Fertility for Transgender Women Before HRT: New Study Provides Answers

When it comes to fertility and transgender women, there are often more questions than answers. But a new study sheds light on a question LGBTQ+ folks hadn't thought to ask.

At Family Equality, we’ve been hard at work developing articles and programs focused on trans fertility and family-building. When we wrote this article on the fertility of trans women, there were more questions than answers… and there still are. But thanks to a new study, we now know the answer to a question we hadn’t thought to ask: 

Before taking hormones, do transgender women have the same fertility options as cisgender men? 

In short, the answer is either maybe or no. 

About the study

The data was presented in 2019, which makes it one of the most recent studies of its kind. The aim of the study was to learn about baseline fertility levels for transgender women, so protocol around fertility preservation could be optimized for this community. The study was performed by looking at the results of semen analyses using parameters that are easy to understand and measure; this means that the findings are likely quite accurate, compared to studies that ask patients to answer questions based on their memory. Only 11 transgender women were included in the study, which is a statistically low number (though not when compared to other studies on trans fertility). The study compared these 11 pre-transition women to 16 cisgender men whose female partners had recently given birth (the researchers wanted to ensure that the control group of cisgender men were fertile). 

What did they find?

“Sperm concentration, total sperm per ejaculate, total motile sperm, volume, and normal sperm morphology were significantly lower in transgender females compared with fertile cisgender men.” 

That means that the number of sperm in each sample was low, the number of sperm that were moving appropriately was low, the amount of semen was low, and the number of sperm with a healthy shape (morphology) was low. 

Whoa. So this means that even before going on hormones, transgender women may be more likely to experience fertility challenges than their cisgender male counterparts. The researchers of this study state that they aren’t sure why this may be– they think that outside stressors might be a factor (the trans women in the study were more likely to experience anxiety and depression than the men in the study), and stress does impact fertility in general. They also suggested that perhaps wearing restrictive undergarments might contribute to these low numbers… but they just aren’t sure why this could be. 

What does this mean for the trans community?

Many trans women postpone transition in the hopes of first having a biological child. It’s difficult to postpone transition, so it’s a good idea to try to maximize your time spent trying to have a baby. A sperm analysis at the beginning of your process will give you valuable insight into your individual fertility, which can empower you and your partner (if you have one) to decide whether you’ll want to utilize assisted reproductive technology to achieve a pregnancy. 

Since we don’t know for sure whether you’ll be able to regain sperm production once you start HRT, this information also means that fertility preservation prior to transition is even more important than we thought. If you’re already experiencing low fertility measures, it may be even harder to bounce back from HRT once you’ve started. A sperm analysis done at a fertility clinic or sperm bank is often covered by insurance, and many clinics offer payment plans if you can’t afford to pay for the visit out-of-pocket. That initial visit is a great first step as you decide how to proceed with your transition and family-building process. They’ll be able to tell you what your baseline fertility levels are, and from there you can make a plan to preserve your fertility now, transition and decide later, or decide to have a child through other means down the road. 

Remember that there are so many ways to become part of a family, and there is no “right” way to do it. If you have prioritized your transition over your fertility, that doesn’t mean that becoming a parent is off the table! You may still be able to regain fertility if you haven’t had bottom surgery, or you can use a sperm donor, marry someone who already has a child, adopt, raise a family member’s child… or any of the many ways that families are formed. There has never been a shortage of amazing kids in need of a loving, supportive adult in their lives. When the time is right, you’ll find them (or they’ll find you).

And until then, stay connected with Family Equality as we continue to build more resources to help people like you along the way.