.”
Max: “How long do I need to go off hormones before I can get eggs, and do I need to do that before I make an appointment at an IVF clinic?”
Dr Charlotte Elder is a Melbourne-based obstetrician and gynaecologist with a special interest in transgender health and a spokesperson for the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.
She says there are blood tests available to check how quickly ovarian function might return.
“The best specialist to do that is a reproductive endocrinologist and most of them are gynaecologists that do fertility procedures,” Elder tells BuzzFeed News.
“There are different protocols for stimulating ovaries for egg collection that take different lengths of time, so definitely talk to an IVF practitioner to get an idea on the times of each one.”
Stern would take Max off testosterone for eight weeks prior to hormonal stimulation, which she says is a rough guide as there are not enough large studies on the ideal period. Then there would be 10–14 days of hormonal stimulation before the egg collection.
Patients are taught how to self-administer hormone stimulation medications using a tiny needle to inject under the skin.
“Before collection, I’d be asking all the usual questions about their family history of reproductive function and hormone conditions, as well as general health and cancer,” she says.
Stern often advises people to do two stimulated cycles.
“It is a pain to go on and off hormones, so they might want to do another egg collection cycle straight away.”
Elder adds that if Max didn’t use IVF and wanted to carry the pregnancy himself he might not have to go off testosterone immediately.
“For trans guys who actually have pregnancies, about a third of them actually conceive while on testosterone,” she says. “But taking testosterone during the pregnancy isn’t advised from the point of view of the foetus.”
Max: “How many months do I need to go through menstruation for? For me that is the most stressful part of this process, because it is going to feel really dysphoric and challenging.”
Stern says most of her trans male patients don’t have to be off their hormones for so long that they actually menstruate.
“You don’t have to be menstruating and usually they won’t menstruate within eight weeks,” she says. “Or we can use other tablets to reduce the risk of this happening if the patient thinks this would be distressing.
“I’d be planning on having everything ready so there are no delays.”
Elder says in her experience, having a reason for the hormonal change (to start a family) can sometimes soften the psychological repercussions of going off hormones.
“I think being in a situation where you’re doing something really positive and creating a family with your partner can make it easier to cope with,” she says.
Max says knowing it is for a “short period of time” will help keep him sane.
“This is my turn if Georgia is going to do that hard work of carrying [the pregnancy].”
Max: “Does going on testosterone affect the quality or age of my eggs compared to a cisgender woman?”
“Interestingly and reassuringly, there is very good evidence testosterone doesn’t negatively impact on your actual egg quality,” Stern says.
Dr Bronwyn Devine is a gynaecologist and fertility specialist with Monash IVF in Sydney and says it is more complicated harvesting sperm from trans women who may have disrupted their chances of conceiving by taking hormones.
“Unfortunately estrogen can have a detrimental effect on sperm production and that can be irretrievable,” she tells BuzzFeed News. “I’ve had young trans women who have got themselves a script for the pill, say through their sister, and they’ve taken that and they come to freeze some sperm at say 17 [years of age] and there’s almost no sperm there.”
Max: “For trans guys who have had a vaginectomy [surgery to remove all or part of the vagina] or ‘cosmetic changes’, does that affect the ability to extract eggs?”
The doctors agreed that the absence of a vagina would influence the chosen method but not the ability to collect eggs.
Eggs are usually removed from the ovaries using an ultrasound–guided probe, to which a fine needle probe is attached. As it passes through the vaginal wall into the ovary it draws fluid (and eggs) from the ovary.
“[A patient without a vagina] would affect the technique, so we normally go through the back of the vagina and the ovaries are just there hanging down; but if needed we could do a laparoscopic [via the abdomen] retrieval, which requires keyhole surgery so has a slightly slower recovery,” Stern says.
Georgia: “Say you’re at an age where you might only have one pregnancy. Are you able to ask for more eggs to be put in for multiple pregnancies? How likely are multiple births?”
“That is not something we tend to do these days,” Devine says. “The problem with multiple pregnancy of any number is that those are complicated pregnancies and people will say ‘I’ve always imagined myself the mother of twins’, or ‘I just want to get both pregnancies out of the way’, but they think of it in a romanticised way, whereas it's about more than just getting a bigger car.”
It is preferable to use a “single good-quality embryo”, she says.
Georgia: “Is it best not to freeze the embryo at all?”
“We used to say in IVF that ‘fresh is best’ but we don’t so much anymore as our frozen embryo rates are as good if not better than our fresh rates, as our freezing technologies have got so good,” Devine says. “People tend to think it is not as good if it has been in a freezer, but it’s not the case with embryos.”
Stern says it depends on when the couple want to fall pregnant.
“To reduce the time off testosterone for Max, he could do a few cycles and freeze and then go back on his hormones so Georgia could just take her time with putting in the embryos,” she says.
IVF Australia advises a stimulated cycle will usually result in the collection of 10–12 eggs, not all of which will fertilise. Pregnancy success rates range from 37% per embryo transfer for patients under 30, to 8.8% per embryo transfer for patients over 40.
Georgia: “I feel like there is so much encouragement for trans guys to have hysterectomies as part of their medical transition process to prevent dysphoric relationships with their bodies, but there is no counselling around fertility preservation. Is this changing?”
“[From a psychosocial perspective] the time to freeze is ideally before you go on your testosterone, although that will not always be possible or appropriate as many young trans men will commence hormones well before they are feeling ready to consider fertility, so it is lucky that the testosterone doesn’t actually damage the fertility in any way,” Stern says.
Children who haven’t gone through puberty can’t freeze eggs, but freezing ovarian tissue for later transplantation is one option.
“For post-pubertal girls and young women about to undergo cancer treatments, they can preserve eggs,” Stern says. “For some trans patients the psychosocial trauma of having to go off your hormones can be bad, but the good news is that testosterone doesn’t make you infertile in the long term like cancer can.
“The trans clinic team at the Royal Children’s Hospital [Melbourne] is really fantastic at managing all aspects of trans care, and transitioning teenagers are counselled about fertility.”
Devine says not all trans children are interested in the counselling.
“The majority of young trans people are going through high school and trying to deal with all the stuff that comes with being a teenager, let alone being a trans teenager, and a lot of them say ‘Look, fertility is not something I want to think about yet,’ and that is OK and we’ll just tell them ‘We can be here as long as you like,’” Devine says.
“We’re more likely to get older trans people, say, a 28-year-old trans guy on testosterone who has had some top surgery and been on hormones and who is well transitioned, but is thinking they might want to get their uterus and ovaries taken out, so is thinking about freezing some eggs soon.”
Georgia: “A friend of mine had a baby with her partner, a cis-woman, and a friend who was the donor. They were going to do the turkey baster thing at home but then got legal advice that you need a doctor present. If the fertility stuff we want to do seems too difficult and we try more traditional ways of conceiving, do we need a doctor present?”
“You can try and conceive with a turkey baster but in terms of efficacy and safety you’d be compromising on both,” Stern says.
“In donor programs the sperm provider gets counselled about the legal implications, which is important because one of the hardest things in these situations is the lack of legal protections if something breaks down in the relationship [between the parents and donor].”
Max: “Are people in IVF clinics going to even know about these procedures, like if a trans guy walks into one of these clinics are they going to have to spend an hour educating the doctor?”
“In all honesty, most of us are seeing LGBTQIA+ patients more commonly now and there is more literature about best practice in our medical journals,” Stern says. “Ask your primary care physician to refer you on, but sometimes there is more expertise in the bigger hospital units with a university affiliation.”
Elder recommends contacting a hospital’s patient liaison officer to discuss any concerns before appointments.
She says reproductive healthcare is improving for LGBTQIA+ patients, particularly trans people planning families.
“There are some really sad situations where trans people haven’t accessed healthcare during pregnancies because they didn’t feel safe and heard, and we know the outcomes for babies are much better if their parents have access to healthcare,” she says. “It is important to find health professionals you trust to provide healthcare in your pregnancy.”
Devine says there is a growing demand for information within obstetrics and gynaecology about LGBTQIA+ reproductive health, and she’s increasingly being asked to speak and write about it.
“I talk to a lot of other doctors about this and things are definitely changing, but of course when trans people encounter services they will still find some ignorance on what it means to be a gender-diverse person, but I’m trying hard to educate my profession.
“Just simple things like get that damn ‘M’ and ‘F’ off your forms, and I don’t care what it says on their Medicare card, just use whatever name and pronoun they want.”
Devine started working with trans patients at a clinic in Canberra.
“I started seeing some trans guys coming through on testosterone who needed pap smears and that kind of thing, and then the first trans couple I helped conceive, it was so wonderful. They’d travelled from Victoria to Canberra and it was so rewarding,” she says.
“I am a cisgender heterosexual woman with no lived experience of what it is like to be gender diverse… but I just love to help people get pregnant.”